N986SW

On December 14, 2016, about 1743 Pacific standard time, a runway incursion occurred at San Francisco International Airport (SFO), San Francisco, California, when SkyWest Airlines flight 5086, a CL-600-2B19, crossed the runway hold short line to runway 28L at the taxiway Juliet (J) intersection while another air carrier flight, a B737, was on takeoff roll. There were no injuries reported to the crew or passengers of either flight. The SkyWest flight was operating under the provisions of Title 14 Code of Federal Regulations Part 121 from SFO to Ontario International Airport (ONT), Ontario, California. Night visual meteorological conditions (VMC) prevailed at the time of the incident.

According to the pilots, the incident flight was an Initial Operating Experience (IOE) flight for the first officer. Prior to pushback, the captain, who was going to be the pilot flying (PF) for the incident flight, provided the first officer (FO) with a briefing which included using the SkyWest acronym WANT. The briefing consisted of the takeoff briefing, the potential taxi route, discussion of hot spots located on the airport, weather, and NOTAMs.

After pushback the ground controller provided the crew with taxi instructions to taxi via "Alpha, Foxtrot, cross 1 left, 1 right to 28 left." During the taxi, while on "Alpha" the controller modified their instructions and issued the crew instructions to taxi via "Alpha, Delta, Bravo, Foxtrot to 28L." The crew briefed the modified clearance to each other and proceeded to taxi via the new instructions.

While the flight was taxiing on "Bravo" the first officer announced to the captain that they were approaching taxiway "Foxtrot." The captain, who had taxied via the modified route "many times" had briefed that the taxi would be a "slight right turn" to taxi on "Foxtrot;" however, he erroneously made a slight left turn onto taxiway "Juliet."

The captain estimated that he went about 5 feet over the runway hold short line and stopped the airplane, because "something did not feel right." He then observed a white light off of the right side of the airplane. Subsequently he heard the controller over the ground frequency saying "stop."

After the departing airplane was airborne, the ground controller subsequently gave the crew modified taxi instructions to taxi to runway 28L, which they followed and subsequently departed for their destination airport.

According to a statement from a representative of the operator for the departing aircraft. Neither flight crewmember observed the airplane crossing the runway hold short line while they were on the departure roll.

FLIGHT CREW INFORMATION

The incident flight crew consisted of a line check airman captain and a first officer.

The captain was 47 years old and held an Airline Transport Pilot (ATP) certificate with a rating for airplane multiengine land and a type rating on the CL-65. Additionally, he held a commercial pilot certificate for airplane single-engine land. He also held an FAA first-class medical certificate dated November 10, 2016, with a restriction of "must wear corrective lenses for near and distant vision." The captain reported he was wearing his glasses at the time of the incident. At the time of the incident he was based at Los Angeles International Airport (LAX), Los Angeles, California, an assistant chief pilot at the LAX base, and a line check airman.

According to the captain's interview summary, he had been employed at SkyWest Airlines for about 17 years, based out of LAX for the preceding 9 years, an assistant chief pilot for the previous 5 years, and had been a check airman for 3 years and 4 months.

He stated that he had operated many flights into and out of SFO, while based at LAX. He also estimated, approximately 10 percent of his line check airman operated flights were into and out of SFO.

The FO was 27 years old and held an ATP certificate with a type rating on the CL-65. He also had commercial pilot privileges for airplane single-engine land. He held an FAA first-class medical certificate dated May 16, 2016, with a limitation of "must wear corrective lenses," which he reported he was wearing at the time of the incident. At the time of the incident he was based at Fresno Yosemite International Airport (FAT), Fresno, California.

METEROLOGICAL INFORMATION

The aviation routine weather report (METAR) for SFO originated from an Automated Surface Observing System (ASOS). The METAR issued prior to the incident stated:

Special Weather Report for San Francisco International Airport on the 15th at 0130Z; wind was from 170 degrees at 9 knots; visibility 10 statute miles; few clouds at 2,100 feet agl, ceiling broken at 2,700 feet agl, overcast at 4,600 feet agl; temperature 14°C; dew point 12°C; altimeter 29.99 inches of mercury; Remarks: automated station with precipitation discriminator, rain ended at 6 minutes past the hour; hourly precipitation amount of 0.0 inches, temperature 14.4°C, dew point 12.2°C, visibility at secondary location not available.

