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B763 / B772, New Chitose Japan, 2007

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Summary
On 27 June 2007, a Skymark Boeing 767-300 rejected its night take off from the 3000 metre-long runway 19R at New Chitose from around 80 knots when an All Nippon Boeing 777-200 which had just landed on runway 19L was seen to be taxying across the runway near the far end. There was no actual risk of collision. Both aircraft were being operated in accordance with conflicting air traffic clearances issued by the same controller. None of the three controllers present in the TWR including the Supervisor noticed the error until alerted by the aircraft rejected take off call.
Event Details
When June 2007
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 767-300ER
Operator Skymark Airlines
Domicile Japan
Type of Flight Public Transport (Passenger)
Origin New Chitose Airport
Intended Destination Tokyo Haneda International Airport
Take off Commenced Yes
Flight Airborne No
Flight Completed No
Flight Phase Take Off
TOF
Flight Details
Aircraft BOEING 777-200 / 777-200ER
Operator All Nippon Airways
Domicile Japan
Type of Flight Public Transport (Passenger)
Origin Tokyo Haneda International Airport
Intended Destination New Chitose Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Taxi
TXI
Location - Airport
Airport New Chitose Airport
General
Tag(s) Aircraft-aircraft near miss,
Inadequate ATC Procedures
HF
Tag(s) ATC clearance error,
Fatigue,
Ineffective Monitoring,
Procedural non compliance
RI
Tag(s) ATC error,
Incursion after Landing,
Runway Crossing,
Near Miss
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Air Traffic Management
Safety Recommendation(s)
Group(s) Air Traffic Management
Investigation Type
Type Independent

Description

On 27 June 2007, a Boeing 767-300 being operated by Skymark Airlines on a passenger flight from Chitose to Tokyo Haneda rejected its take off from a full length departure from the 3000 metre-long runway 19R when a Boeing 777-200 being operated by All Nippon Airways on a passenger flight from Tokyo Haneda to Chitose taxied across the runway in normal night visibility after previously landing on the parallel runway 19L.

Investigation

An Investigation was initiated on the day following the incident by the Aircraft and Railway Accidents Investigation Commission, the responsible body as the time which was subsequently replaced during the course of the investigation by the Japan Transport Safety Board (JTSB) who completed the Investigation and issued the Final Report.

It was noted that the prevailing weather conditions had not been a factor in the event and that it occurred in the hours of darkness. It was also noted that the Captain had been designated as PF on the departing aircraft and that on the arriving aircraft, the Captain had decided that he would act as PF for take off and below 500 feet aal on the approach until the aircraft had reached taxi speed after landing with the First Officer acting as PF for the rest of the flight.


Diagram of the airport showing the matched positions of the two aircraft - Reproduced from the Official Report

It was found that the TWR controller had issued the clearance to the just-landed aircraft to “cross Runway 19R, contact Ground” as the aircraft had reached taxi speed on runway 19L and before it entered the RET ‘B9’. As it entered ‘B9’, the crew had called GND with “Crossing Runway 19R, Spot 7” and been instructed to “continue taxi H6 and J, hold short of H5”, a position in the vicinity of the Terminal. The crew of this aircraft had both seen another aircraft towards the other end of the runway with its lights on as their aircraft had approached the runway intersection on taxiway ‘B9N’ “but it didn’t seem to be moving” and so the taxi was continued.

It was noted that the First Officer of the departing aircraft had been paying particular attention to the aircraft that had just landed on the other runway based on his earlier experience crossing runway 19R after landing on Runway 19L. He had realised then that when an aircraft was lined up at the other end of the runway, it was difficult to see whether it was moving or not when about to cross.

When he had observed that the other aircraft was not going to stop before entering the runway, he had called “crossing traffic” which prompted the Captain to reject the take off from “somewhere at around 80-knot call.

Neither crew reported hearing a contrary clearance being given to the conflicting aircraft but it was apparent that these transmissions, if made when the respective aircraft were on the same frequency, would have occurred at a time when crew attention was necessarily focused on their own aircraft.

