Good afternoon and welcome to the Boardroom of the National Transportation Safety Board.
I am Robert Sumwalt, and I’m honored to serve as the Chairman of the NTSB. Joining us are my colleagues on the Board: Vice Chairman Bruce Landsberg, Member Earl Weener, Member Bella Dinh-Zarr, and Member Jennifer Homendy.
Today, we meet in open session, as required by the Government in the Sunshine Act, to consider an incident in which an Air Canada Airbus A320 lined up to land on a taxiway instead of a runway at San Francisco International Airport on July 7, 2017.
When the incident pilot looked down at the airport on approach, he saw two lighted parallel surfaces. He thought he was seeing Runway 28L and Runway 28 R.
But Runway 28L had been closed less than an hour earlier for construction. What he was seeing was Runway 28R – where the flight was cleared to land – and the parallel taxiway C to its right.
A notice to airmen, or NOTAM, advised of the runway 28 Left closure. The flight crew received this information in a flight release hours before the incident, and then again in-flight before the descent from cruise altitude. The closed runway, 28 Left, was marked with a flashing white “X.”
Was it an easy mistake to make? If you are expecting to see two runways, perhaps. As we will discuss, such an expectation played a key part in this incident. However, there were differences between the runway and the taxiway as well.
As events unfolded, fortunately, no lives were lost, no passengers or crew members were injured, and no aircraft were damaged.
But there were four passenger aircraft lined up on that taxiway: two Boeing 787s, an Airbus A-340, and a Boeing 737, and the Air Canada airplane descended to a low altitude above the taxiway. The crew sensed something was not right, and they initiated a go-around over the taxiway, avoiding aircraft by very narrow margins.
I don’t want to sensationalize it, but this was a very close call.
We have oftentimes found in accident investigations that a whole chain of events must go wrong; fortunately, in this incident, the chain was eventually broken. Preventing the next accident relies on removing links from a potential accident chain at every opportunity.
This afternoon, we’ll examine several aspects of this incident.
We’ll discuss the flight crew’s fatigue, and the role it likely played in their misidentification of the intended landing surface.
We’ll examine expectation bias, and how this may have affected the crew’s perception of the airport environment. We’ll also examine the presentation and priority of the runway closure information that was provided to the flight crew.
In addition, we’ll discuss technology that could provide critical warnings both to pilots and to air traffic controllers when an airplane is not lined up with a runway surface.
Today, the NTSB staff will present the most pertinent facts and analysis found in the draft report. Our public docket, available at www.ntsb.gov, contains more than 700 pages of additional information.
Staff have pursued all avenues in order to propose findings and recommendations to the Board. We on the Board will consider this work, and then question staff to ensure that the final report, truly provides the best opportunity to enhance safety.
Now Managing Director Dennis Jones, if you would kindly introduce the staff.