A KLM Boeing 777-300, registration PH-BVO performing flight KL-836 from Singapore (Singapore) to Amsterdam (Netherlands), was taxiing for departure from runway 02L when the aircraft went past the hold short line without clearance.
Singapore's TSIB reported on Jul 20th 2026 in a brief statement: "On 2 June 2025, a Boeing B777 aircraft crossed the runway holding point at Changi Airport when an arrival aircraft was approaching to land, resulting in a runway incursion." and opened an investigation.
On Aug 31st 2026 the TSIB released their final report concluding the probable causes were (Aircraft A: PH-BVO, Aircraft B: on final approach, RWC: Runway Controller):
- Aircraft A flight crew mistook Aircraft Bs landing clearance as their take-off clearance. They assumed that the runway was used only for take-offs and that any instructions from the runway controller must be pertaining to take-off.
- Aircraft A flight crew perceived the SBL as OFF when the SBL were ON likely because of the strong reflection of the setting sun (which was behind the aircraft) masking the illumination of the SBL.
- Aircraft A flight crew did not adhere to the Aircraft A operators procedures to stop the aircraft and seek clarification from RWC when they opined that RWC was speaking too fast and RWCs instructions were unclear.
- RWC reacted promptly in correcting the wrong readback by Aircraft A but likely caused confusion to Aircraft A and B flight crews by including their two callsigns in the transmission.
The TSIB analysed:
Mistaking landing clearance for take-off clearance
Before arriving at RHP (Runway Holding Position) T1, Aircraft A flight crew was not aware that Aircraft B was on final approach. When RWC issued a landing clearance to Aircraft B, i.e. Red Cap Seven One Five Surface Wind Two Zero Zero degrees at One Zero Knots Two Zero Centre Cleared to Land, PM immediately responded to RWC with Cleared for Take-off K-L-M Eight Three Five Roger on the Wind. The PF then increased the thrust of their engines and Aircraft A continued to taxi towards the SBL (Stop Bar Lights) at RHP T1.
Aircraft A flight crew saw only one aircraft (i.e. Aircraft C) taking off on the runway and no aircraft landing, and had assumed that the runway was used only for take-offs. The investigation team believes that Aircraft A flight crew might have assumed they were next in line for departure and was expecting the next clearance from RWC could only be a take-off clearance for Aircraft A. This expectation could have led them to mistake RWCs landing clearance for Aircraft B as a take-off clearance for their aircraft.
Misperceiving the SBL as OFF
There was no evidence that the SBL had been turned OFF during the occurrence. Aircraft A flight crew had seen the SBL illuminated while they were approaching RHP T1. However, as the aircraft came closer to RHP T1, the flight crew perceived the SBL to be OFF.
The investigation team understands from the Aircraft A flight crew after the occurrence that the strong reflection of the setting sun (which was behind the aircraft) might have masked the illumination of the SBL, making them believe that the SBL were OFF. The investigation team opines that this was possible. The occurrence highlights that flight crews should be mindful that the perception of SBL status can be influenced by environmental conditions, e.g. the sun. If in doubt, flight crews should ascertain the status of the SBL with the air traffic controllers.
Communications between RWC and Aircraft A flight crew
Aircraft A flight crew said they had difficulty understanding RWCs transmissions and perceived that RWC was speaking too fast. In accordance with the operators AOM, flight crew should stop the aircraft if ATCs instructions were not clear. However, prior to the runway incursion, at no time did Aircraft A flight crew stop the aircraft and seek clarification from RWC.
DSB opined that RWCs transmissions were difficult to understand. The investigation team reviewed the air traffic recordings and opined that RWC speech rate and clarity were not abnormal when communicating with Aircraft A, B and C prior to the runway incursion. There was no instance where Aircraft A, B and C flight crews asked RWC to repeat any instructions. The investigation team also opined that it is normal for peoples speech rate to increase when dealing with an urgent situation such as a runway incursion.
RWCs response to incorrect readback
When Aircraft A mistook the landing clearance for Aircraft B as a take-off clearance and transmitted a wrong readback, RWC immediately transmitted Negative that was for Red Cap Seven One Five K-L-M Eight Three Five to Hold at Holding Point Tango One (see paragraph 1.1.10) with intentions to correct the incorrect readback.
The investigation team opines that in this occurrence, using two callsigns within a transmission when trying to correct an incorrect readback was not ideal and likely caused confusion to Aircraft A and B flight crews. This was evident when Aircraft B flight crew immediately sought clarification from RWC as to whether the transmission was for them. The confusion could have been avoided if DSB opined that RWCs transmissions were difficult to understand. The investigation team reviewed the air traffic recordings and opined that RWC speech rate and clarity were not abnormal when communicating with Aircraft A, B and C prior to the runway incursion. There was no instance where Aircraft A, B and C flight crews asked RWC to repeat any instructions. The investigation team also opined that it is normal for peoples speech rate to increase when dealing with an urgent situation such as a runway incursion.
RWCs response to incorrect readback
When Aircraft A mistook the landing clearance for Aircraft B as a take-off clearance and transmitted a wrong readback, RWC immediately transmitted Negative that was for Red Cap Seven One Five K-L-M Eight Three Five to Hold at Holding Point Tango One (see paragraph 1.1.10) with intentions to correct the incorrect readback.
The investigation team opines that in this occurrence, using two callsigns within a transmission when trying to correct an incorrect readback was not ideal and likely caused confusion to Aircraft A and B flight crews. This was evident when Aircraft B flight crew immediately sought clarification from RWC as to whether the transmission was for them. The confusion could have been avoided if Aircraft Bs callsign had not been included in RWCs transmission when correcting Aircraft A flight crews readback.
