Incident Overview
On January 23, 2023, at about 1610 Hawaii standard time, United Airlines flight 384 (UAL384), a Boeing 777-200, and Kamaka Air flight 145 (KMK145), a Cessna 208B, were involved in a runway incursion at Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii. UAL384, operating under 14 CFR Part 121 from Denver International Airport (DEN) to HNL, had 10 crewmembers and 291 passengers. KMK145, a Part 135 cargo flight from Lihue Airport (LIH), carried two flight crewmembers. None of the occupants were injured, and neither airplane was damaged. The closest distance between the two aircraft was 1,173 feet.
Sequence of Events
UAL384 landed on runway 4R at 16:09:16, with the first officer as pilot flying and the captain as pilot monitoring. After landing, the first officer activated thrust reversers and applied manual braking. At about 80 knots, the first officer stowed the reversers and transferred control to the captain as briefed. The captain then directed the first officer to notify the tower of a left turn onto taxiway K. At 16:09:37, before the first officer could transmit, the local controller asked if they had taxiway K, and the first officer confirmed the turn. FDR data showed the airplane exited onto taxiway K at about 46 knots.
Meanwhile, KMK145 was on final approach to runway 4L. At 16:09:42, the controller instructed UAL384 to hold short of runway 4L on taxiway K. The first officer acknowledged. However, the airplane did not stop at the hold-short line and crossed runway 4L. At 16:09:57, ATC instructed KMK145 to hold short of runway 8L. UAL384 then crossed runway 8L, and at 16:10:10, the controller instructed UAL384 to continue and contact ground control.
The captain of UAL384 reported losing situational awareness after exiting runway 4R, believing there was more distance between the runways than actually existed. He was concerned about clearing runway 4R while holding short of runway 4L, and stated he was startled by how quickly the airplane reached runways 4L and 8L. The first officer noted that rolling to the end of the runway would have prevented the incursion.
KMK145's pilot stated that no evasive action was necessary and that he always exited runway 4L at taxiway E.
Background and Contributing Factors
The incident occurred during daytime visual meteorological conditions. UAL384 had been cleared for a visual approach to runway 4R after originally planning an RNAV approach to runway 8R. The crew briefed hot spot HS2 at taxiway K, which was depicted on the airport moving map (AMM) and Jeppesen charts. The hot spot description noted that aircraft landing on runway 4R and exiting left onto taxiway K sometimes fail to hold short of runways 4L/22R and 8L/26R. However, the AMM did not include a Jeppesen ball note stating that wide-body and four-engine turbojets landing on runway 4R should roll to the end and not turn left onto taxiway K without tower approval.
Post-incident, ATC standard operating procedures were amended to require that jet aircraft landing on runway 4R must not hold on taxiway K unless issued a LAHSO clearance and are in a small or large weight category. The hot spot description was also revised to note that when holding short, the aircraft tail may encroach on the landing runway.