Date: 5th February 2024
Location: Singapore Changi Airport, Runway 02C
Aircraft 1: Scoot Boeing 787-9, registration 9V-OJH
Aircraft 2: Korean Air Boeing 787-9, registration HL7209
Operator: Scoot (TR-189), Korean Air (KE-647)
Route: Hangzhou (China) to Singapore (TR-189); Seoul (South Korea) to Singapore (KE-647)
Occupants: 354 (Scoot TR-189), 106 (Korean Air KE-647)
Injuries: None reported
Summary of Events
On 5th February 2024, Scoot Flight TR-189, a Boeing 787-9, was cleared to land on Runway 02C at Singapore Changi Airport while Korean Air Flight KE-647, another Boeing 787-9, was still vacating the same runway. KE-647 had landed moments earlier and was taxiing onto high-speed turnoff T6 but stopped short of the runway holding position marking due to insufficient clearance to manoeuvre.
Despite the runway being partially occupied, the Scoot aircraft continued its landing, crossing the threshold while the Korean Air aircraft remained on RET T6. Singapore’s Air Accident Investigation Bureau (AIB) classified this as a serious incident and issued a final report identifying causal factors and safety lessons.
Sequence of Events
1. Korean Air KE-647 Lands and Vacates Runway:
• KE-647 landed on Runway 02C and was instructed to vacate via high-speed RET T6.
• While manoeuvring, the crew of KE-647 assessed that there was insufficient clearance to turn onto Exit A and decided to stop the aircraft, in line with Crew Resource Management (CRM) protocols.
2. Scoot TR-189 Cleared to Land:
• The Runway Controller (RWC) cleared Scoot TR-189 to land on Runway 02C when the Korean Air aircraft was still in motion on RET T6.
• The clearance was issued under the expectation that KE-647 would vacate the runway before TR-189 arrived.
3. Conflict Realisation:
• As TR-189 approached the runway threshold, the RWC and the Ground Movement Controller (GMC) observed that KE-647 had stopped short of the runway holding position.
• At this point, TR-189 was already over the runway threshold, and the RWC decided not to cancel the landing clearance for safety reasons, citing the critical operational phase of TR-189’s flight crew.
4. Landing Completed:
• Scoot TR-189 landed safely and was instructed to vacate via RET T4.
Causal Factors Identified by AIB
1. Issuance of Landing Clearance:
• The RWC issued landing clearance to Scoot TR-189 in anticipation that KE-647 would vacate the runway in time. This action was in line with ATSP (Air Traffic Service Provider) procedures.
2. Failure to Cancel Landing Clearance:
• The RWC failed to cancel TR-189’s landing clearance despite the runway incursion caused by KE-647 stopping short. This action was not in compliance with ATC procedures outlined in the ATSM (Air Traffic Service Manual).
3. Operational Decision:
• The RWC assessed that a go-around instruction for TR-189 would pose greater safety risks given the aircraft’s position over the threshold and the associated operational challenges for the flight crew.
Aircraft Details
Scoot Flight TR-189 (Landing Aircraft):
• Type: Boeing 787-9 Dreamliner
• Registration: 9V-OJH
• Configuration: Passenger aircraft
• Occupants: 354
Korean Air Flight KE-647 (Vacating Aircraft):
• Type: Boeing 787-9 Dreamliner
• Registration: HL7209
• Configuration: Passenger aircraft
• Occupants: 106
Initial Findings
1. ATC Procedure Adherence:
• While the initial landing clearance was issued correctly, the RWC did not take appropriate steps to ensure the runway was fully clear before allowing TR-189 to land.
2. Crew Resource Management (KE-647):
• The Korean Air crew’s decision to stop the aircraft was consistent with CRM protocols to ensure safety under limited manoeuvring space.
3. Critical Operational Phase:
• The RWC’s decision to allow TR-189 to land rather than initiating a go-around was influenced by the aircraft’s critical position over the runway threshold.
Safety Risks
1. Runway Incursion:
• Partial occupation of the runway increased the risk of collision during landing.
2. Go-Around Risks:
• Issuing a late go-around instruction when an aircraft is in the final critical phase of landing can present operational and safety risks for flight crews.
3. ATC Communication:
• Failure to promptly recognise and address the runway incursion highlights a need for improved coordination and decision-making among air traffic controllers.
Recommendations
1. Enhanced Runway Clearance Procedures:
• Strengthen ATC protocols to ensure landing clearances are issued only when the runway is fully clear of aircraft and vehicles.
2. Improved Decision-Making Training:
• Provide ATC personnel with enhanced training on go-around decision protocols and risk assessment during critical phases of flight.
3. CRM Reinforcement:
• Reinforce CRM procedures for flight crews to ensure effective communication and decision-making when manoeuvring in constrained taxiway conditions.
4. Technology Integration:
• Investigate the feasibility of integrating advanced runway incursion alerting systems to provide real-time warnings to ATC and flight crews.
Safety Lessons
This incident highlights the importance of strict adherence to runway clearance protocols and effective decision-making during critical phases of flight. While the decision to permit the landing mitigated immediate risks, improved coordination between ATC and flight crews could prevent similar occurrences.
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