China Southern A319 at Cheongju on Mar 18th 2016, runway incursion forcing a B738 &quot;go around&quot; the A319

Last Update: March 27, 2018 / 17:28:16 GMT/Zulu time

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Incident Facts

Date of incident
Mar 18, 2016

Classification
Incident

Cause
Runway incursion

Airline
China Southern Airlines

Flight number
CZ-8444

Departure
Cheongju, South Korea

Destination
Dalian, China

Aircraft Registration
B-6039

Aircraft Type
Airbus A319

ICAO Type Designator
A319

Airport
Cheongju International Airport, Cheongju

Airport ICAO Code
RKTU

A China Southern Airbus A319-100, registration B-6039 performing flight CZ-8444 from Cheongju (South Korea) to Dalian (China) with 90 people on board, was taxiing for departure in reduced visibility and had been instructed to hold short of runway 24R at taxiway A3 about 730 meters/2400 feet down the runway.

A Korean Airlines Boeing 737-800, registration HL7786 performing flight KE-1958 from Jeju to Cheongju (South Korea) with 137 people on board, had just touched down on runway 24R when the A319 went past the hold short line. The Boeing crew recognized the danger, pulled their aircraft to the very left edge of the runway managing to avoid the A319 by about 10 meters and rolled out without further incident returning the aircraft onto the runway center line.

South Korea's Ministry of Transport initiated an investigation into the serious incident stating, that the Boeing 737-800 even went beyond the left edge of the runway in order to avoid a collision. The minimum distance between the aircraft were 10 meters (wing tip of B738 to nose of A319). At the time runway 24L was not available for any operation (including taxi). The A319 had been instructed to hold short of the runway however did not comply with the instruction, the reasons are being investigated.

On Apr 1st 2016 the French BEA identified the A319 as B-6039 and reported, South Korea's ARAIB rated the occurrence a serious incident and is investigating.

On Apr 13th 2016 China's Civil Aviation Authority (CAAC) confirmed the occurrence stating that the minimum distance between wing tip of the Boeing and the nose of the A319 had been only 3 meters. China Southern initially did not report essential information and tried to avoid answering all the key questions to explain the occurrence, it also turned out the cockpit voice recorder was deleted. Only after further querying the airline came up with an explanation of the events stating the crew misunderstood an ATC instruction. The CAAC added, that there had been 21 occurrences of runway incursions in the recent 15 months in China, 4 of which were caused by China Southern (editorial note: none of which came into public knowledge following a drastic change of CAAC policy in about 2011 stopping public disclosure of occurrences and even removing information up to 2011 still present on their website up to 2015).

On Mar 27th 2018 South Korea's ARAIB released their final report in Korean concluding the probable cause of the serious incident was:

The crew of China Southern Airlines B-6039 mistook the clearance "Runway 24R, taxi via B3" as clearance to enter the runway at B3 and proceed to the take off position while the clearance actually meant: taxi to runway 24R via B3, hold short of runway 24R. The aircraft thus entered the runway without clearance while HL7786 was just landing on the runway.

Contributing factors were:

- Ground Control did not issue a hold short, holding point or end point in the taxi instruction to B-6039

- China Southern Airlines' training of ground control procedures and ground control procedures' language was insufficient

The ARAIB reported 3 meters of the Boeing 737-800's right hand wing tip would have hit the cockpit area of the A319, had the B738 crew not corrected about 6 meters to their left permitting their right hand wing tip to pass the cockpit of the A319 by 3 meters.

The ARAIB reported the A319 commander (37, ATPL, 11,032 hours total, 9,473 hours on type) occupied the right hand seat and held an ICAO English language rating E-4, the captain under supervision while undergoing line training (31, ATPL, 6,870 hours total, 6,620 hours on type) held an ICAO English language rating E-5 and occupied the left hand seat. A third pilot (28, CPL, 2,190 hours total, 1,900 hours on type), ICAO language rating E-4, occupied the observer's seat as a safety pilot.

The A319 was in contact with ground control and had been cleared "Runway 24R, taxi via B3, Altimeter 29.87" which did not include a clearance to enter the runway and should have resulted in the A319 stopping short of runway 24R at taxiway B3 at the hold short line. The crew however understood the instruction as clearance to enter runway 24R at B3 and backtrack the runway to taxi to the takeoff position. While still on ground control the aircraft thus passed the hold short line.

About 25 seconds after the A319 went across the hold short line the B738 touched down 2200 feet down runway 24R.

3 seconds later the A319 reached the right runway edge and crossed the runway edge beginning to turn to the left to backtrack the runway towards the takeoff position.

11 seconds after the B738 had touched down and about 4100 feet down the runway the crew sighted the A319 and, at a speed of 96.5 knots over ground, initiated an evasive maneouver turning to the left. The minimum distance between the A319's nose and the B738's wing tip was 3 meters/10 feet.

In the analysis portion of the report (not in the factual section) the ARAIB reported that the A319 crew after seeing the lights of the B738 stopped their aircraft, the nose of the A319 was 15 meters inside the runway edge at that point.

