![](media/image1.jpeg){width="1.1402777777777777in"
height="1.1402777777777777in"}National Transportation Safety Board

Runway Incursion Accidents, Serious Incidents, Recommendations, and
Statistics

Deadliest Runway Accidents

● **Tenerife, Canary Islands, March 27, 1977: 583 fatalities.** The
world's deadliest runway accident occurred on March 27, 1977, when Pan
Am (PAA) flight 1736, a Boeing 747, and KLM4805, a Boeing 747, collided
on runway 12 at Tenerife, Canary Islands, killing 583 passengers and
crew. KLM4805 departed runway 12 without a takeoff clearance colliding
with PAA1736 that was taxiing on the same runway during instrument
meteorological conditions.

The Spanish government determined the cause was: "The KLM aircraft had
taken off without take-off clearance, in the absolute conviction that
this clearance had been obtained, which was the result of a
misunderstanding between the tower and the KLM aircraft. This
misunderstanding had arisen from the mutual use of usual terminology
which, however, gave rise to misinterpretation. In combination with a
number of other coinciding circumstances, the premature take-off of the
KLM aircraft resulted in a collision with the Pan Am aircraft, because
the latter was still on the runway since it had missed the correct
intersection."

● **Lexington, Kentucky, August 27, 2006: 49 fatalities.** The deadliest
runway accident in the United States occurred on August 27, 2006 at
about 6:06 a.m., when Comair flight 5191, a Bombardier CL-600-2B19,
N431CA, crashed during takeoff from Blue Grass Airport, Lexington,
Kentucky. The flight crew was instructed to take off from runway 22 but
instead lined up the airplane on runway 26 and began the takeoff roll.
The airplane ran off the end of the runway and impacted the airport
perimeter fence, trees, and terrain. The captain, flight attendant, and
47 passengers were killed, and the first officer received serious
injuries. The airplane was destroyed by impact forces and postcrash
fire. The flight was en route to Hartsfield-Jackson Atlanta
International Airport, Atlanta, Georgia.  Night visual meteorological
conditions prevailed at the time of the accident.

The NTSB determined the probable cause was the flight crewmembers'
failure to use available cues and aids to identify the airplane's
location on the airport surface during taxi and their failure to
cross-check and verify that the airplane was on the correct runway
before takeoff.  Contributing to the accident were the flight crew's
nonpertinent conversations during taxi, which resulted in a loss of
positional awareness and the Federal Aviation Administration's failure
to require that all runway crossings be authorized only by specific air
traffic control clearances. (DCA06MA064) Note: The NTSB on July 27, 2007
classified the accident as a runway incursion.

#### 

#### Fatal Runway Accidents in the United States since 1990

● **Los Angeles, California, February 1, 1991: 34 fatalities.** On
February 1, 1991 at 6:01 p.m. USAir (USA) flight 1493, a B737, and
Skywest (SKW) flight 5569, an SW4, collided on runway 24L at Los Angeles
International Airport, Los Angeles, California, killing 34. USA1493 was
landing on runway 24L and collided with SKW5569 that was holding on the
same runway, at intersection 45, waiting for a takeoff clearance.

The NTSB determined the probable cause was the failure of the Los
Angeles air traffic facility management to implement procedures that
provided redundancy comparable to the requirements contained in the
National Operational Position Standards and the failure of the FAA Air
Traffic Service to provide adequate policy direction and oversight to
its air traffic control facility managers. These failures created an
environment in the Los Angeles Air Traffic Control Tower that ultimately
led to the failure of the Local Controller 2 to maintain an awareness of
the traffic situation, culminating in the inappropriate clearances and
the subsequent collision of the USAir and Skywest aircraft. Contributing
to the cause of the accident was the failure of the FAA to provide
effective quality assurance of the ATC system. (DCA91MA018AB)

#### 

#### ● Atlanta, Georgia, January 18, 1990: 1 fatality. On January 18, 1990 at 7:04 p.m., Eastern Airlines (EAL) flight 111, a B727, collided with N44UE, an Epps Air Service Beechcraft King Air A100, on runway 26R at the William B. Hartsfield International Airport, Atlanta, Georgia. N44UE was on landing roll, preparing to turn off runway 26R when it was struck from behind by EAL111 that had also been cleared to land on the same runway. The pilot of N44UE sustained fatal injuries. The accident occurred in night visual flight rule conditions, with reported visibility 3 miles with fog. 

The NTSB determined the probable cause of the accident was 1) the
failure of the FAA to provide air traffic control procedures that
adequately take into consideration human performance factors such as
those which resulted in the failure of the north local controller to
detect the developing conflict between N44UE and EAL111, and 2) the
failure of the north local controller to ensure the separation of
arriving aircraft which were using the same runway. Contributing to the
accident was the failure of the north local controller to follow the
prescribed procedure of issuing appropriate traffic information to
EAL111, and failure of the north final controller and the radar monitor
controller to issue timely speed reductions to maintain adequate
separation between aircraft on final approach. (DCA90MA017AB)

#### ● Detroit, Michigan, December 3, 1990: 8 fatalities. On December 3, 1990 at 1:45 p.m., Northwest Airlines (NWA) flight 1482, a DC-9, and NWA299, a Boeing 727, collided near the intersection of runways 9/27 and 3C/21C at Detroit Metropolitan/Wayne Country Airport, Romulus, Michigan, that killed 8 people. NWA299 was on its takeoff roll on runway 3C and collided with NWA1482 after it taxied onto the runway. The accident occurred in day instrument meteorological conditions. 

