What happened
On the evening of October 12, 2011, at Kansai International Airport, a runway incursion occurred involving two Boeing 767-300 aircraft. The first aircraft, a Hawaiian Airlines flight (N588HA) bound for Honolulu, was holding short of Runway 06R. Simultaneously, an All Nippon Airways cargo flight, JA8356, was on final approach to the same runway.
As an arriving aircraft passed in front of the Hawaiian Airlines crew, the air traffic controller issued an instruction to the crew of N588HA to hold their position. Shortly thereafter, the controller cleared the ANA cargo flight to land. However, the crew of N588HA entered the runway. Upon realizing the runway was occupied, the controller immediately instructed the ANA flight to disregard its landing clearance and execute a go-around. The incident resulted in no injuries and no damage to either aircraft.
The investigation
The Japan Transport Safety Board (JTSB) examined air traffic control transcripts, cockpit voice recordings, and flight data from both aircraft. The investigation focused on the discrepancy between the controller's instruction to "hold position" and the flight crew's interpretation of the command. Investigators also reviewed the readback provided by the Hawaiian Airlines crew, which did not match the standard phraseology of the original instruction, and why the controller did not request a correction.
Findings
The investigation determined that the primary cause of the incursion was that the departing crew of N588HA misinterpreted a hold instruction as an authorization to enter the runway. Several contributing factors led to this error:
- The crew members had previously experienced similar phrasing in the United States, where such words are used to instruct aircraft to hold on the runway.
- The crew was mentally prepared for an instruction to move onto the runway.
- The instruction was delivered precisely as another aircraft was passing, creating a high-workload moment.
- The crew believed they could complete their takeoff before the arriving aircraft reached the threshold.
Additionally, the controller failed to intervene when the crew's readback—which used non-standard phraseology—did not match the original instruction, as the controller assumed the message had been understood correctly.