Overview
• Operator: United Airlines
• Aircraft Model: Boeing 777-200
• Registration: N774UA
• Flight Number: UA-384
• Route: Denver (DEN) to Honolulu (HNL)
• Date: 23 January 2023
• Occupants: Not specified
• Casualties: None reported
• Nature of Incident: Runway incursion due to failure to hold short after landing
Incident Summary
A United Airlines Boeing 777-200, operating as flight UA-384 from Denver (DEN) to Honolulu (HNL), landed on runway 04R at Daniel K. Inouye International Airport and was instructed to hold short of runway 04L. The crew correctly read back the hold short instruction, but after vacating the runway via high-speed taxiway K, they inadvertently crossed the hold short line and continued onto runway 04L and 08L.
At the same time, a Kamaka Air Cessna 208B, arriving from Lihue (PHLI) and operating flight KMK145, was landing on runway 04L. The Cessna 208 slowed and vacated the runway via taxiway E, approximately 1,173 feet (360 meters) before the intersection with taxiway K, preventing a more serious conflict.
Honolulu Tower instructed UA-384 to continue crossing runway 08L and contact ground control, where the crew was then asked to call the tower via telephone for further discussion.
The NTSB launched an investigation on February 16, 2023, confirming that the runway incursion resulted from the crew’s failure to stop at the designated hold short line, compounded by airport design flaws and inadequate signage on moving maps.
On February 26, 2025, the NTSB released its final report, identifying multiple contributing factors, including design flaws at Honolulu Airport that had previously resulted in similar incidents.
Sequence of Events
Pre-incident Conditions:
• The United Airlines crew landed on runway 04R and was instructed to vacate via taxiway K and hold short of runway 04L.
• The crew correctly read back the hold short instruction.
• A Kamaka Air Cessna 208B was landing on runway 04L at the same time.
Runway Incursion:
• After exiting runway 04R onto taxiway K, the United crew inadvertently crossed the hold short line for runway 04L and continued onto runway 08L.
• By the time the captain realized the mistake, the aircraft was already crossing runway 08L.
• The Kamaka Air Cessna 208B had already exited runway 04L via taxiway E, avoiding a potential collision.
ATC & Aftermath:
• Tower instructed UA-384 to continue taxiing and cross runway 08L.
• After clearing all active runways, ground control directed the United crew to call ATC via telephone to discuss the incident.
• The NTSB launched an investigation on February 16, 2023.
Investigation & Findings
Final NTSB Report (February 26, 2025):
The probable cause of the incident was:
• The continued use of taxiway K, despite an identified history of pilots failing to stop at the hold short line before runway 04L and 08L.
Contributing factors included:
1. An omission in the operator’s moving map display, which failed to show a published restriction prohibiting widebody aircraft from using taxiway K after landing on runway 04R.
2. The captain’s inadvertent failure to stop at the hold short line, partially due to the compressed distance between runway 04R and the hold short line for runway 04L.
3. The FAA’s delayed action to redesign the taxiway layout, which had been flagged as non-compliant with modern airport standards.
NTSB Analysis:
• The United crew correctly read back the hold short instruction but misjudged the short distance between runway 04R and the hold short line for runway 04L.
• Post-incident crew statements confirmed the captain was “startled” by how quickly the aircraft reached the next runway after vacating 04R.
• The first officer had previously noted a caution about runway 04R exits but did not verbally confirm the risk again during taxi.
• The airport’s “hot spot” designation for this intersection had been flagged by the FAA, but no physical changes had been made to the layout.
• The United Airlines electronic moving map lacked a critical restriction note that would have warned the crew not to use taxiway K with a widebody aircraft.
Analysis & Safety Recommendations
For United Airlines & Flight Crews:
• Moving map systems should be updated to include all airport restrictions and critical taxiway advisories.
• Standard operating procedures (SOPs) should reinforce pilot situational awareness when taxiing in complex airport layouts.
• CRM training should emphasize verifying hold short locations using both moving maps and physical airport markings.
For Honolulu International Airport (HNL) & FAA:
• Reconfigure or eliminate taxiway K for widebody aircraft to prevent further incursions.
• Improve hold short signage and runway incursion prevention measures, such as:
• Runway Status Lights (RWSL) to warn pilots of active runways.
• Enhanced markings to clearly indicate mandatory hold short locations.
• ATC procedures should be revised to avoid unnecessary clearance confusion, including:
• Providing explicit taxi instructions before landing roll completion.
• Ensuring aircraft exiting runway 04R are routed more safely.
Weather Conditions at the Time (METAR Reports for PHNL)
• Wind: 230° at 9 knots
• Visibility: 10 miles
• Cloud cover: Few clouds at 2,300 feet, scattered at 3,400 feet, broken at 5,500 feet
• Temperature: 27°C (81°F)
• Altimeter: 29.98 inHg
Disclaimer
“This report is based on available information as of 26 February 2025. While every effort has been made to ensure accuracy, the completeness of the details cannot be guaranteed. If you are the rightful owner of any referenced materials and wish them removed, please email takedown@cockpitking.com.”