The NTSB determined the probable cause was the lack of proper crew
coordination, including virtual reversal of roles by the DC-9 pilots,
which led to their failure to stop taxiing and alert ground controller
of their position uncertainty in a timely manner before and after
intruding onto the active runway. Contributing to the cause of the
accident were (1) deficiencies in ATC services provided by Detroit
Tower, including failure of the ground controller to take timely action
to alert local controller to possible runway incursion, inadequate
visibility observations, failure to use progressive taxi instructions in
low-visibility conditions, and issuance of inappropriate and confusing
taxi instructions compounded by inadequate backup supervision for level
of experience of staff on duty; (2) deficiencies in surface markings,
signage and lighting at airport and failure of FAA surveillance to
detect or correct any of these deficiencies; (3) failure of Northwest
Airlines to provide adequate cockpit resource management training to
line aircrews. (DCA91MA010-AB)

● **St. Louis, Missouri, November 22, 1994: 2 fatalities.** On November
22, 1994 at 10:03 p.m., Trans World Airlines (TWA) flight 427, a MD-82,
collided with N441KM, a Cessna 441, at the intersection of runway 30R
and taxiway R, at the Lambert-St. Louis International Airport (STL) in
Bridgeton, Missouri. The STL ground controller cleared N441KM to taxi to
runway 31 but the crew inadvertently taxied onto runway 30R. The STL
local controller cleared TWA427 for takeoff on runway 30R and collided
with N441KM. The two occupants of N441KM were killed. The accident
occurred in night visual meteorological conditions.

The NTSB determined the probable cause was the Cessna 441 pilot's
mistaken belief that his assigned departure runway was runway 30R, which
resulted in his undetected entrance onto runway 30R, which was being
used by the MD-82 for its departure. Contributing to the accident was
the lack of Automatic Terminal Information Service and other air traffic
control information regarding the occasional use of runway 31 for
departure. The installation and utilization of Airport Surface Detection
Equipment (ASDE-3), and particularly ASDE-3 enhanced with the Airport
Movement Area Safety System (AMASS), could have prevented this accident.
(CHI95MA044AB)

● **Quincy, Illinois, November 19, 1996: 14 fatalities.** On November
19, 1996 at 5:03 p.m., United Express flight 5925, a Beechcraft 1900C,
and N1127D, a Beechcraft King Air A90, collided at the intersection of
runways 13/31 and 4/22 at the uncontrolled airport in Quincy, Illinois,
killing all 14 people in both planes. Flight 5925 was completing its
landing roll on runway 13 and the N1127D was on its takeoff roll on
runway 4 when they collided. The accident occurred in day visual
meteorological conditions.

The NTSB determined the probable cause was the failure of the pilots in
the King Air A90 to effectively monitor the common traffic advisory
frequency or to properly scan for traffic, resulting in their commencing
a takeoff roll when the Beech 1900C (United Express flight 5925) was
landing on an intersecting runway. Contributing to the cause of the
accident was the Cherokee pilot\'s interrupted radio transmission, which
led to the Beech 1900C pilot\'s misunderstanding of the transmission as
an indication from the King Air that it would not take off until after
flight 5925 had cleared the runway. (DCA97MA009AB)

● **Sarasota, Florida, March 9, 2000: 4 fatalities.** On March 9, 2000
at 10:35 a.m., N89827, a C152, and N79960, a C172, collided during
takeoff on runway 14 at the Sarasota-Bradenton International Airport,
Sarasota, Florida, killing 4 people. The tower controller cleared N89827
for takeoff from the approach end and 6.5 seconds later instructed
N79960 to "taxi into position and hold". N89827 collided with N79960
when the airplane entered the runway at taxiway F. The accident occurred
in day visual meteorological conditions.

The NTSB determined the probable cause was the failure of the
supervisor/ground controller and the local controller to provide
effective separation between the accident airplanes on the runway,
resulting in a collision during takeoff. Contributing to the accident
was the failure of the pilot and pilot-rated passenger on board N79960
to ensure that the runway was clear of traffic before taxiing onto the
runway. Also contributing to the accident was the failure of air traffic
control guidance and procedures to incorporate redundant methods of
verifying aircraft position for both controllers and pilots.
(MIA00FA103AB)

**● Chicago, Illinois, December 8, 2005: 1 fatality.** On December 8,
2005 at about 7:14 p.m., Southwest Airlines flight 1248, a Boeing
737-7H4, N471WN, ran off the departure end of runway 31C after landing
at Chicago Midway International Airport, Chicago, Illinois. The airplane
rolled through a blast fence, an airport perimeter fence, and onto an
adjacent roadway, where it struck an automobile before coming to a stop.
A child in the automobile was killed, one automobile occupant received
serious injuries, and three other automobile occupants received minor
injuries. Eighteen of the 103 airplane occupants (98 passengers, 3
flight attendants, and 2 pilots) received minor injuries, and the
airplane was substantially damaged. The airplane had departed from
Baltimore/Washington International Thurgood Marshall Airport, Baltimore,
Maryland.