According to the United States Naval Observatory, Astronomical Applications Department website, official sunset was at 1652 and the end of civil twilight was at 1721 official moonrise was at 1809. The moon was a waning gibbous with 99% of the moon's visible disk illuminated.

AIR TRAFFIC CONTROL INFORMATION

For detailed information about ATC transmissions with the incident flight, ATC equipment available, and ATC procedures, reference the ATC Specialist Report in the docket for this event. Radar data recorded that the B737 passed approximately 188 feet laterally in front of the CRJ.

ADDITIONAL INFORMATION

Runway Incursion Hot Spot

According to the FAA's website, a runway safety hot spot was defined as

"a location on an airport movement area with a history of potential risks of collision or runway incursion, and where heightened attention by pilots and drivers is necessary.

By identifying hot spots, it is easier for users of an airport to plan the safest possible path of movement in and around that airport. Planning is a crucial safety activity for airport users — both pilots and air traffic controllers alike. By making sure that aircraft surface movements are planned and properly coordinated with air traffic control, pilots add another layer of safety to their flight preparations. Proper planning helps avoid confusion by eliminating last-minute questions and building familiarity with known problem areas."

The FAA's website also provided links to hot spot description based on 9 different geographical areas. The link for the "Southwest U.S." brought up pages 493-500 of the FAA Chart Supplement. The introductory paragraphs contained the following definition:

An "Airport surface hot spot" is a location on an aerodrome movement area with a history or potential risk of collision or runway incursion, and where heightened attention by pilots/drivers is necessary.

A "hot spot" is a runway safety related problem area on an airport that presents increased risk during surface operations. Typically it is a complex or confusing taxiway/taxiway or taxiway/runway intersection. The area of increased risk has either a history of or potential for runway incursions or surface incidents, due to a variety of causes, such as but not limited to: airport layout, traffic flow, airport marking, signage and lighting, situational awareness, and training. Hot spots are depicted on airport diagrams as open circles or polygons designated as "HS 1", "HS 2", etc. and tabulated in the list below with a brief description of each hot spot. Hot spots will remain charted on airport diagrams until such time the increased risk has been reduced or eliminated.

SFO had three charted hot spots on the airport diagram and were designated "HS 1," "HS 2," and "HS 3." The airport diagram page included an inset diagram of HS 1 that was enlarged to see detail. The three charted hot spots on the SFO airport diagram page also included textual description. HS 1 included the area where the incursion occurred. The textual description stated:

Pilots instructed to follow Twy B south sometimes continue onto Twy J or Twy F by mistake.

Figure 1: HS 1 Inset on Jeppesen 10-9 Airport Diagram.

SkyWest Airlines Procedures

Departure WANT Briefing

The SkyWest Airlines CRJ SOPM contained the following guidance in regard to the departure briefing:

Weather –

• ATIS/ASOS, etc.

• Takeoff minimums/alternate requirements

• Low visibility taxi/takeoff procedures

• Windshear/gusty wind considerations and limitations

• Cold weather operations (deice/anti-ice)

Airport/Area Departure –

• Runway of departure (e.g., runway length, surface condition, special considerations, etc.)

• Expected taxi route

• SID/ODP/RNAV DPs

• Terrain considerations

• Navigation radio management

• Automation (level of automation to be used during departure and climb)

*Rejected takeoff plan. This must include reasons for rejecting the takeoff and crew duties. The captain calls and accomplishes the rejected takeoff for any warning message or engine failure prior to V1.

• Engine failure after V1 procedures (standard/simple/complex)

NOTAMs –

• ATIS Advisories

• Flight release messages and remarks

Threats –

• Discuss highest threat (e.g., complex taxi procedures, MEL/CDL limitation, terrain)

Runway Status Lights

According to the SkyWest Airlines Managing Director of Safety, Runway Status Lights (RWSL) training was conducted in AQP Continuing Qualification (CQ) Bulletin Training. It was covered in 2005 and 2011. At the time of the incident, SkyWest, expected pilots "to understand RWSL as a part of their basic airmen prerequisite knowledge." The captain received this SkyWest training.

RELEVANT SYSTEMS

RWSL

The FAA website stated the following, in part:

"Runway Status Lights is an essential FAA system which uses Airport Surface Surveillance data to determine vehicle and aircraft locations. Runway Status Lights processes this data using complex software algorithms with adju...