Peach A320 at Tokyo on Dec 22nd 2016, on short final to closed runway

Last Update: February 26, 2018 / 16:06:06 GMT/Zulu time

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Photo of Peach Aviation JA811P, Airbus A320 — Peach Aviation JA811P, Airbus A320 (Photo credit: Alec BHX/KKC / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Dec 22, 2016

Classification
Incident

Airline
Peach Aviation

Flight number
MM-1028

Departure
Taipei, Taiwan

Destination
Tokyo Haneda, Japan

Aircraft Registration
JA811P

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport
Tokyo International Airport, Tokyo

Airport ICAO Code
RJTT

A Peach Aviation Airbus A320-200, registration JA811P performing flight MM-1028 from Taipei (Taiwan) to Tokyo Haneda (Japan) with 164 people on board, was cleared for the approach to Haneda's runway 16L at about 00:38L (15:38Z Dec 21st) and cleared to land on runway 16L, the crew however aligned with runway 23, which was closed for work in progress. Tower noticed the error when the aircraft was descending through 500 feet and instructed the aircraft to go around, the crew complied and climbed out to 6000 feet. The aircraft positioned for another approach to runway 16L and landed safely about 16 minutes after the go around.

Japan's TSB reported the aircraft attempted to land on a closed runway instead of the runway instructed by air traffic control, the aircraft continued the approach to about 500 feet AGL. The aircraft landed on the second approach. An investigation has been opened.

Japan's Ministry of Transport reported the occurrence was rated a serious incident, the TSB have dispatched investigators on site. The aircraft had been cleared to land on runway C from the north (=runway 16L), however, aligned with runway D (=runway 23). Tower instructed the aircraft to go around at about 500 feet AGL, the aircraft landed safely on runway C in the second approach. Runway D was closed for weekly maintenance.

On Feb 26th 2018 Japan's TSB released their final report concluding the probable causes of the serious incident were:

It is probable that the serious incident occurred because aircraft, conducting VOR-A approach to land on runway 16L of Tokyo International Airport, mistakenly tried to approach for runway 23 which was closed.

It is probable that the aircraft mistakenly tried to approach for runway 23 which was closed because advance preparations for VOR A approach by the captain and the first officer were not sufficient, and they could not recognize the runway change instruction to land as a threat and then they failed to manage workloads, properly monitor and advise.

The JTSB reported the captain (62, ATPL, 24,104 hours total, 8,940 hours on type) was pilot flying, the first officer (45, CPL, 3,530 hours total, 405 hours on type) was pilot monitoring.

The crew initially expected to land on runway 34R via the ILS Y procedure, however, ATC assigned them to land on runway 16L via the VOR A approach. The aircraft continued on the VOR-A Approach and descended to MDA, where the vertical speed reduced to 0 fpm, on passing the MAP the autopilot was disconnected and the aircraft began to turn left. About 50 seconds later tower instructed the aircraft to immediately turn right, 10 seconds later instructed to turn right heading 330 and climb to 3000 feet, which was read back by the crew. The lowest altitude reached by the aircraft was 480 feet.

The JTSB reported the captain told in post flight interviews that he instinctively turned left after seeing a bright lit runway and instructed the FO to set the heading bug to 157 (runway 16L heading). He noticed that heading of the aircraft and heading bug disagreed and realized their magnetic heading was 230. The JTSB wrote: "Lots of concerns came up to his mind : he wondered if the runway in front of him might not be runway 16L but runway 23 which was closed, a closed runway must be in complete darkness, he must execute a missed approach and let the Aircraft turn left. Just at that moment, he was instructed from Tokyo Tower that he should climb and turn right immediately. The Captain was first confused about the instruction Tokyo Tower ordered because he was instructed an opposite direction from the one prescribed in the missed approach procedure. However, he received another specified instruction on direction and altitude and followed it. Afterward, it was provided with radar-guidance and landed on runway 16L via visual approach."

The JTSB summarized the tower controller's testimony:

Tokyo Tower received an initial contact from the Aircraft flying for DARKS and instructed to continue approach for runway 16L. He intended to make two aircraft depart prior to landing of the Aircraft. He gave a takeoff clearance to the first one and a "lineup and wait" instruction to the second.

Then he reported that there was one departure traffic on the runway and instructed that the Aircraft should continue an approach. Later, the Aircraft looked like flying a little lower and not turning right for the downwind of runway 16L but turning left, then he felt that it flew strangely and something was wrong with it. Afterward, since it looked continuously turning left toward runway 23 and he should maintain separation between the departure aircraft from runway 16L and the Aircraft, he instructed it to turn right and climb for go-around. He received a readback in a moment but it did not look starting right turn, therefore, he gave a specific instruction: turning 330 degrees and climbing and maintaining 3,000 ft.

Since Tokyo Tower had ever seen the event in which arrival traffic conducting VOR A approach went wrong and ended up to go-around, he had carefully watched the movement of the incoming traffic at that time. He had no concern with the status of each lighting system on runway D because he had already handed over the authority to operate aerodrome lightings to electrical engineer in charge of aeronautical lights (hereinafter refer to as"the Enginer for lights" ) but he remembered that the runway 23 looked brighter than in usual operation at that time, it might be because there were lots of working vehicles there. Regarding operations of lights such as Sequenced Flashing Lights(SFL) and Approach Light System(ALS), those lightings were turned off because they were observing the agreements among those relevant parties in which preventative measures against mistaken approaches for closed runway were described.

When Tokyo Tower looked back this event, he thought that he should have instructed such as "report right break," "report downwind," because those might be beneficial and became reminders for pilots.

Related NOTAM:
A4923/16 - RWY 05/23-CLSD DUE TO MAINT RMK/SEE AIP RJTT AD2.23. 07 14 21 28 1430/2100, 07 DEC 14:30 2016 UNTIL 28 DEC 21:00 2016. CREATED: 27 NOV 13:03 2016

Metars:
RJTT 211700Z 26001KT 9999 FEW030 BKN050 11/08 Q1026 NOSIG RMK 1SC030 7SC050 A3031
RJTT 211630Z VRB03KT 9999 FEW030 BKN050 12/08 Q1026 NOSIG RMK 1SC030 6SC050 A3032
RJTT 211600Z 24003KT 160V290 9999 FEW030 SCT040 13/08 Q1026 NOSIG RMK 1SC030 3SC040 A3032
RJTT 211530Z 24003KT 170V310 9999 FEW025 BKN/// 12/08 Q1027 NOSIG RMK 1CU025 A3033
RJTT 211500Z VRB01KT 9999 FEW030 BKN/// 12/08 Q1027 NOSIG RMK 1CU030 A3035
RJTT 211430Z 27003KT 190V290 9999 FEW030 SCT045 11/07 Q1028 NOSIG RMK 1CU030 3SC045 A3037
RJTT 211400Z 28001KT 9999 FEW040 12/07 Q1029 NOSIG RMK 2SC040 A3039