Wrong Runway Use
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- 1 Description
- 2 Two Fundamentals
- 3 Some Specific Risk Factors
- 3.1 Night
- 3.2 Low Visibility Operations
- 3.3 Lack of precision in RTF communications
- 3.4 Intersection Departures
- 3.5 Work in progress
- 3.6 Parallel Taxiway Use
- 3.7 Late issue or amendment of departure clearances (take off only)
- 3.8 Delayed flights (take off only)
- 3.9 Use of Runways as taxi routes (take off only)
- 3.10 Short Taxi Distances between Terminal and Runway (take off only)
- 4 A Focus for Safe Operations
- 5 Further Reading
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.
- 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.
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
None on SKYbrary
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 Altitude/Height 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.
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.
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.
- MD83, Are/Ostersund Sweden, 2007 (On 9 September 2007, an MD83 being operated by Austrian Company MAP Jet, which was over the permitted weight for the runway and conditions, made a night take off from Are/Ostersund airport, Sweden, very near the end of the runway and collided with the approach lights for the opposite runway before climbing away.)
- CRJ2, Charleston WV USA, 2010 (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.)
- MD88, Groningen Netherlands, 2003 (On 17 June 2003, a crew of a Boeing MD-88, belonging to Onur Air, executed a high speed rejected take-off at a late stage which resulted in overrun of the runway and serious damage to the aircraft.)
- B738, Manchester UK, 2003 (On 16 July 2003, a Boeing 737-800, being operated by Excel Airlines on a passenger flight from Manchester to Kos began take off on Runway 06L without the flight crew being aware of work in progress at far end of the runway. The take off calculations, based on the full runway length resulted in the aircraft passing within 56 ft of a 14 ft high vehicle just after take off.)
- B732, Pekanbaru Indonesia, 2002 (On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
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
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.
- Incorrect Airport Surface Approaches and Landings, SIB No. 2018-06, Feb 2018
- ‘Wrong Runway Departures’ FAA Study 2007
- SAFO 17010: Incorrect Airport Surface Approaches and Landings, 2017
Flight Safety Foundation