May 23, 2023
Michael Hauf
Investigator-In-Charge
National Transportation Safety Board
490 L’Enfant Plaza SW
Washington, DC 20594
Reference: United Airlines, DCA22LA133
Dear Mr. Hauf,
In accordance with National Transportation Safety Board (NTSB) rules, the Air Line Pilots
Association, International (ALPA) submits the attached comments and conclusions concerning
the incident of United Airlines flight 2627, a Boeing 737-9MAX aircraft. This incident occurred
on June 21, 2022, during landing at Pittsburgh International Airport.
The following contains a synopsis of ALPA’s analysis of the facts surrounding the event, based
on the information obtained through the NTSB’s investigation. ALPA’s suggested Safety
Recommendations are based upon these same facts.
History of flight
On June 21, 2022, at about 0944 Eastern Daylight Time (EDT), United Airlines flight 2627, a
B737-9MAX, N37513, landed at Pittsburgh International Airport (PIT), Pittsburgh, Pennsylvania.
The flight was in contact with air traffic control and prior to the landing was cleared for and
acknowledged the clearance to land on runway 28C. However, radar data indicated that the
flight lined up for and landed on runway 28L. After landing, the airplane taxied to the ramp. The
two flight crew members along with the other 172 occupants on board and were uninjured. The
flight was operating under Title 14 Code of Federal Regulations Part 121 as a passenger flight
from Chicago O’Hare International Airport (ORD), Chicago, Illinois to PIT.
ANALYSIS
Flight Management Computer (FMC) screen blanking
During the visual approach (an approach that was backed up with RNAV GPS Y 28C, pre-
programmed into the FMC’s), the captain asked the first officer to extend the centerline from
the SUPPR waypoint in intercept the final approach course. At that time the first officer
reported that both FMC’s blanked out”. The flight was already cleared for a visual approach to
runway 28C and they had the Precision Path Approach Indicator (PAPI) lighting system in sight,
therefore the flight crew elected to continue the visual approach. The flight crew stated that
the FMC’s returned to operational status around 1,000 to 700 feet agl. Once the displays came
back on, there was no approach guidance displayed on the navigational displays.
ATC oversight
United Airlines flight 2627 was cleared for a visual approach to runway 28C. At about 2 miles
from the threshold, United Airlines flight 2627 confirmed with the controller that they were
cleared for the visual approach to runway 28C. The controller advised that there were ground
vehicles in the vicinity of the runway and cleared the flight to land on runway 28C. Shortly
thereafter the controller observed that United Airlines flight 2627 was lined up for runway 28L.
The controller decided it was the safest course of action to have United Airlines flight 2627
continued to land on runway 28L, since there was very little air traffic in the area and no other
aircraft approaching, landing, or taxing on runway 28L.
As stated in FAA Joint Order, JO 7110.65Z, section 3-10-5 Landing clearance:
b. When you become aware that an aircraft is aligned with the wrong surface, inform
the pilot and:
1. Issue control instructions/clearances, or
2. If time permits, verify the pilot is aligned with the correct runway. Issue control
instructions/clearances as necessary.
An example cited states the following:
“Southwest two thirty nine, you appear to be aligned with Runway 27 Left (pertinent
information), Runway 27 Left, cleared to land.”
In case of United Airlines flight 2627, the above statement should have been the course of
action for the controller. Following the example in FAA JO 7110.65Z guidance would have
prevented a wrong runway landing and the subsequent NTSB investigation. Guidance detailed
in FAA JO 7110.65Z only has two options listed, as stated above, one of which would be, either
issue a new clearance such as go-around instructions or landing clearance for the actual runway
the flight is lined up for. The second option, if time permits, confirm with the pilot that they are
lined up for the wrong runway. None of these options were accomplished by the controller for
this incident and the controller elected to allow United Airlines flight 2627 to continue to land
on the wrong runway.
Aircraft based systems
As stated recently by the NTSB, the number of runway incursions — defined as the incorrect
presence of an aircraft, vehicle, or person on a runway — has remained relatively stable over
the past decade, However, there has been a recent increase in the number of the most serious
incursions It would be advisable to review commercial of the shelf (COTS) solutions to assist
with alerting flight crews in case they are aligned on the wrong runway.
Some available products can be retrofitted to current unequipped aircraft through a software
update to the Enhanced Ground Proximity Warning System (EGPWS). Such systems can provide
additional situational awareness to flight crews.
It would be advisable to have the NTSB recommend that all presently operated transport
category aircraft be equipped with such systems, including both current and future delivered
airline aircraft.
Airport Surface Safety Systems
The PIT airport, nor its assigned FAA Air Traffic Control (ATC) tower, does not have runway
safety technologies installed, such as Airport Surface Detection Equipment Model X (ASDE-X) or
Airport Surface Surveillance Capability (ASSC). These surface safety systems are capable of
determining the position and identification of aircraft and vehicles on airport movement areas,
as well as aircraft flying on final approach corridors to each runway. System capability includes
alerting ATC when unsafe conditions between aircraft / vehicles exist within runway safety
areas, detect wrong surface landing alignment, aborted arrival / departures, and arriving
aircraft position.
