Wrong Runway Use
Wrong Runway Use
Description
This review is designed to aid awareness of factors which appear to have contributed to aircraft taking off from, or landing on, the wrong runway so that aircraft operators, airport authorities and air navigation service providers (ANSPs), as well as individual flight crew and air traffic controllers, can consider 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 air traffic service (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 three 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 CRJ1 at Lexington, KY 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
Takeoff from a runway:
On 21 June 2022, a Boeing 737-9 cleared for a visual approach and landing on runway 28C at Pittsburgh landed on the adjacent runway 28L instead. The controller stated that having become aware that the aircraft was lined up with the wrong runway in the absence of any potential hazards, he had decided not to intervene. The crew said that a transient avionics fault on final approach had reduced their opportunity to ensure correct runway alignment but this fault was found to have cleared much earlier. It was noted that runway 28L had sequenced approach lighting whereas 28C had none.
On 24 October 2021, a Bombardier DHC8-400 inbound to Belagavi initially advised to expect a non-precision approach to runway 08 was subsequently cleared for an equivalent approach to runway 26. An approach to runway 08 was then flown without ATC intervention or pilot error recognition, but with no actual consequences. The error was attributed to pilot expectation bias and distraction and controller failure to order a go-around after eventually realising what was happening. The context that had facilitated the errors was considered to be procedure and performance inadequacy at both the aircraft operator and ATC.
On 8 June 2022, a Boeing 757-200 making a night visual approach to Tulsa inadvertently landed on runway 18R instead of 18L as briefed and cleared. ATC did not intervene. Neither pilot recognized the error until the captain realized there was less runway ahead than he had expected. He had planned to "roll long," expecting a the turnoff at the end of the much longer runway 18L. Although both pilots reported not being fatigued, it was concluded that lack of recognition of their error suggested otherwise, and probably facilitated plan continuation bias aided by inability to efficiently integrate available information.
On 24 October 2021, a Shorts SD360 intending to land at the international airport serving Ndola did so at the recently closed old international airport after visually navigating there in hazy conditions whilst unknowingly in contact with ATC at the very recently opened new airport which had taken the same name and radio frequencies as the old one. The Investigation found multiple aspects of the airport changeover and re-designation had been mismanaged, particularly but not only failure to publish new flight procedures for both airports and ensure that NOTAM communication of the changes internationally had been effective.
On 7 September 2019, the crew of a Boeing 737-800 completed a circling approach to runway 18R by making their final approach to and a landing on runway 18L contrary to their clearance. The Investigation found that during the turn onto final approach, the Captain flying the approach had not appropriately balanced aircraft control by reference to flight instruments with the essential visual reference despite familiarity with both the aircraft and the procedure involved.It was concluded that the monitoring of runway alignment provided by the relatively low experienced first officer had been inadequate and was considered indicative of insufficient CRM between the two pilots.
Takeoff from a taxiway:
On 6 September 2019, a Boeing 737-800 began a night takeoff at Amsterdam on a parallel taxiway instead of the runway. A high speed rejected takeoff followed only on ATC instructions. The locally based and experienced crew lost situational awareness and failed to distinguish taxiway from runway lighting or recognise that the taxiway used was only half the width of the nearby runway. It was concluded that an airport commitment to prioritise mitigation of the taxiway takeoff risk based on recommendations made after a previous such event had not led to any action after pushback collisions became a higher priority.
On 2 October 2008, a Boeing 737-400 being used for flight crew command upgrade line training unintentionally landed off a non precision approach at Palembang in daylight on a taxiway parallel to the landing runway. Neither pilot realised their error until the aircraft was already on the ground when they saw a barrier ahead and were able to brake hard to stop only 700 metres from touchdown. It was found that the taxiway involved had served as a temporary runway five years earlier and that previously obliterated markings from that use had become visible.
On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had lost visual watch on the aircraft and regained it only once the aircraft was already at speed.
On 12 July 2015, a Japanese-operated Boeing 767-300 deviated from its acknowledged clearance and lit-centreline taxi routing and began take-off from a parallel taxiway in good night visibility, crossing a lit red stop bar in the process. When ATC observed this, the aircraft was instructed to stop which was achieved without further event. A subsequent take-off was uneventful. The crew did not report the event to their airline or their State authorities because the Captain determined that this case did not need to be reported and these organisations only became aware when subsequently contacted by the Investigating Agency.
On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.
Low Visibility Operations
The special procedures which ATS units apply during low visibility conditions (Low Visibility Procedures (LVP)) and which must be in place for operators to be able to conduct approaches to a decision height (DH) below that applicable to ILS Cat 1, already bring increased safety margins. But in the case of airports identified as of special complexity in relation to this risk (permanently or temporarily due to work in progress), a specific review of risk 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 to 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.
Examples
On 30 November 2022, a Boeing 737-800 took off from Brisbane after entering a temporarily closed section of the departure runway, and the aircraft became airborne within the closed section. A NOTAM had described the closure as a displaced threshold on Runway 01R. A training captain had interpreted a dispatcher's note to mean performance for using the runway in the opposite direction, Runway 19L, was not affected. In addition, ATIS advisory of the reduced landing distance for 19L was not identified and accounted for in performance calculations for landing when the aircraft had arrived. Action to improve the both the presentation and use of NOTAMs followed.
