JAL B763 at Kagoshima on Oct 10th 2015, near collision on final, two simultaneous landing clearances for one runway?

Last Update: December 29, 2016 / 16:44:00 GMT/Zulu time

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Photo of JAL Japan Airlines JA8364, Boeing 767-300 — JAL Japan Airlines JA8364, Boeing 767-300 (Photo credit: Kentaro IEMOTO@Tokyo / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Oct 10, 2015

Classification
Incident

Cause
Near collision

Airline
JAL Japan Airlines

Flight number
JL-651

Departure
Tokyo Haneda, Japan

Destination
Kagoshima, Japan

Aircraft Registration
JA8364

Aircraft Type
Boeing 767-300

ICAO Type Designator
B763

A JAL Japan Airlines Boeing 767-300, registration JA8364 performing flight JL-651 from Tokyo Haneda to Kagoshima (Japan) with about 250 people on board, was on final approach to Kagoshima's runway 34 descending through about 1000 feet when the crew received a TCAS resolution advisory and initiated a go-around. The aircraft positioned for another approach and landed safely about 10 minutes later.

Japan's Ministry of Transport reported that a Britten-Norman Islander on a commercial flight with two crew was intercepting the extended runway center line, when the captain of the Islander spotted the Boeing and initiated a go around. At the same time the TCAS issued a resolution advisory with the Boeing 767, which was descending through 300 meters (1000 feet) about 5.4km (2.9nm) before the runway threshold, the Boeing went around, too. The Boeing landed safely about 10 minutes later, the Islander landed safely shortly afterwards. The occurrence was rated a serious incident, three investigators have been dispatched on site. The minimum separation between the aircraft is to be determined.

Both operators stated that their aircraft had received landing clearance.

On Oct 12th 2015 Japan's Ministry of Transport reported that the crew of the Islander had understood a clearance, that had been issued to the JAL 767, to clear them for landing.

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

The return flight JL-652 was cancelled. The occurrence B763 remained on the ground for the rest of the day and resumed service the following day.

On Dec 28th 2016 the JTSB released their final report concluding the probable cause of the serious incident were:

It is highly probable that this serious incident occurred because the PIC of Aircraft B (BN2) misunderstood the DHC-8 that was flying in front of Aircraft A (B763) to be the relevant preceding aircraft, resulting in Aircraft B entering its final approach path after the DHC-8 and coming into proximity with the following Aircraft A.

It is probable that the PIC of Aircraft B misunderstood the relevant preceding aircraft because the PIC did not correctly understand the traffic information on the type and location of the relevant preceding aircraft provided by the Tower. It is also somewhat likely that the fact that Controller A did not inform Aircraft B of the landing sequence when issuing the instruction to “FOLLOW” contributed to the occurrence of this serious incident.

The JTSB named the B763 aircraft A and the Britten Norman Islander aircraft B, the sketch below clarifies the difficult wording better than any description.

The JTSB wrote:

At 16:43, Aircraft B received an instruction from the aerodrome control position of Kagoshima Airport traffic control tower (hereinafter referred to as “the Tower”) to hold on the downwind leg as the arriving aircrafts were queued, as a result of which Aircraft B circled and held. At 16:46:11, the Controller of the Tower (hereinafter referred to as “Controller A”) informed Aircraft B, which was holding, that the holding time would be about 10 minutes. Subsequently at 16:49:15, Controller A provided the traffic information as “You, following traffic Boeing 767, 13 nm on final,” supposedly meant that the relevant preceding aircraft to be followed by Aircraft B was a Boeing 767 at 13 nm on its final approach. In response, the PIC of Aircraft B responded, “Roger. Looking out.”

Hereafter, Aircraft A was permitted by the Tower to land on Runway 34, and was also informed at the same time that it was in second position in the landing sequence. At 16:50:52, Controller A instructed Aircraft B, which was holding on the downwind leg, as “Previous traffic 9 nm on final. Report traffic in sight.” At 16:51:34, the PIC of Aircraft B sighted a DHC-8 flying on the final approach path about 1 nm from the threshold of Runway 34, assumed it to be the relevant preceding aircraft, and reported “Final traffic in sight.” Hearing this, Controller A judged that Aircraft B had sighted Aircraft A, and instructed it to “Follow the traffic.” The PIC of Aircraft B repeated this instruction and headed to the final approach path without being noticed by Aircraft A.

At around this time, another Controller who was in the control tower (hereinafter referred to as “Controller B”) noticed Aircraft B flying on the base leg just before entering the final approach path, and asked, “Will it enter in front (of Aircraft A)?” On hearing this, Controller A turned his attention to a helicopter (Robinson R22) to which he was planning to give the instruction for approach after Aircraft B, since Aircraft A appeared to be ahead of Aircraft B and he naturally thought that Aircraft B was following Aircraft A. When Controller A again turned his attention to Aircraft B, he noticed that Aircraft B had entered the final approach, and intended to give Aircraft B the instruction to go around. At this time, he received a report from Aircraft A that there was traffic ahead. The Tower then instructed Aircraft B to break to the west and to maintain the altitude.

The PIC of Aircraft A first noticed TCAS information about Aircraft B without any altitude information on HSI*5, and confirmed the presence of Aircraft B near the beginning of the base leg by sight, and informed the F/O. While the PIC of Aircraft A was paying attention to the situation of Aircraft B, Aircraft B cut in to his own flight path, causing him to report to the Tower that “We have traffic ahead.” The PIC of Aircraft A was intending to decide how to avoid it after confirming the instruction issued by the Tower to Aircraft B, but since he had approached even closer to Aircraft B in the meantime, he felt the danger and decided to go around. Just as he instructed the F/O to perform the go-around, the F/O also called “Go around” at about the same time and started the operation for go-around. As soon as Aircraft A started to ascend, he felt anxious as Aircraft B was now out of sight below, but because the Tower instructed Aircraft B to break to the west and not to climb, and Aircraft B responded to that instruction, he continued to ascend on a straight path, and after confirming with the Tower, flew on the missed approach course.

Aircraft B had not noticed the presence of Aircraft A until Aircraft A passed over it to the right, and broke to the west while maintaining altitude as instructed by the Tower.