NTSB Factual Report

This report was modified on Febuary 20, 2009

History of the Flight

On December 26, 2006, about 6:14 PM eastern standard time, British Airways flight BA 209, a Boeing 747-436, British registration G-BNLM, ran over two Runway 12 approach lights at the departure end of runway 30, as the flight turned off the runway after landing at Miami International Airport (KMIA), Miami, Florida. There were no injuries to the 349 passengers and 19 crewmembers. The flight was operating under the provisions of 14 Code of Federal Regulations Part 129 and was en route to KMIA from London Heathrow Airport (EGLL), London, England. The airplane was not damaged and made a scheduled return flight to London later that evening.

The flightcrew stated that this was the first time they had landed on Runway 30 at night. The landing was normal with the first officer flying the airplane. The airplane was slowed to a speed commensurate for taxiing and vacating the runway. Since the last rapid (high-speed) turn off was in close proximity, the flightcrew elected to roll to the end of the runway.

According to the flightcrew, as the airplane proceeded down the runway, the centerline lights became red and white and then red as the airplane neared the runway end. The flightcrew was looking for a right hand turn to vacate the runway, but did not see green lead-off lights from the center of the runway that would indicate the turn. They observed a line of red lights about 50 meters in front of the airplane, which they thought was the stop bar or runway end. The first officer started a turn off the runway using the blue taxiway edge lights as a guide, but stopped the airplane when they realized the light pattern was not as expected. The flightcrew then called for assistance.

When ground personnel arrived, the flightcrew was informed they had crossed over a line of approach lights for Runway 12, and that the airplane had contacted two of the lights for the Runway 12 approach lighting system. The airplane was still on asphalt, and a tug was used to push the airplane back onto the runway. After an inspection showed the airplane had not been damaged, the flightcrew taxied the airplane to the gate.

The flightcrew stated that when they inspected the incident area the next day they determined that the red light bar they associated with the stop bar or runway end was actually lights on top of the approach lights for Runway 12. (According to MIA airport officials, there were no red lights installed at the departure end of Runway 30 that were associated with an approach lighting system, however, there were red obstruction lights on an ILS localizer antenna located 500 feet beyond the runway threshold. )

They observed the actual runway end lights extended outward away from the runway edge adjacent to the approach lights for Runway 12 which they crossed over. Recorded radar data from Federal Aviation Administration (FAA), Miami Approach Control showed that as BA 209 crossed the approach end of Runway 30, it was traveling at a groundspeed of 145 knots. Examination of the Airport Movement Area Safety System (AMASS) replay data showed BA 209 was traveling at approximately 40 knots ground speed as it approached high-speed taxiway Q1, and had decelerated to approximately 30 knots as it passed the taxiway. As BA 209 approached the end of the runway it was traveling at less than 10 knots.

Personnel Information

The captain, first officer, and second first officer each held a British airline transport pilot certificate and each had a current medical certificate.

Airplane Information

The airplane was a Boeing 747-436, British registration G-BNLM, serial number 24055, manufactured in June 1990. The airplane was equipped with four Rolls-Royce RB211-524H engines, each capable of producing 60,600 pounds of thrust.

Meteorological Information

The KMIA 1753 weather observation indicated the following: winds from 340 degrees at 8 knots, gusting to 14 knots, visibility 10 miles, few clouds at 1,500 feet, scattered clouds at 2,100 feet, overcast clouds at 5,500 feet, temperature 18 degrees Celsius (C), dew point 15 C, and altimeter 30.00 inches of mercury (Hg). Information from the U.S. Naval Observatory indicated that sunset at KMIA on December 26, 2006, was at 1738, or about 36 minutes before the incident. End of civil twilight was at 1803. The moon rise was at 1139 and set at 2358. The moon had 40 percent of the disk illuminated.

Communications

There were no reported problems with communications between the flightcrew and air traffic controllers.

Airport Information

KMIA is located approximately 8 statute miles northwest of downtown Miami at an elevation of 8 feet mean sea level. The airport property encompasses 3,220 acres. The airport is owned by Miami-Dade County and is operated by the Miami-Dade Aviation Department. The FAA certified KMIA as a 14 CFR Part 139 airport for use by scheduled air carriers operating aircraft designed for 10 or more seats, and unscheduled air carriers operating aircraft designed for 31 or more seats. The airport has Index E aircraft rescue and firefighting (ARFF) capabilities.

The most recent FAA certification inspection of the airport prior to the incident was conducted in January of 2006, and no discrepancies were reported.

KMIA has a total of four air carrier runways that are certificated under 14 CFR Part 139. Runway 9/27 consists of a grooved asphalt surface that is 13,000 feet in length and 150 feet wide. Runway 8R/26L is grooved asphalt and measures 10,506 feet in length and 200 feet wide. Runway 12/30 is grooved asphalt and is 9,354 feet in length and 150 feet wide. Runway 8L/26R is grooved asphalt and is 8,600 feet in length and 150 feet wide. According to Miami-Dade Aviation Department, Airport Operations, the Runway 12 threshold markings were removed and re-painted in October 2005.

