History of Flight
On August 28, 2008, at approximately 2107 Pacific daylight time, a runway incursion and near-collision occurred between N9219T, a Piper Malibu, and Skywest Airlines flight 69R (SKW69R), a Canadair CRJ-200, at Fresno-Yosemite International Airport (FAT), Fresno, California. Both aircraft were landing on runway 29R and were under the control of the FAT airport traffic control tower. The Malibu was operating under visual flight rules (VFR) as a 14 CFR Part 91 flight from John Wayne Airport to FAT. SKW69R was a 14 CFR Part 121 scheduled air carrier operating under instrument flight rules from Salt Lake City International Airport to FAT. There were 4 crew and 42 passengers aboard the Skywest flight, and 1 pilot and 5 passengers aboard the Malibu. No damage or injuries were reported on either aircraft.
The Malibu pilot contacted the tower at 2101:05 and was cleared to land on runway 29R while approximately 8 miles from the runway. At that time, SKW69R was about 19 miles away. At 2103:38, the Skywest pilot contacted the tower and stated, "visual for 29R and we're slowing." The controller cleared SKW69R to land, advising the pilot that he was following a Malibu on a two-mile final. The Skywest pilot acknowledged and reported the Malibu in sight. Radar data showed the Malibu about 2.5 miles from the threshold and SKW69R about 8 miles from the threshold.
At 2104:27, the local controller instructed the Malibu pilot to plan on exiting at taxiway B3, which was acknowledged. The Malibu crossed the runway threshold at 2105:19. At 2105:51, the controller instructed the pilot to turn left at the next taxiway, B5, and provided further taxi instructions. The pilot acknowledged. Radar data showed the Malibu rolling past taxiway B3 at that time, with SKW69R approximately two miles from the threshold. The Malibu was near taxiway B5/B6 at 2106:14, with multiple targets until 2107:52, when it appeared established southbound on taxiway B5.
SKW69R crossed the threshold at 2106:42. At 2106:54, the controller asked, "Malibu 19T, just verify you are on B5?" The pilot responded, "...uh 19T we're having trouble finding the taxiway." SKW69R passed through the displayed targets for the Malibu at 2107:07. At 2107:10, the Skywest pilot transmitted, "Hey, uh you might not want to let anybody land until he's off the runway... we're just past B5 and the Malibu, SKW69R." The controller apologized and instructed SKW69R to turn left at taxiway B9. At 2107:31, the controller stated, "Malibu 19R... B5 should be right in front of you." The pilot replied, "19T, I think we have it here." Both aircraft taxied to the ramp without further incident. The local controller was relieved from position at 2111.
Airport Information
The incident occurred at the intersection of taxiways B4 and B6 with runway 29R. Runway 29R was 9,227 feet long and 150 feet wide. Taxiway B6 was closed for long-term construction, as was runway 29L. Barricades were placed across taxiway B6 just west of runway 29R. Although signs indicated the intersection was with taxiways B5 and B6, the actual intersection comprised runway 29R, B4, and B6. Aircraft intending to exit runway 29R to follow B5 south must first make a hard left turn onto B4 and then a right turn onto B5. The only sign for B4 was west-facing, intended for use by aircraft landing on runway 11L. Controllers were not aware that the intersection was not posted for B4, nor that taxiway B5 did not technically intersect runway 29R. The correct clearance for N9219T should have been, "Turn left on B4, join B5," but the lack of a B4 sign would have rendered that confusing. Taxiway B5 was not lit but was lined with yellow-orange reflectors (not blue).
The tower controller entered duty with the FAA on August 30, 2006 at Fresno ATCT, completed training in April 2007, and was certified as tower controller in charge on November 24, 2007. He had completed training on all positions in the tower but was still training on radar positions in the TRACON. Before the FAA, he worked as a contract tower controller at Brown Field in San Diego and as a controller in the US Navy. On the day of the incident, he was controller-in-charge (CIC) in the tower cab with a second controller. He released the second controller for a break and took over all positions. The second controller left after a relief briefing and two-minute overlap. Traffic was very light; the runway incursion occurred about 18 minutes after the second controller was relieved.
Controller and Pilot Statements
The controller stated that when N9219T was on approximately two-mile final, SKW69R checked in on six-mile final. He recognized tight spacing and instructed the Malibu pilot to expect to turn off at B3. After the Malibu landed, the controller noticed it had missed B3 and instructed a turn at B5. He saw the Malibu heading southbound and believed it was clear of the runway. He looked at the Malibu two or three times before Skywest landed, each time seeing it headed southbound and clear. The Malibu was still facing southbound when SKW69R passed behind it. The controller could not recall ever being told that an aircraft cannot turn left onto B5 from runway 29R. He was unaware of any procedural changes after the incident. He used binoculars daily but did not use them during this incident.
The pilot of N9219T held a private pilot license with approximately 1,770 hours. He had been to FAT ten to twelve times before. He stated that he was unable to turn off at B3 because the aircraft was heavy with six occupants, which may have contributed to slower deceleration. He continued to B5, made a 90-degree left turn from near the centerline, saw only dirt ahead, and turned right to track along the edge until reaching the exit. He believed the nose wheel was near the edge line. He did not advise the tower of difficulty finding the turnoff. Once he saw the reflectors along B5, he knew he had found the proper taxiway.