– NTSB issues the preliminary report for 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:
On January 23, 2023, about 1611 Hawaii standard time (HST), a runway incursion occurred at the Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii, when United Airlines flight 384 (UAL384), a Boeing 777-200, crossed runway 4L and conflicted with a Kamaka Air flight 145 (KMK145), a Cessna 208B, which was landing on runway 4L; the closest proximity between the two airplanes was 1,173 feet. There were no injuries to the 291 passengers and 10 crew onboard UAL384 or to the 2 crew members onboard KMK145. Neither aircraft was damaged. UAL384 was a regularly scheduled domestic passenger flight operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 from the Denver International Airport (DEN), Denver, Colorado, to HNL. KMK145 was a domestic cargo flight operating under the provisions of 14 CFR Part 135 from the Lihue Airport (LIH), Lihue, Hawaii, to HNL. Daytime visual meteorological conditions prevailed at the time of the incident.
According to the flight crew of UAL384, the taxi, takeoff, departure, and cruise phases of flight 384 were uneventful. The first officer (FO) was the pilot flying, and the captain (CA) was the pilot monitoring (PM). Approximately 80 miles from their planned top-of-descent point, they began to set up for their planned arrival and approach. After they obtained and reviewed the automatic terminal information service (ATIS), company notes, notice to air mission (NOTAMs), and their arrival, landing, and taxi diagrams, they set up the airplane for the arrival and approach. The crew noted that there was construction ongoing at HNL which rendered runway 8L unavailable for landing traffic. Their company notes indicated that B777 aircraft were not allowed to perform land and hold short operations (LAHSO) 8L/26R on runway 4R.
The UAL384 flight crew indicated that before descent, they briefed their planned approach as the RNAV (GPS) to runway 8R. They also retrieved the landing data for both runways 8R and 4R, in case of last-minute re-assignment by arrival or approach control. Their plan was to fly the RNAV approach with landing flaps 25, autobrakes set to level 2, and land on runway 8R with an exit plan to turn left on taxiway R5. If the plan changed to 4R, they would change the plan to flaps 30 and autobrakes 3.
The FO indicated that she initially briefed the taxi to the gate and hot spot at taxiway K prior to descent in case they were given the approach to runway 4R. The hot spot stated, “Aircraft landing runway 4R, and exiting left on taxiway K, sometimes fail to hold short of runway 4L and runway 8L.” She also briefed the taxi plan for runway 8R, then as a backup, she reviewed the landing plan for runway 4R and briefed that they could either taxi down to the end, or possibly exit at taxiway K.
The CA of UAL384 indicated that after leveling at flight level 230, the Honolulu Control Facility (HCF) directed them to proceed direct to the waypoint BAMBO at 10,000 feet MSL. Shortly afterward, the crew switched frequencies to HNL approach control and checked in stating they had the current ATIS. HNL approach control gave them a heading of 220 degrees and told them to expect a visual approach to runway 4R. The flight crew advised approach control that they would plan on that approach and that they were unable to conduct LAHSO.
The FO began the descent and reviewed and loaded the approach to runway 4R into the flight management computer (FMC). She indicated that she changed the landing flap setting from 25 to 30 and changed the autobrake setting from 2 to 3. She briefed the approach and reviewed the exit plan from runway 4R as either rolling to the end or, if speed permitted, a left turn on taxiway “K”.
Information obtained by the NTSB air traffic control (ATC) group indicated that about 1606 HST, UAL384 reported in with the Honolulu control tower and indicated that they were at 1,500 feet, 4 miles from waypoint PERLY, and were planning on landing on runway 4R. The local controller (LC) provided UAL384 with wind information and cleared them to land on runway 4R.
About the same time, the pilot of the KMK145 reported they were descending to 1,500 feet for landing on runway 4L. The LC instructed the pilot to continue to runway 4L and stated that traffic was a heavy Boeing 777 landing on runway 4R. The pilot responded that they were continuing to 4L, they had the traffic in sight, and they would be parking on the north ramp. The LC instructed the KMK145 pilot to maintain visual separation from the Boeing 777, cautioned him about wake turbulence, and that he was cleared to land on runway 4L. The pilot correctly read back all three instructions from the LC.
About 1608, the LC advised UAL384 that a Caravan was on their left, downwind of them and to maintain visual separation. UAL384 acknowledged this and asked for confirmation they were cleared to land runway 4R. The LC confirmed their landing clearance for runway 4R.
The FO indicated that she landed the aircraft on runway 4R, activated the thrust reversers, and began manual braking at approximately 110 knots. As the airplane approached 80 knots, the CA made the 80-knot callout, and the FO stowed the thrust reversers and slowed the aircraft to below 35 knots.
At this time, the FO offered to transfer control of the aircraft to the captain as briefed, and the captain took control and then used his tiller to begin a left turn onto taxiway K. Information obtained by the ATC group indicated that about 1609, the LC asked UAL384 if they “got Kilo?” UAL384 responded, “turn left on Kilo”. The LC instructed UAL384 to hold short of runway 4L and UAL384 acknowledged the hold short request.
The CA indicated that he was surprised by the hold short instruction since he had told approach control that they were unable to conduct LAHSO on runway 4R. He indicated that he lost situational awareness as they exited runway 4R as he thought there was more distance between the runways than there actually was. He was concerned about getting clear of the landing runway and was focused on clearing the hold short line between runway 4R and taxiway K.
The CA also indicated that there doesn’t appear to be enough room for a 210’ long B777 to be fully clear of runway 4R and still hold short of runway 4L and by the time he realized they were passing the runway 4R hold bars painted on the taxiway they were already on runway 8L and had crossed onto runway 4L.
At this time, the tower controller became aware of the runway incursion as UAL384 crossed runway 4L and responded by instructing the pilots of KMK145 to hold short of runway 8L, which they did. The pilot of KMK145 in a phone interview stated that they “normally” exit at taxiway E which was prior to runway 8L, which they did, and that no evasive action was needed or taken.
About 1610, the LC instructed UAL384 to continue to cross runway 8L and contact ground control. UAL384 contacted ground control stating they were clear of runway 4L at taxiway K and going to gate G4. Ground control gave them instructions to taxi on taxiway K, turn left on taxiway Z, and proceed to gate G4.
Figure 1 is a Google Earth screenshot which is overlaid with the ground tracks of UAL384 and KMK145 (indicated with green arrows). The illustration depicts runways 4L, 4R, 8L and taxiway K, and shows the direction of travel for each airplane.
Upon notification, the following NTSB specialists were assigned to investigate this incident: operations, ATC, and flight data recorder. Parties to the investigation include the Federal Aviation Administration (FAA), United Airlines, Boeing, and the National Air Traffic Controllers Association (NATCA).
The digital flight data recorder (DFDR) was removed from the United airplane and shipped to the NTSB’s Vehicle Recorder Laboratory located in Washington, DC, for a download of data. The DFDR was downloaded on February 14, 2023, and the data is currently being analyzed.
During the week of February 6th, 2023, the ATC group convened at Honolulu Control Facility (HCF), Honolulu, HI, and conducted interviews with the controllers on duty at the time of the incident, operations supervisor, and air traffic manager.