What happened
On September 10, 2013, at approximately 08:32 JST, a runway incursion occurred at Kansai International Airport involving a Bell 430 helicopter, registration JA06NR, and a Boeing 767-300, registration JA605A.
The incident began following engine start-up difficulties experienced by the helicopter crew. After a period of troubleshooting an exhaust temperature surge, the helicopter was delayed by roughly 40 minutes. During taxiing, the pilot of the JA06NR failed to request an intersection departure from taxiway A10, instead proceeding under the assumption that such permission had been granted.
While taxiing, the pilot became preoccupied with monitoring engine instruments and managing the perceived pressure of a delayed departure. Despite receiving instructions from the Ground controller to hold short of the runway, the pilot entered the active runway 06R. Simultaneously, the Boeing 767-300, JA605A, was on final approach with landing clearance. Upon observing the helicopter on the runway, the Tower controller instructed the JA605A to execute a go-around. The large aircraft commenced its climb at approximately 300 feet altitude, roughly one mile from the threshold.
The investigation
The JTSB investigation focused on the pilot's actions and the communication breakdown between the helicopter crew and Air Traffic Control. Investigators examined the flight data from JA605A, ATC recordings, and statements from the pilots and controllers. The investigation scrutinized the helicopter's taxi route, the pilot's failure to properly read back instructions, and the impact of the earlier engine malfunctions on the crew's mental state.
Findings
- The pilot of the JA06NR was distracted by monitoring engine instruments and was preoccupied with the recent engine start-up issues.
- A desire to depart quickly to compensate for the delay led to a state of "hurry-up syndrome," causing the pilot to overlook the necessity of halting at the runway holding position.
- The pilot incorrectly assumed that an intersection departure from taxiway A10 was authorized because he had not explicitly requested it.
- The pilot failed to identify the approaching Boeing 767-300 because he was focused on a different aircraft that he believed was the nearest arrival.
- The pilot entered the runway despite explicit instructions to hold short.
Safety action
Aero Asahi Corporation implemented several measures following the incident, including specialized training for the pilot and the integration of "hurry-up syndrome" into Crew Resource Management (CRM) training for all pilots. The company also established stricter operational procedures for helicopter movements at major Japanese airports, including mandatory two-pilot crews for runway operations at certain locations.