TO THE FEDERAL AVIATION ADMINISTRATION: Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A-24-4. (Supersedes A-00-66)
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
April 2, 2026 · NTSB Correspondence · FAA
On September 2, 2025, FAA Administrator Bryan Bedford informed us that the agency is continuing the work described in its previous letter regarding Safety Recommendations A-24-4 through -6. We look forward to receiving your next update.
September 2, 2025 · Recipient Response · FAA
-From Bryan Bedford, Administrator: The FAA will develop an action plan to implement safety recommendations A-24-5 and -6 once the technology in safety recommendation A-24-4 has been developed.
I will keep the Board informed of the FAA’s progress on Safety Recommendations A-24-4 through -6 and anticipate providing an update by August 31, 2026.
May 9, 2025 · NTSB Correspondence · FAA
We understand that you are reviewing these safety recommendations and developing an appropriate action plan. These recommendations are similar to Safety Recommendation A-00-66; however, they specify a flight deck-based alerting system.
Although the FAA has made efforts to reevaluate technologies and procedures to reduce and eliminate runway safety risks, and continues to develop surface technologies to enhance air traffic controller situational awareness, we remain concerned that after 25 years, you still have not required, at all airports with scheduled passenger service, a ground surveillance system that would provide timely warnings directly to flight crews of the potential for a traffic conflict. Pending our review of a detailed plan for responding to these recommendations, the Board has voted to retain the classification of OPEN--UNACCEPTABLE RESPONSE for Safety Recommendations A-24-4 through -6.
September 5, 2024 · Recipient Response · FAA
-From Michael G. Whitaker, Administrator: The FAA is currently reviewing these safety recommendations to develop an appropriate action plan. Additional information will be provided once this process is complete.
June 18, 2024 · NTSB Correspondence · FAA
This letter provides information about the National Transportation Safety Board’s (NTSB) June 6, 2024, report Runway Incursion and Overflight, Southwest Airlines Flight 708, Boeing 737-700, N7827A, and Federal Express Flight 1432, Boeing 767-300, N297FE, Austin, Texas, February 4, 2023, NTSB/AIR-24-02. The details of this incident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.
As a result of this investigation, we identified the following safety issues:
• The lack of air traffic control tower and flight deck technology to detect potential conflicts on a taxiway or runway surface
• The need to ensure, especially during low-visibility conditions, that controllers are aware when pilots, after receiving takeoff clearance, might need extra time on the runway
• The lack of training on the AUS airport’s Surface Movement Guidance and Control System plan and low-visibility operations
• The need for low-visibility operations training at all airports
• The need for CVRs with a 25-hour recording capability
Accordingly, the NTSB issues seven new safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report.
• For airports that are certificated under Title 14 Code of Federal Regulations Part 139 and are currently not equipped with airport surface detection equipment, model X or airport surface surveillance capability, implement surface detection equipment that
o tracks the movement of arriving and departing aircraft,
o determines the proximity between those aircraft, and
o provides air traffic controllers with visual and aural cues of surface movements to aid in their decision-making processes. (A-24-10) (See section 2.3.1.)
• Require air traffic controllers to
o advise pilots, through direct communication and automatic terminal information system broadcasts, when visual contact with aircraft operating on taxiways and runways cannot be established or maintained and
o instruct pilots to provide accurate position reports to aid the controller in determining an aircraft’s location in such conditions. (A-24-11) (See section 2.4.)
• Brief all air traffic controllers about the circumstances of this incident, emphasizing the effect that certain conditions might have on a pilot’s ability to begin a takeoff in a timely manner, including
o low-visibility weather conditions, such as fog;
o ambient conditions, such as temperature; and
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 http://www.ntsb.gov.
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
o surface conditions, such as ice, snow, and other precipitation, as noted in Order 7110.65, Air Traffic Control, paragraph 5 8 4, Departure and Arrival. (A 24-12) (See section 2.4.)
• Amend the Aeronautical Information Manual so that it instructs pilots to inform controllers, before entering an active runway with the intent to depart, when they need time on the runway for any reason before beginning the takeoff roll. (A-24-13) (See section 2.4.)
• Require all airports with a Surface Movement Guidance and Control System plan to ensure that their plans and the associated letters of agreement correspond with each other and the stakeholder duties and responsibilities described in Advisory Circular 120-57, Surface Movement Guidance and Control System. (A-24-14) (See section 2.5.)
