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Earlier this summer, I posted a video of an Air Canada A320 that nearly crashed onto a taxiway at San Francisco International Airport. While the incident occurred over one year ago, the National Transportation and Safety Board (NTSB) has released its initial findings. Here are some excerpts from the news release:
The National Transportation Safety Board determined Tuesday an Air Canada flight crew’s lack of awareness caused the July 7, 2017, overflight of a taxiway at San Francisco International Airport.
The NTSB said in its report the misidentification of taxiway C – as the intended landing runway – resulted from the flight crew’s lack of awareness of the runway 28L closure due to their ineffective review of the notice to airmen (NOTAM) information before the flight and during the approach briefing. Although the (NOTAM) about the runway 28L closure appeared in the flight release and the aircraft communication addressing and reporting system message provided to the flight crew, the presentation of that information did not effectively convey the importance of the runway closure information and did not promote flight crew review and retention.
The probable cause cited fatigue as a contributing factor in the incident. While the flight crew’s work schedule for the incident flight complied with Canadian flight time limitations and rest requirements, the flight and duty-time and rest requirements for the captain would not have complied with US flight-time limitations and rest requirements.
As result of the investigation the NTSB issued six safety recommendations to the Federal Aviation Administration and one to Transport Canada. The recommendations address issues including the need for airplanes landing at primary airports within class B and class C airspace to be equipped with a system that alerts pilots when an airplane is not aligned with a runway surface, more effective presentation of flight operations information to optimize pilot review and retention of relevant information, a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use, and modifications to airport surface detection equipment systems to detect potential taxiway landings and provide alerts to air traffic controllers.
Wow. This potential catastrophe rests squarely on the pilots and their employer, Air Canada. The pilot were fatigued and did not review the NOTAMs prior to flight. I really cannot understand this situation. I hope to have to never write about one of these again.