United B39M at Pittsburgh on Jun 21st 2022, landed on wrong runway

Last Update: August 3, 2023 / 19:30:29 GMT/Zulu time

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Incident Facts

Date of incident
Jun 21, 2022

Classification
Incident

Airline
United

Flight number
UA-2627

Departure
Chicago O'Hare, United States

Destination
Pittsburgh, United States

Aircraft Registration
N37513

Aircraft Type
Boeing 737-900MAX

ICAO Type Designator
B39M

A United Boeing 737-9 Max, registration N37513 performing flight UA-2627 from Chicago O'Hare,IL to Pittsburgh,PA (USA) with 168 passengers and 6 crew, was cleared for a visual approach and was cleared to land on Pittsburgh's runway 28C, however, lined up with runway 28L and continued for a landing on runway 28L. There were no injuries and no damage.

The NTSB opened an investigation into the occurrence. The NTSB wrote:

Upon initial contact with PIT approach control, the flight crew was told to expect a visual approach to runway 32 into PIT. The flight crew briefed the new approach and proceeded to load the ILS 32 approach into the FMC to back up the visual approach.

While being radar vectored on the downwind and descending through about 4,000 feet Mean Sea level (msl), the flight crew indicated that they had a check landing altitude message displayed briefly on the FMC. After the message disappeared and with the autopilot engaged, the aircraft reverted to control wheel steering pitch mode. They selected level change and reselected the autopilot to command mode.

The airplane began its descent at about 0918 EDT, and as they were descending, approach control asked them if they could accept a visual approach to runway 28C. The weather was clear, and the winds were 250 degrees at 4 knots, so they accepted the runway change. The first officer then re-programmed the FMC for the RNAV GPS Y 28C to back up the visual approach.

The flight crew established communication with the local controller when the airplane was approximately 6. 5 miles east of the airport. They crew advised the controller they were on a visual approach to Runway 28C, to which the controller cleared them to land on Runway 28C. According to the captain, approximately 2 miles from SUPPR, on an intercept heading and while descending, “the screen was black, both FMC’s blanked” except for the aircraft communications, addressing and reporting system (ACARS) prompt and no FMC prompt. The captain used heading select and level change on the mode control panel (MCP). However, when the airplane joined an approximate 6-mile final, it was aligned with Runway 28L.

When the airplane was approximately on a 2-mile final and still aligned with Runway 28L, the flight crew requested verification of their clearance to land on Runway 28C. The controller advised the flight crew of mowing in progress in the grass area and cleared them to land on Runway 28C.

The flight crew read back their clearance to land on Runway 28C.

About 0944 EDT, the airplane landed on runway 28L, turned right off the runway, and exited runway 28L at taxiway F5. The controller noticed the airplane was lined up for runway 28L when it was on short final but decided that it was more appropriate to allow the airplane to land given their altitude. The facility reported that the traffic volume was light with routine complexity. The distance from the airport traffic control tower to the runway 28C threshold was approximately 7,500 feet.

On Aug 3rd 2023 the NTSB released their final report concluding the probable causes of the incident were:

The flightcrew’s misidentification of the intended landing runway, which resulted in approach to and landing on the wrong runway. Contributing to the incident was the distraction caused by the dual reset of the flight management computer displays.

The NTSB analysed:

This analysis discusses the incorrect runway landing at Pittsburgh International Airport involving United Airlines flight 2627. The airplane had been cleared to land on runway 28C, but the flight crew aligned the airplane with and landed on parallel runway 28L.

The flight crewmembers reported that, before beginning the descent into the terminal area, the first officer (the pilot monitoring) programmed the flight management computer (FMC) for the area navigation (RNAV) approach to runway 28C. During the descent, the crew was instructed twice by PIT approach control to change the landing runway. The crew was first instructed to expect a visual approach to runway 32; a short time later, the crew was provided vectors for the visual approach to runway 28C.

