What caused the August 2024 Changi runway incursion involving two China Eastern jets?

The Transport Safety Investigation Bureau’s report, released on August 1, 2025, reads like a study in how small, reasonable decisions can stack into a runway incursion. Two China Eastern Airlines arrivals from Shanghai Pudong were sequenced to land on Runway 20R on August 28, 2024, barely a minute apart. The first aircraft, an Airbus A320-200neo, touched down four seconds after 8.12pm. The second, a Boeing 777-300ER, was cleared to land 55 seconds after 8.12pm, with the controller assessing the first jet’s tail was clear of the runway edge and the strip would be vacated by the time the heavier widebody crossed the threshold.

That sequencing made sense on paper. The first aircraft had been instructed to expedite its exit via rapid taxiway W7, and it did turn left within a minute of touchdown. But the crew also slowed further to make a >90-degree turn onto Taxiway W in line with company requirements, bleeding speed to below 18.5km/h. The controller saw a visual alert hinting at a possible incursion risk and, at 8.13:25pm, issued a go-around to the second aircraft—by then about 23 meters above ground and roughly 300 meters from the available landing portion of the runway. The 777’s crew did not acknowledge and landed at 8.13:38pm. No injuries, no damage, and both aircraft taxied in. Yet by definition, the first aircraft was still within the runway strip when the second touched down.

TSIB’s analysis is unsentimental. It attributes causality to the second aircraft’s failure to go around and the first aircraft’s slower-than-expected runway strip exit. The explanation is human, not heroic: the 777’s crew were in a high-load, low-altitude phase of flight—with the enhanced ground proximity warning system calling out altitudes in rapid succession—making it likely the go-around instruction was masked or cognitively deprioritised. That aligns with well-documented human factors research: in final approach, auditory channels saturate and crews can miss discrete transmissions even when fully trained and rested. In other words, this was not a crew ignoring ATC; it was a crew overloaded at the exact second their mental model diverged from the tower’s.

Equally central is the controller’s judgement. TSIB found he complied with Civil Aviation Authority of Singapore procedures that allow a landing when there is reasonable assurance of safe separation. He had nearly nine years on position and actively managed the risk by urging the first aircraft to expedite. He also issued the go-around once it became apparent the strip might not be vacated in time. The system worked as written; the outcome, however, revealed how thin the margins can get when runway occupancy, braking profiles, and taxiway geometry combine at night.

The airline dimension matters. China Eastern subsequently reminded pilots to be vigilant across all phases of flight and to expect low-altitude go-around instructions in the event of unexpected runway incursions. That is not a perfunctory memo. Company SOPs that require very low taxi speeds before sharper turns are defensible for safety and tire wear, but they also elongate runway strip occupancy when rapid exits are tasked under pressure. In complex hubs, operators and regulators increasingly have to reconcile taxiway design, fleet mix, and SOP-driven deceleration profiles with the reality of tight arrival spacing.

Singapore’s regulatory response is pragmatic rather than punitive. CAAS has pushed lessons from the case into biannual simulator training at Changi and Seletar, added regular scenario-based exercises for abnormal situations, and instructed controllers to include the reason when issuing go-around instructions in similar contexts. That last tweak sounds cosmetic, but it is operationally meaningful. A call like “Go around, traffic still in runway strip” can cut through cockpit expectancy and make compliance more likely when seconds are scarce and altitude callouts are competing for the crew’s attention.

The larger systems question is whether technology can narrow the gap left by human expectancy. Changi already uses visual alerts, and global airports are rolling in more robust runway status lights and stop-bar logic to nudge behaviour before voice becomes the only tool left. Yet technology does not eliminate the coordination problem when one aircraft’s deceleration needs collide with another’s planned touchdown. The answer is often more boring than futuristic: conservative spacing when exit certainty is in doubt, stronger shared mental models about when “expedite” still won’t beat geometry, and cockpit discipline to treat any late go-around as routine rather than exceptional.

This episode will be misread if reduced to luck or laxity. It is a reminder that runway safety lives in the seams—between a controller’s reasonable assurance and a crew’s reasonable expectation, between a rapid exit that is fast enough in most cases and an SOP that is slow enough in edge cases. TSIB’s work shows how those seams can be tightened without theatrics: targeted training, clearer rationale in critical calls, and airline-level reinforcement that low-altitude go-arounds are not failures but standard defences.

Changi’s record on incursions remains strong by any fair benchmark, and Singapore’s institutional reflex—study, simulate, standardise—is the right one. The Changi runway incursion investigation ultimately signals a culture that treats “no harm done” as an opportunity to harden the system. That is how high-reliability operations stay high-reliability: not by assuming good outcomes validate thin margins, but by assuming the margins need constant maintenance, especially when the risks are quiet and the runway looks clear.