Currently, 35 airports have ADSE-X and 8 airports have ASSC installed in operational ATC
towers. However, all of these 43 towers may not have the safety logic function installed that
alert ATC when an unsafe condition exists. The FAA should develop National Airspace System
(NAS) policy standardizing these system requirements.
Specifically, for wrong surface landings, NAS policy standards should require the safety logic
system alert ATC (visual AND aural) when aircraft are aligned to land on a taxiway; when ATC
issues a landing clearance to a runway, but the aircraft is aligned to land on a different runway,
similar to United Airlines flight 2627.
ATC Policy Guidance for Airport Surface Safety Systems
FAA Air Traffic Organization (ATO) policy contained in FAA JO 7110.65Z prescribes ATC
procedures and phraseology for use by personnel providing air traffic control services.
Controllers are required to be familiar with the provisions of this order that pertain to their
operational responsibilities and to exercise their best judgment if they encounter situations not
covered by FAA JO 7110.65Z
The FAA JO 7110.65Z contains explicit guidance controllers must follow when a safety logic
system generates an unsafe warning alert. Of note, FAA JO 7110.65Z does not have guidance
that a controller must issue missed approach / go-around instructions when an aircraft is
aligned to a runway that a landing clearance was not issued and no threat exists (i.e., runway is
clear of aircraft, vehicles, personnel). A Safety Risk Management Analysis may be required to
add explicit guidance to FAA JO 7110.65Z when an aircraft aligns with a wrong runway when
there is no imminent threat, but runway/aircraft incompatibility exists.
Runway Awareness and Advisory System (RAAS) (Boeing 737 MAX)
RAAS is a software enhancement hosted within the Enhanced Ground Proximity Warning
System (EGPWS) unit to provide aural advisories to assist flight crew awareness of airplane
position during ground operations, approach to landing, and go-around. The airports in the
RAAS airport database include details for every runway on the airport.
There are significant limitations to the system some of which are detailed below.
When activated, airborne advisories do not ensure that the aircraft will land on the identified
runway nor imply that the aircraft can or cannot be safely landed, stopped, or taken off, from a
runway. They also do not ensure that the aircraft will, or can be, stopped before hold lines, the
runway edges or the runway end.
The absence of advisories does not necessarily imply that the aircraft is approaching a surface
other than a runway. The flight crew is responsible for using other means available to ensure
correct runway selection and the performance calculations are accurate for the conditions.
In the approach environment to PIT, the system, if activated, was designed to annunciate as
follows:
Sounds once each time the airplane:
• Approaches within approximately 3 nautical miles of a runway threshold, and
• Is within 20 degrees of the runway heading, and
• Is within approximately 200 feet plus one runway width of the runway extended
centerline, and is between 750 feet and 300 feet AFE.
Note: The voice annunciation is delayed and sounds at 450 feet altitude if the voice
annunciation would have sounded when the airplane was between 550 feet and 450 feet above
field elevation. If the criteria above are not satisfied before the aircraft descends below 300
feet AFE, the advisory is canceled.
RAAS is one of several automated warning systems in modern aircraft. The design of these
systems expects the crew to hear an announcement and digest the information to determine if
the expected aircraft flight path matches the current flight path. If an announcement indicated
an error the crew would be required to resolve the issue. Significant aural and visual
indications have been demonstrated to be ignored by crew in high workload environments as
part of mitigating task saturation via load shedding. Of significance is the volume of this alert, it
is at a decibel level well below other aural alerts. In this case, a runway announcement that
differed from the expected annunciation only in the 28 center versus 28 left. Additionally, the
system does not annunciate differences in programmed airport and runway from actual airport
and runway alignment.
The event aircraft was equipped with Runway Awareness and Advisory System (RAAS). The
event aircraft’s RAAS system would function for ground operations for crew alerting upon
approaching a runway, when on a runway, or during the landing maneuver if in an undesired
position (i.e. long landing, runway distance remaining) was encountered.
FINDINGS AND SAFETY RECOMMENDATIONS
Findings
• United Airlines flight 2627 lost both FMC screens during a visual approach.
• After the FMC screens came back online all pre-programmed approach guidance was
lost.
• ATC recognized the aircraft lined up to the wrong runway and allowed the aircraft to
land on the incorrect runway.
• ATC decided it was the best course of action to let United Airlines flight 2627 continue a
visual approach and landing on a wrong runway without issuing a new clearance, be it a
go-around or landing clearance.
Safety Recommendations
To FAA
• Reiterate to controllers to issue a new clearance when an aircraft is lined up with a
wrong runway – this can either be a landing clearance to the new runway the aircraft is
aligned to, or go-around instructions.
• Provide controllers additional training to identify wrong surface alignments and take
action accordingly.
• To require installation of aircraft-based systems to alert flight crews when an aircraft is
aligned with a runway that differs or conflicts with initial approach or landing clearance.
• Install airport surface safety systems capable of determining the position and
identification of aircraft and vehicles on movement areas as well as aircraft flying on
final approach corridors to each runway at airports with operational ATC towers.
• Ensure the surface safety system includes safety logic alert algorithms to identify wrong
surface landings that includes alignment to taxiways, alignment to runways that ATC has
not issued a landing clearance.
ALPA appreciates the chance to participate in this investigation and hopes that the attached
Findings and Safety Recommendations will help as the NTSB concludes this investigation.
Captain Steve Demko
ALPA Party Coordinator
