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Wrong Runway Use
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| Article Information | ||
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| Category: | Runway Excursion | 
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| Content source: | SKYbrary | 
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| Content control: | EUROCONTROL | 
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Description
This review is designed to aid awareness of those factors which appear to have historically been conducive to aircraft taking off from, or landing on, the wrong runway so that Aircraft Operators, Airport Authorities and ANSPs, as well as individual flight crew and air traffic controllers, can consider their defences against this risk.
Two Fundamentals
- Flight Crew and ATC Procedures: Loss of Situational Awareness, specifically positional awareness, sometimes but not always aided by complacency, is the most common reason for wrong runway use. Whilst there is currently considerable focus on technical safety nets, a high level of overall procedural rigour and safety culture in both ATS Units and Aircraft Operators provides the tactical foundation for risk mitigation.
- Airport Design: It is important to recognise that some airports are designed in such a way that the possibility of incorrect use of runways is heightened by identifiable ‘opportunities for error’. Whilst isolated wrong runway accidents and serious incidents can occur anywhere, many have occurred at a relatively small number of airports. Anchorage Airport, Alaska USA recorded 3 events of this type between 2002 and 2005. Minor changes to the design, signage or to traffic movement procedures at such airports have been shown to significantly reduce the risk of recurrence. Equally, the proactive identification of relatively high-risk airports, by both aircraft operators and ATS authorities, can aid both take actions to mitigate risk. Such actions include alerting flight crew and controllers at high risk airports. A recent study carried out in the USA showed that the whilst many airports recording above average rates of wrong runway use were busy ones with complex designs, neither factor was a requirement for occurrences. The ‘top four’ airports identified for US Part 121 carrier events in this study (see Further Reading below) were Cleveland, Houston, Salt Lake City and Miami, which are by no means the busiest or most complex US Airports.
Some Specific Risk Factors
Whilst some accidents and serious incidents have had a predominant circumstantial aspect, the most serious accidents have often involved multiple contributory causes. The fatal accident to a Bombardier CRJ 100 at Lexington KT in 2006 was an example of this.
The final opportunity to prevent a wrong runway event is often a positive check by the flight crew of aircraft orientation by reference to the aircraft compass versus the designation of the runway about to be used. However, a significant minority of events involve use of runways or taxiways closely parallel to those cleared for use by ATC.
In the list of circumstantial factors below, some examples which were directly related to them (although not necessarily exclusively) are given where a published official report is available. Some examples are listed under more than one factor.
Night
Statistics tend to show that more errors of this type occur during the hours of darkness. A review of both night RTF procedures and of the installation of use of lighting systems can reduce the risk of runway misuse
Examples
- CRJ1, Lexington KY USA, 2006 (HF RE FIRE) (On 27 August 2006, a CRJ100ER, belonging to Comair, crashed after taking off from the wrong runway at Lexington, Kentucky, USA.)
- B732, London Gatwick UK, 1993 (RE HF) (On 20 October 1993, a Boeing 737-200 being operated by Air Malta on a scheduled passenger flight from Malta to London Gatwick landed at destination on the taxiway parallel to the runway for which landing clearance had been given in good visibility at night after a Surveillance Radar Approach (SRA) terminating at 2 miles from touchdown had been conducted in VMC. There was no damage to the aircraft or injury to the occupants and the aircraft taxied to the allocated gate after the landing.)
- B752, Newark NJ USA, 2006 (RE HF) (On 28 October 2006, a Boeing 757-200 being operated by Continental Airlines on a scheduled passenger flight from Orlando FL to Newark made a landing at destination in night VMC on the parallel taxiway next to the runway for which landing clearance had been issued. The flight crew did not report their error and ATC did not notice it but staff of the Airport Operator had observed it and advised ATC accordingly, after which the flight crew admitted their error.)
