Honolulu, HI, USA
N269ME
CESSNA 172S
N865MA
CESSNA 208B
Runway 22 left/right and 26 left/right were being used for arrivals and departures. The pilot of N269ME was instructed to LUAW on runway 22 left at taxiway P. The LUAW instruction was issued instead of a takeoff clearance because Delta flight 837 was on approach to runway 26 left and could have conflicted with an aircraft departing runway 22 left. The local control 1 (LC1) controller had put three aircraft in line up and wait (LUAW); two on runway 26R and one on runway 22L. Delta flight 837 (DAL837) had landed on runway 26 left and the pilot required additional taxi information to navigate from the runway to the terminal. The location of DAL837 and the taxi route were not in the local controller's traditional field of view but rather behind the controller and more than a mile from the tower cab. Shortly after providing detailed taxi instructions to DAL837, the controller instructed the pilot of Kaleo 1535 to turn inbound, land beyond the intersection of runway 22 left and 26 right and cleared the pilot to land on runway 22 left. The pilot acknowledged runway 22 left. The LC1 was then attending to other traffic issues when the Airport Surface Detection System, Model-X (ASDE-X) alarmed indicating a conflict on runway 22 left where N269ME was in LUAW at the intersection of taxiway P. Kaleo 1535 had crossed the landing threshold of runway 22 left when the LC1 issued go around instructions. Kaleo 1535 initiated a go around and overflew N269ME. The vertical separation was estimated to be within 100 feet. The LC was working the local control 1 (LC1) and local control 2 (LC2) positions combined at the LC1 position. He had three aircraft in LUAW simultaneously and was focused on runway 26 right and 22 right where the three aircraft were LUAW. Services provided to additional aircraft increased workload and created a distraction to the LC1 traffic management/planning actions. The LC1 forgot that he had an aircraft in LUAW on runway 22 left and cleared the Kaleo 1535 flight to land on runway 22 left. The location and orientation of the LC1 position in the tower created a challenge for the LC1 controller when the LC1 and LC2 positions were combined in the tower in that the controller was responsible for areas of the airport he/she could not readily observe and deconflict. The assisting controllers in the tower, the controller-in-charge and the local assistant were otherwise occupied and did not assist the LC1.
On Friday, February 26, 2016 at 1548 Hawaii standard time (HST), a runway incursion occurred on runway 22L at Honolulu International Airport (HNL), Honolulu, Hawaii, when N865MA, a Cessna 208B, overflew N269ME, a Cessna 172, in line up and wait (LUAW) on runway 22L at the taxiway P intersection. The Cessna 208B, registered to Schuman Aviation Company, Limited, Honolulu, Hawaii, was operating as KDS (Kaleo) 1535. The C208B was operating as a single piloted 14 Code of Federal Regulations (CFR), Part 135 scheduled air charter operating from Molokai to HNL with 9 passengers. The C172S was operating under 14 CFR Part 91 as a Georges Aviation Services flight school aircraft based at HNL. Visual meteorological conditions prevailed and there were no injuries to passengers or crew of either aircraft. The HNL local controller (LC) instructed the C172S to LUAW on runway 22L approximately 4 minutes before the C208B was issued a clearance to land on runway 22L. When the C208B was on short final, the airport surface detection equipment, model X (ASDE-X) alarmed indicating a conflict, and the controller instructed the C208B to go around after the C208B had crossed the landing threshold of runway 22L. This resulted in the C208B overflying the C172S in position on the runway. The vertical proximity between the two aircraft was less than 100 feet. The airport was operating with runways 22 left and right and runways 26 left and right in use. This runway configuration occurred approximately 10% of the time at HNL and was considered a non-standard runway configuration. Normal runway configuration was runways 4 left and right and runways 8 left and right. At 1544:30, the HNL LC instructed the pilot of Cessna N269ME to LUAW on runway 22L at the intersection of taxiway P. No traffic advisories were issued to the pilot. The local controller providing services stated during an interview that the Cessna 172 was put into LUAW due to conflicting arriving traffic to runway 26L and other traffic in the tower pattern. At 1544:40 the LC instructed the pilot of an AT72, to LUAW on runway 26 