DCA23LA133

The airport’s continued use of taxiway Kilo, despite an identified risk of pilots repeatedly failing to stop at a hold short line prior to two intersecting runways. Contributing were 1) the operator’s moving map display, which omitted a published restriction on the use of taxiway Kilo for widebody airplanes, 2) the Captain’s resulting inadvertent continuance through the hold-short line, and 3) the FAA’s delayed action to remediate the airport’s legacy design, which did not conform with current airport design standards. .

This incident occurred when United Airlines (UAL) flight 384, a Boeing 777, landed on runway 4R at Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii, and subsequently crossed runway 4L as a Kamaka Air (KMK145) Cessna 208B was landing on runway 4L, resulting in a runway incursion. KMK145 turned left onto taxiway E, which was before taxiway K and the closest distance between the two airplanes was 1,173 ft. According to postincident flight crewmember statements, the UAL first officer was the pilot flying and landed the airplane on runway 4R. Subsequently, there was a transfer of aircraft control to the captain, as they had briefed during the approach. In his statement, the captain indicated that after taking control of the airplane, he asked the first officer to notify the tower that they were turning onto “K”. However, before the first officer could notify the tower of their exit plan, the controller contacted UAL and asked the flight crew, “have you got [taxiway] Kilo?”. The first officer responded, “turn left on Kilo.” The controller then instructed the UAL flight crew to hold-short of runway 4L (which was parallel to runway 4R) on taxiway K, and the first officer acknowledged the hold-short instruction. However, by the time the captain realized the airplane had passed the hold-short line, they were already crossing runway 8L, which intersected runways 4R and 4L, see figure 1. Figure 1. Overhead view showing HNL airport. The blue line shows UAL384’s ground track and the orange line shows KMK145’s ground track. According to the captain’s postincident statement, he was “startled by how quickly” the airplane reached runways 4L and 8L after exiting runway 4R. The captain also thought there would not be “enough room” for the airplane to “be fully clear of” runway 4R and “still hold-short of” runway 4L. Similar to the captain, the first officer “found it confusing that there was no way to be clear of 4R without being on 8L/4L.” The hold-short line for runway 4L was located less than 200 ft from the edge of runway 4R at the widest point (the west side of the hold-short line to the runway 4R centerline), which would not have accommodated a Boeing 777 airplane clearing the active landing runway. According to the post incident interview with the local controller, controllers were aware that airplanes may still be on runway 4R when they must hold short of runways 4L and 8L on taxiway K and to account for this the controllers increase the spacing between approaching aircraft for runway 4R. The area in which runways 4L, 4R, and 8L and taxiway K converge was designated as a runway incursion hot spot because aircraft landing on runway 4R and exiting left onto taxiway K “sometimes fail to hold short” of runways 4L and 8L. According to the Federal Aviation Administration (FAA), the hot spot area, which was considered to be a “legacy complex airfield layout,” did not conform with current airport design standards. The FAA stated that it intended to “continue to work with airport operators to bring non-standard geometry into compliance with future airport development opportunities, wherever possible.” Even though the captain stated he lost situational awareness after the airplane entered taxiway K, the nonconformance of the area in which runways 4L, 4R, and 8L and taxiway K converge contributed to his misjudgment of the distance to the hold-short line and his failure to stop the airplane. The captain also stated they were busy setting up for the new approach and he failed to open the hot spot (HS2) note and read that “aircraft landing on runway 4R and exiting left onto taxiway K sometimes fail to hold short of runway 4L/22R and runway 8L/26R”. He also indicated that the first officer mentioned this HS2 note during the approach briefing but it didn’t register with him. He stated that his expectation bias was that they would probably be too fast to exit at taxiway K and that they would most likely roll to the end and exit at taxiway C. Additionally, both flight crewmembers stated that, unlike the Jeppesen 10-9 chart, there was not a ball note in the airport moving map (AMM) stating, ”Wide body and four engine turbojets landing runway 4R roll to end of runway, no left turn at taxiway K without tower approval” located on the AMM version of the airport diagram and that the AMM was used for the briefing and flying/taxiing of the airplane. If the ball note had been in the AMM, it likely would have raised the crew’s awareness of their susceptibility to the risk and likely affected their decision to use taxiway “K”. The local controller had cleared KMK145 to land on runway 4L and therefore was aware he was required to hold UAL384 short of runway 4L on taxiway K. This inadvertently set the stage for the runway incursion. Had the local controller instead cleared UAL384 to continue their landing rollout to the end of runway 4R, the incursion likely would have been prevented. The investigation of this incident found that the local controller provided an incorrect instruction to the KMK pilot by stating that the airplane should turn “right” at taxiway E and cross “runway 4R.” The controller most likely made that transmission about the same time that he recognized that the UAL airplane had not stopped at the hold-short line, as instructed. The controller realized his mistake and immediately provided the correct instruction to the KMK pilot, which was to turn left on taxiway E and hold short of runway 8L, and the pilot acknowledged those instructions. The controller’s incorrect transmission was not a factor in this incident because the KMK and UAL airplanes were no longer in danger of a collision at that point.