The threshold lights at the departure end of Runway 30 were split-globe, mounted outboard of the runway edges, and were installed in the late 1980s. Chevrons, indicating pavement unsuitable for landing, takeoff, or taxi, were painted on the pad beyond the runway threshold, and had been in place since the late 1980s. FAA approach lights to Runway 12 were upgraded to MALSR approximately three years prior to the incident. Included in the MALSR array were unidirectional green lights mounted across the Runway 12 approach threshold of which two were damaged by the incident airplane.

Toward the departure end of Runway 30, the runway centerline lights changed from all white to alternating red and white lights beginning 3,000 feet from the departure end of the runway, and became all red 1,000 feet from the end. The runway edge lights changed from white to amber 2,000 feet from the threshold and remained until the end of the runway.

On the left side of the runway, "distance remaining" signs were installed at 4,000, 2,000, and 1,000 feet before the threshold. Approximately 500 feet before the runway threshold, on the right side of the runway, was a taxiway sign indicating "Q" with an arrow pointing to the right. Approximately 75 feet before the threshold, the centerline lights of Taxiway Q began at the runway edge and extended perpendicularly to the runway.

There were two localizer antennae installed in the overrun area beyond the departure end of Runway 30. The antenna for Runway 30 was located on the extended runway centerline, and was 500 feet beyond the threshold; the antenna for Runway 26L was located 150 feet laterally and 700 feet beyond the departure end of Runway 30. Both localizer antennae were equipped with two red obstacle clearance lights.

Flight Recorders

The airplane was equipped with a cockpit voice recorder and a digital flight data recorder. The recorders were not retained or readout by the National Transportation Safety Board for this incident.

Wreckage and Impact Information

The airplane's center landing gear made contact with two approach lights as the airplane exited the runway into the asphalt overrun area. The airplane was not damaged. One tire on the center landing gear was changed prior to the airplane departing on the return flight to EGLL.

Tests and Research

FAA Advisory Circular (AC) 150/5340-24 Runway and Taxiway Edge Lighting Systems, published in September 1975, described standards for design, installation, and maintenance of runway and taxiway lighting for airports. Appendix 2 of the AC included diagrams of acceptable methods of light arrangements. On page 3 of the appendix, two locations for placement of threshold lights are shown, both outboard and inboard of the runway edge.

In April of 2004, AC 15/5340-24 was incorporated into AC 150/5340-30, Design and Installation Details for Airport Visual Aids. This AC no longer included the diagram showing threshold lights installed outside the runway edges, except for instances where usable pavement, such as a taxiway, extended beyond the threshold. The AC was revised in April of 2005, and became AC 150/5340-30A. It was again revised in August of 2006 and was renamed AC 150/5340-30B. Neither of these revisions included the former method of installing threshold lights outboard of a runway, except when usable pavement extended beyond the threshold. It is noted that the 2004 and 2005 versions of the AC stated, "The standards contained herein are effective for all new construction. Upgrades for all future lighting systems should use this standard." There was no mention in either AC of any requirement to proactively upgrade existing installations. Page 1 of AC 150/5340-30B, stated that: "All lighting configurations contained in this standard including declared distances and yellow-green taxiway centerline lead-on lines are the only means acceptable to the Administrator and must be incorporated within 6 months after signature of this AC."

Safety Board staff asked the FAA whether or not this requirement applied to existing threshold lighting configurations, as stated in the AC. In an official response dated March 15, 2007, the FAA replied: "This change was not included in the paragraph, Principal Changes, in AC 150/5340-30 because it was not intended that existing systems be modified to conform to the new standard. This change was intended to rapidly implement new taxiway/runway intersection lighting standards, which could be accomplished in the time period specified because the change would only require changing lenses on lighting fixtures. The language, which conveyed a requirement to upgrade taxiway end lighting was inadvertently included. This could not reasonably be accomplished in six months, and it was not our intention to include such a requirement. However, after further consideration, we are currently reviewing our standards for runway end lighting and anticipate additional changes. We expect to make such changes mandatory, and will specify a reasonable compliance period."

Safety Board staff also asked the FAA how many runways in the United States had threshold lights that did not meet the current standard. The FAA replied that they "do not keep any records that indicate the number of Part 139 airports that have threshold lights not meeting the standards in AC 150/5340-30B."

It was noted that, in addition to runway 12/30, runway 8R/26L at MIA had similar threshold lights that did not meet the current standards. AC 150/5340-1J, Standards for Airport Markings, specifies that, "At taxiway intersections with runway ends, the taxiway centerline is terminated at the runway edge..." Similarly, AC 150/5340-30B stated that, "Where operations are not conducted below 1200 ft RVR, neither taxiway centerline lead-on or lead-off may be installed within the confines of the runway. Further, if the taxiway is perpendicular and dead-ends into the runway, the taxiway centerline light nearest the runway must be installed 150 feet from the centerline of the runway. Otherwise, taxiway centerline lights must not extend into the confines of the runway" Taxiway Q at MIA was configured according to the FAA standards for marking and lighting.

On March 1, 2007, MIA completed reinstallation of the threshold lights at the departure end of Runway 30. The lights were staked into the runway, and were configured per current standards outlined in AC150/5340-30B. On March 21, 2007, an inspector from the FAA Southern Region Airports Division performed an annual certification inspection of MIA. No discrepancies were noted.

NTSB Probable Cause

The flightcrew's misinterpretation of available lighting, signage, and airfield marking cues during taxi.