New Findings Regarding Last Year’s Terrifying Incident At SFO

SFO has had a series of close calls over the past couple of years, which have caused the FAA to investigate whether the airport has systemic issues, and what can be done to prevent these issues going forward.

The most dramatic of these incidents was what happened to an Air Canada A320 flying from Toronto to San Francisco on July 7, 2017. The plane was supposed to land on runway 28R, but instead lined up with the parallel taxiway.

That taxiway happened to have four planes parked on it (three of which were “heavies”), which were missed by a matter of feet. The investigation suggested that the planes got within 50 feet of one another, which is virtually nothing.

In May the NTSB released some chilling footage of the incident, which shows just how close of a call this really was:

This had the potential to be the worst single aviation disaster in history, so thank goodness this was avoided. The incident has been under investigation until now, and the NTSB has just released details of the meeting they had yesterday regarding AC759.

There’s an eight page report that’s a very interesting read if you have the time. Here’s what they conclude is the probable cause of the incident:

The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information.

So what it largely boils down to is that the pilots were fatigued, and they didn’t fully seem to be aware of the construction going on.

What I didn’t know until now is that another plane had nearly the same issue just minutes before. ABC7News reports that Delta flight 521 landed four minutes before Air Canada 759 and got close to making the same mistake. I haven’t found data on just how close they got, though that does raise an interesting point.

So clearly it seems like this was an easy mistake to make visually, which further emphasizes the importance of the pilots having correctly processed what the NOTAMs said prior to landing.

Comments

  1. The fact that another airplane had the same problem a few minutes earlier (though they caught it much earlier) makes me really wonder about the approach lights. You can watch night-time approaches on youtube that make it look impossible to mistake the taxiway for the runway because the approach lights mark the runway so clearly.

    If the pilots thought that the approach lights that they saw for 28L, where did they think the approach lights for 28R were? Why would they think that their assigned runway would have no approach lights?

  2. Ban Air Canada from the US until they comply with fatigue standards.

    AC has lobbied the Canadian govt to keep unsafe fatigue standards because it would cost them money.

  3. One thing that hasn’t been adequately explained is how the pilots didn’t see the other aircraft on the runway. For night landings, do pilots not look out the window much and have heads down looking at instruments instead? Did the angle of approach now allow them to actually see the planes that were on the taxiway? Or were they just tired and could see the planes, but just didn’t process what they were seeing.

  4. > One thing that hasn’t been adequately explained is how the pilots didn’t see the other aircraft on the runway.

    They did. They even asked ATC to confirm runway is available

  5. Incident with Air Canada was blown up while nobody knows anything about Delta few moments earlier. Not surprising that NTSB put the blame on foreign carrier instead of local airport management.

    When nationality and sense of entitlement triumphs logic, anything is possible.

    Just like blaming foreign carrier with regards to aviation job. Funny….

  6. @smallmj The issue was that the lights for 28L were completely off, so the crew expected to see two runways and lines up for the strip on the right assuming 28L was still lit. See the expectation bias referenced in the report.

    I love all of the ‘ban them’ people of this forum. I assume the response wouldn’t be the same if it was AA or Delta.

    SFO has major operational issues that are hard to address but key. The number of incidents or near incidents speaks for itself. AC messed up, but let’s not kid ourselves by thinking it’s the only source of the problem. If we do that, then the same thing will happen to another flight (as it did for Delta) and the results may be worse.

  7. Terrifying incident? Wow… you could never be a pilot Lucky. Despite thinking you know so much about aviation. I flew jets for decades including the 744, and trust me way more scary things happen than lining up wrongly and then executing a safe go around which is always the right thing to do.

    You are the scare mongerer that continues to comment on operational incidents/ accidents that you literally know nothing about. As a professional I don’t know enough to comment. If you have a background in such and then investigate as a paid professional… then you can comment.

  8. I was building a hotel under the landing Patten for ORD for 6 months . Unreal skill landing in a Snow storm .We could barely see the plane from the top floor but landed .The planes are so complex and so automatic today it unreal .But if u lose ur flying skills which many do u run into this .

    CHEERs

  9. I just find some of these responses in the forum both ridiculous and nonsensical.

    @bsp – I don’t see how moving traffic to OAK and SJC is a solution. Really? A similar type of event could happen at SJC, they also have 2 parallel runways albeit one is used for takeoff and other for landing. Imagine at SJC that 30L is in repair and only 30R is in operation….

