OPS08IA013B
OPS08IA013B

On August 28, 2008, about 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. Both aircraft were landing on runway 29R at the Fresno-Yosemite International Airport (FAT), Fresno, California, and were under control of the FAT airport traffic control tower. Malibu 9219T was operating under visual flight rules (VFR) as a Title 14 Code of Federal Regulations (CFR) part 91 flight from John Wayne Airport (SNA) to FAT. SKW69R was a 14 CFR part 121 scheduled air carrier operating under instrument flight rules from Salt Lake City International Airport (SLC) to FAT. There were 4 crew and 42 passengers aboard the Skywest flight, and 1 pilot and 5 passengers aboard the Malibu. There were no reports of damage or injuries aboard either aircraft.

History of Flight

N9219T was operating under visual flight rules and had been receiving radar service from FAT Terminal Radar Approach Control (TRACON) as it approached the airport. The pilot contacted the tower at 2101:05 and was cleared to land on runway 29R. N9219T was approximately 8 flying miles from the runway. At that time, SKW69R was approximately 19 flying miles from the runway.

At 2103:38, the pilot of SKW69R contacted the tower, stating, "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 pilot reported the Malibu in sight and acknowledged the landing clearance. Review of radar data showed that N9219T was about 2.5 miles from the threshold, and SKW69R was about 8 miles from the threshold.

At 2104:27, the local controller told the pilot of N9219T to plan on exiting the runway at taxiway B3, and the pilot acknowledged. The aircraft was about 1.2 miles from the threshold. N9219T crossed the runway 29R threshold at 2105:19. At 2105:51, the controller instructed the pilot of N9219T to, "...turn left at the next taxiway which is B5..." and continued with further taxi instructions to the ramp. The pilot acknowledged. According to recorded radar data, N9219T was rolling past taxiway B3 at that time and SKW69R was approximately two miles from the threshold.

Radar data showed N9219T just short of taxiway B5/B6 at 2106:14. There were multiple targets for the aircraft in the vicinity of the runway 29R-B5/B6 intersection until 2107:52, when the aircraft appeared to be established southbound on taxiway B5.

SKW69R crossed the runway 29R threshold at 2106:42. At 2106:54, the local controller transmitted, "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 N9219T at 2107:07. At 2107:10, the pilot of SKW69R 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. The pilot acknowledged.

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 involved taxied to the ramp without further incident. The local controller was relieved from position at 2111.

In a report submitted to the Skywest Flight Safety department, the captain of SKW69R described the incident as follows: "Approximately 18 miles from the airport we were told to slow for traffic on a 4 mile final. We had the traffic, a Piper Malibu, in sight. The Malibu was told to plan exiting at B3. By 1000 feet we were stabilized and clear to land. About then tower told the Malibu to exit at B5 and he responded. We saw the lights of the Malibu leave the center line and exit the runway. By 500 feet both the first officer and I agreed that the aircraft was clear of the runway. While touching down we heard the tower ask the Malibu where he was. Just then we both noticed lights moving close to the edge of the runway. I continued with deployment of the thrust reversers and brought the thrust to max. As I started braking we closed in on the Malibu, and it became obvious I was not going to stop in time. The Malibu was on the left side of the runway heading 290 degrees. I steered to the right edge of the runway and passed without contact. After passing the Malibu I returned to the centerline and informed ATC that there was an aircraft still on the runway. We were given our taxi instructions and taxied to the gate. At the gate we requested the phone number to the tower."

Radar Data

Radar data for this accident was provided by FAT ATCT and was obtained from the FAT ASR-11 located on the airport.

Airport Information

This 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. Consequently, there were barricades across taxiway B6 just west of runway 29R. Although the runway 29 turnoff signs indicated that the intersection was with taxiways B5 and B6, the intersection was actually made up of runway 29R, B4, and B6. Aircraft intending to exit runway 29R and follow B5 south must first make a hard left turn on to taxiway B4 and then turn right on to B5. However, the only sign for taxiway B4 was west-facing and intended for use by aircraft landing on runway 11L. Conversations with the air traffic manager and controllers revealed that although the tower sometimes issued instructions to pilots landing on 29R to turn off on B4, controllers were not aware that the intersection was not posted for B4. They were also unaware that taxiway B5 technically did not intersect runway 29R. It appeared that the correct clearance for N9219T should have been, "Turn left on B4, join B5...", but the lack of a B4 sign would have likely rendered that confusing.

Taxiway B5 was not lit, but was lined with reflectors on both sides. The reflectors were yellow-orange, not blue.