- B763, Atlanta GA, USA 2009 (HF RE) (On 19 October 2009, a Boeing 767-300 being operated by Delta Airlines on a scheduled passenger flight from Rio de Janeiro to Atlanta inadvertently made a landing at destination in night VMC on parallel taxiway ‘M’ instead of the intended and ATC-cleared landing runway 27R. None of the 194 occupants were injured and there was no damage to the aircraft or conflict with other traffic or vehicles. The third rostered crew member had become incapacitated en route with the consequence that neither of the other pilots had been able to take any in flight rest.)
- B744, Taipei Taiwan, 2000 (RE FIRE HF) (On 31 October 2000, Boeing 747-400 being operated by Singapore Airlines on a scheduled passenger flight from Taipei, Taiwan to Los Angeles unintentionally commenced take off on a partially closed runway in reduced (but not low) visibility instead of the correct runway without ATC being aware of the error. The subsequent collision with construction equipment and resultant severe post crash fire destroyed the aircraft killing 83 of the 170 occupants, seriously injuring 39 more and causing minor injuries to 32 others. All three flight crew survived.)
Low Visibility Operations
The special procedures which both aircraft operators and ATS Units already apply during low visibility (Low Visibility Procedures) already bring increased safety margins, but in the case of airports which are identified as of special complexity in relation to this risk (permanently or temporarily due to work in progress), a specific review of risk management by both aircraft operators and ATS Units is likely to be useful.
Example
Lack of precision in RTF communications
Very high standards of situational awareness for both ATC and Flight crew and the corresponding use of appropriate and specific RTF clearances which are closely monitored for correct read back by ATC are essential.
Example
Intersection Departures
A single runway, especially a long one, where intersection departures are used has sometimes led to flight crew turning onto the runway in the wrong direction and taking off in the reciprocal the cleared direction.
Work in progress
A lack of flight crew awareness of closed runways or taxiways has sometimes contributed to wrong runway use as has airport authority failure to carry out prior risk assessment of intended work and implement measures which maintain normal safety standards.
Example
Parallel Taxiway Use
Absence of positional awareness on the part of a complete flight crew has led to both take off and landing on parallel taxiways
Examples
- B738, Oslo Gardermoen Norway, 2005 (RE HF)
- B752, Newark NJ USA, 2006 (RE HF)
- A343, Anchorage AK USA, 2002 (RE HF)
- B732, London Gatwick UK, 1993 (RE HF)
Late issue or amendment of departure clearances (take off only)
The requirements for flight crew briefing or re-briefing and the requirements for FMS navigation set up both mean that late changes to the initial departure expectation (to the runway and/or the post take off routing) offered by ATC in a well-meaning attempt to expedite a take off time or departure routing may lead to errors including wrong runway use. The unexpected addition to flight crew workload can be sufficient to cause standards of completion to drop and/or aircraft ground navigation to be temporarily neglected as both flight crew work ‘heads down’.
Delayed flights (take off only)
Late flight departure and a self-imposed pressure to get airborne as soon as possible has sometimes led to either active or passive loss of positional awareness en route to the runway. Investigations into many near-miss events and some actual incidents include the finding that flight crew were rushing to complete their checklists because of a desire to recover lost time by taking every opportunity to be ready for an opportunity for a quick take off.
Use of Runways as taxi routes (take off only)
When cleared to taxi to a departure runway via another runway, flight crew have sometimes departed from that taxiway instead of turning onto the correct runway, when their take off clearance has been given whilst taxiing on that other runway.
Short Taxi Distances between Terminal and Runway (take off only)
The likelihood of errors in following an ATC ground clearance can be increased when gate to runway distances are relatively short because required flight crew checks must be completed in less time with relatively more heads-down and a consequently greater opportunity for loss of situational awareness.
A Focus for Safe Operations
One if the most effective non technical ways of raising awareness of risks and finding mitigations has been shown to be the introduction of the Local Runway Safety Team (called Runway Safety Action Teams in the USA) which brings together the ANSP and Operators at individual airports.
Further Reading
FAA
Flight Safety Foundation