Pilot Debrief

Airbus A320-211 near San Francisco, CA — 2017-07-08

Final reportDCA17IA148
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Date
2017-07-08
Location
San Francisco, CA, USA
Airport
SFO
Aircraft
Airbus A320-211
Registration
C-FKCK
Category
Airplane
Fatalities
0
Phase of flight
Approach

Probable cause

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 notice to airmen (NOTAM) information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew's failure to tune the instrument landing system frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in crew resource management and (2) Air Canada's ineffective presentation of approach procedure and NOTAM information.

NTSB narrative

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft incident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Incident Report number is NTSB/AIR-18/01. On July 7, 2017, about 2356 Pacific daylight time, Air Canada flight 759, an Airbus A320-211, Canadian registration C-FKCK, was cleared to land on runway 28R at San Francisco International Airport, San Francisco, California, but instead lined up with parallel taxiway C. Four air carrier airplanes (a Boeing 787, an Airbus A340, another Boeing 787, and a Boeing 737) were on taxiway C awaiting clearance to take off from runway 28R. The incident airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before starting to climb. None of the 5 flight crewmembers and 135 passengers aboard the incident airplane were injured, and the incident airplane was not damaged. The incident flight was operated by Air Canada under Title 14 Code of Federal Regulations Part 129 as an international scheduled passenger flight from Toronto/Lester B. Pearson International Airport, Toronto, Canada. An instrument flight rules flight plan had been filed. Night visual meteorological conditions prevailed at the time of the incident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Properly aligning with runway 28R instead of taxiway C could have prevented the incident.

NTSB coding

  • Wrong surface or wrong airport · Approach

Evidence available

  • Video
  • FDR / data
  • ADS-B / radar
  • 53 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 53

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