Skymark B738 and ANA B789 at Tokyo on Jun 15th 2019, ATC operational error, B789 crosses runway while B738 lands

Last Update: April 22, 2021 / 19:44:11 GMT/Zulu time

Bookmark this article
Incident Facts

Date of incident
Jun 15, 2019

Classification
Incident

Flight number
BC-110

Departure
Kobe, Japan

Aircraft Registration
JA73AB

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Skymark Airlines Boeing 737-800, registration JA73AB performing flight BC-110 from Kobe to Tokyo Haneda (Japan), was on final approach to Haneda's runway 34L and was cleared to land on runway 34L.

An ANA All Nippon Airways Boeing 787-9, registration JA885A performing flight NH-115 from Vancouver,BC (Canada) to Tokyo Haneda, had landed about 6 minutes earlier and was cleared to cross runway 34L near the end of the runway just when the Skymark aircraft was on short final at less than 1000 feet AGL. The aircraft entered the runway and crossed the runway, the 737 touched down just after the B789 had left the runway surface.

Japan's TSB have opened an investigation into the occurrence.

On Apr 22nd 2021 the JTSB released their final report concluding the probable causes of the serious incident were:

It is certain that this serious incident occurred because the Aircraft B crossed the runway after being cleared from the Tower West Position, when the Aircraft A was approaching Runway A after receiving a landing clearance from the Tower West Position.

It is highly probable that the Tower West Position issued a clearance of crossing Runway A to the Aircraft B, because the Supervisor A, not recognizing the landing clearance issued to the Aircraft A, urged the Trainee to issue a clearance of crossing the runway to the Aircraft B, and because the Trainee, who forgot issuing a landing clearance to the Aircraft A, issued a clearance of crossing the runway to the Aircraft B according to the instruction of the Supervisor A.

The JTSB reported, the Tower West Position was staffed by an instructor and a trainee and reported:

When the serious incident occurred, the Supervisor A had already gotten about eight years of work experience since acquiring all the certificates in Tokyo Aerodrome Control Facility, and had been appointed as a supervisor in charge of the Trainee since the Trainee joined the same team. The Supervisor A created opportunities to speak with the Trainee at least once every cycle of rotating shifts and supervised the Trainee while evaluating the Trainee’s progress.

After completing the basic training at Aeronautical Safety College, the Trainee was assigned to Tokyo Aerodrome Control Facility as the Trainee’s first work place. After obtaining a qualification as a flight data position controller (FD), the Trainee was officially assigned as a controller in April 2019, and from the end of the same month, the Trainee began to receive the OJT at the ground control position and the tower control position. According to the standard training period prescribed by the Tower, the goal period of the OJT for the Trainee would end in February 2020, and had been in the process of completing approximately one fifth of the training period at the time of the serious incident.

The JTSB analysed:

(1) Situation of clearance of crossing the runway

The Aircraft A was approaching Runway A after being cleared to land from the Tower West Position, however, it is certain that the Trainee, who was carrying out the control operation at the Tower West Position, instructed the Aircraft B to cross Runway A. In addition, it is highly probable that the Supervisor A did not recognize that the Trainee had issued a landing clearance to the Aircraft A.

(2) Judgement and operations by the Trainee

It is highly probable that the Trainee issued a landing clearance to the Aircraft A after confirming that the Aircraft C had reached over the approach lights and judging that it would be possible to set the prescribed separation from the succeeding Aircraft A. In addition, it is highly probable that because the Trainee did not notice the existence of the Aircraft B when the landing clearance was issued, the positional relationship between the Aircraft A and the Aircraft B was not considered. It is probable that the Trainee noticed the existence of the Aircraft B when the Trainee received an initial call from the Aircraft B and was not able to determine with confidence the timing for the Aircraft B to cross the runway.

The Trainee had once decided to have the Aircraft B cross the runway after the landing of the Aircraft A and placed the strips accordingly, however, it is probable that because the Supervisor A urged the Trainee to issue a clearance of crossing the runway to the Aircraft B, the Trainee cleared the Aircraft B for cross the runway as instructed. At this time, it is probable that the Trainee temporarily forgot that the Trainee had issued a landing clearance to the Aircraft A, being directed to instruct the Aircraft C to vacate the runway via Taxiway A12 just before the clearance of crossing the runway.

