What happened
On July 23, 2009, at approximately 09:10 JST, a serious incident occurred at Osaka International Airport involving two aircraft. A Douglas DC-9-81, registration JA8499, operated by JAL Express Co., Ltd., had recently landed on runway 32L and was taxiing toward its parking position. Simultaneously, a Bombardier DHC-8-402, registration JA844C, operated by Japan Air Commende Co., Ltd., was on its final approach to runway 32R with landing clearance.
During the taxiing phase, the crew of JA8499 was focused on reporting that no bird carcasses were visible near taxiway W6, following a previous report of a possible bird strike. While taxiing, the crew of the Douglas DC-9-81 crossed the stop line and entered runway 32R. This movement was detected by the tower controller, who immediately instructed the approaching Bombardier DHC-8-402 to execute a go-around due to the aircraft on the runway.
The investigation
The Japan Transport Safety Board (JTSB) examined air traffic control communication records, radar tracks, and flight data recorder information from both aircraft. The investigation also included interviews with the flight crews and the air traffic controllers involved.
Investigators focused on the sequence of instructions regarding runway crossing and holding short. The investigation revealed that the tower controller had issued an instruction to hold short of runway 32R, but the flight crew of JA8499 misinterpreted this as permission to cross. Furthermore, the investigation looked into the controller's failure to identify the incorrect read-back from the Douglas DC-9-81 crew.