The NTSB determined that the probable cause was the pilots' failure to
use available reverse thrust in a timely manner to safely slow or stop
the airplane after landing, which resulted in a runway overrun. This
failure occurred because the pilots' first experience and lack of
familiarity with the airplane's autobrake system distracted them from
thrust reverser usage during the challenging landing.

Contributing to the accident were Southwest Airlines' 1) failure to
provide its pilots with clear and consistent guidance and training
regarding company policies and procedures related to arrival landing
distance calculations; 2) programming and design of its on board
performance computer, which did not present inherent assumptions in the
program critical to pilot decision-making; 3) plan to implement new
autobrake procedures without a familiarization period; and 4) failure to
include a margin of safety in the arrival assessment to account for
operational uncertainties. Also contributing to the accident was the
pilots' failure to divert to another airport given reports that included
poor braking action and a tailwind component greater than 5 knots.
Contributing to the severity of the accident was the absence of an
engineering materials arresting system, which was needed because of the
limited runway safety area beyond the departure end of runway
31C.  (DCA06MA009)

###### Serious Incidents in the United States

● **Providence, Rhode Island, December 6, 1999.** On December 6, 1999 at
8:35 p.m., United Airlines flight 1448 (UAL1448), a Boeing 757, and
Federal Express flight 1662 (FDX1662), a Boeing 727, were involved in a
runway incursion on runway 5R at the Theodore Francis Green State
Airport, Providence, Rhode Island. No injuries were reported, and
neither aircraft was damaged. The crew of UAL1448 landed on runway 5R
and, during taxi to the terminal, became disoriented and inadvertently
turned on taxiway B and stopped on the edge of runway 5R. FDX1662
departed runway 5R, passing very near UAL1448. The incident occurred
during night instrument meteorological conditions. Reported visibility
was ¼ mile and the runway visibility range was 1,400 feet.
(DCA00SA012AB)

● **Chicago, Illinois, April 1, 1999.** On April 1, 1999 at 2:20 a.m.,
Air China flight 9018 (CCA9018), Boeing 747, and Korean Air flight 36
(KAL36), a Boeing 747, were involved in a near collision on runway 14R
at the Chicago O\'Hare International Airport, Chicago, Illinois.  No
injuries were reported, and neither aircraft was damaged. CCA9018 landed
on runway 14R and was instructed by the tower controller to exit the
runway via a right turn on taxiway T-10, left turn on taxiway K, and to
cross runway 27L to the cargo ramp.  The same controller cleared KAL36
for takeoff as the CCA9018 was exiting runway 14R.  CCA9018 turned right
turn onto taxiway T-10 then turned left onto taxiway M instead of
taxiway K.  CCA9018 entered onto runway 14R as KAL36 was taking off. 
KAL36 flew over 25 to 50 feet over the top of CCA9018. The incident
occurred during night visual meteorological conditions. (DCA99SA054AB)

● **Dallas, Texas, August 16, 2001.** On August 16, 2001 at 10:24 a.m.,
Delta Airlines (DAL) flight 1521, a 737, nearly collided with
Continental (COA) flight 1487, a 737, on runway 18L at Dallas/Fort Worth
International Airport, Dallas, Texas. The tower local controller cleared
COA1487 to land on runway 18R, and then cleared DAL1521 for take off on
runway 18L. About 24 seconds later, the local controller cleared COA1487
to cross runway 18L. The pilots of both airplanes saw a possible
impending collision and took evasive action. COA1487 continued to the
gate and deplaned the passengers. The pilot of DAL1521 reported that the
tail of the airplane scraped the runway. Examination revealed that there
was damage to the skin of the underside of the tail. Radar data
indicates that DAL1521 flew over COA1487 by approximately 100 feet. The
incident occurred in day visual meteorological conditions.

The NTSB determined the probable cause was the local controller clearing
the taxiing aircraft to cross the runway in front of the aircraft on
takeoff roll. Contributing factors were the local controller\'s failure
to follow FAA procedures and directives to visually scan the runway
prior to issuing the crossing clearance, the local controller's
excessive workload, and the tower supervisor\'s inadequate supervision.
(FTW01IA183AB)

● **Los Angeles, California, August 19, 2004.** On August 19, 2004 at
2:55 p.m., Asiana Airlines flight 204 (AAR204), a Boeing 747-400, and
Southwest Airlines flight 440 (SWA440), a Boeing 737, were involved in a
near collision on runway 24L at the Los Angeles International Airport,
Los Angeles, California. No injuries were reported, and neither aircraft
was damaged. The same tower controller cleared AAR204 to land on runway
24L and cleared SWA440 onto the same runway to depart. AAR204 initiated
a go-around and flew over SWA440 by about 200 feet. The incident
occurred during daylight visual meteorological conditions.

