United Airlines Flight 384

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset