Edit Accident: B763 / B763, Kansai Japan, 2007 (RI AGC)

Accident Form

When:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Event Type:	AGC AI AW BS CFIT CS FIRE GND HF LB LOC LOS RE RI WAKE WX
Day/Night:	None Not Recorded Day Night
Flight Conditions:	None Not Recorded VMC IMC On Ground - Low Visibility On Ground - Normal Visibility
One sentence description:	On 20 October 2007, at night, a Boeing 767-300 operated by Air Canada was taxiing for Runway 24L at Kansai International Airport for take-off. Meanwhile, another Boeing 767-300, operated by Japan Airlines, had been given landing clearance and was on approach to the same runway. After an incorrect readback, the Air Canada B767 entered the runway to line up. As a consequence of the runway incursion, the B767 on approach executed a go-around on the instructions of air traffic control.
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Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

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Origin: Destination:

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Airport: In Vicinity of airport:

Airport: In Vicinity of airport:

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Coordinates: Location: ICAO Region: AFIAPACCARSAMEURMIDNAMNAT ICAO Territory: AGANAYBGBIBKCCTDADBDFDGDIDNDRDTDXEBEDEEEFEGEHEIEKELENEPESEVEYFAFBFCFDFEFGFHFIFJFKFLFMFNFOFPFQFSFTFVFWFXFYFZGAGBGCGEGFGGGLGMGOGQGSGUGVHAHBHCHDHEHFHHHKHLHRHSHTHUKLALBLCLDLELFLGLHLILJLKLLLMLOLPLQLRLSLTLULWLXLYLZMBMDMGMHMKMMMNMPMRMSMTMUMWMYMZNCNFNGNINLNSNTNVNWNZOAOBOEOIOJOKOLOMOOOPOROSOTOYPAPGPHPJPKPLPMPOPPPTPWRCRJRKRORPSASBSCSESFSGSKSLSMSOSPSUSVSYTATBTDTFTGTITJTKTLTNTQTRTTTUTVTXUAUBUDUEUGUHUIUKULUMUNURUSUTUUUWVAVBVCVDVEVGVHVIVLVMVNVOVQVRVTVVVYWAWBWIWMWPWRWSYYPZZKZM

Add General Tags

Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures Landing Flare Difficulty

Add AGC Tags

Tags: Call Sign Confusion Loss of Comms Incorrect Readback missed Phraseology Language Clarity Low Fuel Status CPDLC Flight Crew Oxygen Mask Use Take off without clearance Landing without clearance Military Formation Clearance Military/Civil Coordination Provision of Aircraft Performance Data ATC Clearance Cancelled

Tags: Call Sign Confusion Loss of Comms Incorrect Readback missed Phraseology Language Clarity Low Fuel Status CPDLC Flight Crew Oxygen Mask Use Take off without clearance Landing without clearance Military Formation Clearance Military/Civil Coordination Provision of Aircraft Performance Data ATC Clearance Cancelled

Add AI Tags

Tags: CA Incursion DA Incursion PA Incursion TSA Incursion GPS VFR Navigation ATC Complicit Aircraft not in contact with Airspace ATC

Add BS Tags

Tags: Large Birds Flocking Birds Significant Airframe Damage Flight Crew Injury Engine damage Coastal Location Migration Engine Ingestion Prior verbal warning

Add CFIT Tags

Tags: Into water Into terrain Into obstruction No Visual Reference Lateral Navigation Error Vertical navigation error Pressure altimeter setting error VFR flight plan IFR flight plan

Add FIRE Tags

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Add HF Tags

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Add GND Tags

Tags: Taxiway collision On gate collision Aircraft / Aircraft conflict Aircraft / Person conflict Aircraft / Vehicle conflict Aircraft / Object or Structure conflict ATC clearance error Ground de/anti icing Jet Blast / Prop wash Surface Friction Towed aircraft involved Aircraft Push Back Incorrect Parking Position Airbridge Positioning Both objects moving Wingtip clearance Centreline obscured Accepted ATC clearance not followed Surface Lighting control Hold Loading Passenger Loading Cargo Loading Fuel Loading Dangerous Goods Engine Ground Running Engine Powered Systems Test No Flight Crew on Board

Add LB Tags

Tags: Accepted ATC Clearance not followed SID bust Clearance readback error undetected TCAS RA response Manual flight Pressure altimeter setting error