The NTSB determined the probable cause was a loss of separation between
Southwest flight 440 and Asiana flight 204 due to the LC2 relief
controller\'s failure to appropriately monitor the operation and
recognize a developing traffic conflict. Contributing factors included
the FAA\'s position relief briefing procedures, the formatting of the
DBRITE radar displays in the LAX tower, controller fatigue, and the
tower supervisor\'s staffing decisions on the day of the incident.
(LAX04IA302)

● **Boston, Massachusetts, June 9, 2005.** On June 9, 2005 at about 7:40
p.m., Aer Lingus flight 132 (EIN132), an Airbus 333, and US Airways
flight 1170 (USA1170), a Boeing 737, were involved in a runway incursion
at the General Edward Lawrence Logan International Airport (BOS), in
Boston, Massachusetts. No injuries were reported, and neither aircraft
was damaged. Both aircraft were under control of the Boston Air Traffic
Control Tower; the Local Control West (LCW) controller was responsible
for EIN132 and Local Control East (LCE) was responsible for USA1170. At
2339:10, the LCW cleared EIN132 for takeoff from runway 15R. Five
seconds later, forgetting that he released the runway to allow EIN 132
to depart, the LCE cleared USA1170 for departure from runway 9. The
first officer on USA1170 saw EIN102 and pushed the control column
forward to prevent the captain from taking off. Once EIN132 had passed
through the intersection, USA1170 became airborne. AMASS did not
activate because in its current configuration it was not designed to
operate on intersecting runways due to the amount of nuisance alerts.
The incident occurred during daylight visual meteorological conditions.
(NYC05IA095A)

● **Chicago, Illinois, July 23, 2006.** On July 23, 2006 at about 10:00
p.m., Atlas Air flight 6972, (GTI6972), a Boeing 747-400, and United
Airlines flight 1015 (UAL1015), a Boeing 737-300 were involved in a
runway incursion at the Chicago O'Hare International Airport (ORD),
Chicago, Illinois. No injuries were reported, and neither aircraft was
damaged. The local controller cleared GTI6972 to land on runway 14R and
approximately two minutes later, cleared UAL1015 for takeoff from runway
27L. UAL1015 almost collided with GTI6972 as it crossed runway 27L while
on landing roll. The captain of UAL1015 noticed GTI6972 and rotated 10
knots prior to Vr, flew over GTI6972, and missed it by approximately 120
feet. At the time of the incident, the Airport Movement Area Safety
System (AMASS) was in limited mode and did not alert. The incident
occurred during night visual meteorological conditions. (OPS06IA008A)

● **Denver, Colorado, January 5, 2007.** On January 5, 2007 at 7:28
a.m., Key Lime Air flight 4216 (LYM4216), an SW4, and Frontier flight
297 (FFT297), an A319, were involved in a near collision at Denver
International Airport, Denver, Colorado. No injuries were reported, and
neither aircraft was damaged. The pilot of LYM4216 inadvertently entered
runway 35L as FFT297 was on approach to the same runway. As FFT297
descended out of the clouds, the pilot noticed LYM4216 on the runway and
executed a missed approach. The airplanes missed colliding by about 50
feet. The incident occurred in day instrument meteorological conditions.
Weather was reported as 600 overcast, 1100 broken, visibility 1/2 mile,
light snow, mist, and the runway visual range was 5,500 feet.
(OPS07IA001AB)

● **San Francisco, California, May 26, 2007.** On May 26, 2007 at 1:30
p.m., a tower air traffic controller at San Francisco International
Airport cleared SkyWest Airlines flight 5741, an Embraer 120 arriving
from Modesto, California, to land on runway 28R. Forgetting about the
arrival airplane, the same controller then cleared Republic Airlines
flight 4912, an Embraer 170 departing for Los Angeles, to take off from
runway 1L, which intersects runway 28R. After the SkyWest airliner
touched down, the Airport Movement Area Safety System (AMASS) alerted
and the air traffic controller transmitted \"Hold, Hold, Hold\" to the
SkyWest flight crew in an attempt to stop the aircraft short of runway
1L. The SkyWest crew applied maximum braking that resulted in the
airplane stopping in the middle of runway 1L. As this was occurring, the
captain of Republic Airlines flight 4912 took control of the aircraft
from the first officer, realized the aircraft was traveling too fast to
stop, and initiated an immediate takeoff. According to the crew of
SkyWest 5741, the Republic Airlines aircraft overflew theirs by 30 to 50
feet. (OPS07IA004)

