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.
We determined 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.
We made recommendations to the Federal Aviation Administration and to Transport Canada.
