DCA17IA148

NTSB incident investigation · Airbus A320-211 · San Francisco, CA · July 8, 2017

Incident · No injuriesClass 1 · IncidentFinal report
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.

Info processing/decision: identification/recognitionPersonnel issues › Action/decision · Flight crewAll aircraft: 559 casesProbable cause
Airport facilities/design: runway/landing area conditionEnvironmental issues › Operating environment · Awareness of conditionAll aircraft: 61 casesProbable cause
Use of equip/info: use of available resourcesPersonnel issues › Task performance · Flight crewAll aircraft: 41 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Flight crewAll aircraft: 1,391 casesProbable cause
Info processing/decision: expectation/assumptionPersonnel issues › Action/decision · Flight crewAll aircraft: 51 casesProbable cause
Alertness/Fatigue: circadian rhythms or jetlagPersonnel issues › Physical · Flight crewAll aircraft: 9 casesProbable cause
Alertness/Fatigue: lack of sleepPersonnel issues › Physical · Flight crewAll aircraft: 26 casesProbable cause
Communication (personnel): cRM/MRM techniquesPersonnel issues › Task performance · Flight crewAll aircraft: 26 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · OperatorAll aircraft: 106 casesProbable cause
Navigation systemAircraft › Aircraft systems · DesignAll aircraft: 13 cases

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.

Security Camera Video FileItem 1 · .PDF · 35 KBOperational Factors/Human Performance Factual ReportItem 2 · .PDF · 10.2 MBOperational Factors/Human Performance Group - Attachment 1 - Flight Crew Interview SummariesItem 3 · .PDF · 565 KBOperational Factors/Human Performance Group - Attachment 2 - Air Canada Personnel InterviewsItem 4 · .PDF · 613 KBOperational Factors/Human Performance Group - Attachment 3 - Airplanes on Taxiway C Crew StatementsItem 5 · .PDF · 470 KBOperational Factors/Human Performance - Attachment 4 - Preceding Flight Crew StatementItem 6 · .PDF · 219 KBOperational Factors/Human Performance Group - Attachment 5 - Dispatch ReleaseItem 7 · .PDF · 272 KBOperational Factors/Human Performance Group - Attachment 6 - ACARS Traffic LogItem 8 · .PDF · 278 KBOperational Factors/Human Performance Group - Attachment 7 - FAA NOTAMS for SFOItem 9 · .PDF · 98 KBOperational Factors/Human Performance Group - Attachment 8 - Ramp Reconciliation ReportItem 10 · .PDF · 120 KBOperational Factors/Human Performance Group - Attachment 9 - Canadian ATP RequirementsItem 11 · .PDF · 212 KBOperational Factors/Human Performance Group - Attachment 10 - Air Canada Pilots Contractual Pairing and Reserve RulesItem 12 · .PDF · 247 KBOperational Factors/Human Performance Group - Attachment 11 - SFO Runway 28R Approach ChartsItem 13 · .PDF · 1.7 MBOperational Factors/Human Performance Group - Attachment 12 - Route Briefing - The Americas [Excerpt]Item 14 · .PDF · 420 KBOperational Factors/Human Performance Group - Attachment 13 - Air Canada Threat Briefing Reference CardItem 15 · .PDF · 349 KBOperational Factors/Human Performance Group - Attachment 14 - Air Canada Nav Tuning GuidanceItem 16 · .PDF · 231 KBOperational Factors/Human Performance Group - Attachment 15 - Air Canada Non-Precision Approach ProcedureItem 17 · .PDF · 3.9 MBOperational Factors/Human Performance Group - Attachment 16 - Air Canada's Simulator EvaluationItem 18 · .PDF · 873 KBOperational Factors/Human Performance Group - Attachment 17 - QRH Normal - Controlled Rest on the Flight DeckItem 19 · .PDF · 112 KBOperational Factors/Human Performance Group - Attachment 18 - Canadian Aviation Regulations Advisory Council on Flight Crew Fatigue ManagementItem 20 · .PDF · 755 KBOperational Factors/Human Performance Group - Attachment 19 - Incidient Crew Schedule Preceding 90 DaysItem 21 · .PDF · 374 KBOperational Factors/Human Performance Group - Attachment 20 - Incident Crew Training RecordsItem 22 · .PDF · 3.0 MBOperational Factors/Human Performance Group - Attachment 21 - NTSB Email Correspondence with Air Canada Regarding ACARS, CRM Training, and Fatigue PoliciesItem 23 · .PDF · 904 KBOperational Factors/Human Performance Group - Attachment 22 - Previous Captain and Duty Pilot Interview SummariesItem 24 · .PDF · 102 KBOperational Factors/Human Performance Group - Attachment 23 - North Platte Neberaska Weather Radar DataItem 25 · .PDF · 129 KBOperational Factors/Human Performance Group - Attachment 24 - Air Canada Autopilot LimitationItem 26 · .PDF · 141 KBOperational Factors/Human Performance Group - Attachment 25 - Air Canada Email on Captains Reserver Duty DayItem 27 · .PDF · 314 KBOperational Factors/Human Performance Group - Attachment 26 - Email from HoneywellItem 28 · .PDF · 415 KBOperational Factors/Human Performance Group - Attachment 27 - Only Manual Tuned Approach for A320Item 29 · .PDF · 175 KBOperational Factors/Human Performance - Errata 1Item 30 · .PDF · 24 KBAir Traffic Control Factual ReportItem 31 · .PDF · 912 KBAir Traffic Control Factual Report - Erratum and AddendumItem 32 · .PDF · 48 KBAir Traffic Control Factual Report - Attachment 1 Interview SummariesItem 33 · .PDF · 142 KBAir Traffic Control Factual Report - Attachment 2 Previous Safety RecommendationsItem 34 · .PDF · 344 KBAir Traffic Control - Attachment 3 - Mandatory Occurence ReportItem 35 · .PDF · 887 KBAir Traffic Control - Attachment 4 - Daily Record of Facility OperationsItem 36 · .PDF · 720 KBAir Traffic Control - Attachment 5 - Radar DataItem 37 · .PDF · 684 KBAir Traffic Control - Attachment 6 - Position LogsItem 38 · .PDF · 720 KBAir Traffic Control - Attachment 7 - Memorandum For Combining PositionsItem 39 · .PDF · 111 KBAir Traffic Control - Attachment 8 - Memorandum For The Record ASDE-X Testing At SEAItem 40 · .PDF · 755 KBFlight Data Recorder Specialist's Factual Report Attachment 1Item 41 · .CSV · 66.7 MBAircraft PerformanceItem 42 · .PDF · 1.8 MBFlight Data Recorder Specialist's Factual ReportItem 43 · .PDF · 2.7 MBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 44 · .PDF · 1.3 MBAirports Specialist ReportItem 45 · .PDF · 1.9 MBAirports - Attachment 1 - SFO Airport Inspection LogsItem 46 · .PDF · 213 KBAirports - Attachemnt 2 - SFO Airport Lighting LogsItem 47 · .PDF · 4.0 MBAircraft Performance ErratumItem 48 · .PDF · 20 KBAircraft Performance Erratum 2Item 49 · .PDF · 69 KBParty SubmissionItem 50 · .PDF · 1.3 MBHoneywell EGPWS Smart Landing Simulation ReportItem 51 · .PDF · 297 KBCorrespondenceItem 52 · .PDF · 178 KBNTSB - Adopted Board Report, AIR-18/01Item 53 · .PDF · 3.4 MB