Add LOC Tags

Tags: Airframe Structural Failure Significant Systems or Systems Control Failure Degraded flight instrument display Uncommanded AP disconnect AP Status Awareness Non-normal FBW flight control status Loss of Engine Power Crew Incapacitation Flight Management Error Flight Control Error Environmental Factors Bird or Animal Strike Aircraft Loading Malicious Interference Temporary Control Loss Extreme Bank Extreme Pitch Last Minute Collision Avoidance Hard landing Take off Trim Setting Incorrect Thrust Computed Unintended transitory terrain contact Collision Damage Incorrect Aircraft Configuration Aerodynamic Stall

Add LOS Tags

Tags: TCAS RA Mis Flown Accepted ATC Clearance not followed See and Avoid Ineffective Required Separation not maintained Released to Own Separation Level Bust Lateral Navigation Error ATC Error Near Miss Lateral Offset in use Mid-Air Collision Uncommanded AP disconnect Military Aircraft involved Apparent de-selection of transponder Transponder non selection

Add RI Tags

Tags: ATC error Accepted ATC Clearance not followed Incursion pre Take off Incursion after Landing Runway Crossing Intersecting Runways Intersecting extended centrelines Towed aircraft involved Near Miss Ground Collision Phraseology Intentional Premature Rotation Vehicle Incursion

Tags: ATC error Accepted ATC Clearance not followed Incursion pre Take off Incursion after Landing Runway Crossing Intersecting Runways Intersecting extended centrelines Towed aircraft involved Near Miss Ground Collision Phraseology Intentional Premature Rotation Vehicle Incursion

Add RE Tags

Tags: Overrun on Take Off Overrun on Landing Directional Control Undershoot on Landing Wrong Runway Excessive Airspeed RTO decision after V1 High Speed RTO (V above 80 but not above V1) Unable to rotate at VR Frozen Deposits Collision Avoidance Action Parallel Approach Operations Excess Water Depth Late Touchdown Significant Tailwind Component Significant Crosswind Component Thrust Reversers not fitted Landing Performance Assessment Off side of Runway Misalignment on runway Taxiway Take Off/Landing Runway Length Temporarily Reduced Intentional Premature Rotation Incorrect Aircraft Configuration Reduced Thrust Take Off

Add WAKE Tags

Tags: ICAO Standard Wake Separation prevailed ICAO Standard Wake Separation not met Accepted ATC clearance not followed Own separation In trail event Cross track event Pilot over compensation Intersection take off Intersecting extended centrelines Intersecting runways

Add WX Tags

Tags: In Flight Airframe Icing In Flight Icing - Piston Engine In Flight Icing - Turbine Engine CAT encounter En route In-cloud air turbulence Hail damage Volcanic Ash Effects Sand/Dust limited IFV Fog In Cloud on Visual Clearance Precipitation-limited IFV Strong Surface Winds Mountain Waves Lightning Damage Low Level Windshear

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Tags: Emergency Descent Emergency Evacuation Airport Emergency Medical Response MAYDAY declaration PAN declaration “Emergency” declaration Slide Malfunction RFFS Procedures Evacuation difficulties in Water Delay in Declaration of Emergency

Add CS Tags

Tags: Disruptive Pax Turbulence Injury - Cabin Crew Turbulence Injury - Pax with Seat Belts on Turbulence Injury - Pax with Seat Belts off Cabin Stowage - Pax Items Toilet compartment fire Cabin furnishings fire Evacuation slides deployed Pax oxygen mask drop Unauthorised PED use IFE fire Flight deck comms difficulty Cabin air contamination Malicious interference Hand held extinguisher used Evacuation on Cabin Crew initiative Flight Crew Evacuation Command Cabin Crew Incapacitation Cabin Crew Medical Fitness Passenger Illness Faulty or misused PED

Add AW Tags

System(s): Airframe Air Conditioning and Pressurisation Autoflight Communications Electrical Power Equipment / Furnishings Fire Protection Flight Controls Fuel Hydraulic Power Ice and Rain Protection Indicating / Recording Systems Landing Gear Landing Lights Navigation Oxygen Airborne Auxiliary Power (APU) Propellers Rotors Engine - General Engine Fuel and Control Bleed Air Other Emergency Evacuation Contributor(s): Maintenance Error (valid guidance available) Maintenance Error (invalid guidance available) Inadequate Maintenance Schedule Inadequate Maintenance Inspection Inadequate QRH Drills OEM Design fault Damage Tolerance Contributing ADD Component Fault in service Component Fault after installation Pilot verbal-only defect communication Corrosion/Disbonding/Fatigue Cross Connection Engine Compressor Washing

