Eastar B738 at Ibaraki on Aug 22nd 2019, approached wrong runway

Last Update: March 29, 2021 / 13:21:41 GMT/Zulu time

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Incident Facts

Date of incident
Aug 22, 2019

Classification
Incident

Airline
Eastar Jet

Flight number
ZE-681

Destination
Ibaraki, Japan

Aircraft Registration
HL8052

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
RJAH

An Eastar Jet Boeing 737-800, registration HL8052 performing flight ZE-681 from Seoul (South Korea) to Ibaraki (Japan), was cleared for the approach to Ibaraki's runway 03L at about 16:16L (07:16Z), however, aligned with runway 03R, which was occupied by a vehicle. The aircraft went around from very low height, positioned for another approach to runway 03L and landed safely on runway 03L about 9 minutes after the go around.

Japan's TSB reported on Dec 9th 2019, they have opened an investigation into the occurrence. The eastern runway was occupied by a vehicle, when the aircraft attempted to land on the east side runway, not the west side runway as instructed by ATC. The aircraft went around and landed at the western runway 9 minutes later.

On Mar 29th 2021 the JTSB released their final report concluding the probable causes of the serious incident were:

In this serious incident, it is highly probable that because the Captain of the Aircraft misidentified the runway cleared to land, he made an approach for the different runway where an inspection vehicle was running on.

It is somewhat likely that the Captain as the PF did not thoroughly perform the visual recognition of runway, and in addition, the FO as the PM did not adequately monitor the flight status of the Aircraft, which may be involved in the runway misidentification made by the Captain of the Aircraft.

The JTSB analysed:

Insufficient visual confirmation

In the process of visual approach, an aircraft should appropriately make an approach using ground based visual references including runway, etc., however, it is somewhat likely that the Captain judged the timing to maintain the flight path for visual approach only by referring to the information displayed on ND and performed a visual approach procedure in the same manner. Especially, after passing abeam of the Westside runway end until completing the Final turn, it is probable that while it was flying on the base leg, the Captain should have carefully scanned outside the Aircraft on its left side in order to visually confirm the Westside runway from his seat on the base leg, however, during this time he was performing the items on the check list and reducing the speed, thus not paying enough attention to the outside of the Aircraft, and did not clearly identify the Westside runway which it ought to have landed.

It is somewhat likely that when completing the Final turn made by referring to the information displayed on ND, the Captain assumed that the Eastside runway, which looked white ahead, was the runway cleared to land.

Flight crew’s experience

It is somewhat likely that because it was the first time for the flight crew to make a visual approach to the Westside runway at Hyakuri Airfield and, in addition, they concentrated on engaging in flight operations during the approach and following accurately the flight pattern too much to give enough attention to visually confirming the runway, thus, they misidentified the Eastside runway that was first seen on the final approach as the runway cleared to land.

Besides, it is probable that after the Aircraft completed the Final turn, the Captain misidentified the Eastside runway seen ahead as the Westside runway cleared to land, concentrated on stabilizing the aircraft attitude and maintaining the speed and the descent rate in order to establish the stabilized approach, and as a result, being not able to sufficiently scan outside the Aircraft, he was late in realizing the misidentification of runways.

Difference appearance between the two runways

As the Eastside and Westside runways at Hyakuri Airfield are paved with different materials, it is certain that the Eastside runway paved with white colored concrete has more noticeable than the Westside runway when seen from distance. As a result, it is probable that the Captain assumed that the Eastside runway, which has the more noticeable than the Westside runway, was the runway instructed to land until checking the completion of stabilized approach, because the Captain was affected by the attractiveness*10 to the Eastside runway which were closely installed and the two runways came within sight of him, together.

It is required that when making an approach to the Airfield, flight crew should mutually confirm the noticeability of the runway carefully in the approach briefing.

Coordination between flight crew

It is probable that after the Captain and the FO reported each other that the two runways were in sight, there was no communication between them regarding the situation whether the runways were visible or not. It is probable that between the base leg and the completion of the Final turn, the Captain had not visually recognized the runways thoroughly, while the FO thought that the Captain had a sight of the runway cleared to land, and was concentrating on confirming the indication on the instruments in the cockpit. Therefore, it is probable that the FO was not able to advise the Captain until the Aircraft started to make a go-around as he was not aware of the Captain’s misidentification of runways.

It is probable that the PM should have monitored the flight status of the Aircraft, cross-check operations of the PF properly, then need to be aware of the runway misidentification made by the Captain much earlier, and to advise him.

Classification of Severity

It is highly probable that the distance between the Aircraft and the vehicle running on the Eastside runway, when the Captain started to perform a go-around, was approximately 0.8 nm.

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”).

Metars:
RJAH 220900Z 11005KT 9999 FEW020 BKN100 BKN230 26/23 Q1009=
RJAH 220800Z VRB01KT 8000 FEW015 BKN120 BKN230 27/23 Q1009=
RJAH 220728Z 33003KT 280V050 9999 -SHRA FEW015 SCT080 BKN120 27/23 Q1009 RMK 2CU015 3AC080 7AC120 A2980=
RJAH 220700Z VRB01KT 9999 FEW020 BKN150 BKN230 28/22 Q1009=
RJAH 220600Z VRB01KT 9999 FEW030 BKN180 BKN230 27/23 Q1009=
RJAH 220500Z VRB02KT 9999 FEW015 BKN030 BKN180 27/22 Q1009=
RJAH 220400Z 09004KT 040V130 9999 SCT015 BKN030 27/23 Q1009=
RJAH 220300Z 09005KT 9999 -SHRA FEW012 BKN015 26/22 Q1009=
Incident Facts

Date of incident
Aug 22, 2019

Classification
Incident

Airline
Eastar Jet

Flight number
ZE-681

Destination
Ibaraki, Japan

Aircraft Registration
HL8052

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Airport ICAO Code
RJAH

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