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DCA17IA148

2017-07-07 · San Francisco, California, United States · None · 1 aircraft · Status: Completed

Airport SFO

Aircraft involved

Probable cause & findings

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.

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. 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.   Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

  • C Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Flight crew
  • C Environmental issues-Operating environment-Airport facilities/design-Runway/landing area condition-Awareness of condition
  • C Personnel issues-Task performance-Use of equip/info-Use of available resources-Flight crew
  • F Personnel issues-Task performance-Use of equip/info-Use of equip/system-Flight crew
  • F Personnel issues-Action/decision-Info processing/decision-Expectation/assumption-Flight crew
  • F Personnel issues-Physical-Alertness/Fatigue-Circadian rhythms or jetlag-Flight crew
  • F Personnel issues-Physical-Alertness/Fatigue-Lack of sleep-Flight crew
  • F Personnel issues-Task performance-Communication (personnel)-CRM/MRM techniques-Flight crew
  • F Organizational issues-Management-Policy/procedure-Adequacy of policy/proc-Operator
  • — Aircraft-Aircraft systems-Navigation system-(general)-Design
  • — Aircraft-Aircraft systems-Indicating/recording systems-Data recorders (flight/maint)-Capability exceeded

Verbatim from NTSB's published report. Source file NTSB_2017_DCA17IA148.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

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