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ASRS Directline Summer 1992 15
MultipleFactors
Incidents reported to the ASRS are seldom the
result of a single factor. Reviewing the details of
runway incursion narratives reveals a complex
matrix of interrelated causes. Pilot and controller
mistakes may be combined factors in an incident,
or perhaps distraction on the flight deck coupled
with reduced visibility and inadequate airport
signage could be cited. In an effort to reduce this
intricate mass of information to digestible classifications,
this article will examine causal factors
under three main topic areas:
A. Airport Practices and Configurations,
B. Flight Crew Errors, and
C. Controller Errors.
A. AIRPORT PRACTICES and
CONFIGURATIONS
As might be expected, the majority of events took
place at major terminals with complex taxiway
layouts and multi-runway operations. Incidents
were grouped according to three differing classifications:
Intersecting Runways, Parallel
Runways, and Runway Configuration No
Factor.
Configuration
Intersecting Runways
The Intersecting Runways
classification specifies multiple,
intersecting, active runways in
use (simultaneous landing and
departure operations on crossing
runways). This category
accounted for the largest
number of ground conflicts.
Frequently and vigorously,
pilots voiced
serious concern about
the practice of
simultaneous operations on intersecting
runways. In such instances, flight crews are
commonly advised — by ATIS or by controller
restriction — to hold short of the intersecting
runway upon landing.
The Hazards of “Hold Short of the Runway” Instructions
Flight crews either accepted the mandatory
restriction, or were advised “if unable, expect a
go around.” “Intimidation,” fumes one indignant
reporter. Two pilots, unwilling to accept the
limited landing distances, were circled around
for second approaches.
Examination of the report set confirmed the
flight crews’ unease with “hold-short-of …”
instructions to landing aircraft. A number of
aircraft committed an active-runway incursion
during roll-out. The explanations were varied:
operationally, pilots “floated,” “tried to make a
smooth landing,” came in “slightly high,” and/or
“[were] … concerned with a smooth deceleration.”
Combining distraction and communication
factors with intersecting runways, pilots “forgot”
the hold short restriction, “did not hear” the
transmission when issued during reversing, or
became confused as to “where the crossing
runway actually was.” Another pilot “failed to
consider” the reduced landing distance remaining
available on the runway. Go-arounds, high
speed aborts, and critical near collisions resulted
from the intersecting runway transgressions.
“We were cleared for takeoff on Runway 28
with landing traffic on [Runway] 33; the
landing traffic was a single engine light
[aircraft] instructed ‘cleared to land 33, hold
short of Runway 28.’ The [light aircraft] was
going to land too long to hold short of 28, so
he self-initiated a go-around as we were midfield
[on the] Runway 28 takeoff roll. The
[pilot of the light aircraft] was instructed to
make a left turn to avoid our flight path —
which he did … landing clearances that
stipulate hold short of intersecting Runway
instructions are dangerous.”
In another incident, one flight crew landing in
poor visibility caused an abort as they continued
through the intersection, then caused a second
abort as they taxied onto a parallel runway.
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22
34
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16 Summer 1992 ASRS Directline
Parallel Runways
Differing from the “Intersecting” category, the
Parallel Runways classification includes those
incidents where an aircraft exiting a runway
after landing, inadvertently penetrates or
crosses an active parallel runway. At many
airports parallel runways may be very close
together — with minimum
distance between. This category ranked second
in the number of conflicts.
“We were not mentally ready to stop so quickly
after clearing the runway,” explained one
pilot. “The runways are so close,” noted
another reporter, “that you no sooner land
and stop and you are right up to an active
runway.”
Another pilot, landing in reduced visibility
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