What happened
On the night of 19 May 2025, a Boeing B77W operated by China Eastern Airlines, registration B-7868, was on final approach to Runway 02L at Singapore Changi Airport. A preceding aircraft had landed earlier and was taxiing off via Rapid Exit Taxiway W5. As the inbound aircraft approached the threshold, the runway controller determined that the preceding aircraft would not clear the runway strip in time. Consequently, the controller issued a go-around instruction to the inbound flight crew.
The flight crew of the B77W did not clearly hear or understand this initial command, likely due to simultaneous radio altitude callouts in the cockpit. The controller, observing a nose-up attitude on the surveillance screen, assumed the aircraft was initiating the go-around. When the crew queried the transmission, the controller repeated the altitude and heading details but failed to convey the same urgency as the first instruction. The B77W subsequently touched down on the runway while the preceding aircraft was still within the runway strip boundary. No injuries or damage were reported.
The investigation
The Transport Safety Investigation Bureau (TSIB) examined the sequence of communications, the performance of the Advanced Surface Movement Guidance and Control System (ASMGCS), and the operational risk assessments by the air traffic services provider. Investigators reviewed the ASMGCS alerts that triggered during the event, noting that the system functioned as designed but generated frequent warnings during peak traffic periods.
TSIB also analyzed why the flight crew did not recognize the second communication as a mandatory go-around order. The investigation highlighted that the controller’s initial assumption of compliance created a gap in situational awareness, while the crew’s failure to identify the critical nature of the repeated instruction led to the landing. The report notes that the preceding aircraft had paused briefly to confirm its taxi route, which exacerbated the timing conflict.
Findings
The primary causal factor was the failure of the flight crew to execute the go-around instruction while the runway strip remained occupied by another aircraft. Contributing factors included:
- The controller’s misinterpretation of the inbound aircraft’s attitude as a go-around initiation.
- The lack of urgency in the controller’s second communication compared to the first.
- Potential desensitization of controllers due to frequent ASMGCS alerts during peak hours, which may reduce responsiveness to genuine hazards.
- The air traffic services provider’s risk assessment did not fully account for the possibility of go-around instructions being missed or misunderstood by landing crews.
Safety action
Following the incident, the air traffic services provider briefed all aerodrome-rated controllers on the event and initiated a study on ASMGCS alert thresholds to prevent alarm fatigue. The operator issued technical advisories reminding pilots to execute go-arounds immediately upon instruction and launched initiatives to improve communication skills and risk management awareness during approach phases.