An airline crew’s failure to pay attention to important pre-flight information was behind a near-miss at San Francisco International Airport on July 7, 2017.

That’s the conclusion of a National Transportation Safety Board (NTSB) report on how an Air Canada flight mistakenly lined up with a taxiway instead of the runway it was cleared to land on. Four airplanes were on that taxiway, waiting for clearance to take off.

The Air Canada flight got within 60 feet of ground level before a go-around succeeded in making it climb.

Importance of runway closure info missed

The NTSB said in its report the misidentification of taxiway C – as the intended landing runway – resulted from the flight crew’s lack of awareness of the runway 28L closure due to their ineffective review of the notice to airmen information before the flight and during the approach briefing. Although the notice to airmen about the runway 28L closure appeared in the flight release and the aircraft communication addressing and reporting system message provided to the flight crew, the presentation of that information did not effectively convey the importance of the runway closure information and did not promote flight crew review and retention.

“The mistakes identified in this report highlight the need for further review of approach and landing procedures,” said NTSB Chairman Robert L. 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.”

Fatigue contributed to mishap 

The probable cause cited fatigue as a contributing factor in the incident. While the flight crew’s work schedule for the incident flight complied with Canadian flight time limitations and rest requirements, the flight and duty-time and rest requirements for the captain would not have complied with US flight-time limitations and rest requirements.

As result of the investigation the NTSB issued six safety recommendations to the Federal Aviation Administration and one to Transport Canada.  The recommendations address issues including the need for airplanes landing at primary airports within class B and class C airspace to be equipped with a system that alerts pilots when an airplane is not aligned with a runway surface, more effective presentation of flight operations information to optimize pilot review and retention of relevant information, a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use, and modifications to airport surface detection equipment systems to detect potential taxiway landings and provide alerts to air traffic controllers.

To view the abstract of the report, which includes the findings, probable cause, and all recommendations, visit https://go.usa.gov/xPDrW.

The docket material for the Air Canada incident investigation – which contains factual reports for operations, human performance, air traffic control, aircraft performance, airport, and the flight data recorder.  The docket also contains a video that shows the overflight, as well as interview summaries, photographs and other investigative material.

The full report will be available on the NTSB website in several weeks.