Air Busan B734 at Fukuoka on Dec 26th 2010, runway incursion

Last Update: August 31, 2012 / 20:27:43 GMT/Zulu time

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Incident Facts

Date of incident
Dec 26, 2010

Classification
Incident

Airline
Air Busan

Aircraft Type
Boeing 737-400

ICAO Type Designator
B734

Japan's Transportation Safety Board (JTSB) released their final report in Japanese concluding the probable cause of the serious incident was:

The departing aircraft had been instructed to taxi to the holding point of the departure runway, however mistook the instruction as clearance to line up. The tower controller did not check the contents of the readback leading to the situation that the aircraft moved to line up while another aircraft was on short final cleared to land on the same runway.

The mistake to believe the aircraft was cleared to line up was probably caused by one or the combination of following factors:

1) the query for an intersection departure

2) just prior to the "hold short" instruction tower had queried for the aircraft being ready and was told the aircraft was ready

3) the crew believed they would depart before the arriving traffic

4) an incorrect phrase in the hold short instruction that included the taxi route

The JTSB reported that the Air Busan 737 was already taxiing when ground control queried whether they would accept an intersection departure from taxiway W8, which the crew accepted. About 3 minutes later ground instructed: "ABL141, taxi to W8, contact Tower, 118.4" with the crew reading back "Taxi via W8, contact Tower, 118.4, ABL141"

Upon reporting on tower frequency the crew initially used flight number 142, tower queried and the crew corrected their callsign to flight 141. As an immediate response to the correction tower queried "ABL141, Fukuoka Tower, report when ready", received an instant reply "ABL141, ready" and within a second followed up "Roger, hold short of runway 34 via W8" and received the readback "Runway 34 via W8, ABL141", the aircraft subsequently moved past the hold short line W8. 50 seconds after the readback tower recognized the aircraft had moved past the hold short line and instructed "JAL3530, go around, go around due to traffic".

Subsequently ABL141 queried "ABL141, confirm cleared for take off?", tower responded "ABL141, negative, I said you hold short of runway 34 via W8 due to inbound traffic". ABL141 then apologized stating: "I'm sorry, I heard line up".

The JTSB reported that upon crossing the hold short line the arriving JAL 737 was 1.2nm from the runway threshold at 350 feet AGL, at the go-around instruction the JAL 737 was 1.0nm from the runway threshold at 300 feet AGL, the distance between the aircraft was 1.3nm.

Both flight crew of the Air Busan 737 stated in post flight interviews they never heard the words "hold short", but heard "runway 34 via W8" just as their readback was and thus believed they were cleared to line up runway 34.

The tower controller said he did not expect a misunderstanding and was already thinking about the next departures, then provided updated wind information to the arriving aircraft while overlooking the runway. He said in his interview all the controllers at Fukuoka would use the "hold short of runway .. via .." phraseology.

The JTSB analysed that the standard phraseology to instruct an aircraft to stop before a holding point of a runway, by ICAO, FAA or Japanese standards, is: "Hold short of runway .." without any addition. The JTSB added that the word "via" is to be used only in taxi instructions "Taxi ... via ..."

The JTSB concluded their analysis that if the first few words of "hold short of runway 34 via W8" were missed by the crew, they would hear "runway 34 via W8" and therefore assume a "taxi runway 34 via W8" or "line up runway 34 via W8".

The JTSB further analysed that the term "hold short of" MUST be read back upon receiving any such instruction, and the controller MUST verify the correct read back of "hold short", e.g. "hold short of runway 34" being read back "holding short of runway 34". The controller must not assume that a hold short instruction has been received and understood if the readback does not include that term.
Incident Facts

Date of incident
Dec 26, 2010

Classification
Incident

Airline
Air Busan

Aircraft Type
Boeing 737-400

ICAO Type Designator
B734

This article is published under license from Avherald.com. © of text by Avherald.com.
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