● **New York City, New York, July 5, 2007.** On July 5, 2007 at about
9:15 a.m., there was a runway incursion at LaGuardia Airport, New York,
New York involving Delta (DAL) flight 1238, a 737, and Comair (COM)
flight 196, a CRJ1.  There was a developmental training on ground
control (GC) at the time of this incident.  GC requested to cross runway
22 with an aircraft at taxiway F. The local controller approved the
request advising he should cross behind COM flight 425, an E135, which
was landing on runway 22. DAL1238 was inbound, landing behind COM425.
The aircraft following DAL1238 inbound was issued go around instructions
but GC thought that DAL1238 had been sent around. GC then crossed
COM196, on runway 22 at taxiway F, without coordination, as DAL1238
crossed the landing threshold. The FAA originally reported that the
lateral separation of the aircraft was 3,200 feet. The Airport Movement
Area Safety System (AMASS) radar data indicated that the closest
proximity of the aircraft was about 650 feet. The incident occurred
during day visual flight rules conditions.  The FAA classified this
incursion as a Category D.  (OPS07IA007AB)

● **Ft. Lauderdale, Florida, July 11, 2007.** On July 11, 2007 at 2:37
p.m., a runway incursion occurred at the Fort Lauderdale-Hollywood
Airport, Fort Lauderdale, Florida between United flight 1544, an A-320
and Delta Airlines flight 1489, a Boeing 757. The incident occurred in
day visual flight rules conditions, visibility 10 miles, scattered
clouds at 4,800 feet. The ground controller instructed United 1544 to
taxi to runway 9L via taxiway T7. As the flight was taxiing on taxiway D
near runway 9L, the tower local controller noticed the airplane was
going too fast to hold short of the runway. The local controller told
the ground controller to tell United to stop. The ground controller
said, \"UAL 1544 stop, stop, stop\". The crew stopped on runway 9L.
Delta1489 was inbound for landing on runway 9L when the local controller
determined that United1544 was not going to hold short of the runway and
instructed Delta1489 to go around. When the crew received the
instruction, the main landing gear was on the ground. According to the
crew statement, they noted the urgency in the controller\'s voice so
they knew they had to get the aircraft airborne. FAA reported Delta1489
flew over United1544 by less than 100 feet. According to the FAA, the
United crew stated they missed the turn onto taxiway B. The air traffic
control tower is not equipped with either AMASS or ASDE-X. All airport
lighting was functioning normally. (OPS07IA006)

● **Los Angeles, California, August 16, 2007.** On August 16, 2007 at
about 12:57 p.m., a runway incursion occurred involving West Jet (WJA)
900, B737 and Northwest Airlines (NWA) flight 180, an A320, at Los
Angeles International Airport, Los Angeles, California.WJA900 landed on
runway 24R and exited at taxiway Y then changed to ground control
frequency without authorization while the airplane was holding between
the parallel runways. The tower controller cleared NWA180 for takeoff
from runway 24L. Meanwhile, the pilot of WJA900 contracted ground
control and said, \"Ground, WJA900 with you on reverse \[taxiway\]
yankee for gate 35.\" The ground controller assumed that the tower
controller had instructed the flight to cross runway 24L and responded,
\"WJA900, Los Angeles tower, taxi \[via taxiway\] echo to the gate.\"
Ten seconds later, the pilot of WJA900 confirmed that the flight was
cleared to cross runway 24L. The ground controller asked who called and
the pilot again asked WJA900 had not been instructed to cross runway 24L
and told WJA900 to stop. According to the FAA and WJA, the airplane
crossed the hold short line but did not enter the runway. According to
the FAA, the two aircraft missed colliding by 37 feet (wingtip of A320
to the nose of the B737) as NWA180 departed runway 24L. The tower
received an AMASS warning when the pilot was confirming to cross and
before the controller told WJA900 to stop. (OPS07IA009A)

**● Chantilly, Virginia, September 12, 2007.** On September 12, 2007
about 3:13 a.m., a runway incursion occurred at Washington Dulles
International Airport, Washington, D.C. involving N66NJ, a Learjet 35,
during night visual meteorological conditions. Runway 19R, which is
11,501 feet long and 150 feet wide, was closed for surveying and the
runway lights had been turned off. The closure was advertised on the
automatic terminal information service and the tower controller placed
an X on the tower\'s ground radar display as a reminder of the closure.
The closure was also annotated on the tower status display. At the time
of the incident, there was one tower controller in the cab, the second
controller assigned to the shift was on break. The tower controller
instructed N66NJ to taxi into position and hold, then cleared it for
takeoff on the closed unlit runway. The departure controller at Potomac
Terminal Radar Approach Control noticed the radar target depart runway
19R and asked the tower controller if the runway was open, and was told
no. The FAA classified the incident as an operational error.
(OPS07IA010)

● **Memphis, Tennessee, October 11, 2007.** On October 11, 2007 at about
7:40 p.m., N241EP, a Cessna Citation 525, took off on taxiway M at
Memphis International Airport, Memphis, Tennessee during night visual
meteorological conditions. The tower controller cleared the flight for
takeoff on runway 36L when the airplane was on taxiway N. The crew
acknowledged the clearance, turned right, and began takeoff roll on
taxiway M. The tower controller made two transmissions to advise that
the aircraft was departing on a taxiway. The crew of N241EP acknowledged
just after lifting off taxiway M. Holding on taxiway M at M6 was
Pinnacle Airlines (FLG) flight 5905, a CRJ2. The initial report from the
Federal Aviation Administration stated that N241EP over flew FLG5905 by
400 to 500 feet. The FAA classified the incident as a pilot deviation.

