Incident Overview
On Thursday, August 8, 2024, at approximately 13:45 Japan Standard Time, a Eurocopter EC135P2+ helicopter (registration JA824H) landed on Runway 27 at Kobe Airport instead of the assigned helipad. The incident occurred during a test flight conducted by the pilot, a 68-year-old commercial pilot with a total flight time of 11,749 hours 51 minutes, including 8,245 hours 31 minutes on helicopters. The helicopter was on a special flight permission for in-house test flights prior to an airworthiness inspection.
Flight History
The helicopter took off from Kobe Airport's W helipad at 13:28 with the pilot in the right seat and a mechanic in the left seat. After testing radio equipment about 15 km northwest of the airport, the pilot requested landing instructions from air traffic control (ATC) at 13:38. ATC instructed the pilot to report on the right downwind leg of Runway 27 and later cleared the helicopter to land at C helipad, stating "CLEARED TO LAND AT C-HELIPAD 27." The pilot read back the clearance correctly. While flying the traffic pattern, the pilot decided to follow the school's course implementation guidelines precisely, treating the approach as a training exercise. The helicopter made its final turn toward Runway 27 rather than the parallel taxiway where C helipad is located. The pilot did not realize the error until after returning to the workplace and being notified by the Civil Aviation Bureau.
Landing Procedures at Kobe Airport
Within the airport's restricted area, helicopters can land at the runway, W helipad, C helipad, E helipad, and the Grass area. Each helipad and the Grass area are usable only during daylight hours in visual meteorological conditions. E helipad is primarily for transient helicopters, and the Grass area is used for training such as hovering. Touch-and-go and hovering are prohibited at the helipads. For training flights, the school mainly uses the runway for certification flights and helipads for test flights.
Pilot's Recent Flight Activity
The pilot had flown little in the two months before the incident, making only 27 landings in the week prior, only one of which was a runway landing under the pilot's own control. During that landing, the approach was not flown according to the course implementation guidelines.
Air Traffic Control Communication
ATC issued landing clearance using the term "CLEARED TO LAND AT C-HELIPAD 27," adding the runway direction to indicate approach direction. The pilot understood this as clearance to land at C helipad, not Runway 27.
Pre-landing Checks and Visual Contact
The pilot did not reconfirm the landing point after receiving clearance. The mechanic noticed the helicopter heading toward the runway but did not speak up due to uncertainty about ATC communication. ATC visually confirmed the helicopter during its approach but did not perceive it as attempting to land on the runway.
Past Similar Incidents
According to JTSB records, there have been at least 14 cases in the past 18 years where pilots deviated from ATC instructions despite correctly reading them back.