Authorities investigating a near miss at San Francisco have said the incident was probably caused by “the flight crew’s misidentification of Taxiway C as the intended landing runway.” Air Canada flight 759, operated by Airbus A320-211 C-FKCK (c/n 265), was inbound from Toronto shortly before midnight on July 7, 2017 when it was ordered by air traffic control to abort its visual approach. The aircraft, which had mistakenly lined up with the parallel Taxiway C rather than Runway 28R, subsequently descended to less than 100ft, overflying a Boeing 787 and three other aircraft lined up on the taxiway, before the go-around was initiated.
Publishing its final report on the incident the National Transportation Safety Board (NTSB) said the Airbus reached a minimum altitude of around 60ft before starting to climb. The 140 passengers and crew aboard the Air Canada jet were uninjured and there was no damage to the five aircraft.
The investigation determined 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 crew’s 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.”
The NTSB added that situation had been exacerbated by closure of the parallel Runway 28L, which was not lit at the time and was correctly identified with a flashing white ‘X’ placed at the threshold. This, the authority noted, “would not have been in the flight crew’s direct field of view because the ‘X’ was oriented toward the Runway 28L final.” It continued: “Because the flight crew either did not review or could not recall the information about the Runway 28L closure, they expected to see two parallel runways while on approach to SFO and further expected that they would need to fly the approach to the right-side surface. The flight crew’s recent experience flying into SFO would have reinforced these expectations.”
The report identified the “the crew’s failure to tune the instrument landing system frequency to provide backup lateral guidance [as mandated by the carrier], expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in crew resource management” as contributing factors.