    @James – I find it hard to believe that you can come to the conclusion that this was a blown up story targeting a foreign carrier. While Delta made a similar mistake, they realized their error, made adjustments and landed safely. While AC continued on their approach and did not make any adjustments until ATC asked them to go around nearly missing a few planes in the process.

    @Adam – Sorry I have to disagree (and many do as well) that this was a terrifying event. The AC pilot was not aware that they were lining up on the taxiway UNTIL the pilot on UA 1 made the comment and THEN ATC asked AC to go around. If you take a close look at the video, it confirmed that the AC plane came very very close to the second plane on the taxiway. Really, this is not terrifying? Unbelievable.

  10. @Tom Standard practice for aircraft on the taxiway waiting for the runway is to keep their landing lights off. This prevents them from blinding the incoming traffic. The only lights that would be on would be their navigation lights (on the wingtips and tail) plus their anti-collision strobe which is typically on the bottom and top of the aircraft.

    What I don’t understand is why SFO doesn’t just put a big lighted X on the end of the taxiway like they do when they close the runway. It’s pretty hard to miss those when you’re flying, and it’s a standard symbol that pilots would recognize.

  11. Had a near miss on approach into Cairo last month. Was close to midnight and the horrified look on the FA face said it all. There was another aircraft on runway.

  12. Why didn’t ATC mention runway closure and no lights? This should be included in the ATIS message which all aircraft listen to for airoprt information. Includes runway in use, cloud, temp, wind, and nav aid info

  13. @AI – This honestly wouldn’t even make it into the top 5 incident reports I’ve read this month. The only reason its being discussed is because there is audio/video of it so people can see it. Now that’s something to be terrified about.

  14. @Andy – I agree with Al. It’s nice that you as a pilot wouldn’t have been terrified by this, since we rely on pilots to stay calm in these situations to avoid disaster. But to claim this is not objectively terrifying is just dumb. Hundreds of people very nearly died.

  15. Watching the video while sitting comfortably at a desk wasn’t terrifying at all to me or Andy.

    I wonder if the pilots on the taxiway felt differently…

  16. No worse than when Delta 60, a B767, landed on taxiway Mike at ATL. I was the Final controller early that morning. 5 minutes later there would have been a half a dozen planes on that taxiway.

  17. I think for the folks who find this not a terrifying situation fail to put the 2 and 2 together. By merely looking at the video, one may think that it is not a big deal that the pilot just did a go around. But if you listened to the audio, the AC pilot recognized that there seemed to be planes on the “runway” and even questioned tower about it and tower then responded that there were no planes on the runway and AC continued their approach onto the taxiway. It was not UNTIL the pilot on UA 1 said “they are on the taxiway” and then tower said “go around” before AC pulled up and did the go around. The AC just barely missed the Philippine Airlines plane by estimated 10-20 feet. Is this not terrifying??

  18. The detailed account of this incident was bone chilling. I wonder if there’s a comparison of legally minimum rest time based on country. Also, I will be interested in knowing which airlines make the use of ILS mandatory regardless of weather.

  19. Hi Lucky:

    This is indeed a bone-chilling incident. Would appreciate you do the following service for the readers here:

    1. Could you post a country by country comparison of minimum rest period for commercial pilots?

    2. Which airlines mandate the use of ILS regardless of weather condition?

    I have two upcoming transatlantic flights and was leaning towards AC…yet, after reading about this, I am not sure…just paranoid…Thanks.

  20. My role in the airplane is to sit quiet, belted in, on landing. I’ve had a couple of exciting landings, though, that make me happy we had well-rested, problem-solving pilots running the show.

    One was in CLT, when there was a plane on our landing runway that hadn’t taken off. We pulled up abruptly and circled back around. On the hotel shuttle with some flight attendants later, they told me it wasn’t that uncommon for a plane to have, say, a passenger who didn’t sit down, and takeoff got delayed, so the runway wasn’t clear, and it’s only apparent at the last moment. But they weren’t my flight attendants, and the word had gotten around pretty darned fast, so it can’t be that common.

    The other never-to-be-forgotten flight was into Sitka in a fall storm. They closed the airport the second we landed, but flying in we were up on wing, dropping altitude – first one side, then the other, bouncing around in the wind and watching huge waves crashing. Both times – applause on landing, well deserved, and both times, the pilots greeted all departing passengers and received our thanks. The Alaskan pilot had a big grin on his face, as if to say, “Best flight since ‘Nam.”

    Throw a predictable airport problem on top of that, plus fatigue? No, thanks!

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