Juneyao A320 at Okinawa on Mar 18th 2018, commenced takeoff without clearance, high risk of collision on runway

Last Update: February 14, 2019 / 20:03:51 GMT/Zulu time

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Incident Facts

Date of incident
Mar 18, 2018

Classification
Incident

Airline
Juneyao Airlines

Flight number
HO-1332

Departure
Okinawa, Japan

Destination
Shanghai Pudong, China

Aircraft Registration
B-8236

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport
Naha Airport, Naha

Airport ICAO Code
ROAH

A Juneyao Airlines Airbus A320-200, registration B-8236 performing flight HO-1332 from Okinawa (Japan) to Shanghai Pudong (China) with 115 people on board, was cleared to line up runway 18 and wait. The crew read the instruction back correctly, lined up but commenced takeoff.

At the time a Japanese Coast Guard aircraft with 5 occupants on board was still in the process of vacating the runway after landing.

The A320 became airborne and continued to Shanghai for a safe landing.

Japan's Transportation Safety Board (JTSB) rated the occurrence a serious incident involving a high risk of collision and dispatched four accident investigators on site.

On Feb 14th 2019 the JTSB released their final report concluding the probable causes of the serious incident were:

It is highly probable that this serious incident occurred as follows:

Without receiving a takeoff clearance from the Tower, the Aircraft A commenced a take-off roll on the runway where the Aircraft B, which had landed earlier, was still present on the runway; furthermore, although the Aircraft A had failed to hear the Tower’s instructions to stop immediately, it continued take-off roll.

As for the reason that the Aircraft A commenced a take-off roll without a take-off clearance from the Tower, it is somewhat likely that the PIC failed to make mutual confirmation of whether to receive the take-off clearance among the flight crew members and made a hasty judgment that they would have received it.

The JTSB analysed:

Take-off clearance

In principle, it is required that the take-off clearance should be issued in the order of the following words and terms such as “wind direction and wind velocity, runway number, and ‘Cleared for take-off’.” It is necessary for the flight crew member to read back the term “cleared for take-off” clearly.

According to the ATC communications records, it was confirmed that there would be neither the take-off clearance from the Tower to the Aircraft A nor the read-back of “Cleared for take-off” from the Aircraft A to the Tower.

The commencement of a take-off roll of the Aircraft A

It is somewhat likely that the PIC of the Aircraft A, expecting that the take-off clearance would be issued promptly, ran away with the idea from his past experience at Naha Airport that the take-off clearance had been issued at the same time when the Tower started transmitting the instructions for the cancellation of the altitude restriction; therefore, with a hasty judgment he moved the lever to increase the engine thrust and released the brakes.

It was probable that the PIC should have made mutual confirmation of whether to receive the take-off clearance from the Tower among the flight crew members without fail.

On the other hand, it is somewhat likely that while hearing the Tower’s instructions for the cancellation of the altitude restriction and seeing the PIC start to move the thrust lever in front of him, the SO perceived mistakenly that they had received a take-off clearance or he read back inaccurately to the Tower without surely grasping the contents of ATC communications.

It is important for flight crews to find generally possible errors such as hasty judgments and misunderstandings and prevent them from leading up to serious consequences by complying with basic procedures stated in the standard operation procedures (SOP) regarding the read back and mutual confirmation of ATC instructions and appropriately exercising CRM skills for monitors, assertions and others.

Regarding the fact that the Aircraft continued take-off roll

Regarding the fact that the Aircraft A continued take-off roll even though the Tower instructed it to stop immediately, it is highly probable that the flight crew members of the Aircraft A had failed to hear the Tower’s instructions because at that time there were no abnormalities identified in the situation of communications of the Aircraft A, and the flight crews of the other aircraft, who were listening on the same frequency as the Aircraft A, had clearly heard the Tower giving instructions to the Aircraft A to stop immediately.

As for the reason the flight crew members of the Aircraft A had failed to hear the Tower’s instructions, it is somewhat likely that as the Tower interrupted its transmissions to the next departing aircraft and transmitted to the Aircraft A, the flight crew members of the Aircraft A could not recognize that the Tower’s instructions to stop immediately were addressed to them even if the Tower called out “DKH1332” repeatedly.
Flight crew members must listen to the tower communications even after the take-off procedure has started, because the instructions to immediately stop from the tower controller after the take-off roll are issued to avoid the danger.

ATC communications conducted in the observer seat

As the Company allows flight operations with a three-pilot system where an additional flight crew member in the observer seat is in charge of the ATC communications, on-the-job training for ATC communications is frequently conducted in the observer seat.

It is probable that it would be difficult for the flight crew members to confirm that they share the communication contents when ATC communications are conducted by a flight crew member in the observer seat because the seating setups for the flight crew members are separated into the front and rear seats, which make it difficult to confirm their mutual facial expressions. In this case, it is necessary to make more proactive and reliable mutual confirmation among the flight crew members in order to ensure that they grasp the contents of ATC communications and share the information.

As at the time of the serious incident, the SO in the observer seat was on-the-job training for ATC communications; therefore, it is probable that the PIC and the FO should have more carefully monitored and confirmed the ATC communications.

Risk assessment

As shown in Figure 3, the estimated separation between the Aircraft A and the Aircraft B was 1,330 m.

According to ICAO “Manual on the Prevention of Runway Incursions,” it is certain that the severity of risk for this serious incident falls in the “Category C (an incident characterized by ample time and/or distance to avoid a collision).

Metars:
ROAH 181100Z 13005KT 9999 FEW025 21/16 Q1016=
ROAH 181030Z 14006KT 9999 FEW025 21/16 Q1016=
ROAH 181000Z 13006KT 080V160 9999 FEW025 22/16 Q1016=
ROAH 180930Z 13008KT 9999 FEW025 22/15 Q1016=
ROAH 180900Z 13009KT 080V160 9999 FEW027 23/15 Q1015=
ROAH 180830Z 15009KT 9999 SCT027 23/16 Q1016=
ROAH 180800Z 14008KT 090V170 9999 SCT028 23/16 Q1016=
ROAH 180730Z 13008KT 090V170 9999 FEW030 23/15 Q1016=
ROAH 180700Z 14009KT 060V170 9999 FEW030 23/15 Q1016=
ROAH 180630Z 15009KT 9999 FEW030 24/15 Q1016=
ROAH 180600Z 14009KT 090V180 9999 FEW035 24/15 Q1016=
ROAH 180530Z 14010KT 110V180 9999 FEW035 24/15 Q1016=
ROAH 180500Z 12010KT 9999 FEW035 24/15 Q1017=