Following the occurrence ground control instructed the A319 to contact tower. The crew of the B738 explained the close encounter to tower, then turned around backtracking runway 24R to taxiway B3 and vacated the runway to the apron. The A319 reported on tower, backtracked runway 24R, lined up for departure and departed.

The ARAIB analysed that the two aircraft were on different frequencies, the controllers could not provide information about the other traffic on the other frequency. Unknown to the B738 crew the A319 taxied onto the runway as result of misunderstanding their clearance. When the B738 crew got sight of the A319 they used brakes and rudder to turn left, managed to steer the aircraft 6 meters to the left before passing the A319 thus missing the A319 by 3 meters. Had the B738 not turned left the right hand wing tip of the B738 and the nose of the A319 would have collided.

The ARAIB analysed that visibility was close to landing minimum due to fog. The tower controller thus was unable to see the A319 while it taxied towards the runway and crossed the hold short line. Equally, the ground controller was relying on position reports by the crews and could not see the A319 as it crossed the hold short line and taxied onto the runway. Ground controllers and tower controllers are responsible for the safe operation of the runway and therefore need to exchange information. If the aircraft are not visible due to weather or are not displayed on radar, their positions must be communicated before handing the aircraft over to the next controller.

The ground controller told the investigation that he had issued the taxi clearance, observed the A319 begin the taxi and turn into taxiway B3. He subsequently observed the B738 touch down, then announced the presence of the A319 at B3 to the tower controller and handed the A319 off to tower. The ground controller believed the A319 had not entered the runway, however, at that time the A319 had stopped already on the runway. The ARAIB annotated the aircraft had been handed off to tower without precise position information.

The ARAIB analysed that pilots should be trained thorougly in airport signs, markings and lightings. They should also be familiar with the phraseology of communication with ATC, in particular the necessity to obtain a specific clearance to enter a runway for crossing or lining up. They should also be trained in the procedures of ground control. The investigation found that the training materials of the airline did provide such information to the flight crew, it appeared however the training was insufficient. After initial training the crew was referred to self training, in particular ground control procedures. The crew should have obtained a specific clearance to enter the runway while approaching the hold short line of the runway marked with the hold short line as well as wig-wag lights, however, continued onto the runway without verifying their clearance to enter the runway. Given, that the crew held a language proficiency rating of at least E-4 there should have been no issue understanding the phraseology of ground control procedures.

The captain of the A319 was also responsible to be aware of their current position at any time. Should the captain become unsure of his position, he should contact air traffic control and apply the relevant ICAO procedures.

The ARAIB analysed that according to ICAO the phrases for issuing a taxi clearance were: "Runway (number), taxi via (route as necessary)" or "Runway (number), taxi via (route as necessary), (hold short instructions as necessary)". It is possible to issue that taxi instruction with or without the hold short instructions, as this ground based control term does not include any clearance to enter a runway. However, also according to ICAO recommendations, the hold short instructions are more clearly understood by flight crews.

There is no taxiway parallel to the runway, aircraft therefore need to enter the runway at taxiway A3 or B3 and backtrack the runway to the threshold for departure respective backtrack the runway to vacate the runway via taxiway A3 or B3 after landing.

In this scenario it is possible that two aircraft are on the runway at the same time, one backtracking for departure while the other is backtracking to vacate the runway. Misunderstandings appear possible therefore. It would thus be safer to issue taxi instructions with hold instructions such as "Runway 24R, taxi via B3, hold short runway 24R at B3".

The ARAIB analysed the crew resource management within the A319 cockpit. All pilots understood the clearance as "taxi to runway 24R", which further evolved into a "taxi down runway 24R". However, the phrase "Runway 24R, taxi via B3" should not be arbitrarily interpreted, the instruction clearly does not include a clearance to enter the runway. Either pilot in the cockpit should have recognized that they were not cleared to enter the runway and prevented crossing the hold short line. As such, the crew resource management within the cockpit broke down.

Metars:
RKTU 181500Z 09001KT 1600 BR FEW000 SCT200 05/05 Q1012 NOSIG=
RKTU 181415Z 05001KT 2400 BR FEW000 FEW200 05/05 Q1011 NOSIG=
RKTU 181400Z 08001KT 3200 BR FEW000 FEW200 06/06 Q1011 NOSIG=
RKTU 181300Z 22002KT 3200 BR FEW000 SCT200 07/07 Q1011 NOSIG=
RKTU 181247Z 22003KT 4000 BR NSC 07/07 Q1011 NOSIG=
RKTU 181200Z 01001KT 4800 BR NSC 08/08 Q1011 NOSIG=
RKTU 181100Z 15001KT 8000 FEW030 SCT200 09/08 Q1010 NOSIG=
RKTU 181000Z 31001KT 6000 FEW030 SCT200 12/10 Q1009 NOSIG=
RKTU 180900Z 33001KT 6000 FEW030 14/10 Q1009 NOSIG=
RKTU 180835Z 14001KT 4800 BR FEW020 BKN030 14/10 Q1009 NOSIG=