Air Canada Flight 759
C-FKCK, the aircraft involved in the near-miss, in November 2019
Near-miss incident
DateJuly 7, 2017 (2017-07-07)
SummaryNear collision on final approach at night
SiteSan Francisco International Airport
37°36′58″N 122°21′34″W / 37.61611°N 122.35944°W / 37.61611; -122.35944
Aircraft
Aircraft typeAirbus A320-211
OperatorAir Canada
IATA flight No.AC759
ICAO flight No.ACA759
Call signAIR CANADA 759
RegistrationC-FKCK
Flight originToronto Pearson International Airport, Mississauga, Ontario, Canada
DestinationSan Francisco International Airport, San Francisco, California, U.S.
Occupants140
Passengers135
Crew5
Fatalities0
Injuries0
Missing0
Survivors140

On July 7, 2017, an Airbus A320-211 operating as Air Canada Flight 759 was nearly involved in an accident at San Francisco International Airport in San Mateo County, California, United States. The flight, which originated at Toronto Pearson International Airport, had been cleared by air traffic control to land on runway 28R and was on final approach to land on that runway; however, instead of lining up with the runway, the aircraft had lined up with the parallel taxiway, on which four fully loaded and fueled passenger airplanes were stopped awaiting takeoff clearance. The flight crew initiated a go-around prior to landing, after which it landed without further incident. The aircraft on the taxiway departed for their intended destinations without further incident.[1][2][3][4] The subsequent investigation by the National Transportation Safety Board (NTSB) determined that the Air Canada airplane descended to 59 feet (18 m) above the ground before it began its climb, and that it missed colliding with one of the aircraft on the taxiway by 14 feet (4.3 m).

The NTSB determined the probable cause was the Air Canada flight crew's confusion of the runway with the parallel taxiway, with contributing causes including the crew's failure to use the instrument landing system (ILS), as well as pilot fatigue. A retired pilot stated the runway confusion that almost happened "probably came close to the greatest aviation disaster in history"[2][3][4][5] as five airplanes and potentially over 1,000 passengers were at imminent risk of a disaster greater than the Tenerife airport disaster.

Incident

Diagram of Runway 28R and Taxiway C at SFO. AC759 mistakenly lined up to land on Taxiway C, shown with the dotted blue line, instead of Runway 28R, shown with the dashed white line, before being ordered to abort the landing.

At 11:46 p.m. local time, Air Canada Flight 759, carrying 135 passengers and 5 crew members,[4] was cleared to land on Runway 28R. The adjacent Runway 28L had been closed at 10 p.m. local time and its lights were off,[6] except for a 20.5-foot-wide (6.2 m) lighted flashing "X" at the eastern runway threshold.[7] The captain was flying the aircraft and the first officer was monitoring.[7] The two pilots of AC759 acknowledged that they mistook runway 28R for 28L and therefore lined up for landing on the parallel taxiway C,[2][7][8][9] even though runways and taxiways are lit with different colors and intensities.[6] Preliminary post-event investigation results noted that Runway 28R and Taxiway C were lit on default settings (in different colors), and the automatic terminal information service broadcast information was current and advised that 28L was closed and unlit.[7] According to preliminary Transportation Board investigation results, as the weather was clear, the pilots of AC759 were not required to utilize the instrument landing system and relied instead on a visual approach, as typical for the prevailing conditions.[10]

Taxiway C contained four airplanes, three from United Airlines and one from Philippine Airlines, queueing for takeoff.[1] At 11:55:46 p.m. local time, upon spotting aircraft lights approximately 0.7 miles (1.1 km) from the runway, the AC759 pilot asked the tower if he was clear to land on 28R, to which the air traffic controller responded at 11:55:56 p.m., "There's no one on 28R but you,"[1][3][11] when AC759 was approximately 0.3 miles (0.48 km) from the runway threshold.[12] The AC759 pilots "did not recall seeing aircraft on Taxiway C, but something did not look right to them" according to a post-incident interview summary.[7] The crew of Philippine Airlines 115 (PR115) turned on their landing lights to alert AC759 they were lined up on the taxiway.[13][12] The pilot of United Airlines 1 (UA001), the first in line for takeoff, interrupted the radio traffic at 11:56:01 p.m. and asked "Where is this guy going? He's on the taxiway."[1][3] The air traffic controller then ordered AC759 to abort the landing at 11:56:10 p.m. After AC759 acknowledged the go-around, the air traffic controller stated, "It looks like you were lined up for Charlie [Taxiway C] there."[1][3] AC759 had already started to climb before the go-around order.[12]