On January 23, 2023, about 1610 Hawaii standard time (HST), United Airlines flight 384 (UAL384), a Boeing 777-200, and Kamaka Air flight 145 (KMK145), a Cessna 208B, were involved in a runway incursion at Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii. After landing on runway 4R, UAL384 crossed runway 4L as KMK145 was landing on the same runway; the closest distance between the two airplanes was 1,173 ft. None of the airplane occupants (10 crewmembers and 291 passengers aboard UAL384 and 2 flight crewmembers aboard KMK145) were injured, and neither airplane was damaged. UAL384 was a regularly scheduled domestic passenger flight operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121 from Denver International Airport (DEN), Denver, Colorado, to HNL. KMK145 was a domestic cargo flight operating under the provisions of Title 14 CFR Part 135 from Lihue Airport (LIH), Lihue, Hawaii, to HNL. Daytime visual meteorological conditions prevailed at the time of the incident. According to flight data recorder (FDR) data, UAL384 departed DEN about 0939 (1239 mountain standard time). The taxi, takeoff, departure, cruise, and descent phases of flight were uneventful. The first officer was the pilot flying, and the captain was the pilot monitoring. KMK145 departed LIH at 1530:46 with a pilot flying and pilot/loader aboard. According to postincident flight crewmember statements, before UAL384 began its descent into HNL, the first officer briefed the MAGGI3 arrival with the BITTA transition and briefed the RNAV (GPS) approach to runway 8R. The first officer obtained the automatic terminal information service (ATIS), gate assignment, and landing data via the aircraft communications addressing and reporting system (ACARS) for runways 4R and 8R. ATIS indicated that instrument and visual approaches were available for runways 4R and 8R and stated “LAHSO [land and hold-short operation] runways hold-short of 8L” and “[pilots] advise if unable.” The first officer then set up for the planned arrival and approach into HNL. After receiving the ATIS, the crewmembers reviewed the company notes for the airport, NOTAMs, arrival, landing, and taxi diagrams. Both crew members noted that there was construction on runway 8L making it unavailable to landing traffic. Additionally, the company notes for HNL indicated that B-777 airplanes were not allowed to perform land and hold-short operations (LAHSO) when landing on runway 4R. Using information from the airport moving map (AMM), as allowed by UAL procedures, they also briefed their anticipated taxi route to the gate for landing runway 8R. Additionally, in case they were given runway 4R, they briefed the anticipated taxi plan which included possibly exiting at taxiway “K” or exiting at the end of the runway on taxiway “C.” Furthermore, in her postincident statement, the first officer indicated that she briefed the published hot spot, referred to as HS2, (see figure 2) located at taxiway “K” in case they were given runway 4R for landing. Figure 2. HS2 hot spot area involving taxiway K and surrounding runways. The arrow points to the hold-short line for runways 4L and 8L. This hot spot was depicted on the first officer’s airport moving map (AMM) display, which was part of her electronic flight bag. The Jeppesen navigation chart for HNL (dated October 28, 2022) indicated that HS2 was considered to be a hot spot because aircraft landing on runway 4R and exiting left onto taxiway K “sometimes fail to hold short” of runways 4L/22R and 8L/26R. The first officer further briefed that they planned to land on runway 8R with flaps 25 and an autobrake setting of 2; however, if air traffic control (ATC) assigned them runway 4R they would then land with flaps 30 and an autobrake setting of 3. After the briefing was complete, the flight crew accomplished the descent checklist. According to air traffic control (ATC) voice recordings, at 