Changes Are Being Made At SFO Following Last Month’s Close Call

On Friday, July 7, 2017, an Air Canada flight had an incident at SFO. The A320 was flying from Toronto to San Francisco, and accidentally lined up with the taxiway instead of the runway. To make matters worse, there were four planes on the taxiway that were waiting to take off (a United 787 headed to Singapore, a Philippine Airlines A340 headed to Manila, a United 787 headed to Sydney, and a United 737 headed to Orlando), so you can imagine how much fuel they had.

The Air Canada pilots were clearly confused. On final approach they asked air traffic control to confirm that the runway was clear, because they saw lights on it. Air traffic control confirmed the runway was clear. The Air Canada plane only realized it was about to land on the taxiway when the pilots of one of the planes waiting for takeoff told ATC what was going on. Days after the event we found out that the planes were less than 50 feet apart.

As it turned out, the reason the pilots confused the taxiway for the runway was that one of the runways was closed that evening. SFO has two parallel runways, and the left runway wasn’t in use, and the lights were off. They were supposed to land on the right runway, and to the right of that was a taxiway. Since the left runway wasn’t visible, they accidentally mistook 28R for 28L, and the taxiway for 28R.

It goes without saying that this shouldn’t happen, and that the runway and taxiway lights are different colors to avoid issues like this.

However, the great thing about most aviation disasters (or near disasters, in this case) is that we learn from them and improvements are made. We’ve now learned what changes are being made at SFO as a result of AC759. Per SFGATE:

The Federal Aviation Administration will now require pilots landing at night to do an instrument landing, using the runway’s advanced guidance systems, when a parallel runway is closed. In addition, two air traffic controllers must be on duty through the late-night arrival rush, said Ian Gregor, an FAA spokesman.

What makes aviation so incredibly safe nowadays is the number of redundancies in place. Neither of these things should be necessary if everything is going as planned. However, now we know about the potential for confusion (even if this was still primarily pilot error), and this is even less likely to happen in the future.

Comments

  1. I don’t know why they don’t just have a giant illuminated Red X at the end of a runway, just like they do when its closed for maintenance or due to an incident. Surely it would be hard to put embed some LED’s into the surface. Would have avoided this completely, as the pilots would have easily been able to see the closed Red X, and the lit up one next to it.

  2. @Troy – They can’t put a big X on the runway because an X on a runway means the runway is closed and nobody is allowed to land on it. Putting a big X on an active runway would lead to more confusion

  3. @Patrick – but the runway wasn’t active. As per Ben’s notes – the runway was not in use and the lights were off.

    Understand it’s not practical to drag a big X out every time the runways not in use, but surely with lighting technology we could embed LED’s which could remotely be turned on and off at the same time as the runway lights.

  4. @Patrick you misunderstand. Troy suggested putting a red X on 28L, the closed runway. I agree with this idea.

  5. If the fix was this simple – use the ILS (duh) and hire another controller – then someone should be fired for mismanagement. This is perhaps the greatest near miss of all time. It is someones job to think about these things. That person should be …. updated.

  6. This is understandable pilot error. There should be a big red X on a closed runway, how else would you visibly know until it’s too late.

  7. @Steve – exactly my thoughts. I mean whilst a second controller might catch it, it’s still leaving it open to chance and human error.

    Whilst with the different colour lights it should be pretty obvious to a pilot, it’s easy to understand (and some what scary) exactly how this could have occurred. Your expecting two sets of lights, and there was two sets of lights.

  8. The thing that threw me off is that normally there wouldnt even be any aircraft (or very few) on TWY C anyways. Certainly not any commercial aircraft, since the terminal is on the other side. But I believe the normal taxiway they use (Foxtrot) from 1L eastbound was closed as well. At least it was when I flew out a few weeks back. Dont know if they spent all night crossing runways (which would also add some complexity/risk) or using TWY Z to navigate west of the 28s – not familiar enough with the op. to know for sure. One guy assigned to a rush anywhere is tough as is.

  9. Isn’t it scary that in the 21st century pilots cannot even be trusted to fly their own planes anymore? Imagine what will happen when automation takes over more aspects of our life. The human race truly is killing itself. What an awful time to be alive.

  10. I agree with the red X. But what gets me are the huge array off lights off the coast clearly visable while the taxi way does not have these. There was a pic taken at night and whike the green taxi lights looked bright, its hugely obvious there are no lights. Weird.

  11. What on Earth are the people above talking about “recommending” a big red X and implying you’ve figured something out regulations have been requiring for…..decades? Lol my heavens. There WAS a massive, 20+ foot X lit up as bright as can be in front of 28L…. it’s visible for MILES on approach. On a clear night like that evening it’s likely you could’ve seen that for a full 10 mile final. What @Ian says above is correct.

    The real question mark is why Air Canada and perhaps SFO tower didn’t report this for 2 full days. That delay meant the cockpit voice recorder was taped over so investigators will never get to hear what on Earth was going on in that cockpit. I cannot imagine what they were thinking or doing, but my lord I want to know some clues what led them to this complete failure of basic airmanship. They were lined up on a perfectly clear night with a taxiway stacked with aircraft, and end up overflying one of the planes by perhaps as much as 10 yards. A first down. A shame investigators will never hear the CVR because that’s what I think anyone would be most interested in. From this former commercial pilot: I don’t think those pilots should be flying again. Pretty scary stuff.

  12. I was one of the passengers of Philippine Airlines PR 105 bound for Manila that night and you can really feel the vibrating sound and vibration inside the 340 aircraft..Pilots of Air Canada should be suspended.

  13. Um… what? You mean the lights on the closed runway? That’s about as logical as asking after a plane lands on a closed runway why the runway lights were on.

  14. @Ben

    The rule change is actually more specific, and dictates that two people should be in the *tower*. This is a very important distinction. When the near-disaster occurred there were two controllers on duty, but only one of them was in the tower at the time.
    http://www.eastbaytimes.com/2017/08/17/exclusive-sfo-makes-changes-for-pilots-air-traffic-controllers-after-air-canada-close-call/

    On a related note, and East Bay Times editorial is charging the FAA and Air Canada hindered the investigation. I can’t disagree.
    http://www.eastbaytimes.com/2017/08/15/editorial-air-canada-faa-hindered-investigation-of-sfo-near-miss/

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