Afterwards, the pilot of UA001 radioed the tower saying, "Air Canada flew directly over us," and the air traffic controller responded, "Yeah, I saw that, guys."[1] During the first approach, AC759 flew for 1⁄4 mile (0.40 km) over Taxiway C, descended to an altitude as low as 81 feet (25 m) and approached as close as 29 feet (8.8 m) laterally to the four airplanes waiting on Taxiway C before being ordered to abort the landing.[11][14][15] According to the flight data recorder, the pilots advanced the thrust levers when the airplane was 85 feet (26 m) above the ground. The airplane descended as low as 59 feet (18 m), approximately 2.5 seconds after the thrust levers had been advanced.[7] Following a reconstruction of events, one pilot not involved in the incident noted that had the crew waited five more seconds before pulling up, it would have collided with the third airplane (UAL 863) on the taxiway.[15] There was also less than 10 to 20 feet (3.0 to 6.1 m) separation between the bottom of the Air Canada aircraft and the tail of the Philippine Airlines A340.[16]

SFO was the first airport in the United States to install an Airport Surface Surveillance Capability (ASSC) system,[17] which should have alerted the tower of a potential conflict between runway and taxiway movements.[10] AC759 disappeared from the local controller's ASSC display for twelve seconds, between 11:55:52 and 11:56:04 p.m. local time (from shortly after the AC759 pilot asked for confirmation that 28R was clear, to the time the UA001 pilot noted that AC759 was lined up for Taxiway C), as AC759 was too far off-course from 28R.[12]

AC759 completed its go-around and landed without incident after the second approach.[1] A single air traffic controller was monitoring ground and tower frequencies, which would typically be handled by two controllers.[10][12]

Aircraft

The aircraft flying AC759 that night was C-FKCK, an Airbus A320-200.[11][18] The aircraft was 24.5 years old on the day of the incident, first flying in December 1992.[19]

N62895, the Boeing 737-900ER involved as flight UAL 1118
RP-C3441, the Airbus A340-300 involved as flight PAL 115
N29961, the Boeing 787-9 involved as flight UAL 1
N13954, the Boeing 787-9 involved as flight UAL 863
Aircraft and flights involved in the incident[15][20]
AirlineFlight #AircraftCapacityRegistrationOriginDestination
Air CanadaACA 759Airbus A320-200146C-FKCK Toronto San Francisco
United AirlinesUAL 1Boeing 787-9252N29961 San Francisco Singapore
Philippine AirlinesPAL 115Airbus A340-300254RP-C3441 Manila
United AirlinesUAL 863Boeing 787-9252N13954 Sydney
United AirlinesUAL 1118Boeing 737-900ER179N62895 Cancún

Investigation

The incident was not considered reportable under then-current federal regulations,[21] but former NTSB chairman Jim Hall called it "the most significant near-miss we've had in this decade" and urged the NTSB to re-evaluate those reporting requirements.[22] The United States National Transportation Safety Board (NTSB) was informed of the incident on July 9, and took the lead on the investigation, with assistance from the Federal Aviation Administration (FAA). The Transportation Safety Board of Canada (TSB) served as a facilitator to convey information between Air Canada and the NTSB.[4] TSB released preliminary information from Occurrence No. A17F0159 on July 11, 2017.[11][18] NTSB assigned identification number DCA17IA148 to the incident.[23]

A retired pilot stated that SFO requires "precision flying" as the two runways (28R and 28L) are laterally separated by 750 feet (230 m), and Taxiway C is separated from 28R by less than 500 feet (150 m).[24] Other pilots pointed out that some airlines require all aircraft to use the instrument landing system (ILS) regardless of weather or visibility, which would have led the crew to realize that they were not lined up with runway 28R.[2] Dave Jones, then California Insurance Commissioner and a passenger on AC759, wrote a letter to Air Canada a week after the incident requesting their cooperation with the investigation.[6][15]

Preliminary NTSB investigation results from flight data recorder telemetry, released on August 2, 2017, indicate that AC759 reached a minimum altitude of 59 feet (18 m) above ground level, comparable to the 55 ft 10 in (17.02 m) tail height of a Boeing 787-9, two of which were on Taxiway C.[7][25] The cockpit voice recorder had been overwritten before the investigation was launched,[12] as C-FKCK flew three more flights on July 8 before the NTSB was informed of the near-miss on July 9.[22]

Final stages

In a September 25, 2018, board meeting, the NTSB cited as probable cause the pilots mistaking taxiway C for runway 28R due to overlooking the closure of runway 28L in the NOTAM report. Contributing factors included not taking advantage of the ILS, which was not in use by the flight crew, in the flight management system (FMS) visual approach; and pilot fatigue. The crew's body clock was at the Toronto 03:00 Eastern Time: the first officer had no significant rest for 12 h, and the captain for 19 h – he would not have been able to fly under US pilot fatigue rules. Transport Canada planned to bring its pilot rest rules in line with international standards later in 2018.[26] New regulations were announced in December 2018, closer to international standards but criticized as substandard by the Air Canada Pilots Association.[27]

