JAC DH8D and ANA B763 at Fukuoka on May 23rd 2010, simultaneous landing and takeoff clearances

Last Update: May 5, 2012 / 15:50:42 GMT/Zulu time

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Incident Facts

Date of incident
May 23, 2010

Flight number
3X-3626

Destination
Fukuoka, Japan

Aircraft Registration
JA844C

ICAO Type Designator
DH8D

A JAC Japan Air Commuter de Havilland Dash 8-400, registration JA844C performing flight 3X-3626 from Miyazaki to Fukuoka (Japan) with 75 passengers and 4 crew, was on approach to Fukuoka's runway 16 in low visibility and had received landing clearance about 4.4nm before touchdown.

An ANA All Nippon Airways Boeing 767-300, registration JA602A performing flight NH-487 from Fukuoka to Okinawa (Japan) with 121 passengers and 7 crew, was taxiing for departure towards holding point E2 runway 16 and reported ready for departure about 1 minutes after the Dash 8 received landing clearance.

Tower cleared the Boeing 767 for takeoff from runway 16, which prompted the commander of the Dash 8, at this point 2.3nm from touchdown at about 900 feet MSL, to query tower "confirm landing clearance runway 16". Tower at this point recognized his error, instructed the Dash 8 to go around, the aircraft was was 1.8nm from touch down, and cancelled the takeoff clearance for the Boeing 767 changing the instruction to line up runway 16 and wait.

The Boeing 767 departed a short time later, the Dash 8 positioned for a second approach. Both aircraft landed safely at their destinations.

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

Although aircraft A (JA844C) had received landing clearance on runway 16 aircraft B (JA602A) received takeoff clearance from runway 16, which implied aircraft B was permitted to taxi onto the runway despite another aircraft on short final to the same runway.

The tower controller forgot the presence of aircraft A due to poor visibility on short final, lack of verification with tower's radar display and the rather long period of time between issuing the landing clearance and takeoff clearance, which decreased attention and awareness.

The JTSB analysed that the usual workflow of a tower controller prior to issuing a takeoff clearance would be: visual check of the final approach, check of the radar display and check of the runway.

At the day of the incident the aircraft was not visible on final approach due to low visibility, the arriving Dash 8 however was painted on the radar display but not observed by the sole tower controller when the departing Boeing reported ready for departure. A runway inspection had been done earlier, and the tower controller was occupied with visually finding the inspection vehicle to assure it had vacated the runway, then he issued the takeoff clearance forgetting about the arrival.

The trainee controller on the ground position, sitting alongside the tower controller (the radar display being available to both positions) noticed the arriving Dash 8 on the radar display but assumed the tower controller was aware of the arrival, he also could not hear tower's transmissions and thus did not intervene.

The instructor controller, monitoring the trainee ground controller from the back seat, was not aware of the arrival and pending conflict.

The use of flight strips as an additional safe guard at Fukuoka Air Traffic Control (tower) had been discontinued in January 2010 following several evaluations between 2000 and 2010 and a serious incident which had not been prevented by flight strips. The reasoning at the time had been that amending the flight strips required additional attention by controllers and thus became a distraction in the scanning and planning tasks performed by controllers.

The investigation released two safety recommendations to the Civil Aviation Authority of Japan:

- to conduct a top to bottom review of the basic operation of air traffic control at Fukuoka with regards to safe implementation of the procedures and to take preventive steps to take advantage of the results of the review

- re-instate the flight strips and make use of the flight strips as additional safe guard to remember instructions issued

Another safety recommendation was released to Fukuoka's Aerodrome Administration to introduce a dual controller (dual watch) system, re-introduce flight strips, ensure safe implementation of basic control operations and human error prevention.
Incident Facts

Date of incident
May 23, 2010

Flight number
3X-3626

Destination
Fukuoka, Japan

Aircraft Registration
JA844C

ICAO Type Designator
DH8D

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