On 23 July 2021, the takeoff roll of a Boeing 737-800 making an intersection departure from Yerevan on a non revenue positioning flight using reduced thrust in daylight exceeded the length of runway available by 81 metres but was undamaged and completed its intended flight. The Investigation found that the Onboard Performance Tool when preparing for departure had been wrongly configured but that when the crew realised there was insufficient runway length left to reject the takeoff, the thrust had not been increased and the response had been the commencement of a slow rotation 20 knots before the appropriate speed.
On 18 September 2018, an Airbus A320 crewed by a Training Captain and a trainee Second Officer departing Sharjah was cleared for an intersection takeoff on runway 30 but turned onto the 12 direction and commenced takeoff with less than 1000 metres of runway ahead. On eventually recognising the error the Training Captain took control, set maximum thrust and the aircraft became airborne beyond the end of the runway and completed its international flight. The Investigation attributed the event to the pilots’ absence of situational awareness and noted that after issuing takeoff clearance, the controller did not monitor the aircraft.
On 16 May 2013, a DHC6-300 on a domestic passenger flight made a tailwind touchdown at excessive speed in the opposite direction of the of 740 metre-long runway to the notified direction in use and, after departing the runway to one side during deceleration, re-entered the runway and attempted to take off. This failed and the aircraft breached the perimeter fence and fell into a river. The Investigation identified inappropriate actions of the aircraft commander in respect of both the initial landing and his response to the subsequent runway excursion and also cited the absence of effective CRM.
On 3 March 2021, a Boeing 737-800 departing Lisbon only just became airborne before the end of runway 21 and was likely to have overrun the runway in the event of a high speed rejected takeoff. After a significant reporting delay, the Investigation established that both pilots had calculated takeoff performance using the full runway length and then performed takeoff from an intersection after failing to identify their error before FMS entry or increase thrust to TOGA as the runway end was evidently about to be reached.
Parallel Taxiway Use
Absence of positional awareness on the part of a complete flight crew has led to both takeoff and landing on parallel taxiways
Examples
On 6 September 2019, a Boeing 737-800 began a night takeoff at Amsterdam on a parallel taxiway instead of the runway. A high speed rejected takeoff followed only on ATC instructions. The locally based and experienced crew lost situational awareness and failed to distinguish taxiway from runway lighting or recognise that the taxiway used was only half the width of the nearby runway. It was concluded that an airport commitment to prioritise mitigation of the taxiway takeoff risk based on recommendations made after a previous such event had not led to any action after pushback collisions became a higher priority.
On 2 October 2008, a Boeing 737-400 being used for flight crew command upgrade line training unintentionally landed off a non precision approach at Palembang in daylight on a taxiway parallel to the landing runway. Neither pilot realised their error until the aircraft was already on the ground when they saw a barrier ahead and were able to brake hard to stop only 700 metres from touchdown. It was found that the taxiway involved had served as a temporary runway five years earlier and that previously obliterated markings from that use had become visible.
On 24 September 2015, a Boeing 737-400 cleared for a night take-off from Sharjah took off from the parallel taxiway. The controller decided that since the taxiway was sterile and the aircraft speed was unknown, the safest option was to allow the take-off to continue. The Investigation noted that the taxiway used had until a year previously been the runway, becoming a parallel taxiway only when a new runway had been opened alongside it. It was noted that the controller had lost visual watch on the aircraft and regained it only once the aircraft was already at speed.
On 12 July 2015, a Japanese-operated Boeing 767-300 deviated from its acknowledged clearance and lit-centreline taxi routing and began take-off from a parallel taxiway in good night visibility, crossing a lit red stop bar in the process. When ATC observed this, the aircraft was instructed to stop which was achieved without further event. A subsequent take-off was uneventful. The crew did not report the event to their airline or their State authorities because the Captain determined that this case did not need to be reported and these organisations only became aware when subsequently contacted by the Investigating Agency.
On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.
Late issue or amendment of departure clearances (takeoff only)
The requirements for flight crew briefing or re-briefing and the requirements for Flight Management System navigation set up both mean that late changes to the initial departure expectation (to the runway and/or the post takeoff routing) offered by ATC in a well-meaning attempt to expedite a takeoff 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 (takeoff 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 takeoff.
Use of Runways as taxi routes (takeoff 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 takeoff clearance has been given whilst taxiing on that other runway.
Short Taxi Distances between Terminal and Runway (takeoff 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 of 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 Teams (LRST) (called Runway Safety Action Teams in the USA) which brings together the ANSP and Operators at individual airports.
Further Reading
EASA
- Incorrect Airport Surface Approaches and Landings, SIB No. 2018-06, Feb 2018
FAA
- ‘Wrong Runway Departures’ FAA Study 2007
- SAFO 17010: Incorrect Airport Surface Approaches and Landings, 2017
Flight Safety Foundation
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