NTSB · Safety Recommendation

Safety Recommendation A-24-002

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 91K, 135, and 121 operators to incorporate into their standard operating procedures a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross, as indicated by runway signs, unless an installed automated system already provides an aural advisory.

Safety Issue and Context

This report discusses the January 13, 2023, runway incursion incident involving American Airlines (AAL) flight 106, a Boeing 777-200, and Delta Air Lines (DAL) flight 1943, a Boeing 737-900, at John F. Kennedy International Airport (JFK), Queens, New York. The flight crew of the AAL airplane was instructed to taxi to runway 4L for departure and cross runway 31L; however, the crew crossed runway 4L, where the DAL airplane had just begun its takeoff roll. The local controller cancelled the DAL airplane’s takeoff clearance, and the DAL flight crew rejected the takeoff.

Safety issues discussed in this report include (1) the need for additional risk mitigation strategies to prevent flight crew surface navigation errors that result in runway incursions; (2) the need for a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross as indicated by runway signs; and (3) the lack of flight deck technology to detect potential traffic conflicts. As a result of this investigation, the National Transportation Safety Board issues eight new safety recommendations to the Federal Aviation Administration (FAA), reiterates one previously issued recommendation to the FAA, and supersedes two recommendations.

Response History

May 9, 2025 · NTSB Correspondence · FAA

We understand that the FAA believes encouraging flight crews to confirm runway crossings could disrupt established pilot procedures and communications with air traffic control. We note that operators are required to have a safety management system (SMS), which includes a process for determining specific pilot requirements in these situations, and existing FAA guidance includes runway surface safety best practices.

FAA Advisory Circular (AC) 120-74B states the following:

When flightcrew members verbally confirm their understanding of the instructions, they then have a chance to discover and correct any misunderstandings and thus prevent hazardous situations from developing. This verbal coordination/agreement should be accomplished at the following times: When approaching any hold short line, verbalize “approaching (specific runway number) hold short line.”

Despite this guidance being available before this incident, the operator did not require its flight crews to verbally crosscheck the runway number displayed on the runway signs. Noticing those signs was the last opportunity for the incident flight crew to detect and correct the captain’s surface navigation error before the incident occurred. We continue to believe that reading the runway number aloud could have alerted the flight crew to the fact that the airplane was about to cross the wrong runway. We also point out that such a procedure would be easy to perform and is similar to other common safety-related checks. Therefore, we urge you to reconsider your position.

In the meantime, pending our review of an appropriate plan, the Board has voted to classify Safety Recommendation A-24-2 OPEN-- UNACCEPTABLE RESPONSE.

September 5, 2024 · Recipient Response · FAA

-From Michael G. Whitaker, Administrator: In response to this safety recommendation, the Federal Aviation Administration (FAA) believes that an additional required confirmation of runway crossing could be distracting to the established procedures of pilots and interfere with ATC communications. Crew situational awareness of the aircraft's position occurs well before they arrive at the runway environment.

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