(3) Coordination with other positions by the Supervisor A

The controllers instruct aircraft within the area under their own control through radio communication and carry out the operations of ATC service while coordinating with other relevant positions over the direct line or face-to-face communications regarding entering and leaving aircraft. When the serious incident occurred, the Tower West Position was carrying out the operations of ATC services while coordinating with the ground control position (West) to its left and the ground control position (North) to its right. While sometimes coordinating with other positions instead of the Trainee, the Supervisor A continued the OJT. For the towed aircraft which the Trainee concerned about, the Supervisor A also coordinated with the ground control position (North) instead of the Trainee, however, it is probable that during this time, the Supervisor A was not able to monitor the operations by the Trainee. Therefore, it is highly probable that the Supervisor A failed to listen to the communications between the Trainee and the Aircraft A, overlooked the Trainee’s operation related to the strips, and failed to realize that the Trainee had given a landing clearance to the Aircraft

A. Because the OJT is conducted while both of the supervisor and the trainee are carrying out the operations of ATC services at the same position, it is necessary to ensure that both parties communicate well with each other to prevent the perception gap between them, and share the situation awareness and intention.

(4) Using strips as reminders

The Civil Aviation Bureau of the Ministry of Land, Infrastructure, Transport and Tourism instructed all air traffic control organizations to use the strips for arrival aircraft as reminders. According to Tokyo Aerodrome Control Facility, they use the stamp on the aircraft strip as a reminder by attaching it when an instruction is issued to the aircraft under its own control. It is probable that it is shown that the strip with the attached stamp did not function as a reminder since the Trainee had forgotten that the Trainee had already issued a landing clearance to the Aircraft A when the Trainee issued a clearance of crossing the runway to the Aircraft B, and the Supervisor A did not notice that the Trainee had issued a landing clearance to the Aircraft A. It is probable that the controllers are required to confirm the strips when issuing clearances especially for take-off, landing, entering or crossing a runway, and make effective use of those strips as reminders.

(5) Environment to supervise training

The controllers at the aerodrome control facility carry out the operations of ATC services by scanning through the TAPS screen on the control console while widely scanning aircraft, runways and others seen outside the window of the ATC tower. In addition to these operations, the supervisor needs to monitor the operations by the trainee and usually stays behind the trainee so as not to come within sight of the trainee. As a result, it is probable that the supervisor will be a little away from the TAPS screen, which makes it difficult for the supervisor to grasp the situation of electronic strips and other information shown on the screen. Besides, it is somewhat likely that because changing from paper strips to electronic ones enabled the delivery of strips among control positions and all their strip-related operations to be electronically conducted, it might make difficult for the supervisor monitoring behind the trainee to grasp the trainee’s behaviors.

When introducing TAPS, Tokyo Aerodrome Control Facility made the Management of change by conducting the survey of the controllers about the layout of a display, etc. and installed TAPS in the installation position and angle so that there would not be any difference from the traditional system in respect of the visibility and operability. However, it is desirable to newly perform the risk evaluation after identifying hazardous risks from a standpoint of the supervisor during OJT.

(6) Classification of Severity

It is highly probable that the distance between the Aircraft A and the Aircraft B, when the Aircraft B entered the runway, was approximately 8,400 m (about 4.5 nm).

It is certain that the serious incident falls under the severity classification of Category C (An incident characterized by ample time and/or distance to avoid a collision) of “the Manual on the Prevention of Runway Incursions” of ICAO with classification tools provided by ICAO. (See Attachment “Severity Classifications of Runway Incursions”).
Incident Facts

Date of incident
Jun 15, 2019

Classification
Incident

Flight number
BC-110

Departure
Kobe, Japan

Aircraft Registration
JA73AB

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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

You can read 4 more free articles without a subscription.

Subscribe now and continue reading without any limits!

Are you a subscriber?
Login
Subscribe

Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.

Free newsletter

Want to know more and stay ahead? Get our free weekly newsletter and join 4855 existing subscribers.

By subscribing, you accept our terms and conditions and confirm that you've read our privacy policy.

Send tip

Support AeroInside by sending a small tip amount.

Related articles

Newest articles

Subscribe today

Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.

Pick your plan and subscribe

Partner

Blockaviation logo

A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.

Virtual Speech logo

Train yourself online in VR with the special course for aviation: "Crisis Communications: Airlines". Find out more.

Get updates

Never miss an article from AeroInside. Subscribe to our free weekly newsletter and join 4855 existing subscribers.

By subscribing, you accept our terms and conditions and that you've read our privacy policy.

AeroInside Blog
Popular aircraft
Airbus A320
Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American Airlines
United
Delta
Air Canada
Lufthansa
British Airways