After seeing the news about a flight mistakenly landing on a Taxiway yesterday, I looked up some information on this topic. I found a report from the Japan Transport Safety Board regarding the Korean Air incident involving a mistaken landing on a Taxiway at Akita Airport. I decided to study it briefly. (The original report is 30 pages long; here, I have only translated and excerpted a small portion.)

The report is dated November 28, 2008, and the incident occurred on January 6, 2007. The investigation took one year and ten months. The summary of this serious incident is that on that day, a Korean Air Boeing 737-900, registration HL7724, took off from Incheon. When landing on Runway 10 at Akita Airport, it mistakenly landed on a Taxiway parallel to the Runway. This Taxiway is located on the south side of the Runway.

The records from the Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR) are as follows: 12:12:35 Altitude 2700 feet. The First Officer reported seeing the airport, and the Captain also confirmed seeing it. At this time, the aircraft was 7.4 nautical miles from Runway 10. Afterwards, the aircraft continued to descend. At 12:14, altitude was 1500 feet, distance 3.6 nautical miles from the airport. 14:09 Captain “The one in the middle is the Runway, right?” 14:12 First Officer “What?” 14:13 Captain “The one in the middle is the Runway, right?” 14:15 First Officer “Yeah, yeah.” 14:16 Captain “Huh? Is it the middle one? Or the one on the side?” 14:17 First Officer “The PAPI is on the left. The PAPI is next to the Runway. So the Runway should be on the right.” 14:22 Captain “What is that wide area on the right?” 14:25 First Officer “On the right?” 14:27 Captain “Yes.” 14:30 Captain “Is that the Runway? The wider side.” 14:35 First Officer “Is it on the right side?” 14:37 Captain “Yes, further to the right.” 14:38 First Officer “Ah, what is the one on the left? Captain, the one on the left…” 14:39 Captain “That really is it. Is the PAPI far away?” 14:42 First Officer “Yes. One thousand, clear to land.” 14:44 Captain “Check.” 14:45 Captain “Ah, I’m still worried. Can’t see very clearly. The wider one further to the right should be the Runway, right?” 14:51 First Officer “Yes, yes, yes.” 14:52 Captain “We’ll land there then.” 14:54 Instrument sound “Autopilot OFF” 14:57 Captain “But why is the PAPI so far away?” 14:59 First Officer “Yeah.” 15:00 Captain “It’s my first time flying to Runway 10…” 15:02 First Officer “One hundred above.” (Call when 100 feet above MDA) 15:04 Captain “Check.” 15:06 Captain “I’m really still not comfortable.” 15:07 Instrument sound “Minimum” 15:09 Captain “Landing.” 15:10 First Officer “Roger.” 15:12 Instrument sound “Five hundred” 15:14 Captain “Stabilized.” 15:15 First Officer “Check.” 15:17 Captain “Ah, why does this new Runway look like it’s still under construction?” 15:20 First Officer “Yeah.” 15:21 Captain “It certainly looks like it.” 15:23 First Officer “Yeah, it certainly is, Captain.” 15:24 Captain “It is, right?” 15:25 First Officer “Yes.” 15:26 DFDR “VNAV OFF” (Distance approx. 0.8 NM) 15:28 Captain “Oh, oh, ah.” 15:32 Captain “Something’s wrong, something is wrong.” 15:36 First Officer “F/D off then on.” 15:37 Captain “Flight director, off then on.” 15:41 Captain “Oh dear.” 15:46 Instrument sound “50, 40, 30, 20, 10” 15:52 Captain “Oh dear.” 15:53 DFDR “0ft”

The Captain’s statement after the incident: During the VOR No. 1 non-precision approach procedure, LNAV/VNAV mode was used. During the Descent, there was moderate rain. At an altitude of 2000 feet, the wind speed was about 30 knots, and the outline of the airport was faintly visible. The crosswind was relatively strong, and combined with the movement of the wipers, the field of view was quite narrow. On the ND (Navigation Display), the approach procedure was on course, and the Runway was displayed on the HUD via the FDGC (Flight Director Guidance Cue). During the approach, the First Officer and I confirmed the position of the Runway with each other, but ultimately, we felt we should trust the ND and HUD displays. The reasons for not recognizing the Runway after emerging from the clouds during the Descent were:

1. Normally during a VOR approach, the HUD’s FDGC points to the Runway, but in this case, it did not.
2. Visibility was poor due to rain, and due to the strong crosswind, the drift angle was quite large, making it difficult to confirm the Runway (The Runway was offset to the side). The Heading of the VOR No. 1 approach procedure and the Runway alignment were both 105 degrees. Furthermore, we were not aware beforehand that the extension of the UWE VOR was exactly aligned with the Taxiway, not the Runway. (Author: This is critical!! Also, from the dialogue between the pilots, it is clear that the crew was not entirely sure of the Runway’s position. If they had requested the airport to turn on the lights, this result would not have happened.)

The First Officer’s statement after the incident: There was no turbulence during the Descent; the weather at high altitude was good. There was moderate rain from low altitude until touchdown. At 3000 feet, the wind direction was 160-170 degrees, and the wind speed was around 40 knots. The airport was sighted below 2000 feet, at a distance of about 4-5 nautical miles. Due to the rain, the Runway was not very clear, but two runways could be vaguely seen. Because the PAPI was on the left side of the Runway, I reported to the Captain that the one near the PAPI should be the Runway. However, I still could not determine the position of the Runway, so we continued flying. I felt the PAPI position was abnormally far away. I checked the charts and found that the approach procedure Heading and the Runway direction were both 105 degrees. Therefore, I concluded that the current Heading should be correct and that it was the Runway.

The statement from the Akita Airport Tower Air Traffic Controller after the incident: When I visually sighted the aircraft, it was about 2 nautical miles away. (Due to the viewing angle) I could not tell at that time that the aircraft’s Heading was problematic. However, when the aircraft entered the Runway end, I noticed something was abnormal, but by then there was no time to take measures, and the aircraft had landed. There were no issues on the ATC side.

The statement from another Akita Airport Tower Air Traffic Controller after the incident: The weather conditions at the time were VMC, cloud ceiling 4000 feet, and observed visibility was 10 km, but it felt like visibility towards Runway 10 was not good. Because it was VMC, the Approach Light Beacon (ALB) was not turned on. However, I later thought it would help the crew, so I turned on the ALB. (Author: Regrettably, the crew did not notice these lights.) When I saw the aircraft, the distance was about 2 nautical miles. At 1 nautical mile, I felt the altitude was slightly low, but there were no major anomalies. The problem was discovered after the aircraft landed. The UWE for the VOR No. 1 approach procedure is located 0.8 nautical miles west of the extension of Runway 10. (Because it is not in a straight line) Usually, some aircraft turn early, some turn late; every pilot handles it slightly differently.

The report indicates the main causes of this incident: The Captain and First Officer misunderstood the positions of the Runway and Taxiway, neglected to confirm with the relevant authorities, and did not grasp beforehand the information that the approach procedure Heading was parallel to the Runway. The Captain also had a misunderstanding regarding the knowledge that the HUD’s FDGC points towards the Runway direction.

Author’s comments: CRM issues; Korean Air did not fully grasp the issues with Akita Airport arrival procedures; If the airport had notified the crew after turning on the ALB lights, the crew might have reconfirmed the Runway position; The Captain’s over-reliance on the HUD display; The fact that Akita Airport’s VOR approach Heading is parallel to the Runway direction might be common knowledge for domestic airlines, but it is fatal for foreign carriers who have no way of knowing beforehand; These small issues accumulating together can create major safety hazards. The work of flying really allows for no carelessness.

End