MIA07IA031

NTSB incident investigation · Boeing 747-436 · Miami, FL · December 26, 2006

Incident · No injuriesIncident investigationFinal report
Date
December 26, 2006, 18:14 local (23:14 UTC)
Place
Miami, FL
Injuries
368 uninjured
Damage
No damage
Phase of flight
Taxi
Aircraft
G-BNLMBoeing 747-436
Weather
Visual (VMC) · Night
Status
Completed · report March 3, 2009
Report
Approved by Office Director
Parties
FAA/FSDO, NTSB AS-60
Case key
65075

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The flightcrew's misinterpretation of available lighting, signage, and airfield marking cues during taxi.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

On ground/water collision with objectTaxi - from landing
Visual lookout - inadequateFlightcrewCause
Airport/facilities - inadequateFactor

Analysis

After a normal landing on runway 30, a runway the flightcrew had not previously landed on at night, the flightcrew taxied the airplane to the end of the runway, intending to depart the runway at the last taxiway. The flightcrew passed the taxiway exit, overran the departure threshold of runway 30, and struck two lights associated with the approach lighting system for runway 12, breaking the lights off at their bases. The airplane was not damaged, and, after being towed from the overrun area, taxied to the gate under its own power.

The flightcrew stated to investigators that they observed the runway centerline lights initially alternated red and white and then became all red as they taxied the airplane toward the runway threshold. They stated that they were looking for a right turn to vacate the runway but did not see any green lead-off lights leading to the taxiway. They further stated that they observed a line of red lights about 50 meters (about 160 feet) in front of the airplane, which they thought were part of the stop bar indicating the runway threshold. The first officer started to turn off the runway using the blue taxiway edge lights as a guide, but immediately stopped the airplane when both he and the captain realized the light pattern was not as expected. The investigation revealed that the red lights that the flightcrew observed were obstruction lights mounted on top of an Instrument Landing System localizer antenna, approximately 500 feet beyond the runway threshold. The actual runway threshold was marked with eight red lights, consisting of four lights extending out from each side of the runway edge.

The lighting, signage, and airfield markings of runway 30 were operational and in accordance with Federal Aviation Administration (FAA) specifications; however, the flightcrew did not correctly utilize or interpret these cues to determine their exact location during taxi. The runway 30 centerline lights changed from all white to alternating red and white lights beginning 3,000 feet from the runway threshold and became all red lights beginning 1,000 feet from the runway threshold. The runway edge lights changed from white to amber 2,000 feet from the runway threshold and remained amber until the end of the runway. On the left side of the runway, "distance remaining" signs were installed at 4,000 feet, 2,000 feet, and 1,000 feet before the runway threshold. Approximately 500 feet before the runway threshold, on the right side of the runway, a taxiway sign was installed, indicating "Q" with an arrow pointing to the right. Approximately 75 feet before the runway threshold, the centerline lights of Taxiway Q began at the runway edge and extended perpendicular to and away from the runway. Additionally, twelve parallel white bars were painted along the width of the runway surface to mark the threshold and yellow chevrons were painted on the blast pad beyond the runway threshold to indicate unusable pavement.

FAA advisory material for new runway threshold lighting installations and for reconstruction of existing installations recommends that threshold lights extend from the runway edge inboard toward the center of the runway, and not outboard like those on the incident runway; however, existing installations, such as those on the incident runway, were permitted by the FAA. The taxiway at the end of the runway did not have taxiway lead off lights extending to the center of the runway, but the taxiway did have centerline lights beginning at the runway edge, per FAA requirements. Although the flightcrew said they were confused by the location of the runway threshold lights, they had numerous other indications available to identify their position on the runway, all of which were in compliance with FAA guidance. Each of these indications would have been visible from the cockpit and are intended to help the flightcrew navigate without incident. However, the flightcrew did not heed the numerous lighting, signage, and airfield markings for runway 30, and instead focused on lights that were located well beyond the runway threshold to the exclusion of all other indications.

