Saturday, July 22, 2017

Air Canada Pilots Reportedly Didn’t Use Normal Navigation Aids in Close Call at San Francisco: Investigators have tentatively determined the crew didn’t utilize an available instrument landing system in the July 7th approach

Air Canada flight 759, Airbus A-320, C-FKCK: Incident occurred July 07, 2017 at San Francisco International Airport (KSFO), San Francisco, California

The Wall Street Journal 
By Andy Pasztor
Updated July 21, 2017 7:55 p.m. ET


WASHINGTON—Pilots of an Air Canada jet failed to use a ground-based guidance system when they nearly landed by mistake on a taxiway at San Francisco International Airport two weeks ago, potentially coming within dozens of feet of airliners on the ground, according to people familiar with the investigation.

As more details emerge about the incident, these people said, investigators have tentatively determined the crew didn’t utilize the available instrument landing system U.S. carriers typically require pilots to rely on for precision approaches in similar circumstances. The issue hasn’t been reported before, and it isn’t known why the crew failed to call up the instrument system for backup during the visual landing prior to breaking off the approach.

In addition, the incident posed a greater hazard than initially believed to four planes filled with passengers and lined up on the taxiway to take off, because revised estimates indicate the closest separation may have been significantly less than 100 feet.

Pilots of the Airbus A320 jet, arriving from Toronto just before midnight on July 7, lined up to land on a taxiway parallel to their designated runway. They continued the approach despite one of the pilots commenting about what appeared to be unexpected lights on the tarmac in front of them.

U.S. and Canadian investigators previously said in separate statements that the jet, carrying 140 people, passed over roughly the first quarter-mile of the taxiway, descended to less than 100 feet above the ground and ended up flying over the first taxiing jet before safely climbing away.

The latest estimates peg the closest separation between 70 feet and less than 30 feet, according to two people familiar with the details, though that could change.

Nobody was hurt and Air Canada flight 759 landed safely after pulling up and circling around. But safety experts described the event as potentially catastrophic, with the A320 swooping toward three large Boeing 787s and a smaller Boeing 737 crammed with passengers before heeding a last-second instruction from a controller to climb.

The heads of Canada’s Transportation Safety Board and the U.S. National Transportation Safety Board, which is heading up the probe, declined to comment Thursday, when asked about the investigation on the sidelines of a pilot-union safety conference. The airline has said it is cooperating with investigators but declined to provide details about the incident. A spokesman for the union that represents Air Canada pilots declined to comment.

The incident is unusual partly because taxiway lights are different colors than those used universally to mark the edges and centerlines of runways. Commercial pilots consider it second nature to break off an approach and climb away from an airport if they have any suspicions a plane, vehicle or other obstruction is on the runway.

Roughly a mile from the airport, one of the pilots told the tower “I can see lights on the runway there,” and then asked for confirmation of clearance to land, according to unofficial audio of communications archived online. Moments later, after the controller confirmed there were no other planes on the runway and with the landing jet skimming over the planes on the taxiway, a pilot in one of aircraft said: “Where is this guy going? He’s on the taxiway.”


Departing and parked aircraft intersect at San Francisco International Airport on July 11. The airport is known for closely spaced runways. 


The San Francisco airport has parallel runways located unusually close to each other, and part of the cockpit confusion may have been prompted by the fact that one of those strips was closed and its lights were off, according to people familiar with the investigation. So the crew, expecting to see two sets of parallel lights, apparently mistook illumination on the taxiway for runway lights.

The pilots and the San Francisco tower controller who instructed the plane to go around for another landing attempt have been interviewed by NTSB investigators, but so far nothing has been released. The controller may have been distracted by another task after clearing the Air Canada jet to land, according to one person familiar with the details.

John Cox, an industry consultant and ex-commercial aviator who previously headed the safety organization for the union that still represents Air Canada pilots, said “confirmation bias” could have been a factor. The pilots were used to seeing parallel lighting during the approach, according to Mr. Cox, and convinced themselves what they observed conformed to that expectation.

San Francisco’s closely spaced runways are known among pilots for sometimes creating traffic delays and difficult landing approaches in low visibility, but that doesn’t seem to have been a factor this time.

Pilots landing on the wrong runway or mistakenly flying over a runway rank among the Federal Aviation Administration’s top safety issues when it comes to air-traffic control. But instances of airliners attempting to land on taxiways are rare.

In 2009, a Delta Air Lines Inc. cockpit crew mistakenly landed a big jet on a taxiway at Atlanta Hartsfield International Airport in good weather and visibility, but nobody was hurt. The mistake occurred before dawn, after a 10-hour flight from South America, and with the crew distracted by a medical issue affecting one of the pilots.

Investigators in the San Francisco incident are trying to determine, among other things, whether fatigue or distraction may have played a role.

https://www.wsj.com

The National Transportation Safety Board traveled to the scene of this incident.

Aviation Incident Preliminary Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

NTSB Identification: DCA17IA148
Scheduled 14 CFR Part 129: Foreign operation of Air Canada
Incident occurred Friday, July 07, 2017 in San Francisco, CA
Aircraft: AIRBUS 320, registration: C-FKUK
Injuries: Unavailable

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators used data provided by various sources and may have traveled in support of this investigation to prepare this aircraft incident report.

On July 7, 2017, about 2356 Pacific daylight time, Air Canada flight 759, an Airbus A-320, C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), San Francisco, California, but instead lined up on parallel taxiway C, which had four air carrier airplanes on it awaiting takeoff clearance (a Boeing 787 that was first in line followed by an Airbus A340, another Boeing 787, and a Boeing 737). The flight descended below 100 feet above the ground and initiated a go-around after overflying the first airplane on the taxiway. The flight was operating under 14 Code of Federal Regulations Part 129 as an international scheduled passenger flight from Toronto/Lester B. Pearson International Airport, (YYZ), Toronto, Canada. Night visual meteorological conditions prevailed at the time of the incident.

3 comments:

Anonymous said...

How can a pilot continue an approach when on less than a mile final to the runway directly ahead there are airplanes facing you with their lights on?

Were they just going to land despite seeing the lights directly in front of them because the guy in the tower had cleared them to land?

So much for see and avoid!

Anonymous said...

Completely unacceptable pilot error. Suggests the pilots did not familiarize themselves with the basic layout of the airport, could not distinguish between runway lights and lights on an aircraft, and failed to use available safety equipment on approach. The whole cockpit crewmembers should have their licensing yanked for good, and Air Canada's operations into SFO should be suspended until they identify the problems in their training and show they've addressed them. Says this SFO pilot and aircraft owner who doesn't want to get landed on while sitting on a taxiway.

Anonymous said...

Firing people is a very serious step but I don't see another path here....

The pilots performed at an unacceptably low level that violated the most important aspect of their responsibilities -- - safeguarding the lives of passengers.

It is widely known in aviation that complacency kills.

These pilots were complacent in not using technology available to them as backup and in making assumptions about what they would see based on earlier experiences. The controller was complacent and seems not to have noticed the problem. If these early findings are confirmed I am not comfortable with these individuals continuing in their roles. Sadly, they should all be fired or at least put through a full year of vigorous retraining at lower pay to make sure they will never repeat such a mistake again. As little as 30 feet was all that came between what happened and the potential deaths of 1,000 people. Anybody who flies needs to pause to reflect on that.

All aviation needs to be reminded--complacency kills.