On 16 February 2008, during daylight and in poor visibility, a Boeing 747-400, operated by Japan Airlines, was holding on a taxiway next to runway 01R of New Chitose Airport, Japan. A Douglas MD-90-30 operated by the same airline landed on the same runway and was still on the runway when the B747 was cleared to line up and wait. Shortly after lineup the B747 began its takeoff roll without receiving such clearance and subsequently was instructed to abort the takeoff. The crew of the B747 successfully rejected the takeoff.
This is an extract from the Investigation Report (AI2009-1) on the serious incident published by Japan Transport Safety Board (Japan Transport Safety Board (JTSB)):
[…]On February 16, 2008, […] a Boeing 747-400D (hereafter called “the aircraft A”) operated by Japan Airlines International Co., LTD. […] began its taxi bound for Tokyo International Airport from spot 14 of New Chitose Airport[…]. A total of 3 pilots were on board in the cockpit of the aircraft A, a captain was at the left pilot seat as PF [Pilot Flying], a trainee pilot for first officer promotion training (hereafter called “the trainee”) was at right pilot seat as PM [Pilot Monitoring, or PNF, primarily responsible for non-manoeuvring duty], and a first officer seated at observer seat.
On the other hand, Douglas MD-90-30 (hereafter called “the aircraft B”), […] was cleared to land by the local controller of the Chitose Aerodrome Control Tower (hereafter called “the tower”) […]
Aircraft A was issued clearance to line-up and wait after aircraft B touched down.
It is seen from the summary of all data sources that the landing traffic made a full stop on the runway and resumed movement after 13 seconds thus prolonging the time that was needed to vacate the active runway.
[…]10:32:30 The tower informed the aircraft A, “JAPAN AIR 502, EXPECT IMMEDIATE TAKE-OFF, TRAFFIC LANDING ROLL AND INBOUND TRAFFIC 6 MILES” […]
10:32:37 The aircraft A replied to the tower, “ROGER, JAPAN AIR 502”.
Few seconds after, aircraft A accelerated - its action was observed by the controller and he gave instruction for immediate stop. The tower also gave “go around” instruction to the other traffic that was 6 NM from touch-down.
Figure 1. Taxied Routes, Source: JTSB, AI2009-1
Complex meteorological conditions prevailed during the time of the incident. According to the Report, prevailing visibility was between 400 m and 600 m, and vertical visibility was between 200 ft and 300 ft, in snow showers.
The braking action on the runway was medium to poor (0.26~0.29), above 80% of the runway was covered by dry compacted snow. The depth of the contamination was between 10 and 80 mm.
The written statement of the captain of aircraft A enclosed in the Report, could be summarised around the following points:
- The use of word ‘immediate’ left a notion of urgency in the situation;
- The trainee failed to read-back correctly, but the captain decided to proceed without noting it;
- The word ‘take-off’ was used instead of departure.
The analysis of the event includes summary points:
- When the aircraft A was waiting for the takeoff clearance on the runway, the aircraft B on the same runway was not visible from the aircraft A, under low visibility due to snowfalls.
- As the controller did not request "REPORT CLEAR OF ACTIVE" to the aircraft B going ahead, there was no means for the flight crews of the aircraft A to know the time when the runway cleared off by the aircraft B.
- Because the runway occupation of the aircraft B was prolonged, and the controller had psychological oppression about the separation between the aircraft A and the approaching aircraft C, the controller issued ATC information that contained "IMMEDIATE TAKE-OFF".
- It is not described in Air Traffic Control Procedures and Air Traffic Control Regulations that "TAKE-OFF" is used at the takeoff clearance and its cancellation, besides, not using it in principal, and the controller did not have such recognition.
- The captain of the aircraft A, having severe meteorological condition, and being aware of the separation with the approaching aircraft C, was psychologically in the state of "set" that it comes next to be the takeoff clearance, moreover, because the operation of thrusts increase had been started immediately after beginning of the information, and the attention directed to engine instruments, so the controller's information was not caught accurately. From these, the captain of the aircraft A mistook the ATC information for a takeoff clearance.
- As other flight crews of the aircraft A could not also catch the information by the controller accurately, and regarding the receipt of the takeoff clearance, there was a possibility that the system allowing advice to the captain had not been established sufficiently, therefore an advice to reconfirm was not done.
- When the aircraft B was still on the runway, the controller who confirmed the aircraft A began the takeoff run with the ASDE indicator, issued to the aircraft A the stop instruction and had the takeoff run aborted.
The report offers several safety recommendations expressed as "safety opinions to the Minister of Land, Infrastructure, Transport and Tourism, Japan":
- Review of Crew Resource Management (CRM) training program To supervise the company to perform reviews in contents and timing of the CRM training program, to improve the environment that is easy for other flight crews including the trainee to advise to the captain positively in a case with the doubt for judgment / operation of the captain in line training.
- Reconsideration of ATC terminology etc.
- To prevent the mis-entering into the runway or the mis-departure, etc, to conduct the following items […]:
- To stipulate the usage restriction of “take-off” which has a possibility that the flight crew may misunderstand, and to consider necessity of usage restriction for other terms, and executed the education concerning it thoroughly to air traffic controllers, and to decrease the possibility of the misunderstanding in the ATC communications.
- To study reducing load to air traffic controllers from manpower and facility standpoint, in the airport where the air traffic volume is large, with the severe operation condition of the aircraft, and marginal weather conditions not to be seen the aircraft easily from the air traffic controller.
- To study measures considering that air traffic controllers should understand the flight crew's situation and needs enough, and for doing their tasks.
The report also includes some of the immediate actions that were taken by various institutions to eliminate the discrepancies found during the investigation.