The vice chairman of the US National Transportation Safety Board, Bruce Landsberg, has published a commentary on the NTSB’s blog on the human factors and systemic failures which led to the near-miss collision on 7 July 2017 between an Air Canada A320, inbound from Toronto, and four other aircraft awaiting takeoff at San Francisco International Airport.
Landsberg suggests that the events, which occurred near midnight, had the potential to be twice as deadly as the 27 March 1977 collision between two Boeing 747s on the runway in Tenerife; an incident which killed 583 people and remains the deadliest crash in aviation history.
In the Air Canada incident, disaster was averted by 13 feet, when pilots realized their error and aborted landing, but it was a very close call. //
The problem was that the Air Canada pilots did not realize the parallel runway (28 Left) was closed, and lined up for landing on a nearby taxiway instead of their assigned runway. //
The NTSB investigation was hampered somewhat by what happened next. The captain, exhausted, did not notify the Air Canada dispatcher of the incident before going to bed. At that point, he had been awake for 19 hours.
“The captain was not technically ‘on duty’ that whole time, and, under Canadian regulations for reserve crew members, he still could have been available for duty for another 9 hours,” Landsberg says. “If we expect solid human performance where lives are at stake, fatigue rules need to be based on human factors science. The NTSB has recommended that Canada’s fatigue regulations be modified.”
When the captain filed his report 16 hours later, the aircraft had already taken off on a morning flight. The 2-hours of cockpit voice recorder (CVR) data was overwritten.
Recommendations from the NTSB report are based on what investigators could deduce from the evidence available.
One is that the FAA revise the format of NOTAMs (Notices to Airmen), something which the agency was originally tasked with doing in 2012.
“NOTAMs contain dozens of notices of varying importance, such as closed taxiways, wet runways, and small, unlit towers miles from the airport. Information about closed runways, however, is critical,” Landsberg states. “From a human factors perspective, we found that the presentation of information in the NOTAM the crew received did not effectively convey the information about the runway closure.