The TWR controller stated that when the departing aircraft called that it was rejecting take off because an aircraft was crossing the runway, he had initially presumed that this was for aircraft technical reasons but, upon seeing the inbound aircraft moving from taxiway ‘A8S’ towards taxiway ‘D’, had then realised that he had given it takeoff clearance by mistake, having been under the impression that he had instructed it to “line up and wait”. He had been in the TWR position for about 1.5 hours when the incident occurred.

He noted that because it is hard to see the southern end of the runways at night, the ASDE was sometimes used to assist ground traffic position awareness but he had not used it on this occasion because the weather was fine. He stated that “there are no rules about the time at which to rotate the controllers’ shift, thus the timing for rotating the shift is determined by the watch supervisor who also has the coordinator duty.

It was noted that the ANSP for the civil airport of New Chitose and the adjacent similarly aligned and linked runways of Chitose military airbase (the former Chitose civil airport) is the Japanese Military. When the investigated incident occurred, there had been four personnel on duty in the TWR, the TWR and GND controllers, a trainee carrying out traffic recording duties and the Watch Supervisor. It was noted that the person in charge of the entire ATC night shift is the “Control Section Chief” who is present in the TWR only when the Japanese military airbase is active.

Recorded data showed that the departing aircraft had rejected its takeoff about 500 metres from the beginning of the runway and had come to a stop 31 seconds later at about 750 metres further on. The crossing aircraft had been occupying the same runway from 4 seconds before the take off was rejected for a period of 19 seconds and the closest distance between the two aircraft on the runway as a result of the prompt rejected take off had been approximately 1400 metres. If the rejected take off had not been made, it was calculated that the departing aircraft would have been about 1000 metres from the crossing aircraft as the latter cleared the runway.

The Investigation undertook a detailed review of both procedures and controller working practices at airport and found some aspects of concern.

The formal statement on the Probable Cause of the Incident (in which Aircraft A is the departing aircraft and Aircraft B is the arriving one) was as follows:

“It is estimated that this serious incident was caused because the Tower Controller issued takeoff clearance to Aircraft A by mistake despite that he had planned to instruct it to hold on 19R, while allowing Aircraft B to cross 19R without realizing the mistake, and Aircraft A which started takeoff run, visually confirmed Aircraft B crossing 19R and rejected the takeoff.

Concerning the erroneous issuance of takeoff clearance by the Tower Controller, it is considered possible that he had been tired out and kept working at the same control position over an hour without knowing when the next rotation personnel would take over his position, thereby causing his attentiveness to slacken.

As for the fact that the controller didn’t realize his mistake until Aircraft A reported him of its reject, it is considered that this is so because he had been thinking that Aircraft A would be holding at the takeoff run starting point of 19R, and he was not watching carefully the Aircraft until Aircraft B finished crossing 19R as the control of it had been transferred over the Ground control after issuing the crossing 19R clearance, and also he was not watching the airport surface carefully as he was concerned with Aircraft C making a visual approach.

In addition, regarding that neither the Watch Supervisor nor the Ground Controller noticed the mistake made by the Tower Controller, being unable to grasp the condition until Reject was reported, it is considered that this is so because the proper personnel assignment was not made, as the watch supervisor was charging concurrently as several positions such as the coordinator position, and the ground controller was charging as the coordinator position when the watch supervisor left his position, and it was unable to pay attention appropriately and evenly, and unable to pay attention to the entire manoeuvring area of the airport.”

Safety Recommendations

The Investigation, noting that air traffic control service at New Chitose Airport is assigned by the Ministry of Land, Infrastructure, Transport and Tourism to the Ministry of Defence, made the following proposals as a result of the Investigation:

  • that the Minister of Defence should review the work system of controllers and take necessary measures in order to ensure safe air transport.
  • that the Minister of Defence should examine thoroughly and take preventive measures for human errors by reviewing and stipulating the procedure for transfer of communication and control, improving the communications between the Tower and the Ground by arranging their positions closer to each other, and so on.
  • that the Minister of Defence should examine the opportunity for system implementation which will prevent runway incursions caused by human error, and take necessary measures.
  • that The Minister of Land, Infrastructure, Transport and Tourism should endeavour to share information on airport traffic control support systems etc. with the Ministry of Defence, if necessary, taking appropriate action such as improving cooperation in system implementation and so on.

The Final Report of the Investigation was adopted by the Board on 22 October 2008 and published on 28 November 2008.

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