United 1448 Runway Incursion

Sometimes it is good to revisit old material such as this famous runway incursion.  Here is some data I found on it recently.

From the NTSB Board Meeting of June 13, 2000:

On December 6, 1999, at about 8:35 p.m., United Airlines flight 1448, a Boeing 757, was involved in a runway incursion on runway 5 Right at Theodore Francis Green State Airport, near Providence, Rhode Island. At the time of the incident, it was dark and the reported visibility was one-quarter mile.

After United 1448 landed on runway 5 Right, the tower controller instructed the flight crew to proceed to the terminal using taxiways November and Tango, and report crossing runway 16.

During their taxi in the fog, the flight crew became disoriented and turned onto taxiway Bravo by mistake. They then provided incorrect position reports to the tower controller. The airplane ended up at the intersection of Runway 16 and Runway 23 left. Note that Runways 23 Left and 5 Right are opposite ends of the same runway.

Shortly afterward, a Federal Express aircraft taking off from runway 5 Right passed very close to United 1448. The subsequent conversation between the tower controller and United 1448 shows continued uncertainty about the aircraft’s position. For example, there will be several references to Runway 23 right while the airplane is actually on 23 left.

Anybody who’s ever taxied an airplane in low visibility knows that situational awareness is critical. In most cases, radio communication is the only way air traffic control can positively identify an aircraft’s location. If the pilots don’t know where they are, then neither does air traffic control. This was a hard lesson learned by the crew of United 1448 in what could have been another Tenerife.

Aside from heavy fog, it was business as usual at Providence, Rhode Island on December 6, 1999. United 1448, a Boeing 757 has just landed and they are cleared to the ramp via taxiways November and Tango.

The first mistake is made by United 1448 as they make a wrong turn on taxiway Bravo which leads back to 5R/23L – the active runway.  Unaware of the situation, Providence Tower clears FedEx 1662, a 727, for takeoff.

Perhaps out of caution, or maybe sensing that something is wrong United 1448 asks “are we cleared across straight ahead on November?” 1448 unknowingly misleads ATC into thinking that they are holding short of the inactive runways 23R and 16, and they are cleared to cross. Mistake number two.

What follows is nothing short of terrifying. Amid a confused transmission you can actually hear the thrust from departing FedEx 1662 as United exclaims “somebody just took off!” But the story doesn’t end there.

Realizing the existence of a problem, ATC tells United 1448 to stop – a sound plan. At this point United 1448 makes it clear that they are lost. At this point only three facts are known:

1.            Somebody just took off close enough to scare United 1448.

2.            The flight crew are on a runway.

3.            United 1448 is near the Kilo taxiway (which only crosses one runway – 5R).

At this point there is enough information out there for ATC to piece together the whereabouts of United 1448 – or at the very least raise a red flag that the airplane may be on the active runway. As United 1448 attempts to explain their situation Tower cuts them off, “United, stand by please.” That’s ATC lingo for shut up.

What follows is unthinkable. Amidst the confusion, Tower clears another aircraft, US Air 2998, for takeoff. Strike three. Knowing the inherent danger in this situation, United 1448 makes one last plea to the tower controller. “Ma’am I’m trying to advise you, we’re on an active runway.”

But the controller is still locked into the premise that United 1448 is on the other runway and hastily clears US Air for takeoff again! There’s the fourth link in the accident chain and there appears to be nothing the United crew can do about it.

And here’s where exceptional decision making comes in. US Air 2998 saves the day by choosing to remain clear of all runways despite continued pressure to take off from Providence tower.

This is a vivid reminder that we all need maintain a “big picture” view of the airport environment and do our part to maintain safety. There’s just no guarantee that anybody else, even ATC, is going to operate in your best interests.

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