Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight. Unlike the airspace above the United States, which spans millions of square miles, the runway environment is a far more limited area, often with a steady stream of aircraft taking off and landing on intersecting runways, sometimes in poor weather and with limited visibility. These conditions put aircraft at an increased risk for ground collisions and excursions (overrunning or undershooting the runway during takeoff or landing). Runway accidents have the potential for significant loss of life and injury. For example, in March 1977, in what remains the world's deadliest aviation accident, two passenger jumbo jets collided on a runway at Tenerife, in the Canary Islands, killing 583 passengers and crew. In the United States, the deadliest U.S. runway incursion accident occurred in August 2006 when Comair flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board. From the 1977 Tenerife accident through the present day, the NTSB continues to investigate serious runway collisions and runway overruns and departures.
Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action—often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers. Requiring specific air traffic control clearance for each runway crossing would reduce the chances that an airplane will inadvertently taxi onto an active runway on which another aircraft is landing or taking off.
Situational awareness is also important in addressing runway excursions. Pilots need accurate information on runway conditions. Equipment should be properly set for takeoff or landing and function properly. Pilot training and procedures should emphasize conducting distance assessments for all landings, especially on contaminated runways; training on maximum performance stopping on a slippery runway; and identifying the appropriate runway for their aircraft.
Open Recommendations that represent critical safety priorities
A-24-2 to the FAA: Encourage Title 14 Code of Federal Regulations Part 91K, 135, and 121 operators to incorporate into their standard operating procedures a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross, as indicated by runway signs, unless an installed automated system already provides an aural advisory.Safety Recommendation A-24-003
A-24-3 to the FAA: Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent tasks during taxi and develop and implement effective risk mitigation strategies considering human factors principles.
A-24-4 to the FAA: Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on a runway or taxiway and traffic on approach to land. (Supersedes A-00-66)
A-24-5 to the FAA: Require that the technology developed in response to Safety Recommendation A-24-4 be installed in all newly certificated transport-category airplanes. (Supersedes A-00-66)
A-24-6 to the FAA: Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A-24-4. (Supersedes A-00-66)
A-24-7 to the FAA: Evaluate the effectiveness of the activation logic for the runway status light system considering the circumstances of this incident.
A-24-8 to the FAA: Using the findings of the evaluation conducted in response to Safety Recommendation A-24-7, update the runway status light system activation logic as necessary to improve system effectiveness.
A-24-9 to the FAA: Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (Supersedes A-18-31)
A-24-10 to the FAA: For airports that are certificated under Title 14 Code of Federal Regulations Part 139 and are currently not equipped with airport surface detection equipment, model X or airport surface surveillance capability, implement surface detection equipment that
- tracks the movement of arriving and departing aircraft,
- determines the proximity between those aircraft, and
- provides air traffic controllers with visual and aural cues of surface movements to aid in their decision making processes.
A-24-11 to the FAA: Require air traffic controllers to
- advise pilots, through direct communication and automatic terminal information system broadcasts, when visual contact with aircraft operating on taxiways and runways cannot be established or maintained and
- instruct pilots to provide accurate position reports to aid the controller in determining an aircraft’s location in such conditions.
A-24-12 to the FAA: Brief all air traffic controllers about the circumstances of this incident, emphasizing the effect that certain conditions might have on a pilot’s ability to begin a takeoff in a timely manner, including
- low-visibility weather conditions, such as fog;
- ambient conditions, such as temperature; and
- surface conditions, such as ice, snow, and other precipitation, as noted in Order 7110.65, Air Traffic Control, paragraph 5-8-4, Departure and Arrival.
A-24-13 to the FAA: Amend the Aeronautical Information Manual so that it instructs pilots to inform controllers, before entering an active runway with the intent to depart, when they need time on the runway for any reason before beginning the takeoff roll.
A-24-14 to the FAA: Require all airports with a Surface Movement Guidance and Control System plan to ensure that their plans and the associated letters of agreement correspond with each other and the stakeholder duties and responsibilities described in Advisory Circular 120-57, Surface Movement Guidance and Control System.
A-24-15 to the FAA: Direct training administrators at airports with a Surface Movement Guidance and Control System plan to require initial and annual refresher training for all stakeholders, including air traffic controllers and airport operations personnel, on the information in the airport’s plan.
A-24-16 to the FAA: Require training administrators at all operating air traffic control towers to conduct annual refresher training on low-visibility operations.
Updated August 22, 2024