The Federal Aviation Administration (FAA) received six recommendations: identifying approaches requiring an unusual manual frequency input; displaying it noticeably on aeronautical charts; reviewing NOTAMs to prioritize and present relevant information; requiring aircraft landing in B or C airspace to alert pilots when not aligned with a runway; modifying airports to alert on collision risks and clearly showing closed runways, as construction lighting on 28L looked like ramp lighting.[26]

Air Canada is simplifying its SFO approach charts and includes SFO-specific training in aircraft simulators, trains its staff to reduce expectation bias, and will retrofit new aircraft like the Airbus A220 and Boeing 737 Max with dual head-up displays to enhance situational awareness in low-visibility, high-risk approaches.[26]

The NTSB published their final report in September 2018; five recommendations were made.[16]

As the pilots were slow to report the incident, the airplane had made another flight and the cockpit voice recording was recorded over. The NTSB has stated that it wants faster incident reporting and considers recommending capturing the last 25 hours, an increase from two hours.[28]

A former NTSB investigator observed deficiencies in the investigation, criticizing the board for avoiding introspection and indicating that it is more reactive than proactive. The report faults Air Canada for reporting too late and erasing the voice record, but notes that the NTSB only requires notification when an aircraft lands or departs on a taxiway, or when a collision is avoided after a runway incursion, and neither happened. It also dismisses a comparable taxiway mishap in Seattle-Tacoma by Alaska Airlines (Flight 27) in December 2015, that was still in the preliminary investigation stage at the time (NTSB assigned identification number DCA16IA036 to the incident).[29][30]

The recommendation to improve the NOTAM system led to an ICAO initiative to reform it. Robert Sumwalt, Chairman of the NTSB, described NOTAMs as "a bunch of garbage that nobody pays any attention to".[31]

Aftermath

Following the incident, in early August the Federal Aviation Administration modified nighttime landing procedures at SFO, forbidding visual approaches at night "when an adjacent parallel runway is closed" and replacing them with instrument approaches, either ILS or satellite-based, and requiring two air traffic controllers in the control tower "until the late-night arrival rush is over".[32]

As of December 2023, Air Canada no longer uses flight number 759 on its Toronto to San Francisco flights, instead they use four different flight numbers for the route. Flight number AC737 is used for the morning flight, flight numbers AC741 and AC743 are used for the afternoon flights, and the flight number AC745 is used for the evenings. Additionally, Air Canada only uses the Airbus A320 on the morning flights, while the two afternoon flights uses the Boeing 737 MAX and the evening flight uses the Airbus A220 instead.[33][34][35][36]

