On 30 November 2019, an Airbus A320 (JA806P) was being operated by Peach Aviation on a scheduled domestic passenger flight into Tokyo Haneda. Just before it touched down on destination landing runway 34L in night VMC as cleared, a small car began to cross the temporarily closed intersecting runway near the opposite end of the landing runway. Separation reduced to a minimum of 1,417 metres as the A320 approached half way along the 3000 metre-long runway before it began to exit it at about two thirds of its length by which time the car was clear of the runway.
After notification of the event the day it occurred, the Japan Transport Safety Board (JTSB) classified it as a Serious Incident and an Investigation was carried out. Relevant data were successfully downloaded from the aircraft FDR and the vehicle GPS unit and recorded ATC data were also available. It was noted that the 30 year-old Captain had a total of 4,251 hours flying experience. The 61-year old vehicle driver was found to have attended an in-house safety training course for construction in restricted areas just over three weeks before the investigated event occurred.
Runway B (04/22) was closed for planned night work and the process of measurement in preparation for work for the part of the runway south of its intersection with active runway A (34L/16R) had begun. One of the other two runways - C (16L/34R) was also closed and the other one - D (05/23) was active (see the illustration below) which also shows three designated aircraft taxi/towing routes across closed runway 04/22.
The Closure Coordination diagram showing the successive separations of the landing aircraft and the incursion vehicle. [Reproduced from the Official Report]
Shortly before the incursion occurred, the Field Manager of the construction work requested ATC clearance for a vehicle crossing of the most southerly towing route in order to reach a more northerly part of closed runway 04/22 and was initially instructed to hold short whilst two aircraft taxied across which they then did. Shortly after this, the A320 was on final approach to runway 34L and, with about 8 nm to go, received a landing clearance. Believing that ATC clearance was necessary only for the taxi/towing routes indicated in green on the Closure Coordination Diagram which was included in the daily work schedule report, the Field Manager then repeated his earlier request and after receiving clearance crossed the runway using the designated route. As he then reached the intersection of the active and closed runways, the Field Manager confirmed that the runway surface at the intersection was painted red which as he understood indicated that it was closed and could therefore be crossed without clearance. He therefore began to do so, just as the A320 was about to touch down as cleared on runway 34L, without the controller or pilots being aware.
The vehicle cleared the active runway when the decelerating aircraft was passing the halfway point marking and as it cleared the runway strip the distance between the aircraft and the car was at its minimum of 1,417 metres. The runway controller did not notice the incursion at any point and only realised it had happened when the driver requested clearance to cross the next of the three designated taxi/towing routes on the otherwise closed runway. The flight crew also subsequently stated that they had not seen vehicle at any time during its incursion.
Why It Happened
There was no mention in the guidance material prepared by the contractor for their employees of the need to obtain ATC clearance in order to cross the active runway. This was attributed to the deficient ‘Construction Safety Training Course Materials’ prepared by Airport’s ‘Flight Information Officer’ which provided the primary source for contractor workforce training which did not include any mention of specific rules on crossing between the two parts of the closed runway 04/22 bisected by the active runway 16R/34L. In respect of why these ‘Construction Safety Training Course Materials’ were materially deficient, it was concluded that this had been because the risk of unauthorised crossing of the active runway at the intersection by a contractor’s vehicle “did not become clear until the 5 November Serious Incident occurred”.
The Probable Cause of the investigated Serious Incident was recorded as “when the aircraft was landing on runway 34L as cleared, a work vehicle entered and crossed the runway without clearance from the controller".
Two Contributory Factors were also identified:
- Workers did not understand that clearance from the Controller is necessary to cross an active runway.
- The intersection of runway 16R/34L with the temporarily closed intersecting runway was shown as having closed status in the diagram the vehicle driver referred to.
Safety Action taken as a result of the Investigation findings was noted to have included, but not been limited to, in edited summary, the following:
The Japan Civil Aviation Bureau:
- has revised the Guideline for Airport Operations to construction workers to state that they may only drive within the aircraft manoeuvring area if they can show that they can satisfy one of the following:
- have passed the driver training course and test specified by the airport administration.
- have held a vehicle operation permit for the Airport within the past year.
- any person who obtains a vehicle operation permit shall submit the documents that prove they have the knowledge required to operate a vehicle in the restricted area.
- Now requires that a driver not so qualified may drive a vehicle in the aircraft manoeuvring area if it is being led by a vehicle driven by a person who has taken and passed the driver training course and test or may drive a vehicle when accompanied and supervised by such a person.
- Now requires that its personnel supervising construction work on the airport shall ensure that the main contractor and subcontractors diligently observe the requirement that when carrying out the work involving the closure of either of the intersecting runways 16R/34L and 04/22 at their intersection, even if an entry clearance is obtained for one of these runways, the other runway shall not be entered without further permission from the runway controller and even when both these runways are closed, ATC clearance is required before crossing the intersection.
- The Procedures for access to aircraft movement areas specified as or required by the Airport Regulations have been amended as follows:
- Construction vehicle drivers are required to take a safety training course and examination.
- The driving qualifications of those who have taken the Construction Driver Training Course and passed the test shall not extend to vehicle operation “on and around active runways" and it shall, in principle, be prohibited for construction workers to enter the vicinity of active runways.
- Work and vehicle travel at and around the intersection part of runways 16R/34L and 04/22 shall only be performed during times when both runways are closed unless a standard ID card holder oversees the work or drives the vehicle.
- In addition to the existing requirement for internally illuminated safety cones, temporary holding positions shall be marked with a white dashed line and Internally illuminated safety cones installed 10 metres before the runway strip boundary at locations where construction workers are not allowed to enter active runways without clearance from ATC and a temporary holding position marking shall be placed on the shoulder of the runway as a guide to the location of the cones. All construction workers shall be informed of these arrangements through safety training courses and other means.
- The weekly closure planning map already requires that ATC clearance shall be required to cross the intersection of runways 16R/34L and 04/22 and it is now required that painted colour of this intersection shall be white rather than red.
- When the intersection of runways 16R/34L and 04/22 involves an active runway which is described as closed in the submitted daily work schedule report, the duty Flight Information Officer shall not accept the report until guidance has been provided and correction made.
- The intersection of runways 16R/34L and 04/22 shall be circled on the Runway Restriction Record Document which must clearly state that clearance from the controller shall be required to drive through the intersection part and this document shall be used to alert each Construction Supervision Officer about the intersection part during the night-time joint briefing. This Officer shall also directly brief their workers on this requirement.
The Contractor Involved:
- Has decided that all their workers, both employees and sub contractors, who are involved in work at Haneda Airport shall be given detailed explanations of important points in the Safety Training Course Materials for construction within the Restricted Areas of the airport and a confirmation test shall be conducted.
- Decided that they will create a work plan where active runways are not be crossed and taxiway crossing is avoided as much as possible and it will now illustrate the location of wireless communication points and points requiring safety consideration.
The Final Report was adopted by the JTSB on 7 April 2023 and published in both English translation and the definitive Japanese version on 27 April 2023. No Safety Recommendations were made.