JAL B763 at Tokushima on Apr 5th 2015, cleared to land on occupied runway

Last Update: August 26, 2016 / 14:59:14 GMT/Zulu time

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Photo of JAL Japan Airlines JA8299, Boeing 767-300 — JAL Japan Airlines JA8299, Boeing 767-300 (Photo credit: Hyougushi / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Apr 5, 2015

Classification
Incident

Airline
JAL Japan Airlines

Flight number
JL-455

Departure
Tokyo Haneda, Japan

Destination
Tokushima, Japan

Aircraft Registration
JA8299

Aircraft Type
Boeing 767-300

ICAO Type Designator
B763

A JAL Japan Airlines Boeing 767-300, registration JA8299 performing flight JL-455 from Tokyo Haneda to Tokushima (Japan) with 67 people on board, was cleared to land on Tokushima's runway 29 when just before touch down the crew noticed a vehicle about 800 meters down the runway and went around, the main gear made contact with the runway. The aircraft climbed over the vehicle, positioned for another approach and landed safely about 10 minutes after going around.

Japan's TSB rated the occurrence a serious incident and opened an investigation reporting that a working vehicle was stationary on the runway when the aircraft was on final approach.

Tokushima Airport reported a runway light needed to be replaced, an engineer drove onto the runway with his vehicle and was replacing the light when tower forgot about the presence of the vehicle and cleared the aircraft to land.

On Aug 25th 2016 the JTSB released their final report concluding the probable cause of the serious incident was:

It is highly probable that the serious incident occurred as Aircraft A attempted to land because the Tower had issued a landing clearance to Aircraft A on the runway occupied by the Work Vehicle.

It is probable that the Tower had issued a landing clearance to Aircraft A to land because the Supervisor, who had the combined duties of the Tower and the Ground, had forgotten about the presence of the Work Vehicle. It is probable that contributing factors were that, in a situation in which only one Air Traffic Controller was on duty in the aerodrome control tower and no support could be received from other controllers, he was preoccupied with selecting a runway for the Departure Aircraft, and that he did not use a reminder indicating that the runway was unusable for take-offs and landings.

The JTSB reported that tower had cleared a work vehicle onto the runway at 10:40L to replace a number of bulbs in the runway distance marker lights. About 3 minutes later the worker entered the runway.

At 10:50L JL-455 reported on approach frequency and requested ILS Z runway 29, approach vectored the aircraft for that approach.

At 10:51L a departing flight reported on tower frequency and requested runway 11 for departure.

At 10:53L approach handed JL-455 off to tower, the aircraft contacted tower 9 seconds later and received landing clearance 17 seconds after hand off by approach.

At 10:57:07L JL-455 descended through 900 feet AGL, the crew disconnected the autopilot.

At 10:57:54L the departure requested pushback and taxi clearance was issued clearance for pushback and with instructions to taxi to runway 11.

At 10:58:05L JL-455 crossed the runway threshold.

At 10:58:17L the main gear of JL-455 touched down, at the same time the TOGA button was pressed and the go around was initiated.

At 10:58:19L the aircraft became airborne again.

At 10:58:24L the aircraft passed over the vehicle.

The JTSB reported that following the initiation of the go around the aircraft passed the vehicle at a height of 40 feet, 12 meters.

The JTSB summarized statement by the crew that they got to see the runway descending through 1000 feet AGL. Together with the automated call 30 feet the captain, pilot flying, heard the first officer calling "Go Around", was puzzled by the call as he thought there was no problem with the landing and looked to the first officer and saw him staring straight ahead, so the captain looked forward and noticed a single orange light near taxiway N4 and thus became aware of the presence of vehicle on the runway. The captain immediately pressed TOGA, then commenced pitch control in order to avoid a tail strike.

The JTSB reported that a single controller, actually supervisor, was present in the control room at that time and was operating both ground and tower frequencies. The supervisor assumed control of both tower and ground at 10:10L, about 40 minutes prior to the serious incident.

When the supervisor cleared the vehicle onto the runway, he thought he could handle the situation by memory alone with only a few takeoffs and landings pending and therefore did not use the runway closed/occupied marker. He then coordinated the pending departure from runway 11. When JL-455 reported on frequency, he scanned the runway for being free and issued landing clearance then returned attention to the departure working out a plan to avoid a conflict between arrival on runway 29 and departure on runway 11 on the taxiways.

Just before JL-455 touched down the supervisor noticed the vehicle on the runway and remembered that he cleared the vehicle onto the runway, but before he could react he saw the aircraft going around.

The maintenance engineer had noticed that two more lights than noted and scheduled were not illuminated and thus changed those bulbs, too. He did this by driving his vehicle to near the light, exit the vehicle, replaced the bulb, enter the vehicle and drive to the next light. He was driving towards the threshold of runway 29, the arriving aircraft should have been in line of sight therefore. However, the worker did not see any traffic. He finished his job and was turning around to exit the runway at taxiway S-3 when he got sight of the arriving aircraft in the mirrors, and accelerated as fast as he could. He noticed the aircraft had touched down and lifted off again, then the aircraft climbed over him without collision. There was no particular reason why he used S3 to vacate the runway except that he always used that exit while performing maintenance on the runway, there was no reason why he couldn't have used the much nearer exits S-5 or N-5.

The JTSB analysed: "Though permitting entry to the runway and allowing this work to be done, the Tokushima Air Training Group (ATG) in principle only allowed it to be undertaken at night after flight operations had ended or early in the morning before the start of operations. On the day; however, permission for the work was given by the Operation Duty Officer. According to the description in 2.9.3, a bulb replacement work for a few burned-out bulbs that had occurred individually in the runway distance marker lights was a non-urgent work; however, it is probable that the fact that this work was undertaken during the time when take-offs and landings were scheduled, contrary to the basic principle, was the contributing factor of the occurrence of the serious incident. It is probable that the Worker did not contact the Tower to the effect that he intended to leave the runway using a forward taxiway instead of using the nearest one after finishing the work, and that additional work locations not originally scheduled had arisen, because he was not sufficiently aware that the time of occupation of the runway should be kept to the minimum. It is somewhat likely that the Worker was not sufficiently aware of this because the education given to the Worker by the ATG was inadequate."