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NTSB issues ASDE-X and airport lighting recommendations following Atlanta taxiway landing
3 March 2011

On October 19, 2009, about 06:05 a Boeing 767, N185DN, operating as Delta Air Lines flight 60, landed on taxiway M at Atlanta-Hartsfield-Jackson International Airport (ATL), Georgia. No injuries to the 11 crew or 182 passengers were reported, and the airplane was not damaged. Night visual meteorological conditions prevailed.

During the descent and approach, the flight crew was assigned a number of runway changes; the last of which occurred near the final approach fix for runway 27L. While the flight was on final approach, the crew was offered and accepted a clearance to sidestep to runway 27R for landing. Although the flight crew had previously conducted an approach briefing for runways 27L and 26R, they had not briefed the approach for runway 27R and were not aware that the approach light system and the ILS were not available to aid in identifying that runway.

The captain maneuvered for the sidestep from runway 27L to 27R and lined up on “the next brightest set of lights” he saw. The first officer was preoccupied during the final approach with attempting to tune and identify the ILS frequency for runway 27R. Just prior to the airplane touching down, the captain realized they were landing on a taxiway. The airplane landed on taxiway M, 200 feet north of, and parallel to, runway 27R. The local controller did not notice the crew’s error until after the airplane had landed. The taxiway was unoccupied, and the flight crew was able to stop the aircraft safely and taxi to the gate.

The National Transportation Safety Board (NTSB) determined that the probable cause of this incident was the flight crew’s failure to identify the correct landing surface due to fatigue.
Contributing to the cause of the incident were:

  1. the flight crew’s decision to accept a late runway change,
  2. the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and
  3. the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.

 

The National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Perform a technical review of Airport Surface Detection Equipment-Model X to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. (A-11-12)

At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment-Model X to detect improper operations, such as landings on taxiways, and provide alerts to air traffic controllers that these potential collision risks exist. (A-11-13)

Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control panels that do not provide direct indication of airport lighting intensities, the air traffic manager annually reviews and compares, with the airport operator, the preset selection settings configured in the tower lighting control system to verify that they comply with FAA requirements. (A-11-14)

Revise Advisory Circular 150/5345-56A, “Specification for L- 890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances for, or modifications to, airfield lighting preset standards prescribed in Federal Aviation Administration requirements. (A-11-15)

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