N145KA

HISTORY OF FLIGHTOn January 23, 2023, about 1610 Hawaii standard time (HST), United Airlines flight 384 (UAL384), a Boeing 777-200, and Kamaka Air flight 145 (KMK145), a Cessna 208B, were involved in a runway incursion at Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii. After landing on runway 4R, UAL384 crossed runway 4L as KMK145 was landing on the same runway; the closest distance between the two airplanes was 1,173 ft. None of the airplane occupants (10 crewmembers and 291 passengers aboard UAL384 and 2 flight crewmembers aboard KMK145) were injured, and neither airplane was damaged. UAL384 was a regularly scheduled domestic passenger flight operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121 from Denver International Airport (DEN), Denver, Colorado, to HNL. KMK145 was a domestic cargo flight operating under the provisions of Title 14 CFR Part 135 from Lihue Airport (LIH), Lihue, Hawaii, to HNL. Daytime visual meteorological conditions prevailed at the time of the incident.

According to flight data recorder (FDR) data, UAL384 departed DEN about 0939 (1239 mountain standard time). The taxi, takeoff, departure, cruise, and descent phases of flight were uneventful. The first officer was the pilot flying, and the captain was the pilot monitoring. KMK145 departed LIH at 1530:46 with a pilot flying and pilot/loader aboard.

According to postincident flight crewmember statements, before UAL384 began its descent into HNL, the first officer briefed the MAGGI3 arrival with the BITTA transition and briefed the RNAV (GPS) approach to runway 8R. The first officer obtained the automatic terminal information service (ATIS), gate assignment, and landing data via the aircraft communications addressing and reporting system (ACARS) for runways 4R and 8R. ATIS indicated that instrument and visual approaches were available for runways 4R and 8R and stated “LAHSO [land and hold-short operation] runways hold-short of 8L” and “[pilots] advise if unable.”

The first officer then set up for the planned arrival and approach into HNL. After receiving the ATIS, the crewmembers reviewed the company notes for the airport, NOTAMs, arrival, landing, and taxi diagrams. Both crew members noted that there was construction on runway 8L making it unavailable to landing traffic. Additionally, the company notes for HNL indicated that B-777 airplanes were not allowed to perform land and hold-short operations (LAHSO) when landing on runway 4R.

Using information from the airport moving map (AMM), as allowed by UAL procedures, they also briefed their anticipated taxi route to the gate for landing runway 8R. Additionally, in case they were given runway 4R, they briefed the anticipated taxi plan which included possibly exiting at taxiway “K” or exiting at the end of the runway on taxiway “C.” Furthermore, in her postincident statement, the first officer indicated that she briefed the published hot spot, referred to as HS2, (see figure 2) located at taxiway “K” in case they were given runway 4R for landing.

Figure 2. HS2 hot spot area involving taxiway K and surrounding runways. The arrow points to the hold-short line for runways 4L and 8L.

This hot spot was depicted on the first officer’s airport moving map (AMM) display, which was part of her electronic flight bag. The Jeppesen navigation chart for HNL (dated October 28, 2022) indicated that HS2 was considered to be a hot spot because aircraft landing on runway 4R and exiting left onto taxiway K “sometimes fail to hold short” of runways 4L/22R and 8L/26R.

The first officer further briefed that they planned to land on runway 8R with flaps 25 and an autobrake setting of 2; however, if air traffic control (ATC) assigned them runway 4R they would then land with flaps 30 and an autobrake setting of 3. After the briefing was complete, the flight crew accomplished the descent checklist.

According to air traffic control (ATC) voice recordings, at 15:54:40, the captain contacted the Hawaii Control Facility H sector approach controller. At that time, the airplane was descending through an altitude of 14,000 ft mean sea level. The approach controller provided instructions, and subsequently a clearance, for a visual approach to runway 4R at HNL. The captain notified the approach controller that they would be unable to conduct a LAHSO in which the airplane would land on runway 4R and hold short of intersecting runway 8L. In their postincident statements, the flight crew members indicated that the first officer then briefed their approach and plan to land. The exit plan from runway 4R would be either “rolling to the end” or making a left turn onto taxiway K (the latter of which depended on the airplane decelerating as expected on the runway).

