Looking London Landing Tokyo, the wrong runway at Haneda:mindFly

Synopsis

On Thursday, December 22, 2016, an Airbus A320-214, registered JA811P, operated by PeachAviation Co., Ltd, as the scheduled Flight 1028 of the company, while approaching runway 16L of Tokyo International Airport, mistakenly tried to approach for runway 23 which was closed at 00:39 JST. An air traffic controller in the control tower noticed the situation and instructed it to go around at the position of about 5 miles east of the airport. Afterwards, the aircraft landed on runway 16L at 00:55 JST via visual approach following radar-vectored.

JTSB Full investigation report

Estimated flight route

Probable cause, JTSB report

It is probable that the serious incident occurred because aircraft, conducting VOR-A approach to land on runway 16L of Tokyo International Airport, mistakenly tried to approach for runway 23 which was closed.

It is probable that the aircraft mistakenly tried to approach for runway 23 which was closed because advance preparations for VOR A approach by the captain and the first officer were not sufficient, and they could not recognize the runway change instruction to land as a threat and then they failed to manage workloads, properly monitor and advise.

MindFly Human Factor analysis

Tokyo Approach instructed that the Aircraft would be set to land on runway 34R. Later, Tokyo Approach reported that he expected to change landing runway to runway 16L. As per the investigation report, the Captain was amazed because he did not expect any possibilities of landing runway change at all and he had no idea about the reason for this change, but he thought that he could manage to address this situation because it was good weather around the Airport. He asked the FO to set up MCDU15, but later he noticed that the FO looked confused.

Expectation Bias 

Purdue University carried out a study of accidents incidents of landing on wrong runways and wrong airports. One of the reasons for landing at the wrong surface is that flight crew have a mental picture of the airport and orientation of the runways, this is compared with what the pilot see outside. The pilots misjudge the time, speed, distance and; finally, misidentify the landing surface through the distortion of facts of the facts of reality (Antuano & Mohler, 1989). The pilots are thus, disoriented and are inadequately informed by the external visual environment. This is more so when transiting from instrument conditions to visual conditions. 

Visual cognition is limited by the number of computations it can perform, because the brain can process only a fraction of the visual faculties in detail, and by the inherent ambiguity of the information entering the visual system (Christopher, 2011). The brain prioritizes the information to reduce the burden. Attention prioritizes stimulus processing on the basis of motivational relevance, and expectations constrain visual interpretation on the basis of prior likelihood. 

The expectation is the state of the brain that reflects prior information about what is possible or probable in the forthcoming sensory environment. Expectation leads to faster acquisition and interpretation of the visual input. 

Conclusion

The crew had prepared and briefed for an ILS approach for runway 34R. The position of the runway from the arrival route would have been turning left after crossing point ‘KAIHO’ and the runway would have been straight ahead.

ILS 34R, runway position with respect to the initial track flown

The Captain had this mental image in mind when he prepared and briefed for the approach. The last minute change of runway to use runway 16L did not reprocess the mental image. The Captain flew the arrival route and the moment he saw a runway on his left, he turned and aligned with the runway. This is what he was expecting to see visually. The mental image matched with the visual image and expectation bias over ruled all visual indications of a wrong runway and that too a closed runway.

It is imperative not only to reprogram the FMS for a correct visual representation of the runway on the navigation display but also to reprogram the mental image. The supporting crew plays an important role in this situation but is also challenged due to suddenly increased workload. The importance of briefing is exemplified here. We all carry out normal briefings but the SOP must also include strategies for handling change and that too last minute change. Unless there is a plan B ready and you are convinced and reprogrammed mentally, do not proceed.

My paper on “Inattentional blindness during visual approach”. This could have been the worlds worst air disaster.

 

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