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.
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