• Direct training administrators at airports with a Surface Movement Guidance and Control System plan to require initial and annual refresher training for all stakeholders, including air traffic controllers and airport operations personnel, on the information in the airport’s plan. (A-24-15) (See section 2.5.)
• Require training administrators at all operating air traffic control towers to conduct annual refresher training on low-visibility operations. (A-24-16) (See section 2.5.)
In addition, the NTSB reiterates the following recommendations to the FAA:
• 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 2.3.2.)
• 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 2.3.2.)
• 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 2.3.2.)
• 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) (See section 2.6.)
• 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 section 2.6.)
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 (new Safety Recommendations A-24-10 through -16 and reiterated Safety Recommendations A-18-30, A-24-4 through -6, and A-24-9). 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 reiteration of A-24-6 from the report “Runway Incursion and Overflight Southwest Airlines Flight 708, Boeing 737-700, N7827A, and Federal Express Flight 1432, Boeing 767-300, N297FE, Austin, Texas, February 4, 2023,” published 6/18/2024:
2.3.2 Flight Deck Technology
The flight deck of a certificated transport-category airplane is configured with various systems that supplement the information presented on flight instruments; such systems provide flight crews with visual and aural annunciations to increase a crew’s situational awareness. Both the SWA and FedEx airplanes were equipped with TCAS, as required, to alert pilots about nearby in-flight (intruder) traffic and the need to take evasive action to avoid a midair collision. (As previously stated, TCAS was not designed to prevent runway incursions.)
However, transport-category airplanes are not currently required to have a system that would (1) provide visual and aural cues of nearby airplanes operating on an airport surface and (2) alert flight crews when a potential surface conflict exists.
The FedEx airplane, a Boeing 767, was equipped with an autoland system, which allowed the flight crew to monitor other systems related to the airplane’s approach without having to look outside the airplane to locate the runway.
The FedEx first officer, as the pilot monitoring, would have focused his attention during the approach on scanning and monitoring the flight instruments, but the first officer reported that he looked outside the airplane because of concerns about the SWA airplane’s location. As previously stated, the first officer saw a light and then the silhouette of the SWA airplane and called for a go-around. It was fortunate that the FedEx first officer observed the SWA airplane on the runway. The FedEx captain reported that he did not see the SWA airplane, but, as the pilot flying, he would have been focused on the flight instruments to execute the approach.
Although the controller was responsible for providing accurate and timely information to the FedEx flight crew regarding the traffic on runway 18L, he was unable to see the SWA airplane in the low-visibility conditions that existed at t
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-24-6 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: 2.3.3 Flight Deck Technologies for Preventing Runway Incursions The NTSB has long advocated the development of technologies for the prevention of runway incursions.
The NTSB has, for example, recommended systems to alert air traffic controllers to the presence of traffic conflicts. This resulted in the development of ASDE-X. The ASDE-X installation at JFK likely prevented this incident from becoming an accident; however, it required adequate time for the controller to detect the warning, identify the problem, and determine the necessary action before attempting to contact the DAL1943 flight crew. Moreover, the FAA is no longer installing ASDE-X at US airports because it considers the system too expensive to install and maintain. Therefore, many airports currently lacking this technology will not have access to it in the future.
In 2000, the NTSB recommended that the FAA require, at all airports with scheduled passenger service, a ground movement safety system that would prevent runway incursions, with the capability of providing a direct warning to flight crews (Safety Recommendation A-00-66). In the accompanying letter, the NTSB suggested that these direct warnings could be provided through such means as RELs and stop bars located at all runway/taxiway intersections, or by other means, such as a datalink.
This incident highlights the limitations of RELs (which will be discussed in section 2.4) and suggests that crew positional awareness would be enhanced by a flight deck display of ground traffic with both visual and aural conflict alerts. Flight deck technology for improving flight crew awareness of surface traffic and alerts to potential conflicts has been developed. Such systems could use ADS-B data to display the location of traffic that is on, approaching, or departing a runway, in the air or on the ground. This capability would provide a redundant means for flight crews to detect the presence of another aircraft (in addition to visually scanning the external environment).
Such systems could aurally alert and visually display to flight crews potential traffic conflicts that could prevent them from entering a runway where another airplane is departing, without pilots having to rely solely on visual scanning of the outside environment or on the intervention of a controller who has detected or received an alert about a conflict, thereby providing an additional laye