Singapore's TSIB reported on Jul 20th 2026 in a brief statement: "On 2 June 2025, a Boeing B777 aircraft crossed the runway holding point at Changi Airport when an arrival aircraft was approaching to land, resulting in a runway incursion." and opened an investigation.
On Aug 31st 2026 the TSIB released their final report concluding the probable causes were (Aircraft A: PH-BVO, Aircraft B: on final approach, RWC: Runway Controller):
- Aircraft A flight crew mistook Aircraft Bs landing clearance as their take-off clearance. They assumed that the runway was used only for take-offs and that any instructions from the runway controller must be pertaining to take-off.
- Aircraft A flight crew perceived the SBL as OFF when the SBL were ON likely because of the strong reflection of the setting sun (which was behind the aircraft) masking the illumination of the SBL.
- Aircraft A flight crew did not adhere to the Aircraft A operators procedures to stop the aircraft and seek clarification from RWC when they opined that RWC was speaking too fast and RWCs instructions were unclear.
- RWC reacted promptly in correcting the wrong readback by Aircraft A but likely caused confusion to Aircraft A and B flight crews by including their two callsigns in the transmission.
The TSIB analysed:
Mistaking landing clearance for take-off clearance
Before arriving at RHP (Runway Holding Position) T1, Aircraft A flight crew was not aware that Aircraft B was on final approach. When RWC issued a landing clearance to Aircraft B, i.e. Red Cap Seven One Five Surface Wind Two Zero Zero degrees at One Zero Knots Two Zero Centre Cleared to Land, PM immediately responded to RWC with Cleared for Take-off K-L-M Eight Three Five Roger on the Wind. The PF then increased the thrust of their engines and Aircraft A continued to taxi towards the SBL (Stop Bar Lights) at RHP T1.
Aircraft A flight crew saw only one aircraft (i.e. Aircraft C) taking off on the runway and no aircraft landing, and had assumed that the runway was used only for take-offs. The investigation team believes that Aircraft A flight crew might have assumed they were next in line for departure and was expecting the next clearance from RWC could only be a take-off clearance for Aircraft A. This expectation could have led them to mistake RWCs landing clearance for Aircraft B as a take-off clearance for their aircraft.
Misperceiving the SBL as OFF
There was no evidence that the SBL had been turned OFF during the occurrence. Aircraft A flight crew had seen the SBL illuminated while they were approaching RHP T1. However, as the aircraft came closer to RHP T1, the flight crew perceived the SBL to be OFF.
The investigation team understands from the Aircraft A flight crew after the occurrence that the strong reflection of the setting sun (which was behind the aircraft) might have masked the illumination of the SBL, making them believe that the SBL were OFF. The investigation team opines that this was possible. The occurrence highlights that flight crews should be mindful that the perception of SBL status can be influenced by environmental conditions, e.g. the sun. If in doubt, flight crews should ascertain the status of the SBL with the air traffic controllers.
Communications between RWC and Aircraft A flight crew
Aircraft A flight crew said they had difficulty understanding RWCs transmissions and perceived that RWC was speaking too fast. In accordance with the operators AOM, flight crew should stop the aircraft if ATCs instructions were not clear. However, prior to the runway incursion, at no time did Aircraft A flight crew stop the aircraft and seek clarification from RWC.
DSB opined that RWCs transmissions were difficult to understand. The investigation team reviewed the air traffic recordings and opined that RWC speech rate and clarity were not abnormal when communicating with Aircraft A, B and C prior to the runway incursion. There was no instance where Aircraft A, B and C flight crews asked RWC to repeat any instructions. The investigation team also opined that it is normal for peoples speech rate to increase when dealing with an urgent situation such as a runway incursion.
RWCs response to incorrect readback
When Aircraft A mistook the landing clearance for Aircraft B as a take-off clearance and transmitted a wrong readback, RWC immediately transmitted Negative that was for Red Cap Seven One Five K-L-M Eight Three Five to Hold at Holding Point Tango One (see paragraph 1.1.10) with intentions to correct the incorrect readback.
The investigation team opines that in this occurrence, using two callsigns within a transmission when trying to correct an incorrect readback was not ideal and likely caused confusion to Aircraft A and B flight crews. This was evident when Aircraft B flight crew immediately sought clarification from RWC as to whether the transmission was for them. The confusion could have been avoided if DSB opined that RWCs transmissions were difficult to understand. The investigation team reviewed the air traffic recordings and opined that RWC speech rate and clarity were not abnormal when communicating with Aircraft A, B and C prior to the runway incursion. There was no instance where Aircraft A, B and C flight crews asked RWC to repeat any instructions. The investigation team also opined that it is normal for peoples speech rate to increase when dealing with an urgent situation such as a runway incursion.
RWCs response to incorrect readback
When Aircraft A mistook the landing clearance for Aircraft B as a take-off clearance and transmitted a wrong readback, RWC immediately transmitted Negative that was for Red Cap Seven One Five K-L-M Eight Three Five to Hold at Holding Point Tango One (see paragraph 1.1.10) with intentions to correct the incorrect readback.
The investigation team opines that in this occurrence, using two callsigns within a transmission when trying to correct an incorrect readback was not ideal and likely caused confusion to Aircraft A and B flight crews. This was evident when Aircraft B flight crew immediately sought clarification from RWC as to whether the transmission was for them. The confusion could have been avoided if Aircraft Bs callsign had not been included in RWCs transmission when correcting Aircraft A flight crews readback.
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