China Eastern A319 at Okinawa on Jul 5th 2012, runway incursion

Last Update: May 28, 2015 / 13:43:49 GMT/Zulu time

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Photo of China Eastern Airlines B-2332, Airbus A319 — China Eastern Airlines B-2332, Airbus A319 (Photo credit: woinary / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Jul 5, 2012

Classification
Incident

Cause
Runway incursion

Airline
China Eastern Airlines

Flight number
MU-2046

Departure
Okinawa, Japan

Destination
Shanghai, China

Aircraft Registration
B-2332

Aircraft Type
Airbus A319

ICAO Type Designator
A319

A China Eastern Airlines Airbus A319-100, registration B-2332 performing flight MU-2046 from Okinawa (Japan) to Shanghai (China) with 27 people on board, was taxiing for departure, had been instructed and acknowledged to hold short of runway 18.

An AirAsia Japan Airbus A320-200, registration JA01AJ performing route verification flight JW-8665 (flight to be introduced by August 2012) from Tokyo Narita to Okinawa (Japan) with 38 people on board, was on final approach to Okinawa's runway 18 at about 13:24L (04:24Z) but needed to go around when the China Eastern A319 taxied past the hold short line and lined up on the runway. The aircraft positioned for a second approach and landed safely.

The A319 departed shortly after the runway incursion and reached Shanghai safely and ahead of schedule.

Japan's TSB rated the occurrence a serious incident and opened an investigation.

On May 28th 2015 Japan's Transportation Safety Board (JTSB) released their final report concluding the probable cause of the serious incident was:

It is highly probable that the serious incident occurred because the departing aircraft (Aircraft A) made an incursion onto the runway despite being instructed to hold short of the runway, causing the arriving aircraft (Aircraft B), which had already been cleared to land, to attempt to land on the same runway.

It is highly probable that Aircraft A entered the runway because the flight crewmembers of the aircraft misheard and misunderstood the instruction to hold short of the runway as an instruction to hold on the runway and could not find the arriving aircraft, as well as because the Tower Controller did not recognize that the readback from Aircraft A was incorrect and consequently did not confirm or correct the readback.

It is somewhat likely that noise occurring in the sound of the hold instruction from the Tower Controller contributed to the mishearing of the hold instruction by the flight crewmembers, and also that the misunderstanding by the flight crewmembers that they were allowed to enter the runway and the mind that there was no arriving aircraft contributed to the result that the flight crewmembers could not find the arriving aircraft.

It is also somewhat likely that the following contributed to the fact that the Controller did not notice the incorrect readback and failed to confirm or correct the readback.
- The Tower Controller heard the readback from Aircraft A over a loudspeaker without wearing a headset.
- The readback from Aircraft A was unclear.
- The Tower Controller assumed that her own instructions were read back correctly.

The JTSB reported that the China Eastern Airlines Airbus A319-100 (Aircraft A) was taxiing from parking position 43 towards departure runway 18.

The commander of the flight (47, ATPL, 11,581 hours total, 10,434 hours on type) occupied the right hand seat and assumed the role as pilot monitoring, the first officer (28, CPL, 4,948 hours total, 4,698 hours on type) occupied the left hand seat and assumed the role as pilot flying, another first officer (24, CPL, 1,071 hours total, 821 hours on type) occupied the observer's seat.

The aircraft was turning from taxiway A onto taxiway E0, when the crew contacted tower and received clearance: "Hold short of Runway One
Eight. Report when ready." and read back: "(inarticulate sound)
Runway One Eight, report ready." The arriving aircraft (Aircraft B), the AirAsia A320, was 3.5nm from touchdown descending through 1090 feet AGL at that time.

About 20 seconds after the readback the A319 crossed the hold short line on taxiway E0, the A320 was 2.7nm from touchdown descending through 920 feet AGL.

While lining up on runway 18 the A319 crew reported ready for departure, 3 seconds later tower instructed the A319 to stand by and the arriving A320 to go around, the A320 was 2.1nm from touchdown descending through 770 feet AGL.

The JTSB summarized crew testimony that the first officer in the observer's seat had been responsible for ATC radio communication. The first officer understood "Line up and wait. Report when ready", actually all three pilots in the cockpit had the same understanding, and read this back. The captain further stated that before entering the runway he checked the approach to his right and did not see any aircraft on final.

The JTSB summarized the controller's testimony that because of the foreign call sign the controller was extra careful to transmit "report when ready" and adding "hold short of runway 18". The JTSB wrote: "Although the readback from Aircraft A was not clear, the Tower
Controller heard that it sounded like “Hold short of Runway 18, report when ready.”" The controller stated, that no head set was being used, the microphone was held in the hand and was pointed towards the mouth while issusing instructions, and the loudspeakers were used to hear the aircraft.

The JTSB described the hold short instruction and readback sound recordings: "Unclear portions caused by pop noise (noise occurring when sound is cracked by excessive strength of the voice or by blowing into a microphone) are recorded on the voice of the Tower Controller. This noise primarily occurs on consonant sounds, and is particularly prominent in the “Hold short” portion, in the transmission beginning at 13:23:23, which instructed Aircraft A to hold short of the runway. The readback of this hold instruction from Aircraft A began at 13:23:30. The beginning portion of the readback “Line up and wait” was recorded unclear voice and was very difficult to read. Moreover, as indicated in the figure below, from 13:23:28, immediately after the hold instruction from the Tower was completed, Japan Airlines Flight 906 (hereinafter referred to as “Aircraft D”), which had been instructed on the Ground frequency to taxi to the runway, began to read back the instruction, and the readback from Aircraft A was overlapping the latter half of the readback from."

The JTSB analysed: "the Tower Controller stated that she conducted communications without wearing a headset but by holding it in her hand, and that the tip of the voice tube was pointed toward her mouth; therefore, it is highly probable that the pop noise described in 2.5.1 occurred because the breath of Tower Controller struck directly the opening in the tip of the voice tube when she uttered words. The controller also stated that she clearly added “Hold short of Runway 18”; therefore, it is probable that prominent noise was caused when the Tower Controller stressed the “Hold short” portion. It is probable that if the headset had been properly worn, the tip of the voice tube would have been positioned at a right angle to the Tower Controller’s lips, and this pop noise would not have occurred; therefore, in order to transmit a clear voice when a headset is used, it is considered necessary for Controllers to engage in their duties by wearing the headset as described in the manufacturer’s instruction manual mentioned in 2.5.3."

The JTSB continued analysis: "the readback of Aircraft A on the Tower frequency overlapped the readback of Aircraft D on the Ground frequency for 1.2 seconds, and it is highly probable that the readbacks of Aircraft A and Aircraft D were audible from the loudspeakers of the Local Control Console and the Ground Control Console. Therefore, it is somewhat likely that the masking occurred over the auditory sense of the Tower Controller, who did not wear a headset, and influenced her hearing ability on the “Hold short” part in the readback of Aircraft A."

Metars:
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ROAH 050130Z 19013KT 9999 FEW015 SCT020 31/25 Q1011 RMK 1CU015 3CU020 A2986
ROAH 050100Z 18012KT 9999 FEW015 SCT/// 31/26 Q1011 RMK 2CU015 A2985