JAC DH8D at Fukuoka on Jul 8th 2012, cleared for takeoff despite Cessna on short final

Last Update: April 26, 2013 / 13:28:11 GMT/Zulu time

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Incident Facts

Date of incident
Jul 8, 2012

Classification
Incident

Aircraft Registration
JA847C

ICAO Type Designator
DH8D

On Apr 26th 2013 the Japanese Transport Safety Board released their final report (in English!, see below) concluding the probable cause of the serious incident was:

It is highly probable that this serious incident occurred because, when Aircraft A (arrival aircraft) was approaching Runway 34 of Fukuoka Airport after it received a landing clearance from the Tower, Aircraft B (departure aircraft) entered the runway as the Tower instructed it to wait there.

The Tower instructed Aircraft B to wait on the runway though it had already issued a landing clearance to Aircraft A. It is highly probable that this occurred because the Tower temporarily had forgotten the existence of Aircraft A.

It is probable that the Tower had forgotten the existence of Aircraft A because he wanted to let many waiting News-gathering Helicopters and scheduled departure flights depart soon, and that this distracted the TowerÂ’s attention. In addition, the strip for Aircraft A did not serve as a reminder because the Tower removed it from the strip bay, and it is probable that this also affected the occurrence of the incident.

The JTSB reported the privately owned Cessna 172 was approach Fukuoka under visual flight rules, and after being cleared to join the approach pattern a first time the controller, due to traffic congestion, changed mind and instructed the Cessna to hold 1nm east of the aerodrome and removed the flight strip from the strip bay. Before that the Dash 8 had already requested engine start up clearance and taxi clearance on ground control frequency, the aircraft was taxiing towards the holding point runway 34. Upon reporting on tower frequency the crew requested departure from intersection taxiway E11 and was instructed to hold short of the runway at E11. Tower subsequently cleared the Cessna to join a right hand base, then cleared the aircraft to land on runway 34.

2:20 minutes later tower cleared the Dash 8 to line up runway 34 and wait. The instruction was read back correctly and the aircraft proceeded onto the runway.

46 seconds after the instruction to line up the runway tower informed the arriving Cessna that winds were from 330 degrees at 11 knots.

27 seconds after the wind information tower instructed the Cessna to go around, which was acknowledged and the pilot initiated a go around 0.8nm short of the runway threshold.

The JTSB reported that the pilot of the Cessna had heard the clearance to line up the runway and wait and thus expected to go around flying the base and final leg in a position to be able to go-around any time starting to slightly offset to the runway center line to the east in preparation to separate from the possibly departing traffic during the go-around. When the instruction to go around and turn east arrived, the pilot was not surprised and immediately commenced the already prepared maneouver. The pilot did not see any particular danger.

The JTSB quoted the controller stating, that the traffic volume had been light but gradually increasing. A shooting incident had occurred near the aerodrome, a number of news helicopters requested to depart in response to the incident amongst a number of scheduled departures. The news helicopters would depart right into the arriving traffic creating concerns of separation, the tower thus coordinated with approach to take the arriving aircraft to a lower altitude to permit the three helicopters depart. After coordination the tower controller had forgotten about the arriving Cessna and therefore instructed the Dash 8 to line up on the runway. Usually, arriving VFR traffic would use a left hand pattern and thus were directly visible to the controller, small aircraft in the right hand pattern however were difficult to see, the Cessna was not visible on the Tower Display Subsystem and the strip bay did not show the Cessna, too. The strip bay had contained the flight strip of the Cessna however was removed from the strip bay, when the controller instructed the aircraft to hold 1nm east of the aerodrome, because the strip bay had run full due to the departing helicopters. The controller should have re-inserted the strip when he cleared the Cessna a second time to join the base leg however failed to do so, which together with losing the aircraft from mind a few minutes later prevented the controller recognizing the arrival on final.

The JTSB analysed that due to the congested traffic the Dash 8 crew was not able to understand which aircraft was cleared to land. In addition, the Cessna may have been difficult to spot on its base leg for the crew of the Dash 8. The JTSB analysed: "If a landing/take-off clearance is issued to one aircraft at a time, it is easy for aircraft to grasp the traffic condition around them. It is considered that if landing clearances had been so issued, it would have been more likely that the PIC of Aircraft B noticed inappropriate control instructions, etc."

The JTSB analysed regarding the wind report to the Cessna, that although the arriving Cessna had slipped from the controller's mind he still had some memory of an arrival without recalling that this aircraft had already been cleared to land.

Two safety actions were taken as result of the investigation.

Editorial notice and Thanks to the JTSB: In July 2011 the JTSB rearranged their website improving both useability, accessibility and attractivity of the site speeding up and easying access to relevant informations, introducing also colour codes for aviation, road, rail and other matters permitting to recognize aviation relevant information even without being able to read/understand Japanese. The Aviation Herald, after seeing that huge improvement, sent an e-mail to the JTSB thanking for and commending the changes and a nice exchange resulted during which The Aviation Herald submitted the recommendation to release all final reports in English including those, that seem to concern only Japanese traffic (with all persons involved in the occurrence capable of speaking Japanese), arguing, that lessons out of such events can be learned by aviators around the planet. The JTSB at that time argued that budget constraints would not permit translation of all reports, however they were highly favourable towards the recommendation. Early this year The Aviation Herald noticed a first "domestic" report being published in both English and Japanese, now seeing a second such report suggesting that the JTSB has followed up on the recommendation and with that move enables aviators around the globe to also learn the lessons out of events in Japan. The Aviation Herald's hat is off to the JTSB, thanks for a superb service in the interest of aviation safety.
Incident Facts

Date of incident
Jul 8, 2012

Classification
Incident

Aircraft Registration
JA847C

ICAO Type Designator
DH8D

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