Factual narrative

This report was modified on Febuary 20, 2009

History of the Flight

On December 26, 2006, about 6:14 PM eastern standard time, British Airways flight BA 209, a Boeing 747-436, British registration G-BNLM, ran over two Runway 12 approach lights at the departure end of runway 30, as the flight turned off the runway after landing at Miami International Airport (KMIA), Miami, Florida. There were no injuries to the 349 passengers and 19 crewmembers. The flight was operating under the provisions of 14 Code of Federal Regulations Part 129 and was en route to KMIA from London Heathrow Airport (EGLL), London, England. The airplane was not damaged and made a scheduled return flight to London later that evening.

The flightcrew stated that this was the first time they had landed on Runway 30 at night. The landing was normal with the first officer flying the airplane. The airplane was slowed to a speed commensurate for taxiing and vacating the runway. Since the last rapid (high-speed) turn off was in close proximity, the flightcrew elected to roll to the end of the runway.

According to the flightcrew, as the airplane proceeded down the runway, the centerline lights became red and white and then red as the airplane neared the runway end. The flightcrew was looking for a right hand turn to vacate the runway, but did not see green lead-off lights from the center of the runway that would indicate the turn. They observed a line of red lights about 50 meters in front of the airplane, which they thought was the stop bar or runway end. The first officer started a turn off the runway using the blue taxiway edge lights as a guide, but stopped the airplane when they realized the light pattern was not as expected. The flightcrew then called for assistance.

When ground personnel arrived, the flightcrew was informed they had crossed over a line of approach lights for Runway 12, and that the airplane had contacted two of the lights for the Runway 12 approach lighting system. The airplane was still on asphalt, and a tug was used to push the airplane back onto the runway. After an inspection showed the airplane had not been damaged, the flightcrew taxied the airplane to the gate.

The flightcrew stated that when they inspected the incident area the next day they determined that the red light bar they associated with the stop bar or runway end was actually lights on top of the approach lights for Runway 12. (According to MIA airport officials, there were no red lights installed at the departure end of Runway 30 that were associated with an approach lighting system, however, there were red obstruction lights on an ILS localizer antenna located 500 feet beyond the runway threshold. )

They observed the actual runway end lights extended outward away from the runway edge adjacent to the approach lights for Runway 12 which they crossed over. Recorded radar data from Federal Aviation Administration (FAA), Miami Approach Control showed that as BA 209 crossed the approach end of Runway 30, it was traveling at a groundspeed of 145 knots. Examination of the Airport Movement Area Safety System (AMASS) replay data showed BA 209 was traveling at approximately 40 knots ground speed as it approached high-speed taxiway Q1, and had decelerated to approximately 30 knots as it passed the taxiway. As BA 209 approached the end of the runway it was traveling at less than 10 knots.

Personnel Information

The captain, first officer, and second first officer each held a British airline transport pilot certificate and each had a current medical certificate.

Airplane Information

The airplane was a Boeing 747-436, British registration G-BNLM, serial number 24055, manufactured in June 1990. The airplane was equipped with four Rolls-Royce RB211-524H engines, each capable of producing 60,600 pounds of thrust.

Meteorological Information

The KMIA 1753 weather observation indicated the following: winds from 340 degrees at 8 knots, gusting to 14 knots, visibility 10 miles, few clouds at 1,500 feet, scattered clouds at 2,100 feet, overcast clouds at 5,500 feet, temperature 18 degrees Celsius (C), dew point 15 C, and altimeter 30.00 inches of mercury (Hg). Information from the U.S. Naval Observatory indicated that sunset at KMIA on December 26, 2006, was at 1738, or about 36 minutes before the incident. End of civil twilight was at 1803. The moon rise was at 1139 and set at 2358. The moon had 40 percent of the disk illuminated.

Communications

There were no reported problems with communications between the flightcrew and air traffic controllers.

