B763/DH8D, Fukuoka Japan, 2010
B763/DH8D, Fukuoka Japan, 2010
Summary
On 10 May 2010, the TWR controller at Fukuoka cleared a Bombardier DHC8-400 to land on runway 16 and then a minute later whilst it was still on approach cleared a Boeing 767-300 to line up and take off on the same runway. Only a query from approaching aircraft which had been cleared to land prompted by hearing a take off clearance being given for the same runway alerted ATC to the simultaneous runway use clearances. As it was too late to stop the departing aircraft at the holding point, its clearance was changed to line up and wait and the approaching aircraft was instructed to go around.
Event Details
When
10/05/2010
Day/Night
Day
Flight Conditions
On Ground - Normal Visibility
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Take-off Commenced
No
Flight Airborne
No
Flight Completed
No
Phase of Flight
Taxi
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Missed Approach
Location
Location - Airport
Airport
HF
Tag(s)
ATC clearance error,
Distraction,
Ineffective Monitoring,
Procedural non compliance
RI
Tag(s)
ATC error,
Incursion pre Take off
Outcome
Damage or injury
Yes
Non-aircraft damage
Yes
Non-occupant Casualties
No
Off Airport Landing
Yes
Ditching
Yes
Causal Factor Group(s)
Group(s)
Air Traffic Management
Safety Recommendation(s)
Group(s)
None Made
Investigation Type
Type
Independent
Description
On 10 May 2010 in normal day visibility, a Boeing 767-300 being operated by ANA on a domestic scheduled passenger flight from Fukuoka to Okinawa was cleared to line up and take off on runway 16 for which, a minute earlier, a landing clearance had been issued to another scheduled domestic passenger flight, a DHC8-400 being operated by Japan Air Commuter and inbound to Fukuoka from Miyazaki. ATC were unaware of the error until a request was made by the DHC8 to confirm their landing clearance prompted by hearing a line up and take off clearance being given to the departing aircraft. The approaching aircraft, which was Instrument Meteorological Conditions (IMC) at the time, was instructed to go around and the clearance for the departing aircraft clearance was changed to ‘line up and wait’ so that there was no actual risk of collision.
Investigation
An Investigation was carried out by the JTSB. It was noted that the ATC error had been detected by the inbound aircraft due to their use of the radio to monitor traffic in their vicinity rather than by ATC. A ‘line up and take off’ clearance had been issued to the 767 as it taxied towards the holding point which had been heard by the DHC8 on approach which had already received a landing clearance about a minute earlier when just over 4nm from touchdown. This prompted the DHC8 crew to query their landing clearance and the controller who had issued both clearances was thus prompted to cancel the take off clearance and instruct the DHC 8, by this time inside 2nm from touchdown, to go around. Because of this, no actual risk of conflict ultimately existed, although as the 767 was unable to stop before it had crossed the holding point, its cancelled clearance was replaced with ‘line up and wait’.
The situation in the TWR at the time of the TWR controller’s ‘double clearance’ was considered to have been somewhat relaxed after an improvement to VMC at the airport following an earlier period of reduced visibility. Around this time, the supporting “flight data position controller” had received a report that bird strike remains had been found on an aircraft which had arrived at Tokyo Haneda from Fukuoka and it was decided that a runway inspection should be carried out. The allocated inspection vehicle was travelling south on the parallel taxiway at the time of the incident and it was suggested that the TWR controller “had been concerned about the timing for starting this runway inspection.
It was noted that prior to the investigated event, it had been decided to discontinue the use of arriving IFR aircraft strips because it was decided that the appropriate focus should be on improving the monitoring of the situation outside the VCR rather than using an internal reminder. Departure strips were still in use.
It was also noted that whilst it had already been agreed that a US-type RWSL system should be introduced at Fukuoka, the REL component was not due to be installed until fiscal year 2011 followed by the THLs, once the prior “overlying (of) the runway base” had been completed, in fiscal year 2012. Had such a system been in place at the time of the investigated double clearance, with the RELs set to be illuminated when an approaching aircraft reaches 2nm from the runway threshold, it was noted that when the departing aircraft approached the runway as in this incident, they would have been illuminated.
The Investigation concluded that it was “highly probable” that the investigated Serious Incident had occurred because the controller involved had forgotten the existence of the arriving aircraft and despite the prevailing IMC had failed to check the radar monitor showing traffic on approach.
Safety Action taken at Fukuoka as a result of the event consisted of efforts to ensure compliance with existing ATC procedures plus the introduction of reminder strips in the VCR for ‘Approach’ separately from ‘Landing’ instead of the ‘Arrival’ aircraft strip. In addition, Fukuoka TWR has enhanced operational oversights by introducing a controller-in-charge position.
The Final Report of the Investigation AI2012-3 was published on 27 April 2012. No Safety Recommendations were made.
