NTSB Finds Lessons In Near-Disaster At SFO


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.