MaxAvSafety: ATC Error/ Incident!

MaxSez: we all make mistakes fellows. I emphasize “ALL”!

The Japan Transport Safety Board (JTSB) concluded in their investigation into a serious runway incursion incident that a preoccupied air traffic controller at Tokushima Airport cleared a Boeing 767 to land while an airport vehicle was still on the runway.

A Boeing 767-346 (registration JA8299) operated as Japan Air Lines flight JL455 from Tokyo-Haneda to Tokushima attempted to land at the runway 29 when the flight crew noticed a vehicle on the runway. The aircraft briefly touched down but the pilots selected go around power and the aircraft climbed away safely. The aircraft passed over the vehicle at a height of 40 feet (12 m).

The second approach was also aborted due to turbulence, and the plane landed in the third attempt at 11:24 JST, half an hour after the incident.
At the time of the incident, the vehicle was on the duty to exchange a runway distance marker lights. However, the controller of Tokushima Tower forgot the presence of the vehicle on the runway, and gave a landing clearance to JL455. The ATC of the Tokushima Airfield is operated by Japan Maritime Self-Defence Force.

Probable Causes:
It is highly probable that the serious incident occurred as JA8299 attempted to land because local control at Tokushima Aerodrome control tower had issued a landing clearance to JA8299 on the runway occupied by the Work Vehicle.
It is probable that the Tower had issued a landing clearance to JA8299 to land because the Supervisor, who had the combined duties of the Tower and the Ground, had forgotten about the presence of the Work Vehicle. It is probable that contributing factors were that, in a situation in which only one Air Traffic Controller was on duty in the aerodrome control tower and no support could be received from other controllers, he was preoccupied with selecting a runway for the Departure Aircraft, and that he did not use a reminder indicating that the runway was unusable for take-offs and landings.

Official accident investigation report
investigating agency: Japan Transport Safety Board (JTSB) – Japan
report status: Final
report number: AI2016-4
report released: 25 August 2016
duration of investigation: 1 year and 5 months
(Aviation Safety Net)


This is interesting. I don’t have a whole lot of knowledge or experience in accident investigation, but am I the only one that finds it odd that it took one year and five months to determine that the control “forgot” about the vehicle on the runway? I imagine the control might have admitted that in the first interview. Or is it a matter of they’re that backed up with safety investigations?


MaxSez: @Flightfan84… all things are political in aviation safety. Big money plus in the Orient one must consider “Face”. In this case the Controller was military. Now that’s a lot of Face in JP.


Now all of it makes complete sense. I knew about NTSB being political, and no surprise regarding the money factor. Well said.

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Wow, this is interesting!

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Okay @Maxmustang this is very interesting. Thank you for posting this so I could read it.


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