In his postincident statement, the captain stated that they were busy setting up for the new approach and he failed to open the hot spot note and read “Aircraft landing 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 the hot spot note during the approach briefing but that 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.

According to their crew statements and follow-up answers, “neither pilot left the AMM” and were using the AMM version of the airport diagram and not the chart version of the Jeppesen 10-9. For a pilot to read the textual information from an associated hot spot in the AMM, they would have to touch the electronic flight bag screen on the hot spot, and it would expand the area and provide the textual depiction of the associated hot spot. The information on the AMM for HS2 did not have the following additional note, which is present in the Jeppesen 10-9: “Wide body and four engine turbojets landing runway 4R roll to end of runway, no left turn at taxiway K without tower approval.”

At 1606:12, the captain contacted the HNL air traffic control tower and reported the airplane’s altitude (1,500 ft) and the expected landing runway (4R). The local controller provided the UAL384 flight crew with wind information and cleared the airplane to land on runway 4R.

ATC provided the KMK145 pilot with vectors for runway 4L, and the pilot acknowledged that information. At 1606:27, the KMK145 pilot contacted the local controller and reported that the airplane was descending to 1,500 ft for a landing on runway 4L. The local controller instructed the KMK145 pilot to continue to runway 4L and informed the crew about traffic (the UAL384 Boeing 777) that would be landing on runway 4R. The pilot responded that the traffic was in sight. The controller then instructed the KMK145 pilot to maintain visual separation from the Boeing 777 and cleared the KMK145 airplane to land on runway 4L. The pilot acknowledged these instructions.

During a postincident interview, the pilot of KMK145 reported that, as the airplane entered the left downwind leg for the visual approach to runway 4L, he maintained visual contact with the UAL384 airplane and expected to exit runway 4L at taxiway E. The pilot also reported that the KMK145 airplane’s approach speed was about 90 knots, which was “normal” for the approach.

At 1608:57, the local controller advised UAL384 that a Cessna Caravan was to the left and downwind of their airplane’s position and that the Caravan crew would maintain visual separation. The UAL384 captain acknowledged this instruction and asked for confirmation that the airplane was cleared to land runway 4R. The controller confirmed the landing clearance for runway 4R.

According to FDR data, UAL384 landed on runway 4R at 1609:16. The first officer activated the thrust reversers and began manual braking when the airplane’s speed had decreased to about 110 knots. As the airplane continued to decelerate, the first officer stowed the thrust reversers at about 80 knots. At that time, the first officer transferred control of the airplane to the captain as briefed. The captain stated that the transfer of airplane control occurred before taxiway K.

The captain asked the first officer to let the tower know they were turning onto “K”. However, at 1609:37, the controller asked the flight crew, “have you got [taxiway] Kilo?” before the first officer could contact the tower. The first officer responded, “turn left on Kilo.” About 1609:39, FDR data showed that the airplane’s groundspeed when they exited onto taxiway K was about 46 knots. At that time, the KMK145 airplane was on short final approach to runway 4L.

The controller then instructed (at 1609:42) the UAL384 flight crew to hold-short of runway 4L on taxiway K, and the first officer acknowledged the hold-short instruction. At 1609:49, FDR data showed that the UAL384 airplane was traveling at a groundspeed of about 24 knots and was already on taxiway K and about 100 ft away from the hold-short line for runway 4L. In a postincident statement, the UAL384 captain reported that he was “surprised” by the hold-short instruction. (As previously stated, the airplane was precluded by company procedures from landing on runway 4R and holding short of runway 8L.)

The UAL384 airplane subsequently crossed runway 4L without stopping at the hold-short line on taxiway K. At 1609:57, ATC instructed the KMK145 airplane to hold short of runway 8L, and the pilot acknowledged the instruction. At that time, the UAL384 airplane was still on taxiway K past the hold-short line markings. At 1610:10, the controller instructed UAL384 to continue to cross runway 8L and contact ground control.

At 1610:21, the local controller instructed the KMK145 pilot to turn “right” onto taxiway E and cross “runway 4R.” The pilot questioned the instruction to turn right at the taxiway, and the controller then advised the pilot to turn left on taxiway E and hol...