See also

References

  1. 1 2 3 4 5 6 7 Gafni, Matthias (July 10, 2017). "Exclusive: SFO near miss might have triggered 'greatest aviation disaster in history'". San Jose Mercury News. Retrieved July 18, 2017.
  2. 1 2 3 4 Gafni, Matthias (July 11, 2017). "SFO near-miss: Air Canada flight got 'extremely close' to planes on taxiway, pilot on ground alerted tower, averted disaster". San Jose Mercury News. Retrieved July 18, 2017.
  3. 1 2 3 4 5 Levenson, Eric; Chan, Stella; Hassan, Carma; Ostrower, Jon (July 11, 2017). "Air Canada plane nearly lands on a crowded taxiway at San Francisco airport". CNN. Retrieved July 18, 2017.
  4. 1 2 3 4 Spurr, Ben; Howells, Laura (July 11, 2017). "'Close to the greatest aviation disaster in history:' Air Canada pilot almost lands on busy taxiway". The Star. Retrieved July 18, 2017.
  5. ↑ Dangerfield, Katie (July 11, 2017). "Air Canada plane almost lands on crowded taxiway at San Francisco airport". Global News Canada. Retrieved July 18, 2017.
  6. 1 2 3 Gafni, Matthias (July 12, 2017). "'11 seconds to impact': Expert calculates how close SFO near-miss was to disaster". San Jose Mercury News. Retrieved July 18, 2017.
  7. 1 2 3 4 5 6 7 "NTSB Issues Investigative Update on San Francisco Airport Near Miss" (Press release). National transportation Safety Board. August 2, 2017. Retrieved August 3, 2017.
  8. ↑ Croft, John (August 4, 2017). "NTSB: SFO Runway Lighting Confused Air Canada Pilots". Aviation Daily. Retrieved August 16, 2017.
  9. ↑ Rapoport, Geoff (August 5, 2017). "Air Canada Flight Misses By Four Feet". AVweb. Retrieved August 16, 2017.
  10. 1 2 3 Gafni, Matthias (July 21, 2017). "SFO close call: Air Canada pilot was not using guidance system, source says". San Jose Mercury News. Retrieved July 22, 2017.
  11. 1 2 3 4 Gafni, Matthias (July 13, 2017). "Officials: Air Canada plane flew for a quarter-mile over taxiway before anyone noticed". San Jose Mercury News. Retrieved July 18, 2017.
  12. 1 2 3 4 5 6 "Landing Approach to Taxiway at San Francisco International Airport". National Transportation Safety Board. August 2, 2017. Retrieved August 3, 2017.
  13. ↑ Tucker, Jill (August 17, 2017). "Changes made at SFO after Air Canada jet's close call". San Francisco Chronicle. Retrieved August 18, 2017.
  14. ↑ Croft, John (July 14, 2017). "TSB: Air Canada A320 Overflew Four Aircraft". Aviation Daily. Retrieved August 16, 2017.
  15. 1 2 3 4 Gafni, Matthias (July 17, 2017). "NTSB: Air Canada close-call at SFO was even worse than first reported". San Jose Mercury News. Retrieved July 18, 2017.
  16. 1 2 "Taxiway Overflight Air Canada Flight 759 Airbus A320-211, C-FKCK San Francisco, California, July 7 2017" (PDF). National Transportation Safety Board. September 25, 2018.
  17. ↑ Schofield, Adrian (January 12, 2012). "FAA Extends Surveillance System To Nine Airports". Aviation Week. Archived from the original on July 29, 2017. Retrieved July 22, 2017.
  18. 1 2 Occurrence No.: A17F0159 (Report). Transportation Safety Board of Canada, ASIS. July 11, 2017. Retrieved July 18, 2017.
  19. ↑ "C-FKCK Air Canada Airbus A320-200". Planespotters.net. Retrieved September 8, 2017.
  20. ↑ Air Canada A320 nearly lands on taxiway! Close Call at SFO on YouTube
  21. ↑ 49 CFR 830.5
  22. 1 2 Gafni, Matthias (August 9, 2017). "'Critical' evidence in near air-disaster at SFO erased". San Jose Mercury News. Retrieved August 16, 2017.
  23. ↑ "NTSB Identification: DCA17IA148". National Transportation Safety Board. July 2017. Retrieved July 19, 2017.
  24. ↑ Riva, Nicole (July 11, 2017). "Air Canada plane avoids disaster in San Francisco". Canadian Broadcasting Corporation. Retrieved July 18, 2017.
  25. ↑ 787 Airplane Characteristics for Airport Planning (PDF) (Report). Boeing Commercial Airplanes. December 2015. Retrieved August 3, 2017. Document Number D6-58333, Revision L
  26. 1 2 3 Ghim-Lay Yeo (September 25, 2018). "Pilot error behind Air Canada A320 near-miss at San Francisco". FlightGlobal.
  27. ↑ Harris, Kathleen; Thibedeau, Hannah (December 12, 2018). "'Profoundly disappointed': Pilots call new safety rules to address flight fatigue 'substandard'". CBC News. Retrieved December 19, 2018.
  28. ↑ David Koenig (October 12, 2018). "Safety officials want faster reporting of aviation incidents". The Associated Press.
  29. ↑ William Tuccio (November 8, 2018). "Opinion: When A Near-Accident Requires Deeper Investigation". Aviation Week & Space Technology.
  30. ↑ Hradecky, Simon (December 29, 2015). "Incident: Alaska B739 at Seattle on Dec 19th 2015, landed on taxiway". The Aviation Herald.
  31. ↑ Freed, Jamie (April 28, 2021). "'Bunch of garbage': Campaign to ease pilot overload from antiquated safety warnings". Reuters. Retrieved June 15, 2022.
  32. ↑ Jon Hemmerdinger (August 17, 2017). "FAA changes San Francisco landing procedures after A320 near miss". Flightglobal.
  33. ↑ "AC737 (ACA737) Air Canada Flight Tracking and History". FlightAware. Retrieved December 15, 2023.
  34. ↑ "AC741 (ACA741) Air Canada Flight Tracking and History". FlightAware. Retrieved December 15, 2023.
  35. ↑ "AC743 (ACA743) Air Canada Flight Tracking and History". FlightAware. Retrieved December 15, 2023.
  36. ↑ "AC745 (ACA745) Air Canada Flight Tracking and History". FlightAware. Retrieved December 15, 2023.

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