Final report of Air Canada near-collision points to pilot fatigue
In the beginning of July 2017, an Air Canada Airbus A320 operating flight ACA759 had a near-miss incident at San Francisco airport, when it started landing at the wrong pathway, where four other airplanes were queuing for take-off. The final report of the United States National Transportation Safety Board (NTSB) released on September 25, 2018, states that it could have caused “the worst aviation accident in history”.
According to the report, the incident was due to the flight crew “ineffective review of notice to airmen (NOTAM) information before the flight and during the approach briefing.” The failure was mainly blamed on fatigue from both pilots and Air Canada’s “presentation of approach procedure and NOTAM information.”
Air Canada's captain was supposed to inform his airline about the San Francisco incident as early as possible. However, he did not do so because he was reportedly “very tired” and it was “very late.” The captain was awake for 19 hours and his copilot for 12 hours at the time of the incident. The NTSB calls for a change of regulation by Transport Canada to address such risk of fatigue.
The captain waited until the next day, 16 hours after the incident. At the time, the Cockpit Voice Recorder (CVR) had already been erased. The NTSB highlights the need to report dangerous situations more quickly before evidence is lost. It recommends for the CVR files to be kept for 25 hours, instead of 2 under the current regulation.
The NTSB also calls for several technical improvements. A study should be conducted to modify the signalization of a closed runway during night operations. The FAA should also collaborate with “aircraft and avionics manufacturers and software developers to develop the technology for a cockpit system that provides an alert to pilots when an airplane is not aligned with the intended runway surface.”
The incident, which occurred on July 7, 2017, at San Francisco International Airport (SFO), involved an Air Canada Airbus A320 almost colliding with four airplanes queuing for takeoff, when the plane started landing on a taxiway instead of a runway.
Air Canada flight 759 was cleared to land on runway 28R at San Francisco International Airport, but the airplane lined up on parallel taxiway C, which had four airplanes on it awaiting takeoff clearance. Air Canada flight 759 descended below 100 feet above the ground and initiated a go-around after overflying the first airplane on taxiway C.
A document previously released by the NTSB stated that the lowest point at which the plane descended was 60 feet. If both Air Canada 759 and the Philippine Airlines A340 on the taxiway were aligned, they were a mere foot away from colliding.
The footage released by the NTSB in May 2018 shows how close the plane came to a tragedy.