What happened
On 7 September 2019, a China Shanghai Airlines Boeing 737-800, registration B-1949, was performing a scheduled international flight from Pudong International Airport to Gimhae International Airport. While executing a circling approach to land on runway 18R, the aircraft mistakenly lined up with and landed on runway 18L, which was an unauthorized runway for that approach.
The flight was operating under Visual Flight Rules (VFR) and was subject to turbulent conditions caused by the nearby typhoon Lingling. As the aircraft transitioned through the right-hand traffic pattern, the crew was cleared to land on runway 18R. However, during the maneuvering phase, the aircraft overshot the intended final approach course for 18R and instead intercepted the course for 18L. Although the local controller identified the deviation and instructed the crew to go around at 16:46:49, the aircraft touched down on the unauthorized runway just seconds later.
The investigation
The ARAIB investigation examined the flight path, radar data, and cockpit performance. Analysis of the radar screen confirmed that the aircraft overshot the authorized final approach course for runway 18R. The investigation also reviewed the aircraft's flight pattern, noting that the crew had flown a significantly narrower turning pattern than standard, and was flying approximately 200 feet lower than the typical pattern altitude.
Investigators also reviewed the crew's performance and cockpit resource management. The investigation found that the captain was heavily focused on managing the aircraft's attitude and descent rate due to the heavy workload imposed by the strong winds. Furthermore, the first officer, who was inexperienced with the specific procedures at Gimhae International Airport, focused primarily on monitoring flight instruments rather than providing runway identification assistance.
Findings
- The flight crew utilized a narrow turning pattern that failed to properly align the aircraft with the final approach course for runway 18R.
- The captain misidentified the Precision Approach Path Indicator (PAPI) for runway 18L as the PAPI for the authorized runway 18R.
- There was a breakdown in cockpit resource management (CRM), as the first officer did not adequately assist with runway identification or communicate the deviation to the captain.
- Strong winds from the typhoon contributed to the aircraft's unstable flight path and increased the pilot's workload.