AINsight: State of (Runway) Confusion

 - August 27, 2021, 12:24 PM

Pilots attempting to take off or land on the wrong surface is a serious threat to flight safety. These “runway confusion” events often involve multi-crew transport-category aircraft, with pilots lining up their aircraft for takeoff or landing on either a taxiway or the wrong runway.

The most recent event involved a Turkish Airlines Airbus A330-300 at New Jersey’s Newark International Airport (KEWR). Shortly after midnight on August 7, the airliner was cleared to take off from Runway 22R at the intersection of Taxiway W.

Rather than turning onto Runway 22R, the crew taxied across the runway and turned onto Taxiway P, which parallels Runway 22R to the east, and began its takeoff roll. The air traffic controller canceled the takeoff clearance, and the aircraft rejected its takeoff at approximately 90 knots. The aircraft slowed to its taxi speed after traveling roughly 4,600 feet down the taxiway.

Runway confusion events are often precursors of a runway incursion and potential collision between aircraft, airport vehicles, or construction equipment. Each of these events is complex and has multiple contributing factors that include human, environmental, and technical elements. Fortunately, there are also many opportunities to mitigate this risk. In the case of the KEWR event, an alert controller—and light traffic—averted a potential disaster at one of the busiest U.S. airports.

Two of the most notable runway confusion events involved one airliner attempting to land on a taxiway in San Francisco (KSFO) and a regional jet at Blue Grass Airport (KLEX) in Lexington, Kentucky, that departed the wrong—and too short—runway. The latter killed 49 people and seriously injured the first officer, the sole survivor of the accident.

The FAA classified the KSFO attempted landing event as an “extreme example of [an] incorrect surface approach and landing.” During this July 2017 incident, an Air Canada Airbus A320 conducting a visual approach to Runway 28R misidentified Taxiway C as the runway and overflew four airliners sitting on the taxiway. Runway 28L was closed and unlit.

A crewmember on one of the waiting airliners identified the misalignment of the approaching jet and made a radio broadcast that the aircraft was “on the taxiway.” The Air Canada flight crew then initiated a go-around after descending within 14 feet of one of the airliners on the taxiway.

This was a serious event. A collision involving five commercial airliners would potentially be ranked as the deadliest air disaster in history. The investigation cited the flight crew’s lack of awareness of the Runway 28L closure (“It was buried in the notams,” they said), fatigue, and the pilot’s failure to tune in the ILS frequency as factors contributing to this incident.  

Since the KSFO incident, the FAA published Safety Alert of Operators (SAFO) 17010, “Incorrect Airport Surface Approach and Landings,” which offers some best practices to prevent such events. These best practices include a stabilized approach, using technology to support the most precise approach available, and a great discussion on CRM, pilot monitoring skills, and the need to go around when there is any doubt.

Unlike the KEWR or KSFO runway confusion events, the passengers and crew of Comair Flight 5191 were not as lucky. In August 2006, a Bombardier CRJ-100ER inadvertently departed Runway 26—3,500 feet takeoff distance available—at KLEX. Air traffic control cleared the aircraft to take off from Runway 22 (7,003 feet takeoff distance available). The taxiway from the terminal led to both Runways 26 and 22; the first runway encountered was Runway 26, which was shorter, narrower, and unlit.

After rotation, the regional jet became airborne momentarily after striking a berm and crashing into trees on the airport property. The aircraft was destroyed, killing 47 passengers and 2 crewmembers.

Following its investigation, the NTSB determined that the probable cause of the accident was the “flight crewmembers' failure to use available cues and aids to identify the airplane's location on the airport surface during taxi and their failure to cross-check and verify that the airplane was on the correct runway before takeoff. Contributing to the accident were the flight crew's non-pertinent conversations during taxi, which resulted in a loss of positional awareness.”

After the Comair accident, the FAA commissioned a study on wrong runway departures. Contributing factors related primarily to human and environmental elements. The top human elements were related to poor CRM skills, procedural issues, human factors, communications and managing distractions, interruptions, and time pressures. Top environmental elements were primarily associated with airport design issues (airport configuration, signage, lighting, markings, and complexity) and weather.

Pilots operate, at times, in a wildly complex operational environment chock full of distractions and interruptions. Toss in poor lighting conditions, weather, and other fun stuff like fatigue or language barriers and it becomes easier to understand why a flight crew might line up on the wrong surface.

Most training programs do not account for these realities and do little to promote resiliency—the ability to recover and return to standard ops.

Before departure, a lot of the risk can be mitigated by preflight preparation that includes familiarization with the airport (such as taxiways and departure procedures) and applicable notams. As an observation, pilots tend to over-brief items related to the arrival and approach and under-brief the taxi plan and departure procedures.

Many taxi charts highlight runway “hot spots” where there is a potential for a runway incursion, but pilots rarely step back and discuss why it is one. As an example, “HS-1” at Salt Lake City (KSLC – chart 10-9) is a similar set-up to the Comair accident—a single taxiway (Taxiway M) leads to the threshold of two different runways (Runways 32 and 35). Likewise, when you get to the runway, it may be useful to have looked at the 10-9A chart and review the runway lighting—for instance, does it have centerline lighting?

Preflight preparation and briefing are all part of a strategic plan. To account for changes, flight crews must be flexible and adapt those plans, but also have some tactical plans up their sleeves. Consider one of the widely used best practices that came out of the Comair accident—the runway verification procedure or runway heading check. The procedure goes like this: the captain verifies the runway signage, markings, and orientation, and the first officer verifies the runway markings and heading.

Yes, it is a good procedure, but it could be better. Consider the Turkish Airlines event at EWR involving an intersection takeoff at night. Using the same procedures as described above would have resulted in the exact same outcome—the aircraft would attempt to take off from a taxiway.

Departing from the intersection of Runway 22R and Taxiway W (located in the displaced threshold) would have the aircraft physically located roughly 900 feet before the Runway 22R markings. Likewise, the runway heading check (while on the parallel Taxiway P) would have revealed the exact same heading as Runway 22R—219-degrees magnetic.

In this example, as well as the Comair accident, it would be worthwhile to pause on the runway and observe the lighting—runway edge lights should be white, it has centerline lighting, and so on. If for some reason, there are blue taxiway lights (KEWR) or no lights (KLEX), there might be a problem.

In addition to solid training and procedures, the use of technology is another way to mitigate the risk of runway confusion events. Many electronic flight bag applications now can display own-ship position on an airport moving map. In the FAA study on wrong runway takeoffs, own-ship position was rated as one of the most effective tools to eliminate runway confusion.

Likewise, tools such as Honeywell’s Runway Awareness and Advisory System (RAAS) or Smart Landing systems would have likely alerted the flight crews in each of these events.

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached at