Incident Boeing 787-9 Dreamliner HL7209,
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ASN Wikibase Occurrence # 346005
 
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Date:Friday 24 February 2023
Time:11:02
Type:Silhouette image of generic B789 model; specific model in this crash may look slightly different    
Boeing 787-9 Dreamliner
Owner/operator:Korean Air
Registration: HL7209
MSN: 34818/788
Year of manufacture:2018
Fatalities:Fatalities: 0 / Occupants: 273
Aircraft damage: None
Category:Incident
Location:Singapore-Changi International Airport (SIN/WSSS) -   Singapore
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:Singapore-Changi International Airport (SIN/WSSS)
Destination airport:Seoul-Incheon International Airport (ICN/RKSI)
Investigating agency: TSIB Singapore
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Korean Air flight KE647, a Boeing 787-9 Dreamliner, was scheduled for departure from runway 02R of Changi Airport, Singapore. While taxiing to Runway 02R, the aircraft taxied into a closed section of a taxiway. The aircraft’s nose landing gear tyres hit and
damaged a marker board of about 3m in length that demarcated the boundary of the taxiway closure area and came to a stop about 100m beyond the marker board. There was no injury and no damage to the aircraft other than some scuff marks on the nose landing gear tyres.


CONCLUSIONS
1 Both the PF and the PM misread the effectivity end time of NOTAM A0445/23. This had resulted in the flight crew missing information regarding the closure area along Taxiway T and expected a relatively straightforward taxi route from
Taxiway T to Taxiway K.
2 The expectation of a straightforward taxi route had likely resulted in the flight crew not getting themselves to be familiar with other taxiways along Taxiway T. The PM was expecting Taxiway P1 to be perpendicular to Taxiway T (which was parallel to Taxiway T) and had difficulty in locating Taxiway P1.
3 Although the PM had read back correctly GMC1’s taxi instruction of using Taxiways P3 and P1 to reach Taxiway K, the PM seemed to have missed the part on Taxiway P3 for the taxi instruction.
4 The PF had mistaken the red and white stripes of a marker board as a ground marking and did not recognise the significance of the red and white marking. This could be due to his preconceived belief that the taxi instruction was straightforward from Taxiway T to Taxiway K and thus missed recognising the marker board.
5 The PM had likely missed the marker board due to the distraction in locating Taxiway P1.
6 The flight crew’s performance in term of crew resource management had not been optimal.

Accident investigation:
cover
  
Investigating agency: TSIB Singapore
Report number: 
Status: Investigation completed
Duration: 7 months
Download report: Final report

Sources:

TISB

Revision history:

Date/timeContributorUpdates
28-Sep-2023 10:17 harro Added
28-Sep-2023 10:17 harro Updated

Corrections or additions? ... Edit this accident description

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