Taxiway Overflight Air Canada Flight 759 Airbus A320-211, C-FKCK, San Francisco, California July 7, 2017
Executive Summary
On
July 7, 2017, about 2356 Pacific daylight time (PDT), Air Canada flight
759, an Airbus A320-211, Canadian registration C-FKCK, was cleared to
land on runway 28R at San Francisco International Airport (SFO), 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 (CFR) 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.
Probable Cause
The
National Transportation Safety Board determines 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 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.