Add Safety Net Mitigation

Malfunction of Relevant Safety Net: None Yes No GPWS: None Effective Partially effective Available but ineffective TAWS: None Effective Partially effective Available but ineffective TAWS with RAAS: None Effective Partially effective Available but ineffective TCAS: None Effective Partially effective Available but ineffective STCA: None Effective Partially effective Available but ineffective MSAW: None Effective Partially effective Available but ineffective APM: None Effective Partially effective Available but ineffective APW: None Effective Partially effective Available but ineffective Mode 'S' EHS: None Effective Partially effective Available but ineffective Wind Shear Escape Guidance: None Effective Partially effective Available but ineffective Stall Protection: None Effective Partially effective Available but ineffective A-SMGCS: None Effective Partially effective Available but ineffective EMAS: None Effective Partially effective Available but ineffective TOCWS: None Effective Partially effective Available but ineffective

Add Causal Factor Group(s)

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Add Safety Recommendations

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Accident Report text:

==Description== On 20 October 2007, at night, a [[B763|Boeing 767-300]] operated by Air Canada was taxiing for Runway 24L at Kansai International Airport for take-off. Meanwhile, another Boeing 767-300, operated by Japan Airlines, had been given landing clearance and was on approach to the same runway. After an incorrect readback, the Air Canada B767 entered the runway to line up. As a consequence of the [[Runway Incursion|runway incursion]], the B767 on approach executed a [[Go-around|go-around]] on the instructions of air traffic control. ==Synopsis== The following is an extract from Aircraft Serious Incident Investigation Report (AI2009-02), published by Japan Transport Safety Board ([[JTSB]]) '''"08m:36s The Tower sought confirmation from Aircraft-A''' [Air Canada Boeing 767] '''on whether it was ready for departure.''' '''08m:40s Aircraft-A replied, “That’s affirmative.”''' '''Around 08m:40s Aircraft-A stopped short of the runway holding position markings on Taxiway A1, and NWA69 [a flight that was on short final, inbound to land before Aircraft B], which was just before touchdown, passed by.''' '''08m:43s The Tower instructed Aircraft-A, “Roger that. Hold short of runway 24L.” The position of Aircraft-B [Japan Airlines B767] was about 6.5nm away from the 24L threshold at this point.''' '''08m:46s Aircraft-A replied to the Tower, “To position 24L.”"''' The Report includes the following reconstruction of the event : [[File:RI Air Canada Kansai Japan.jpg|none|thumb|400px|alt=RI Air Canada Kansai Japan|'''Figure 1''':''' Extract from Figure 1 - Estimated track of aircraft A.''''' Source: JTSB, AI2009-2'']] There were three pilots in the cockpit of aircraft A: the captain, the co-pilot and a Cruise Relief Pilot They all provided similar description of the event. Here is part of the statement of the captain: [...] '''"One aircraft had just landed''' [NWA69] '''and another one aircraft was approximately 4 nm on final. There were no lighted stop bars at the hold point and air traffic did not seem heavy. The Tower gave us clearance as “Air Canada 036, to line up and wait runway 24L.” The line up clearance was unconditional. The landing aircraft was clearing the runway. The flight lined up and after waiting for about 1 minute 30 seconds, Aircraft-B inquired if they had landing clearance, so we flashed our lights. The Tower then cleared Aircraft-B to make a go-around. We were instructed to vacate 24L via Taxiway A3. Once clear, the Tower inquired if we had received clearance to enter the runway, we responded, “Absolutely affirmative” (received clearance)."'''[...] Extract of the statement of the Tower controller is given bellow: [...]'''"When NWA69 landed, I asked Aircraft-A whether they were ready, and the aircraft replied they were ready. However, considering the facts that Aircraft-A taxied slowly, did not contact the Tower early and its movement was slow because of the long-distance flight, and that it would take time for the landed NWA69 to vacate the runway, I decided not to let Aircraft-A depart before the landing of Aircraft-B.''' '''I instructed Aircraft-A to “Hold short of runway.” Although the read-back from Aircraft-A was not clear at the time, I heard “hold” before “position 24L,” so I made judgments that the aircraft would hold short (of runway), and issued Aircraft-B landing clearance. I instructed NWA69 to contact the Ground.''' '''Aircraft-B said, “Confirm, cleared