What happened
On January 8, 2022, at Kagoshima Airport, a serious incident occurred involving a Cessna 172P, registration JA4061, and an ATR 42-500, registration JA04JC. The incident involved a student pilot performing a solo flight as part of flight training.
During the sequence of events, the trainee pilot of the Cessna 172P was taxiing toward Runway 34. After receiving instructions to hold short of the runway, the pilot misinterpreted a subsequent air traffic control instruction. Due to the presence of the word "continue" in a previous command, the trainee pilot incorrectly inferred a clearance to "line up and wait" and began moving toward the runway.
Simultaneously, the ATR 42-500 was on final approach to the same runway. The trainee pilot, unable to clearly understand the radio communications and feeling nervous due to the pace of the controller's speech, failed to recognize the approaching traffic. The student pilot also failed to properly apply the parking brake, causing the aircraft to creep forward past the holding point. To avoid a collision, the air traffic controller instructed the ATR 42-500 to perform a go-around. The two aircraft were separated by approximately 2,160 meters at the moment the go-around was initiated.
The investigation
The JTSB investigation examined various sources, including flight data recorders from the ATR 42-500, cockpit voice recordings from the Cessna 172P, air traffic control communication logs, radar tracks, and airport surveillance footage. The investigators focused on the communication breakdown between the trainee pilot and the tower controller, as well as the training standards provided by the operator, New Japan Aviation Co., Ltd.
Findings
- The primary cause was that the Cessna 172P entered the runway while the ATR 42-500 had been cleared to land.
- The trainee pilot misinterpreted the ATC instructions, specifically inferring a runway entry clearance because they could not comprehend the actual holding instruction.
- The trainee pilot was prone to remaining silent rather than seeking clarification when faced with confusing radio communications.
- The flight school's training program focused on essential phraseology rather than a full range of ATC communications, and the pilot's ability to handle complex instructions was not sufficiently verified before granting solo flight privileges.
- The air traffic controller, attempting to reduce the burden on the student pilot, provided traffic information without a mandatory read-back requirement, which contributed to the pilot's lack of situational awareness.