- Date
- July 7, 2017, 23:56 local (Jul 8, 2017, 06:56 UTC)
- Place
- San Francisco, CA
- Damage
- No damage
- Phase of flight
- Approach
- Aircraft
- C-FKCKAirbus A320-211
- Defining event
- Approach: Wrong surface or wrong airport
- Weather
- Visual (VMC) · Night/dark
- Status
- Completed · report October 26, 2018
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- NTSB office
- Major Investigations Division
- Safety recommendations
- Yes
- Case key
- 95528
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.
On this page
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.
Findings · 11
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
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.
Factual narrative
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.
Aircraft
- Registration
- C-FKCK
- Reported as
- Airbus A320-211 (211)
- Category
- Airplane
- Serial number
- 265
- Built
- 1992
- Airframe hours
- 82,427
- Engines
- CFM CFM56-5A1, 25,000 lbs thrust, turbo fanCFM CFM56-5A!, 25,000 lbs thrust, turbo fan
- Damage
- No damage
- Flight
- Part 129
- Operator
- Air Canada
- Registered owner
- Air Canada
- Airworthiness certificate
- Standard, Transport
- Last inspection
- AAIP · June 25, 2017
- Departed
- YYZ · Toronto, OF
- Destination
- SFO · San Francisco, CA
- Flight plan
- IFR
- Airport
- SFO · San Francisco International, runway 28R, 11,870 × 200 ft, asphalt
- Equipment
- Electronic multifunction display, Data recorder, Auto-pilot, Stall warning system, Onboard weather, Electronic primary flight display
Weather
- Conditions
- Visual (VMC) · Night/dark
- Wind
- 290° at 9 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 61 °F, dew point 48 °F
- Altimeter
- 29.92 inHg
Docket · 53
The files NTSB released with the investigation on May 2, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 116 MB in all.