Airport Information

KMIA is located approximately 8 statute miles northwest of downtown Miami at an elevation of 8 feet mean sea level. The airport property encompasses 3,220 acres. The airport is owned by Miami-Dade County and is operated by the Miami-Dade Aviation Department. The FAA certified KMIA as a 14 CFR Part 139 airport for use by scheduled air carriers operating aircraft designed for 10 or more seats, and unscheduled air carriers operating aircraft designed for 31 or more seats. The airport has Index E aircraft rescue and firefighting (ARFF) capabilities.

The most recent FAA certification inspection of the airport prior to the incident was conducted in January of 2006, and no discrepancies were reported.

KMIA has a total of four air carrier runways that are certificated under 14 CFR Part 139. Runway 9/27 consists of a grooved asphalt surface that is 13,000 feet in length and 150 feet wide. Runway 8R/26L is grooved asphalt and measures 10,506 feet in length and 200 feet wide. Runway 12/30 is grooved asphalt and is 9,354 feet in length and 150 feet wide. Runway 8L/26R is grooved asphalt and is 8,600 feet in length and 150 feet wide. According to Miami-Dade Aviation Department, Airport Operations, the Runway 12 threshold markings were removed and re-painted in October 2005.

The threshold lights at the departure end of Runway 30 were split-globe, mounted outboard of the runway edges, and were installed in the late 1980s. Chevrons, indicating pavement unsuitable for landing, takeoff, or taxi, were painted on the pad beyond the runway threshold, and had been in place since the late 1980s. FAA approach lights to Runway 12 were upgraded to MALSR approximately three years prior to the incident. Included in the MALSR array were unidirectional green lights mounted across the Runway 12 approach threshold of which two were damaged by the incident airplane.

Toward the departure end of Runway 30, the runway centerline lights changed from all white to alternating red and white lights beginning 3,000 feet from the departure end of the runway, and became all red 1,000 feet from the end. The runway edge lights changed from white to amber 2,000 feet from the threshold and remained until the end of the runway.

On the left side of the runway, "distance remaining" signs were installed at 4,000, 2,000, and 1,000 feet before the threshold. Approximately 500 feet before the runway threshold, on the right side of the runway, was a taxiway sign indicating "Q" with an arrow pointing to the right. Approximately 75 feet before the threshold, the centerline lights of Taxiway Q began at the runway edge and extended perpendicularly to the runway.

There were two localizer antennae installed in the overrun area beyond the departure end of Runway 30. The antenna for Runway 30 was located on the extended runway centerline, and was 500 feet beyond the threshold; the antenna for Runway 26L was located 150 feet laterally and 700 feet beyond the departure end of Runway 30. Both localizer antennae were equipped with two red obstacle clearance lights.

Flight Recorders

The airplane was equipped with a cockpit voice recorder and a digital flight data recorder. The recorders were not retained or readout by the National Transportation Safety Board for this incident.

Wreckage and Impact Information

The airplane's center la

Aircraft

Registration
G-BNLM
Reported as
Boeing 747-436
Category
Airplane
Serial number
24055
Engine
Rolls-Royce RB211-524, 60,600 lbs thrust, turbo fan
Damage
No damage
Flight
Part 129
Registered owner
British Airways
Airworthiness certificate
Standard, Transport
Departed
EGLL · London
Destination
KMIA · Miami, FL
Flight plan
IFR
Airport
KMIA · Miami International, runway 30, 9,354 × 150 ft, asphalt

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 1, 2006
Seat
Left
Flight hours
14,600 total · 6,400 in this make and model · 10 in the last 24 hours
Role
Co-pilot
Age
33
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Flight hours
7,000 total · 3,000 in this make and model
Role
Co-pilot
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Unknown
Seat
Center
Flight hours
3,800 total

Weather

Conditions
Visual (VMC) · Night
Wind
340° at 8 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
5,500 ft overcast
Temperature
64 °F, dew point 59 °F
Altimeter
30.00 inHg
Observed at
KMIA, 1 nm away