RUNWAY INCURSION Runway safety and ground operations high visibility issue for FAA and pilots Accident on 11/22/94 at 2203 hrs at STL highlights seemingly innocuous error which proved fatal Accident involved a Cessna 441 Conquest and TWA MD-80

RUNWAY INCURSION Pilot of Conquest had 8,000 hrs flight time (2,000 hours in type) Conquest landed at 2140 on Rwy 30R and dropped off passenger at Midcoast At 2158 pilot called for taxi Grnd Control: “Back-taxi into position, hold, Rwy 31; let me know on this frequency when ready for departure”

RUNWAY INCURSION TWA instructed to taxi to Rwy 30R for departure 2201 hrs, TWA cleared for takeoff 2202 hrs, Conquest pilot advised “Kilo Mike’s ready to go on the right side” Controller response “Roger, I can’t roll you simultaneously with the, uh, traffic departing from the right. Just continue holding in position.”

RUNWAY INCURSION Both TWA pilots saw Conquest shortly after reaching 80 kts, and both applied brakes; Captain used left rudder to steer around Right wing of MD-80 sliced through top of Conquest 2 pilots on Conquest killed, and aircraft destroyed; no serious injuries on TWA

RUNWAY INCURSION Pilots expect to hear particular clearance Conquest pilot seemingly had preconception that he would be cleared for departure on Rwy 30R, having landed on that runway Other traffic using 30R and 30L Rwy 31 only used for departures, and only by regional airline and general aviation

RUNWAY INCURSION ATIS identified active runways as 30R and 30L; rwy 31 not identified Rwy 31 very close to Midcoast ramp and shown as Taxiway Whiskey Rwy 31 was lit (though dimly) and had runway markings and signs, but was half the width of 30R and 30L

RUNWAY INCURSION Specific errors: Pilot had preconceived expectation Pilot didn’t read back runway Pilot didn’t use his strobe lights (didn’t usually turn on until takeoff) Pilot did not use standard phraseology Complacency, darkness, fatigue, and non-standard airport configuration may also have been links in this accident chain