NTSB Finds Lessons In Near-Disaster At SFO

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The NTSB held a probable-cause hearing on Tuesday in Washington, D.C., to discuss their findings and issue conclusions and recommendations regarding the close call at San Francisco International Airport in July 2017, when an Air Canada A320 lined up on a crowded taxiway instead of the designated runway. The board found the flight crew misidentified Taxiway Charlie as the landing runway due to “a lack of awareness” that a parallel runway was closed, and also found that information provided to the flight crew by both the FAA and the airline was confusing and ineffective. Crew fatigue was cited as a contributing factor.

The FAA already has changed the operating procedures at SFO to eliminate visual approaches at night when an adjacent parallel runway is closed. “The mistakes identified in this report highlight the need for further review of approach and landing procedures,” said NTSB Chairman Robert Sumwalt. “This event could very easily have had a catastrophic outcome. The recommendations issued as a result of this investigation, if implemented, will help prevent the possibility of a similar incident from occurring in the future.”

The board recommended that the FAA should do a better job of communicating Notam information to flight crews and should find more effective ways to mark closed runways. Also, the FAA as well as aircraft and avionics manufacturers should develop systems both on the airport and in the cockpit to alert flight crews and controllers if an aircraft lines up on the wrong runway. The board also said Transport Canada should revise its current regulations to address the potential for fatigue when pilots are called from reserve duty to operate evening flights “that would extend into the pilot’s window of circadian low.”

The board’s investigation was the first time the NTSB has reported on an event in which there were no injuries and no aircraft damage, according to John DeLisi, head of the NTSB’s Office of Aviation Safety. With four airliners on the taxiway and one in the air, about 1,100 lives were potentially at risk. An abstract of the report is posted online (PDF); the full and final report will be posted on the NTSB website in several weeks.

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Comments (5)

For all those armchair pilots who immediately dumped all blame on the Air Canada pilots in this episode, think twice. The report findings once again show how a sequence of events outside the cockpit can materially contribute to an accident (or near accident).

Here the pilots on a visual approach at night drew a logical conclusion that the two lit "runways" were the parallel runways and properly chose the right hand one. Yes, they did not update their airport information to learn of the closed unlit runway, and are at fault because of that. But as the NTSB points out, there was no visual or ATC backup to let them know of the closed runway and that they were not lined up with the runway. Recognizing this, night visual approaches are now banned when one runway is closed.

Also, they were operating with or on the edge of fatigue, which dulls critical thinking (It was 3 AM Toronto time when they landed). Fortunately for all a disaster was narrowly avoided.

Posted by: CHRISTOPHER MOON | September 25, 2018 11:30 PM    Report this comment

Chris you are right. As much as we think we would never do such a thing, I have been humbled many times by mistakes I never thought I would make. Humans are fallible things no matter how smart we think we are.

I not going to cast judgement on these fellows; I'm just thankful some other astute people saw it coming and alerted them in time. As they say it's a license to learn, even at the ATP level.

Posted by: A Richie | September 26, 2018 8:41 AM    Report this comment

"there was no visual or ATC backup to let them know of the closed runway"

Was the runway closure not being advertised in the ATIS broadcast? Closures like that usually are part of the ATIS comments around here.

Posted by: David Bunin | September 26, 2018 8:42 AM    Report this comment

So true. I think many of us initially blamed the crew and didn't consider there were other significant factors. Almost every accident has a chain of events that leads up to the event.

Maybe the FAA could mandate that closed runways at major airports require flashing red X markers on the runway. Runways with the new FAROS system could also flash the PAPI and Threshold Hold Lights (THL) too. Another option would be to change the color of the runway edge lighting system to red and even flash too.

Posted by: Phil Nelson | September 26, 2018 10:58 AM    Report this comment

Currently flying trips arriving in the dark early AM at KSFO.. The airport frequently closes and opens various runways mostly during night hours to take advantage of reduced airport traffic.. Airport NOTAMS and ATIS made note of all runway closures.. Departures off of 28L and Landing 28R, both runways were fully lite up.. Even at night, with a soft light setting, the approach light system will highlight the runway..

I'm leaning towards Fatigue / Pilot & ATC Error / and poor pilot monitoring from the non-flying pilot..

Posted by: Tom O'Toole | September 26, 2018 2:33 PM    Report this comment

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