TO THE FEDERAL AVIATION ADMINISTRATION: 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.
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 conducting an engineering analysis of this incident to determine if any potential modifications would have illuminated the runway entry lights at JFK sooner. We also note that, after completing this analysis, you plan to assess the feasibility of implementing any modifications identified.
We believe the engineering analysis that you described is a necessary first step to addressing both recommendations. Pending completion of that work and a plan for implementing any modifications identified, the Board has voted to classify Safety Recommendations A-24-7 and -8 OPEN-- ACCEPTABLE RESPONSE.
September 5, 2024 · Recipient Response · FAA
-From Michael G. Whitaker, Administrator: The FAA will conduct an engineering analysis of the event and determine potential modification(s) to allow for the earlier illumination of the runway entry lights at John F. Kennedy International Airport. Upon conclusion of the analysis, the impact will be assessed for the feasibility of implementation.
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
.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-24-8 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: 1.9.1.1 Surface Detection Technology The NTSB issued Safety Recommendation A-00-66 on July 6, 2000.24 The recommendation asked the FAA to do the following: 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.
On August 25, 2017, the FAA stated that it was continuing to install runway status lights at some larger airports with scheduled passenger service to “provide a direct indication to pilots and vehicle operators when a runway is unsafe for entry, crossing, or departure … reducing the time it takes to alert them of potentially unsafe situations.”
The FAA also stated that runway status light systems require the installation of ASDE-X or the airport surface surveillance capability (ASSC).25 On December 1, 2017, the NTSB stated that the recommendation remained classified as Open—Acceptable Response and expressed interest in learning about the solutions under consideration for airports that would not be receiving a runway status light system. On July 2, 2021, the FAA stated that, of the 35 US airports with ASDE-X and the 8 airports with ASSC, 20 airports had runway status lights.
The FAA also stated that its “Runway Incursion Prevention through Situational Awareness” initiative was working to identify different types of potential surveillance system technologies, including low-cost solutions that are suitable for smaller airports. Additionally, the FAA stated that it was further exploring technologies, including ADS-B In applications that could provide situational awareness and direct alerts to pilots; however, the avionics to implement such a system did not yet exist.
On March 24, 2022, the NTSB stated that it was encouraged to learn that the FAA was exploring viable and affordable technologies that could directly warn flight crews about potential runway incursions given that ASDE-X, ASSC, and runway status light systems might not be practical at all airports. Safety Recommendation A-00-66 remained classified Open—Acceptable Response. On October 13, 2023, the FAA reported that in June 2023 it hosted an industry event to determine how to enhance controller situational awareness of an airport su