Wrong Runway Use
Wrong Runway Use
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 CRJ1 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
Take off from a runway:
On 25 September 2019, an ATR 72-600 about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.
Take off 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 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 27 November 2010, a Finnair Airbus A340-300 unintentionally attempted a night take off from Hong Kong in good visibility from the taxiway parallel to the runway for which take off clearance had been given. ATC observed the error and instructed the crew to abandon the take off, which they then did. The Investigation attributed the crew error partly to distraction. It was considered that the crew had become distracted and that supporting procedures and process at the Operator were inadequate.
On 10 February 2010 a KLM Boeing 737-300 unintentionally made a night take off from Amsterdam in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation noted the familiarity of the crew with the airport and identified apparent complacency.
On a 23 October, 2005 a Boeing 737-800 operated by Pegasus Airlines, during night time, commenced a take-off roll on a parallel taxiway at Oslo Airport Gardermoen. The aircraft was observed by ATC and stop instruction was issued resulting in moderate speed rejected take-off (RTO).
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 DH below that applicable to ILS Cat 1, 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 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 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.
On 19 January 2010, PSA Airlines CRJ 200 began take off from Charleston with an incorrect flap setting. After late crew recognition, a rejected take off was commenced at V1+13KIAS and an overrun into the EMAS bed at approximately 50knots followed. It was noted that had the overrun occurred prior to installation of the EMAS bed, the aircraft would probably have run down the steep slope immediately after the then-available RESA. The flap setting error was attributed non-adherence to a sterile flight deck. The late reject decision to an initial attempt to correct the flap error during the take off.
On 16 August 2008, an AMC Airlines Boeing 737-800 inadvertently began a night take off from an intersection on runway 27L at Paris CDG which left insufficient take off distance available before the end of the temporarily restricted runway length. It collided with and damaged obstructions related to construction works in progress on the closed section of the runway but sustained only minor damage and completed the intended flight to Luxor. The context for the flight crew error was identified as inadequate support from the Operator and inadequate airport risk assessment for operations with a reduced runway length.
On 9 August 2012, a serviceable Cobham Leasing Fan Jet Falcon overran the 2291 metre long runway at Durham Tees Valley after beginning rejecting take off from above V1 because of a suspected bird strike. The crew believed there was a possibility of airframe damage from a single medium sized bird sighted ahead which might have been hit by the main landing gear. It was found that the overrun distance had been increased by low friction on the stopway and noted that the regulatory exemption issued for operation without FDR and CVR was no longer appropriate.
On 5 February 2012, an Airbus A340-300 started its takeoff from an intermediate point on the runway for which no regulated takeoff weight information was available and had only become airborne very close to the end of the runway and then climbed only very slowly. The Investigation found that as the full length of the planned departure runway was not temporarily unavailable, ATC had offered either the intersection subsequently used or the full length of the available parallel runway and that despite the absence of valid performance data for the intersection, the intersection had been used.
On 11 March 2017, contrary to crew expectations based on their pre-flight takeoff performance calculation, an Airbus 340-300 taking off from the 3,800 metre-long at Bogata only became airborne just before the end of the runway. The Investigation found that the immediate reason for this was the inadequate rate of rotation achieved by the Training Captain performing the takeoff. However, it was also found that the operator’s average A340-300 rotation rate was less than would be achieved using handling recommendations which themselves would not achieve the expected performance produced by the Airbus takeoff performance software that reflected type certification findings.
On 8 December 2011, an Airbus A340-300 did not become airborne until it had passed the end of the takeoff runway at Rio de Janeiro Galeão, which was reduced in length due to maintenance. The crew were unaware of this fact nor the consequent approach lighting, ILS antennae and aircraft damage, and completed their intercontinental flight. The Investigation found that the crew had failed to use the full available runway length despite relevant ATIS and NOTAM information and that even using rated thrust from where they began their takeoff, they would not have become airborne before the end of the runway.
On 8 March 2017, a Boeing MD83 departing Ypsilanti could not be rotated and the takeoff had to be rejected from above V1. The high speed overrun which followed substantially damaged the aircraft but evacuation was successful. The Investigation found that the right elevator had been locked in a trailing-edge-down position as a result of damage caused to the aircraft by high winds whilst it was parked unoccupied for two days prior to the takeoff. It was noted that on an aircraft with control tab initiated elevator movement, this condition was undetectable during prevailing pre flight system inspection or checks.
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
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.
On 25 February 2010, an Aeroflot Airbus A320-200 unintentionally made a daylight take off from Oslo in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation identified contributory factors attributable to the airline, the airport and the ANSP.
On 27 November 2010, a Finnair Airbus A340-300 unintentionally attempted a night take off from Hong Kong in good visibility from the taxiway parallel to the runway for which take off clearance had been given. ATC observed the error and instructed the crew to abandon the take off, which they then did. The Investigation attributed the crew error partly to distraction. It was considered that the crew had become distracted and that supporting procedures and process at the Operator were inadequate.
On 10 February 2010 a KLM Boeing 737-300 unintentionally made a night take off from Amsterdam in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation noted the familiarity of the crew with the airport and identified apparent complacency.
On a 23 October, 2005 a Boeing 737-800 operated by Pegasus Airlines, during night time, commenced a take-off roll on a parallel taxiway at Oslo Airport Gardermoen. The aircraft was observed by ATC and stop instruction was issued resulting in moderate speed rejected take-off (RTO).
Late issue or amendment of departure clearances (take off 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 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 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.
Related articles
- Runway Designators
- Intersection Take Off: Guidance for Controllers
- Intersection Take Off: Guidance for Flight Crew
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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