TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent tasks during taxi and develop and implement effective risk mitigation strategies considering human factors principles.
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 you are developing an information for operators (InFO) message with guidance about load closeouts, flight computer loading, and taxi checklists that should be run while the aircraft is stopped. We also understand that the InFO will remind flight crews that if, while taxiing, they receive a task that diverts their attention, they are required to stop taxiing until that task has been completed.
This recommendation asks you to encourage operators to use their SMS to identify errors and then develop mitigations based on those findings. However, we believe publishing an InFO with the risk mitigation that you described would encourage flight crews to refrain from performing concurrent tasks while taxiing and, therefore, represents an acceptable alternate solution. Pending our review of the published InFO, the Board has voted to classify Safety Recommendation A-24-3 OPEN-- ACCEPTABLE ALTERNATE RESPONSE.
September 5, 2024 · Recipient Response · FAA
-From Michael G. Whitaker, Administrator: In response to this safety recommendation, the Federal Aviation Administration (FAA) will publish an Information for Operators (InFO). This InFO will include information about load closeouts, flight computer loading, and taxi checklists to be run while the aircraft is stopped. In addition, this InFO will also include information that when there is a new task that diverts a crew’s attention from the taxi, it will require the crew to stop the taxi until those tasks are completed. The FAA believes that this control will mitigate external hazards.
June 11, 2024 · NTSB Correspondence · FAA
This letter provides information about the National Transportation Safety Board’s (NTSB) May 29, 2024, report Runway Incursion and Rejected Takeoff, American Airlines Flight 106, Boeing 777-200, N754AN, and Delta Air Lines Flight 1943, Boeing 737-900, N914DU (NTSB/AIR-24-01). The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at
As a result of this investigation, we identified the following safety issues: • 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; • the lack of flight deck technology to detect potential traffic conflicts on a taxiway or runway surface; • the need for additional risk mitigation strategies to reduce the likelihood that flight crew surface navigation errors result in runway incursions; and • the need for cockpit voice recorders with a 25-hour recording capability. Accordingly, the NTSB makes the following safety recommendations to the FAA.
Additional information regarding these recommendations can be found in the noted sections of the report. • 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. (A 24 2) (See section 2.3.1.)
• Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent tasks during taxi and develop and implement effective risk mitigation strategies considering human factors principles. (A-24-3) (See section 2.3.2.) • Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on a runway or taxiway and traffic on approach to land. (A-24-4) (See section 2.3.3.)
• Require that the technology developed in response to Safety Recommendation A 24 4 be installed in all newly certificated transport-category airplanes. (A 24 5) (See section 2.3.3.) • Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A 24 4. (A 24 6) (See section 2.3.3.) • Evaluate the effectiveness of the activation logic for the runway status light system considering the circumstances of this incident. (A 24 7) (See sections 1.9.1.1 and 2.4.1.)
• Using the findings of the evaluation conducted in response to Safety Recommendation A 24 7, update the runway status light system activation logic as necessary to improve system effectiveness. (A-24-8) (See sections 1.9.1.1 and 2.4.1.) • Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (A 24 9) (See sections 1.9.1.2 and 2.6.)
In addition, the NTSB reiterates the following recommendation to the FAA: • Require all newly manufactured airplanes that must have a cockpit voice recorder (CVR) be fitted with a CVR capable of recording the last 25 hours of audio. (A-18-30) In the same report, we also classified the following safety recommendations: • Require, at all airports with scheduled passenger service, a ground movement safety system that will prevent runway incursions; the system should provide a direct warning capability to flight crews. In addition, demonstrate through computer simulations or other means that the system will, in fact, prevent incursions.
(A-00-66) Safety Recommendation A-00-66 is classified Closed—Unacceptable Action/Superseded in section 2.3.3 of the report. This recommendation is superseded by Safety Recommendations A-24-4 through -6. • By January 1, 2024, require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (A-18-31) Safety Recommendation A-18-31 is classified Closed—Unacceptable Action/Superseded in section 2.6 of the report. This recommendation is superseded by A-24-9, which is classified Open—Unacceptable Response.
The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations A-24-2 through -9, reiterated Safety Recommendation A-18-30, and classified Safety Recommendations A-00-66 and A-18-31). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov.
If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. Justification for A-24-3 from report "Runway Incursion and Rejected Takeoff, American Airlines Flight 106, Boeing 777-200, N754AN, and Delta Air Lines Flight 1943, Boeing 737-900, N914DU," May 29, 2024, John F. Kennedy International Airport, Queens New York:
2.3.2 American Airlines Policy on Completing the Load Closeout
The captain was ultimately responsible for verifying that the load closeout was acceptable before takeoff.
The NTSB evaluated policies and procedures in the American Airlines FOM on crew performance of tasks related to the load closeout.
The FOM stated that required tasks included verifying the received messages and comparing the TPS tablet application output and load closeout numbers against documents obtained from operations for reasonableness. This was essential, in part, to ensure that the crew was using the appropriate reference speeds during the takeoff. The crew was also required to review the load closeout to determine if any restricted articles were onboard, in which case they were to ensure that they had a corresponding Notice to Captain (NOTOC).
Any discrepancies were required to be corrected before takeoff. After the incident, American Airlines confirmed that tasks related to the load closeout are considered essential to the safety of flight and are part of required pre-takeoff checks that can be accomplished during taxi.
In the postincident interview, the captain said that he did not normally need to perform these tasks during taxi because load closeouts typically arrive soon after the airplane pushes back from the gate. He said that he normally made a point of crosschecking the load closeout with the FO and completing related tasks before departing the ramp area.
In this case, however, he said that he decided to begin the taxi before receiving the load closeout because AAL106 had a third flight crewmember (the FB). He explained that many of the flights he operated from JFK to London had only two flight crewmembers, and he believed the presence of the FB would allow the crew to handle more tasks during the taxi while maintaining a manageable workload.
The captain delegated to the FB the duty of following up with dispatch to ensure that the load closeout was received; however, the captain could not delegate crosschecking the takeoff performance numbers with the FO.
As previously discussed, load closeout-related tasks subsequently played a role in the captain’s distraction and surface navigation error.
The American Airlines FOM stated that flight crewmembers should use a continuous loop process for actively monitoring and updating their progress and location during taxi. This includes