15:54:40, the captain contacted the Hawaii Control Facility H sector approach controller. At that time, the airplane was descending through an altitude of 14,000 ft mean sea level. The approach controller provided instructions, and subsequently a clearance, for a visual approach to runway 4R at HNL. The captain notified the approach controller that they would be unable to conduct a LAHSO in which the airplane would land on runway 4R and hold short of intersecting runway 8L. In their postincident statements, the flight crew members indicated that the first officer then briefed their approach and plan to land. The exit plan from runway 4R would be either “rolling to the end” or making a left turn onto taxiway K (the latter of which depended on the airplane decelerating as expected on the runway). In his postincident statement, the captain stated that they were busy setting up for the new approach and he failed to open the hot spot note and read “Aircraft landing runway 4R and exiting left onto taxiway K sometimes fail to hold short of runway 4L/22R and runway 8L/26R”. He also indicated that the first officer mentioned the hot spot note during the approach briefing but that it didn’t register with him. He stated that his expectation bias was that they would probably be too fast to exit at taxiway K and that they would most likely roll to the end and exit at taxiway C. According to their crew statements and follow-up answers, “neither pilot left the AMM” and were using the AMM version of the airport diagram and not the chart version of the Jeppesen 10-9. For a pilot to read the textual information from an associated hot spot in the AMM, they would have to touch the electronic flight bag screen on the hot spot, and it would expand the area and provide the textual depiction of the associated hot spot. The information on the AMM for HS2 did not have the following additional note, which is present in the Jeppesen 10-9: “Wide body and four engine turbojets landing runway 4R roll to end of runway, no left turn at taxiway K without tower approval.” At 1606:12, the captain contacted the HNL air traffic control tower and reported the airplane’s altitude (1,500 ft) and the expected landing runway (4R). The local controller provided the UAL384 flight crew with wind information and cleared the airplane to land on runway 4R.   ATC provided the KMK145 pilot with vectors for runway 4L, and the pilot acknowledged that information. At 1606:27, the KMK145 pilot contacted the local controller and reported that the airplane was descending to 1,500 ft for a landing on runway 4L. The local controller instructed the KMK145 pilot to continue to runway 4L and informed the crew about traffic (the UAL384 Boeing 777) that would be landing on runway 4R. The pilot responded that the traffic was in sight. The controller then instructed the KMK145 pilot to maintain visual separation from the Boeing 777 and cleared the KMK145 airplane to land on runway 4L. The pilot acknowledged these instructions. During a postincident interview, the pilot of KMK145 reported that, as the airplane entered the left downwind leg for the visual approach to runway 4L, he maintained visual contact with the UAL384 airplane and expected to exit runway 4L at taxiway E. The pilot also reported that the KMK145 airplane’s approach speed was about 90 knots, which was “normal” for the approach.   At 1608:57, the local controller advised UAL384 that a Cessna Caravan was to the left and downwind of their airplane’s position and that the Caravan crew would maintain visual separation. The UAL384 captain acknowledged this instruction and asked for confirmation that the airplane was cleared to land runway 4R. The controller confirmed the landing clearance for runway 4R.   According to FDR data, UAL384 landed on runway 4R at 1609:16. The first officer activated the thrust reversers and began manual braking when the airplane