What happened
On 28 August 2024, at approximately 20:13 hrs, a runway incursion occurred at Changi Airport involving two China Eastern Airlines aircraft. An Airbus A320-200neo, registration B30AV, was in the process of vacating Runway 20R via Rapid Exit Taxiway W7. During this maneuver, the flight crew slowed the aircraft to comply with operator procedures requiring speeds below 10kt for certain turns.
Simultaneously, a Boeing 777-300ER, registration B2021, was on final approach to the same runway. As the Runway Controller (RWC) assessed that the Airbus A320-200neo would likely not clear the runway strip in time, a go-around instruction was issued to the Boeing 777-300ER. However, the flight crew of the Boeing 777-300ER did not acknowledge or respond to the instruction. The aircraft continued its approach and touched down on Runway 20R while the first aircraft was still within the runway strip area. No injuries or aircraft damage were reported.
The investigation
The investigation examined the sequence of communications and the movement of both aircraft. It was established that the RWC initially issued a landing clearance for the Boeing 777-300ER after observing that the tail of the Airbus A320-200neo appeared to be clear of the runway edge. However, as the Airbus A320-200neo slowed significantly to navigate the taxiway, the risk of an incursion increased, prompting the subsequent go-around command.
Investigators also looked into the visibility of the instruction to the second crew. The investigation noted that the flight crew of the Boeing 777-300ER was in a high-workload phase of operation, which may have impacted their ability to perceive the radio transmission.
Findings
- The runway incursion was caused by the Boeing 777-300ER landing while the Airbus A320-200neo had not yet fully vacated the runway strip.
- The flight crew of the Airbus A320-200neo was following standard operator procedures by limiting taxi speed to under 10kt during a turn, whereas the RWC expected a faster clearance.
- The flight crew of the Boeing 777-300ER likely missed the go-around instruction due to the high cognitive and visual workload associated with the landing phase of flight.
- The Air Traffic Service Provider's (ATSP) procedures allowed for a marginal situation where the go-around instruction was issued at a very low altitude, leaving little time for a response.
Safety action
Following the incident, the ATSP implemented several measures:
- Distributed a reminder to all air traffic controllers to remain vigilant and prioritize go-around instructions when separation is at risk.
- Integrated this incident into the recurrent training syllabus for controllers to highlight the risk of unacknowledged instructions.
- Initiated a comprehensive safety review of operations to re-evaluate existing procedures.
Additionally, the aircraft operator reminded its pilots to maintain high vigilance during all flight phases, specifically regarding low-level go-around instructions.