to land?” so I checked NWA69 and other aircraft on the Tower Display Subsystem (hereinafter referred to as “TDS”), and replied “cleared to land.” I thought the confirmation of clearance was just another confirmation of the issuance of clearance. When''' […] '''I looked at the side of 24L, I noticed that Aircraft-A had entered the runway and I instructed Aircraft-B to make a go-around."''' According to the information, provided in the report, there were some ground facilities that were inoperative during the event: [...]'''"Aerodrome lights were lit in compliance with the specified night luminous intensity based on the weather condition of that night. However, because runway renovation work was under way in the Airport at that time, the following aerodrome lights related to Runway A were inoperative, and aeronautical information had been issued.''' # '''Runway center line light (RCLL)''' # '''Runway touchdown zone light (RTZL)''' # '''Stop bar light (STBL)''' # '''Runway guard light (RGL)''' # '''Taxiway center line light (TWCL)''' '''The Airport has a stop bar system (comprised of STBL, RGL, RCLL, control console, etc.) showing the holding point for taxiing aircraft. However, it was not the condition to be able to operate the stop bar system at the time of the serious incident, due to the suspended use of lights (3) to (5) above."'''[...] Further, the report specifies some differences in the phraseologies adopted by the Civil Aviation Bureau of Japan and NAV Canada, concerning lining-up on the runway. Also, it lists the conditions under which the operation of stop bar lights is obligatory. Some notes are given on the reliability of the Tower Display Subsystem (TDS): [...]'''"The ARTS-F''' [automated radar terminal system - a system to display ATC information, such as flight number, altitude and ground speed] '''of the Airport has TDS within the control tower, allowing for easy recognition of aircraft on the ground within the airport. However, the system also has weak points, such as that some areas could not be surveyed due to reasons such as being hidden behind a building, that ghost targets may appear due to unnecessary reflection of radio waves, and that the performance deterioration of ASDE ''' [Airport Surface Detection Equipment] is unavoidable during rainfall. '''Therefore, controllers are frequently required to manually input the aircraft data such as flight numbers for departure targets. Thus, it is difficult to say that TDS can surely display all targets of the aircraft on the ground with data on such aircraft."'''[..] Section four of the report gives the probable cause: [...]'''"It is presumed that this serious incident occurred as follows: The flight crewmembers of the departure aircraft (Aircraft-A) who was instructed from the air traffic controller to hold short of the runway, read back incorrectly after mishearing the instruction as to enter the runway; and the controller also misidentifying the read-back and not confirming it; accordingly the departure aircraft kept entering into the runway; this made the arrival aircraft (Aircraft-B), which already received a landing clearance from the controller, attempt to land on the same runway as a result."''' Section five of the report contains the measures that were either planned or implemented after the event: * In Canada, the ATC phraseology concerning instruction to enter runway before take-off was changed to conform with the recommendations of [[ICAO|ICAO]]; * Civil Aviation Bureau of Japan (CABJ) instructed all ATC facilities once again to bring to the attention of all controllers the importance of read-back and prompt correction. In addition, CABJ made an inspection at Kansai Airport, thus providing a summarised safety report, pointing out measures for immediate deployment as well as items for mid-term future implementation: ** Confirmation of read-back; ** Notice to pilots on exact read-back; ** Measures to diminish human factors related errors; ** Support by ATC system -studies on possible implementation of ground movement system with upgraded capabilities. ==Related Articles== '''RI''' * [[Runway Incursion]] * [[Runway Incursion : Investigation Check List - Aircraft Operator|Runway Incursion: Investigation Checklist - Aircraft Operator]] * [[Accident and Serious Incident Reports: RI]] '''AGC''' * [[Air-Ground Communication]] '''HF''' * [[Human Factors]] '''General''' * [[Missed Approach]] ==Further Reading== *For further information, see the [http://www.skybrary.aero/bookshelf/books/802.pdf full report - AI2009-02] by JTSB. [[Category: Accident and Serious Incident Reports]]

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