right at the intersection of taxiway E, after which he instructed the pilot of a heavy B767, to cross runway 26 right at the intersection of taxiway S advising the B767 pilot that traffic was holding (on runway 26 right) upfield. At 1545:03 the LC instructed the pilot of a B757, to LUAW on runway 26 right (at the approach end). There were three aircraft in LUAW, two on runway 26R and one on runway 22L. After clearing a helicopter to proceed inbound between runways 26 right and 26 left, directing the pilot of a departing aircraft to change to departure control frequency, and providing taxi and holding instructions to the pilot of an arriving Air Force KC-135, the LC cleared the AT72 for takeoff from runway 26 right at the intersection of taxiway E. At 1545:48 the LC instructed the pilot of Kaleo 1535 to continue for runway 22 right and advised of traffic departing runway 26 right. The pilot of Kaleo 1535 acknowledged the LC with "Kaleo fifteen thirty-five, two two right". The LC repeated to the pilot of Kaleo 1535 to continue for runway 22 right, traffic departing runway 26 right. The pilot of Kaleo 1535 acknowledged runway 22 right. At 1546:14 the LC instructed the pilot of Delta flight 837, a heavy Airbus A-330-300 that had just landed on runway 26 left, to "turn right at romeo mike, romeo alpha, romeo bravo, bravo, hold short two six right at sierra". The pilot of Delta 837 responded with "okay, uh Delta eight thirty-seven uh heavy understand right at romeo mike, romeo alpha, and then a left at romeo alpha romeo bravo short of eight left?" The LC responded with "Delta eight thirty-seven heavy hold short of runway two six right at sierra". The pilot responded with "okay hold short of two six right at sierra for Delta eight thirty-seven heavy we're going Romeo mike, romeo alpha romeo um bravo was it?" At 1546:53 the LC instructed the pilot of Moku 36, the AT72 that had previously departed runway 26 right, to turn left heading 180 [degrees]. The pilot of Moku 36 acknowledged. The LC then cleared Delta 1434, in LUAW at the approach end of runway 26 right, for takeoff. The pilot of Delta 1434 acknowledged runway 26 right. At 1547:10 the LC transmitted to Delta 837 "Delta eight thirty-seven heavy, it's gonna be romeo alpha to romeo bravo with a right turn on bravo holding short of runway two six right at sierra". The pilot of Delta 837 responded with "okay we copy that romeo mike, romeo alpha, romeo bravo, right on bravo hold short two six right at sierra, Delta eight three seven". At 1547:25 the LC instructed the pilot of Kaleo 1535 to "turn inbound, land beyond the intersection runway two two left, cleared to land". The pilot of Kaleo 1535 responded with "two two left cleared to land and beyond the intersection Kaleo fifteen thirty-five". The LC then transmitted "Delta thirty-six heading 180, contact departure", followed by "Hawaiian two eight seven, Honolulu tower runway two six left cleared to land." The pilot of Hawaiian 287 responded with "cleared to land two six left Hawaiian two eight seven." The controller then asked the pilot of Hawaiian 287 if he wanted [to land] runway 26 right. The pilot responded with "oh yea I'll take it". The LC responded with "keep your speed up, change to two six right, cleared to land Hawaiian two eighty-seven" The pilot responded, "two six right, Hawaiian two eighty-seven". At 1548:02 the LC instructed the pilot of recently arrived Air Force KC-135, that was holding short of runway 26R at the intersection of taxiway T, to cross runway 26 right at taxiway T and contact Hickam on frequency 133.6 and to cross with no delay. The pilot of the KC-135 acknowledged. At 1548:23 the LC instructed the pilot of Delta 1434 to contact departure heading 200 [degrees]. The pilot acknowledged. At 1548:26, the LC instructed Kaleo 1535 to go around. The pilot of Kaleo 1535 acknowledged. The LC then instructed the pilot of Kaleo 1535 to make right traffic for runway 22 right. The pilot acknowledged. At 1549:35 the LC cleared the pilot of N269ME for takeoff from runway 22 left at the intersection of taxiway P. ?
The air traffic controller's decision to clear an aircraft to land on a runway occupied by another aircraft that had previously been instructed to line up and wait. Contributing to the runway incursion was the failure of the air traffic controller to visually scan the landing surface prior to issuing a clearance to land and failure of the assisting controllers to monitor and assist the local controller with the developing situation.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
