What happened
On July 21, 2019, an Asiana Airlines Airbus A321-231, registered HL8256, was taxiing at Naha Airport for a scheduled departure to Inchon International Airport. The flight was operating with a slight delay due to a technical issue involving the automatic shutdown of the APU, which required the crew to perform a crossbleed engine start.
As the aircraft taxied toward Taxiway E1, the tower issued instructions regarding altitude restrictions for the departure. During this period, the pilot in command (PIC) mistakenly interpreted the instruction to "hold short of runway" as an instruction to "line up and wait." Simultaneously, a Japan Transocean Air Boeing 737-800, registered JA01RK, was on its final approach to Runway 18, having already received landing clearance.
Without receiving proper authorization, the Airbus A321-231 entered Runway 18. The tower controller, noticing the incursion, immediately instructed the Boeing 737-800 to execute a go-around. The two aircraft were approximately 3,334 meters apart at the time of the incident.
The investigation
The Japan Transport Safety Board (JTSB) examined several sources, including flight data recorders from both aircraft, cockpit voice recordings, air traffic control communications, radar tracks, and airport monitoring camera footage. The investigation focused on the crew's interpretation of ATC instructions and the lack of internal cross-checking during the taxi phase.
Findings
- The pilot in command of HL8256 was preoccupied with verifying taxiway charts and managing the recent change in altitude restrictions, leading to the misunderstanding of the hold short instruction.
- The first officer was focused on updating the Flight Management System (FMS) with the new altitude parameters and was not monitoring the external environment.
- The flight crew failed to perform the mandatory cross-check of ATC clearances as required by their company's flight operations manual.
- The tower controller identified the runway incursion visually and acted promptly to command the approaching aircraft to abort its landing.
Safety action
Asiana Airlines has implemented several measures to prevent a recurrence, including updating airport information for all crews, modifying standard taxi callouts, and conducting remedial training for the involved crew members.