What happened
On the early morning of December 22, 2016, an Airbus A320-214, registered JA811P, operated by Peach Aviation Co., Ltd., was conducting a scheduled approach to Tokyo International Airport. While performing a VOR A approach intended for runway 16L, the flight crew inadvertently directed the aircraft toward runway 23. At the time of the incident, runway 23 was closed for operations.
At approximately 00:39 JST, while the aircraft was at an altitude of roughly 480 feet and about 5 nautical miles east of the airport, an air traffic controller identified the error and ordered the crew to execute a go-around. Following this instruction, the aircraft stabilized and eventually completed a successful landing on runway 1 and 16L at 00:55 JST via a radar-vectored visual approach. There were 164 people on board, including 158 passengers and six crew members; no injuries or aircraft damage were reported.
The investigation
The Japan Transport Safety Board (JTSB) examined the flight crew's approach preparations, the cockpit's management of the situation, and the airline's training protocols. The investigation focused on why the crew failed to recognize the runway change instruction as a significant threat and why they were attempting to use a closed runway. Investigators reviewed the cockpit voice and flight data recorders, as well as the company's procedures for managing irregular operations and the adequacy of their training regarding airport-specific runway closure schedules.
Findings
- The primary cause of the incident was the crew's mistaken attempt to approach runway 23, which was not in service.
- The flight crew had not performed sufficient advance preparations for the VOR A approach procedure.
- The crew failed to effectively manage their workload and did not properly monitor or communicate the risks associated with the runway change instruction.
- There was a failure in threat and error management (TEM) regarding the recognition of the closed runway as a critical operational hazard.