The NTSB determined the probable cause was the pilot\'s inadvertent
departure from a taxiway instead of a runway. (OPS08IA001)

**● Baltimore, Maryland, December 2, 2007.** On December 2, 2007 at
about 7:21 p.m., Comair flight 5412 (COM5412), a Bombardier Regional Jet
(CRJ), departed runway 15R and over flew America West (AWE) flight 83,
an Airbus A320, that had landed on runway 10 at Baltimore/Washington
International Thurgood Marshall Airport (BWI), Baltimore, Maryland
during night visual meteorological conditions. Weather conditions were:
wind calm, visibility 5 statute miles, light rain and mist, ceiling
1,000 feet broken and 3,000 feet overcast. The tower controller had
cleared AWE83 to land on runway 10 and AWE83 was approximately 6 mile on
final approach when the ATC local controller cleared COM5412 for takeoff
on runway 15R. COM5412 was on taxiway A about 500 feet short of runway
15R when the takeoff clearance was issued. AMASS alerted. COM5412
rotated at taxiway F and over flew AWE83, at the intersection of runways
10 and 15R. The initial report from the Federal Aviation Administration
stated that COM5421 over flew AWE83 by 300 feet. AWE83 exited runway 10
at runway 22.

The NTSB determined the probable cause was the local controller\'s
failure of maintaining awareness of the situation and failing to provide
the appropriate separation between the two aircraft operating on
intersecting runways. Providing separation between aircraft is a first
duty priority, in accordance with FAA Order 7110.65. (OPS08IA002B)

**● Teterboro, New Jersey, December 27, 2007.** On December 27, 2007 at
8:02 a.m., a runway incursion occurred at Teterboro Airport (TEB),
Teterboro, New Jersey involving East Coast Jets (ECJ) flight 81,
registration number N818MV, a Hawker 25, and N90AM, a G5. There was
training in progress on ground control and there was a certified
professional controller on local control. Tower staffing included a
tower supervisor, a local controller, a ground controller and ground
control developmental and a fight data/clearance delivery controller.
ECJ 81 had landed on runway 6 and was advised by the local controller
after landing to \"turn left at taxiway bravo if able, cross \[runway\]
one contact ground\". ECJ81 exited the runway at taxiway B and contacted
ground control for taxi to the Meridian FBO located on the north side of
the airport. The developmental ground controller requested approval from
the tower local controller to taxi ECJ81 across runway 1 at taxiway B.
The local controller approved the request. About this time, N90AM called
local control for takeoff and was directed to taxi into position and
hold on the approach end of runway 1. The local controller, who was
responsible for 2 aircraft and had 2 previous operational errors with
some similarities, cleared N90AM for takeoff as ECJ81 was crossing the
runway. The developmental ground controller reminded the local
controller of the crossing and advised that it was not complete. The
local controller, anticipating that appropriate separation would exist
prior to N90AM beginning takeoff roll, instructed ground controller to
expedite the crossing of ECJ81 and did not cancel the takeoff clearance.
According to the Federal Aviation Administration, the closest proximity
was 4,000 feet. The incident occurred during day visual meteorological
conditions.

The NTSB determined the probable cause was the TEB tower local
controller\'s failure to ensure that the runway was free of all known
ground vehicles, equipment, and personnel before permitting a departing
aircraft to start takeoff roll. (OPS08IA004A)

**● St. Augustine, Florida, February 6, 2008.** On February 6, 2008 at
about 7:55 p.m., the pilot of N140FT, a Piper PA-28-161, departed on
runway 6 at St. Augustine (SGJ) Airport, St. Augustine, FL, and ran off
the end of the runway into the marshy waters of the Intracoastal
Waterway. According to the pilot, \"The air traffic controller told me
that I was good there and gave me clearance to depart 31. I understood
that to mean I was on \[runway\] 31 and clear for departure so I
completed my pre-takeoff checklist and began my ground roll. Then I
noticed I was on the wrong runway and tried to stop, but was too late
and the momentum carried me into the marsh.\" According to the FAA\'s
preliminary report, the student solo pilot arrived from Deland, Florida
and requested to taxi back to the active runway for departure. The
controller instructed the pilot to make a left turn on B2 then taxi to
runway 31 via taxiway B, and hold short of runway 31 at taxiway B4. The
pilot acknowledged the clearance. The pilot taxied past taxiway B4 and
went onto runway 6/24. While on runway 6/24 and short of runway 31, the
pilot requested progressive taxi instructions from the tower controller.
The controller advised the pilot, \"You\'re fine where you\'re at. Are
you ready to go?\" The pilot stated that he was ready to depart. The
controller instructed \"Zero foxtrot tango, runway 31 at runway six
intersection, cleared for takeoff left turn southbound.\" The pilot read
back \"cleared for takeoff.\" According to the preliminary report, the
tower controller observed the aircraft make a turn onto runway 31 at
runway 6 intersection and then returned to do administrative duties,
(the hourly weather). The pilot had departed straight ahead on runway 6
from the intersection of runway 6/31 with approximately 200 feet of
runway remaining. A short time later the pilot buzzed the tower door and
advised the controller that he had ran off the runway into the
Intracoastal Waterway.