The tower controller entered on duty with the FAA on August 30, 2006 at Fresno ATCT. He completed training in the tower 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 the radar positions in the TRACON. Before coming to the FAA, the controller had worked one year as a contract tower controller at Brown Field in San Diego, and from 2000 until 2003 was a controller in the US Navy at Meridian, Mississippi, providing tower and GCA services.

In the period leading up to the incident, the controller was controller-in-charge (CIC) of the tower cab, working with a second controller who was handling all other positions in the tower except for CIC. They were the only persons in the tower cab. The CIC elected to release the second controller for a break, and took over all positions by himself. The second controller left the cab after the required relief briefing and two minute overlap. Traffic was very light. The runway incursion occurred about 18 minutes after the second controller was relieved. Malibu 19T checked in on a 10 mile final. The controller cleared the aircraft to land on runway 29R. He stated that when aircraft are switched to the tower by the approach control they just call; there was no handoff procedure required. When N9219T was on approximately 2 mile final, Skywest 69R checked in on 6 mile final. The Skywest pilot stated that he was slowing down. The controller pointed out the Malibu traffic to follow, and the Skywest pilot acknowledged. The controller said he recognized that the spacing between the two aircraft could be tight, so he instructed the pilot of the Malibu to expect to turn off at taxiway B3. The pilot acknowledged.

After the Malibu landed, the controller noticed that the aircraft had missed the turn off at B3. He instructed the pilot to turn left on the next taxiway, B5. The controller saw the aircraft heading southbound across runway 29R and thought that it was clear of the runway. The Skywest aircraft landed shortly afterward, perhaps one minute later. The controller stated that he looked at the Malibu two or three times after it landed but before Skywest landed. Each time the aircraft appeared to be headed southbound and clear of the runway. The Malibu was still facing southbound when Skywest 69R passed behind it.

Asked if he had ever seen another aircraft turn off at B5 at night, the controller said he recalled only one other time; a Tomahawk had turned off there during the previous week. The pilot appeared to have no difficulty locating taxiway B5. As part of his initial training at Fresno, the controller did receive an airfield tour but it included only the taxiways and did not include the intersection where this incident occurred.

The controller was asked about his original decision to release the second controller for a break and take over all positions on his own. Review of position documentation showed that the second controller had only been on position for 38 minutes and was scheduled to go off duty at 2200. There appeared to be no compelling reason to go to a single controller operation. The controller stated that he was, "...trying to be a nice guy." He added that he would not make that mistake again. He also noted that management instructions are to keep two controllers on duty in the cab as much as possible, and that he was aware of that at the time. Because of staffing constraints, it was common for the tower to run a single controller operation for the first 60 to 90 minutes of the day shift and the last 60 to 90 minutes of the evening shift. Midnight shifts were routinely staffed by one controller in the tower and one in the approach control.

The controller could not recall ever being told during his training that an aircraft technically cannot turn left on taxiway B5 from runway 29R. He was unaware of any procedural changes or other instructions issued by tower management after the incident occurred because he has not worked since then.

Asked about the use of binoculars in the tower, the controller stated that he used them every day, sometimes to observe runway turnoffs. However, he did not use binoculars during the incident involving Skywest and the Malibu.

The pilot of N9219Twas interviewed via telephone, and provided the following information in response to questions:

The pilot held a private pilot license with Airplane - Single Engine Land and Instrument ratings. He had approximately 1,770 hours of flight experience, and had been to FAT ten to twelve times before this flight. In the period leading up to his incident he flew about ten to twenty hours a month. He estimated that about 30 percent of his total flight hours were at night. His last night trip to FAT was about 3 months before the incident flight. He stated that in the past he had usually landed on runway 29L, and he did not recall ever having used taxiway B5 before. He did not have a taxi chart out for use after landing.

The pilot stated that he was cleared to land on runway 29R, and was unable to turn off on taxiway B3. The aircraft was fairly heavy, with six occupants, and that may have contributed to slower than normal deceleration, but he was unable to cite any other specific reason for missing the turnoff. He continued to B5, and made a 90 degree left turn from about the centerline of the runway. As he approached the edge of the runway, he saw only dirt ahead so he turned right to track along the edge until reaching the exit. He believed that the aircraft's nose wheel was near the edge line. When he reached the exit, he turned left off the runway.

The pilot was aware that there was another aircraft cleared to land on runway 29R, and while he was looking for the turnoff he considered going off the paved surface into the dirt. He did not advise the tower that he was having difficulty finding the turnoff. Once he saw the reflectors along B5, he knew he had found the proper taxiway.

Since the incident, the pilot discussed the event with both the air traffic manager at Fresno ATCT and FAA Flight Standards personnel.

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