Japan TransOcean B734 at Okinawa on Jun 3rd 2015, continued landing onto occupied runway despite instruction to go around
Last Update: April 27, 2017 / 14:52:44 GMT/Zulu time
Japan's Transportation Safety Board rated both occurrences, the runway incursion forcing the rejected takeoff as well as the continuation of landing despite instruction to go around, as serious incidents each and dispatched three investigators on site.
Japan's Ministry of Transport reported the captain was aware of the other aircraft on the runway but thought it would pose no problem for landing.
On Apr 27th 2017 Japans's TSB (JTSB) released their final report concluding the probable causes of the two serious incidents were:
It is certain that this serious incident occurred as follows: when the Aircraft B rejected a takeoff on the runway 18 due to the Aircraft A crossed over in its front, and the Aircraft C landed on the runway 18 before its vacating.
It is probable that the Aircraft C landed on the runway was because the PIC, recognizing the existence of the Aircraft B on the runway when the FO started flare, as it had been issued the landing clearance by the aerodrome control tower, although he could not confirm the trend of the Aircraft B, based on his experience at the airport and on the same type of aircraft and the landing performance, it was judged by the PIC that it could land safely. It is also somewhat likely that the judgment is related to the fact the PIC could not confirm the trend of the Aircraft A which had crossed over the runway.
Regarding the Aircraft C landed on the runway although the aerodrome control tower of the aerodrome control facility instructed it to execute a go-around, it is probable that it had already landed on the runway and the reverse thrust operation was started when the PIC and the FO were recognizing the instruction. In addition, it is probable that it was involved that the instruction of executing a go-around had missed the timing.
It is highly probable that the reason why the Aircraft B rejected take-off is that, while the PIC was in the situation that he was not able to determine the flight direction of the Aircraft A approaching its departure course after the take-off of the Aircraft A and because the PIC of the Aircraft B felt a serious danger in the continued take-off; therefore, he decided to reject the take-off. Besides, it is highly probable that, regarding the take-off of the Aircraft A, its pilots misunderstood the take-off clearance for the Aircraft B as the clearance for their aircraft, as well as the Pilot and the Load-master carried out external visual checks; however, it was due to delay in noticing the Aircraft B that commenced a take-off roll.
Moreover, regarding the fact that the pilots of the Aircraft A misunderstood the take-off clearance for the Aircraft B as their take-off clearance, although they could not accurately hear what was transmitted to them by the Tower, it is probable that they did not make confirmation of the contents of the transmission. Besides, it is probable that the pilots of the Aircraft A did not notice misunderstanding the take-off clearance, as there was nothing pointed out from the Tower to the wrong read-back of the Aircraft A.
It is probable that because the Aircraft A was not pointed out from the Tower to the wrong read-back, as the Tower was not able to hear its read-back. About this matter, it is probable that because the characteristics of the VHF receiver used for air traffic control communication was involved.
The JTSB labelled the helicopter as aircraft A, the ANA Boeing 737-800 Aircraft B, that rejected takeoff, and the landing TransOcean Boeing 737-400 Aircraft C.
The JTSB analysed that weather had no role into both serious incidents.
The JTSB analysed that the principles of how VHF transmitters/receivers work, in particular overlapping readbacks by both Aircraft A (helicopter) and Aircraft B (B734) both acknowledging the previous takeoff clearance to the B734, the brief readback by the helicopter crew could not be heard by tower, who thus remained unaware that the helicopter had incorrectly assumed the takeoff clearance for them and thus no correction of the false readback occurred. The JTSB wrote: "It is somewhat likely that in the current state of the VHF radio telephone receiver of the present ATC facilities, when two or more aircraft simultaneously transmit signals to the ATC facilities at the same frequency, the weaker signal transmission form an aircraft is suppressed when received by the receiver of the ATC facilities and there is a possibility that a phenomenon that the control agency cannot perceive the received signal perceive at all in the future. When aircraft transmit on the same frequency at the same time, it is desirable that CAB inform the persons involved ATC communications that the air traffic controllers might be unable to recognize the situation."
The JTSB analysed that the helicopter pilot, seated in the right hand seat of his helicopter, departing in takeoff direction to the right of the runway could not see the landing and departing traffic on the runway. The pilot instructed his loadmaster to look out for landing and departing traffic on the runway, however, it was likely the loadmaster looked at the approach path mainly and therefore did not report the aircraft on the departure roll timely.
The JTSB analysed that the copilot of the helicopter doing radio communications was puzzled by being instructed to stand by when requesting takeoff clearance but being given hovering clearance shortly followed by an "IMMEDIATE TAKEOFF" clearance. The co-pilot did not fully understand the callsigns though but knowing the congestion of the aerodrome assumed they were cleared for immediate takeoff. The JTSB wrote: "In the case where the Pilot could not hear contents of ATC communication even partly or uncertain of it, it is considered necessary to make basic correspondence to request for confirmation from the ATC facilities. In addition, as described in 2.1.2(1) and (2), it is considered to be an effective means for the ATC communication that does not occur misunderstanding to determine a procedure in order to securely understand the contents of the ATC communication. As described in 2.1.2 (2), the Co-pilot, when being instructed to stand-by with the call "STAND BY" from the Tower in response to the take-off request made by himself, read back the instruction and requested for a clearance of hovering, it was required to understand the meaning of the "STAND BY" specified in the standards for ATC Operational Procedure described in 2.14.7."
The JTSB analysed that the captain of the departing ANA B738 observed the helicopter departing along taxiway A-5 but was unsure about the aircraft's trajectory. The captain also was aware of the risks involved rejecting takeoff at high speed. Being unable to determine the trajectory of the helicopter he felt a serious danger in the continued takeoff and therefore called "Reject", which the pilot monitoring, the first officer, promptly radioed to tower.
The JTSB analysed that the captain of the B734 was aware of the previous departure and, when they received landing clearance, observed the B738 in the departure roll. Shortly afterwards he observed the helicopter crossing the runway, focussed on the departing Boeing and did not notice any slow down. The first officer, seeing the helicopter flying away to the west, thought the Boeing would continue takeoff, both pilots therefore concluded a go around was not necessary and continued the approach.
Just when the first officer of the B734 was about to initiate flare for landing the captain realized the B738 was still on the runway, took control of the aircraft and, judging from his experience of aircraft performance on both aircraft types, concluded they could continue landing safely, they were cleared to land, they could not fully determine the flight trajectory of the helicopter and therefore continued landing.
The JTSB analysed that the captain had already engaged thrust reversers when tower instructed the go-around. With the thrust reversers deployed regulations and FCOM required a full stop landing to be completed, the FCOM stated the aircraft can not fly safely after the thrust reversers were deployed.
The JTSB analysed that 570 meters of separation remained between the two Boeing Aircraft. As such they rated the category of risk of collision as C (An incident characterized by time and/or distance to avoid collision).
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ROAH 030300Z 20013KT 9999 FEW015 BKN/// 29/26 Q1010
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ROAH 030200Z 20013KT 9999 FEW015 BKN/// 28/25 Q1010
This article is published under license from Avherald.com. © of text by Avherald.com.
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