The NTSB determined the probable cause was the pilot\'s failure to
adhere to the controller\'s takeoff instruction. Contributing to the
incident was the controller\'s failure to properly monitor the flight,
and the controller\'s decision to perform lesser duty priorities during
the takeoff roll. (OPS08IA006)

**● Teterboro, New Jersey, June 25, 2008.** On June 25, 2008 at 5:34
a.m., a runway incursion occurred at Teterboro Airport, Teterboro, New
Jersey.  A Learjet 45, Windrider flight 988, landed on a closed runway.
Runway 1/19 had been closed by airport operations at 5:05 a.m.  A
lighted X, indicating that the runway was closed, was placed at the
departure end of the runway. Additionally, the controller placed two
runway incursion devices, which are memory aides to remind the tower
controller of the closure, at the local control position. However, the
controller did not notify the approach control facility, New York
Terminal Radar Approach Control, of the runway closure. Twenty-seven
minutes after the closing of the runway, the approach controller called
the tower controller to request a visual approach to runway 19 for
flight 988. The tower controller approved the request.  The airplane
flew over two employees who were working north of the displaced
threshold of runway 19 and landed on the runway. The automatic terminal
information service information \"H\" did not include the closed runway.
(OPS08IA009)

**● Seattle, Washington, July 2, 2008.** On July 2, 2008 at 10:36 p.m.,
a runway incursion occurred at the Seattle-Tacoma International Airport
(SEA), Seattle, Washington. Airtran flight 227, B737, crossed runway 34R
without a clearance while Northwest flight 106, A332 was departing. The
FAA reported the two airplanes missed colliding by 400 feet vertically
as the Airbus overflew the 737. (OPS08IA007)

**● Teterboro, New Jersey, July 9, 2008.** On July 9, 2008 at 10:10
a.m., a Cessna 172 (N316AS) and, a Dessault Falcon 200 (N277QS) were
also involved in a runway incursion at Teterboro Airport. The Cessna
landed on runway 19 and requested a back taxi to the approach end of
runway 19 for departure.  The ground controller instructed the pilot to
taxi to runway 19 via taxiway L and to hold short of runway 19. 
However, the pilot was not instructed to hold short of runway 24, which
intersected runway 19. The airplane had crossed the hold line for runway
24 but not over the runway edge when the tower controller cleared the
Falcon for takeoff on runway 24.  The tower cancelled the Falcon\'s
clearance once it was determined that the Cessna was across the runway
hold line.  The FAA reported the two airplanes were 1,200 feet apart.
The incident occurred during the day shift with a front line manager and
two air traffic control specialists on position.   (OPS08IA010AB)

####### *Most Wanted List of Transportation Safety Improvements*

Runway incursion prevention has been on the NTSB's "Most Wanted List" of
safety improvements since the list was inaugurated in 1990. In November
2007, Board Members voted to keep the topic on the list, add three
recommendations to the issue area, and keep its "red" color code
denoting that actions by the FAA were "unacceptable."

The current 4 runway safety recommendations on the list are A-00-66,
A-00-67, A-00-68 and A-07-57. All are described below.

######### 

######### Recommendation History

Since 1973, the NTSB has issued about 100 safety recommendations
regarding runway incursions to the FAA and various other agencies. These
recommendations addressed the need for improvements in air traffic
control operations, training, procedures, and hardware; pilot training;
airport signage, lighting and markings; airplane conspicuity; and
incident reporting.

Currently there are 13 open safety recommendations dealing with runway
incursions:

● Amend FAA Order 7110.65, "Air Traffic Control," to require that
controllers provide traffic advisories to the flight crew of each
aircraft operating on intersecting runways where flightpaths converge.
***Current classification: open-acceptable. (A-00-34)***

● Amend the Aeronautical Information Manual to inform pilots that
controllers will issue traffic information about aircraft operating on
intersecting runways where flightpaths converge and explain the
rationale for the procedure. ***Current classification: open-acceptable.
(A-00-35)***

● Require, at all airports with scheduled passenger service, a ground
movement safety system that will prevent runway incursions. The system
should provide a direct warning capability to flight crews. In addition,
demonstrate through computer simulations or other means that the system
will prevent incursions*. **Current classification: open --
unacceptable. (A-00-66)*** (Recommendation A-00-66 replaced A-91-29
after numerous runway incursion investigations determined that a direct
warning to the cockpit was necessary.)