Once on the base leg of the approach, the crew reported that the airport was in sight, and the controller cleared the airplane for the visual approach to runway 28C. The captain (the pilot flying) stated he visually acquired the precision approach path indicator (PAPI) lights. Runways 28C and 28L both had PAPI lights located on the left side of the respective runway. The captain stated that he observed one set of PAPI lights, which he thought were associated with runway 28C.

The captain requested that the first officer extend the centerline of the approach from the next waypoint, at which time the first officer reported that both FMC control display units had blanked, taking away the backup lateral and vertical navigational guidance to runway 28C.

Although the PAPI lights provided vertical guidance, the first officer attempted to diagnose and restore the FMC's lateral guidance, which created a distraction at a critical phase of the flight that reduced the crew’s opportunity to ensure correct runway alignment. A postincident review of FMC data showed that the FMCs experienced a dual reset when the airplane was at an altitude of about 4,000 ft (3,350 ft above ground level). The FMCs rebooted and began transmitting valid data 23 seconds later when the airplane was about 3,128 ft above ground level, about 4 minutes away from touchdown.

While on final approach, the crew requested that the controller confirm that the airplane was cleared to land on runway 28C; the controller provided this confirmation. However, at some point afterward, the controller observed that the airplane was aligned with runway 28L. After verifying that no conflicting traffic existed, the controller decided to allow the flight to continue and land on runway 28L rather than issue a go-around instruction at a low altitude. This flexibility is permitted by Federal Aviation Administration Order 7110.65Z, which allows controllers to exercise their best judgment if they encounter situations not covered by the order. The flight crew subsequently aligned the airplane with and landed on parallel runway 28L, which was located about 1,200 ft to the left of intended runway 28C. Because runway 28L and runway 28C were closely located, it would have been challenging for the controller to have visually detected the misalignment.

The crew stated that, after the airplane landed, the first officer rechecked the automatic terminal information service broadcast, and they thought that it indicated that the PAPI lights for runway 28L were out of service. However, a review of the broadcast revealed that the PAPI lights for runway 10L were out of service.

The dual FMC reset was due to an issue with the system’s software, which was known before the incident. A fix was identified and released about 1 month before the incident. The dual blanking of the FMC control display units did not cause the flight crew to align the airplane with and land on the wrong runway given that the airplane was operating in visual meteorological conditions and the flight was cleared for the visual approach to runway 28C.

Although the incident airplane had a runway awareness and advisory system (RAAS) installed in the cockpit, the operator did not select the option to provide crews with an aural alert for the runway that the airplane would be approaching in flight. If the operator had selected this option, the system would have alerted the incident flight crew that the airplane was aligned with a runway that was not consistent with the landing clearance provided by air traffic control, which might have precluded the wrong runway landing.
Aircraft Registration Data
Registration mark
N37513
Country of Registration
United States
Date of Registration
Lch hmijbqjmlnmfk Subscribe to unlock
Manufacturer
BOEING
Aircraft Model / Type
737-9
Number of Seats
Mh Subscribe to unlock
ICAO Aircraft Type
B39M
Year of Manufacture
Kmkp Subscribe to unlock
Serial Number
Hpgcb Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
CdkedA Subscribe to unlock
Engine Count
F Subscribe to unlock
Engine Manufacturer
MchmAkkq Subscribe to unlock
Engine Model
AkAfpbjcjffAb Subscribe to unlock
Engine Type
H dcmehi Subscribe to unlock
Pounds of Thrust
meqb Subscribe to unlock
Main Owner
NfkmikbhbmAnpccglhkfemAp cAkngimkg jjfklkejnqj AdilbeghdqAgcnphielflhidi Subscribe to unlock
Incident Facts

Date of incident
Jun 21, 2022

Classification
Incident

Airline
United

Flight number
UA-2627

Departure
Chicago O'Hare, United States

Destination
Pittsburgh, United States

Aircraft Registration
N37513

Aircraft Type
Boeing 737-900MAX

ICAO Type Designator
B39M

This article is published under license from Avherald.com. © of text by Avherald.com.
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