United B772 at Honolulu on Jan 23rd 2023, runway incursion

Last Update: February 26, 2025 / 21:23:17 GMT/Zulu time

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Incident Facts

Date of incident
Jan 23, 2023

Classification
Incident

Cause
Runway incursion

Airline
United

Flight number
UA-384

Departure
Denver, United States

Destination
Honolulu, United States

Aircraft Registration
N774UA

Aircraft Type
Boeing 777-200

ICAO Type Designator
B772

Airport
Honolulu International Airport, Honolulu

Airport ICAO Code
PHNL

A United Boeing 777-200, registration N774UA performing flight UA-384 from Denver,CO to Honolulu,HI (USA), had landed on Honolulu's runway 04R and was instructed to hold short of runway 04L, the crew correctly read back that instruction. The crew vacated runway 04R via high speed turn off K and went past the hold short line runway 04L and runway 08L, tower instructed the crew to continue cross runway 08L and contact ground. On ground the crew was instructed to call a tower phone number.

A Kamaka Air Cessna 208 performing a scheduled flight from Lihue,HI to Honolulu,HI (USA), was landing on runway 04L at that time, touched down, slowed and vacated the runway via taxiway E about 360 meters/1200 feet short of the intersection of runway 04L, runway 08L and taxiway K.

On Feb 16th 2023 the NTSB reported: "NTSB investigating Jan. 23 runway incursion at Honolulu Int'l Airport that occurred when a United Boeing 777 crossed runway 4L and conflicted with Cessna 208B that was landing on runway 4L. No damage or injuries reported."

On Feb 26th 2025 the NTSB released their final report concluding the probable causes of the incident were:

The airport’s continued use of taxiway Kilo, despite an identified risk of pilots repeatedly failing to stop at a hold short line prior to two intersecting runways. Contributing were 1) the operator’s moving map display, which omitted a published restriction on the use of taxiway Kilo for widebody airplanes, 2) the Captain’s resulting inadvertent continuance through the hold-short line, and 3) the FAA’s delayed action to remediate the airport’s legacy design, which did not conform with current airport design standards.

The NTSB analysed:

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.

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.





Metars:
PHNL 240353Z 23009KT 10SM FEW023 SCT034 BKN055 27/19 A2998 RMK AO2 SLP152 SHRA DSNT NW T02670189=
PHNL 240253Z 22009KT 10SM FEW022 FEW035 SCT050 27/19 A2997 RMK AO2 SLP149 VCSH NW AND N TCU DSIPTD T02720194 55001=
PHNL 240153Z 21010KT 10SM FEW023TCU FEW035 SCT050 28/20 A2997 RMK AO2 SLP147 VC TCU NE VCSH NW AND N-NE T02780200=
PHNL 240053Z 21009KT 10SM FEW023 FEW035 SCT070 28/21 A2997 RMK AO2 SLP147 T02780211=
PHNL 232353Z 22009KT 10SM FEW026 FEW035 SCT070 27/21 A2998 RMK AO2 SLP150 T02720206 10283 20217 56022=
PHNL 232253Z 20009KT 10SM FEW025 FEW038 28/19 A3000 RMK AO2 SLP157 T02780194=
Aircraft Registration Data
Registration mark
N774UA
Country of Registration
United States
Date of Registration
bjAqplkkqkiq Subscribe to unlock
Manufacturer
BOEING
Aircraft Model / Type
777-222
Number of Seats
ln Subscribe to unlock
ICAO Aircraft Type
B772
Year of Manufacture
Qhjd Subscribe to unlock
Serial Number
J cfq Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
Piig m Subscribe to unlock
Engine Count
Subscribe to unlock
Engine Manufacturer
Bbdkm be Subscribe to unlock
Engine Model
Jbqnl dkkki Subscribe to unlock
Main Owner
Qjcdh iAl cdkmhkjleiehmkpdceqhAkjbcjjdefkAnddffnc dbjpdcn dgie ifqqpjlhdfkfi pdmpAbbigljjfjlfAbiipgdf Subscribe to unlock
Incident Facts

Date of incident
Jan 23, 2023

Classification
Incident

Cause
Runway incursion

Airline
United

Flight number
UA-384

Departure
Denver, United States

Destination
Honolulu, United States

Aircraft Registration
N774UA

Aircraft Type
Boeing 777-200

ICAO Type Designator
B772

Airport
Honolulu International Airport, Honolulu

Airport ICAO Code
PHNL

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