● Require that all runway crossings be authorized only by specific air
traffic control clearance, and ensure that all U.S. pilots, foreign
pilots flying into the U.S., and ground personnel responsible for the
movement of aircraft, receive adequate notification of the change.
***Current classification: open -- unacceptable. (A-00-67)***

● Require that, when aircraft need to cross multiple runways, air
traffic controllers issue an explicit crossing instruction for each
runway after the previous runway has been crossed. ***Current
classification: open -- unacceptable. (A-00-68)***

● Discontinue the practice of allowing departing aircraft to hold on
active runways at nighttime or at any time when ceiling and visibility
conditions preclude arriving aircraft from seeing traffic on the runway
in time to initiate a safe go-around maneuver. ***Current
classification: open -- unacceptable. (A-00-69)***

● Adopt the landing clearance procedure recommended by International
Civil Aviation Organization. ***Current classification: open --
unacceptable. (A-00-70)***

● Require the use of standard International Civil Aviation Organization
phraseology for airport surface operations, and periodically emphasize
to controllers the need to use this phraseology and to speak at
reasonable rates when communicating with all flight crews, especially
those whose primary language is not English. ***Current classification:
open -- unacceptable. (A-00-71)***

● Require that all 14 *Code of Federal Regulations* Part 91K, 121, and
135 operators establish procedures requiring all crewmembers on the
flight deck to positively confirm and cross-check the airplane's
location at the assigned departure runway before crossing the hold short
line for takeoff. This required guidance should be consistent with the
guidance in Advisory Circular 120‑74A and Safety Alert for Operators
06013 and 07003. ***Current classification: open -- await response.
(A-07-44)***

● Require that all 14 *Code of Federal Regulations* Part 91K, 121, and
135 operators install on their aircraft cockpit moving map displays or
an automatic system that alerts pilots when a takeoff is attempted on a
taxiway or a runway other than the one intended. ***Current
classification: open -- await response. (A-07-45)***

● Require that all airports certificated under 14 *Code of Federal
Regulations* Part 139 implement enhanced taxiway centerline markings and
surface painted holding position signs at all runway entrances.
***Current classification: open -- await response. (A-07-46)***

● Prohibit the issuance of a takeoff clearance during an airplane's taxi
to its departure runway until after the airplane has crossed all
intersecting runways. ***Current classification: open -- await response.
(A-07-47)***

● Revise Federal Aviation Administration Order 7110.65, "Air Traffic
Control," to indicate that controllers should refrain from performing
administrative tasks, such as the traffic count, when moving aircraft
are in the controller's area of responsibility. ***Current
classification: open -- await response. (A-07-48)***

***FAA Runway Incursion Statistics***

On October 1, 2007, the Federal Aviation Administration (FAA) adopted
the ***International Civil Aviation Organization (ICAO) definition of a
runway incursion as*** "any occurrence at an aerodrome involving the
incorrect presence of an aircraft vehicle or person on the protected
area of a surface designated for the landing and take-off of aircraft."

***The ICAO definition is broader than the previous FAA definition which
said a runway incursion was \"any occurrence in the airport runway
environment involving an aircraft, vehicle, person, or object on the
ground that creates a collision hazard or results in a loss of required
separation with an aircraft taking off, intending to take off, landing,
or intending to land.\"***

##### Calendar Year Total Incursions Rate per 1 million ops {#calendar-year-total-incursions-rate-per-1-million-ops .unnumbered}

##### (FAA definition) (FAA definition) {#faa-definition-faa-definition .unnumbered}

1999 321 4.7

2000 431 6.4

2001 383 5.9

2002 336 5.2

In 2000, Congress mandated FAA begin reporting runway incursion data by
fiscal year instead of calendar year.

##### Fiscal Year Total Incursions Rate per 1 million ops Total Incursions {#fiscal-year-total-incursions-rate-per-1-million-ops-total-incursions .unnumbered}

**(FAA definition) (FAA definition) (ICAO definition\*)**

2000 405 5.9

2001 407 6.2

2002 339 5.2

2003 323 5.2 583

2004 326 5.2 504

2005 327 5.2 530

2006 330 5.4 806

2007 370 6.0 893

2008 **\*** 764 (as of 7/17/08)

***\* FAA changed its definition of a runway incursion to the ICAO
definition on October 1, 2007, which is the beginning of the 2008 fiscal
year.***

###### Resources

-   National Transportation Safety Board: <http://www.ntsb.gov/>

Aircraft Owners and Pilots Association's (AOPA) Air Safety Foundation
offer an online interactive runway safety course to all pilots:
<http://www.aopa.org/asf/runway_safety>

FAA's runway safety information, programs and data:
<http://www.faa.gov/runwaysafety>

ICAO *Manual: Prevention of Runway Incursions:*
<http://www.icao.int/fsix/res_ans.cfm>

-   History Channel: *Mega Disasters: Deadly Jet Collision* (7-8-08)
    Synopsis: In March, 1977, on Tenerife, Canary Islands, 583 people
    were killed when two Boeing 747s collided at Los Rodeos Airport. It
    was the world\'s worst aviation disaster. Though decades have
    passed, root causes for the tragedy remain with us today. The
    problem is called \"runway incursions,\" meaning any incorrect
    presence of aircraft, vehicles or persons on an airfield. For the
    last decade, the U.S. has seen roughly 300 incursions per year. Most
    are not serious, but some have been very near misses\--and others
    have taken lives. Unless significant changes continue to be made in
    airport infrastructure, aviation technology, and professional
    training, any American airport could be the site of the next
    tragedy.

July 18, 2008