Asiana A320 at Seoul on Nov 15th 2019, landed on wrong and occupied runway

Last Update: January 8, 2021 / 18:12:54 GMT/Zulu time

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Photo of Asiana Airlines HL7738, Airbus A320 — Asiana Airlines HL7738, Airbus A320 (Photo credit: Alec BHX/KKC / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Nov 15, 2019

Classification
Report

Airline
Asiana Airlines

Flight number
OZ-8708

Departure
Gwangju, South Korea

Destination
Seoul Gimpo, South Korea

Aircraft Registration
HL7738

Aircraft Type
Airbus A320

ICAO Type Designator
A320

An Asiana Airlines Airbus A320-200, registration HL7738 performing flight OZ-8708 from Gwangju to Seoul Gimpo (South Korea), had prepared the landing runway before departure based on then ATIS information indicating runway 32R was used for landing. The crew intended to perform an automatic landing. The crew departed, climbed the aircraft to cruise FL190 and was on approach to Gimpo Airport when ATC cleared the flight for an ILS approach to and landing on runway 32L. Despite that clearance the aircraft touched down on runway 32R when another airliner was cleared to cross runway 32R at taxiway E about 2500 meters down the runway and went past the hold short line. The controller realizing the A320 had landed on the wrong runway instructed the crossing airliner to speed up crossing the runway, at that point the A320 was 1810 meters from the crossing airliner. When the crossing airliner had exited the runway, the A320 had slowed down to 27 knots speed over ground and began to vacate the runway at taxiway D3.

South Korea's ARAIB released their final report in Korean only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Korean only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).

The ARAIB concludes the probable causes of the serious incident were:

The crew had entered the landing runway information at the time of departure. The landing runway was changed and ATC cleared the flight to land on the changed runway. The crew however remained unaware of the change and continued landing on the prepared but wrong runway.

Contributing factors:

- Neglect to check ATIS information and failure to comply with flight procedures by the crew
- Insufficient monitoring of the flight track by tower to detect approaches to wrong runways

The ARAIB analysed that the captain was pilot monitoring and the first officer was pilot flying. At the time at and before departure from Gwangju the ATIS Information G at Gimpo Airport announced runway 32R was used for landings. At 17:16L the crew prepared their FMS for landing on runway 32R. Following flight preparation, while passengers were boarding at Gwangju, Gimpo Airport changed their ATIS now indicating runway 32L, ATIS switched to Information H, was used for landings at 17:48L. The aircraft took off from Gwangju at 17:55L, reached FL190 at 18:03L, started the descent at 18:10L, at that time ATIS Information J was active, the captain listened to ATIS until hearing the identifier J, did not check the further ATIS information, and just noted the letter J down. The captain thus remained unaware that the runway had changed. The captain should have checked ATIS carefully and in full.

On approach to Gimpo Approach Control advised the crew their landing runway would be 32L, the captain read back 32L, however, did not recognize they had setup for 32R and thus did not initiate reprogramming of the FMS or switch of the approach plates. Tower later cleared them to land on runway 32L, but again the switch from 32R and 32L remained undetected by the crew. The captain had "fixed" runway 32R in his mind and thus did not monitor and recognize that they were actually talking about runway 32L.

The preceeding traffic (that later conflicted with the A320 on runway 32R) had been about 6-8nm ahead of the A320, landed on runway 32L and was taxiing to the apron. Tower had been monitoring their flight progress and verified they were indeed on approach to runway 32L at the correct profile. Tower subsequently zoomed his radar display out and thus did not detect that the A320 had joined the extended runway center line of 32R. Only at low altitude the controller became aware through a visual check that the A320 was approaching the wrong runway but deemed it unsafe to instruct a go around, rather instructed the crossing aircraft to accelerate crossing.

The ARAIB further analysed that the departure of HL7728 was rushed due to a delay. The first officer was not familiar with Gimpo Airport, there was lack of cockpit resource management causing no communication about the pre-flight preparation of the FMS and leaving the first officer in state of guessing and dependence which led to a false judgement of the situation. In addition, the approach briefing was skipped removing another barrier of defense.