Air Canada issues new report on dramatic near miss at SFO last year

SAN FRANCISCO (KGO) -- California Insurance Commissioner Dave Jones was a passenger on the Air Canada flight.

"When I watched the video of how close we came I was terrified," said Jones.

The mistake could have triggered the worst aviation disaster in American History.

Today, Air Canada shared the report it submitted to NTSB explaining why the flight crew incorrectly perceived SFO Taxiway C as Runway 28R.

The probable cause according to Air Canada, SFO's inadequate lighting of the runway and ongoing construction on another runway, making it difficult for the crew to distinguish between the runway it was supposed to land on and the parallel taxiway.

The Federal Aviation Administration tells ABC7 News immediately after the incident occurred it required pilots landing at SFO at night to do an instrument landing when a parallel runway is closed, instead of a visual approach.

RELATED: Air Canada flight nearly lands on taxiway at San Francisco International Airport
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Details are emerging about what could have been a serious incident at San Francisco International Airport last Friday night when an Air Canada plane from Toronto nearly landed on the taxiway.

Air Canada's report also says the "controller in charge" failed to provide direction to the flight crew.

Aviation Expert Chris Zwingle is a Retired Captain.

" I would view any party's input including FAA, including the city of San Francisco that owns the airport, Air Canada, as taking a defensive position," said Zwingle.

"The finding that Canada allows its pilots to fly planes when they're fatigued and have been up for 19 hours to me is very very troubling and ought to be changed," said Jones.

NTSB's recommendations today included a system that would alert pilots when an airplane is not aligned with a runway surface.

NTSB will issue its final report in the coming weeks.

10 Key Conclusions:

1. Delta Flight 521 which landed four minutes prior to Air Canada 759 got close to making the same mistake as Air Canada.

2. Both captains were unaware of the construction lighting on runway 28L, or changes to airport lighting due to construction. The flight crew of Delta 521 reported "construction lights were so bright we could not determine the location of the inbound runway."

3. The notification about the runway construction was on page 8 of the 28 page flight plan Air Canada received from SFO, crew members could not recall whether they noticed it.

4. Delta Flight 521 reports "aircraft on Taxiway C were stopped and had their taxi lights off, which helped created this misconception that Taxiway C was runway 28R."

5. Only one Air Traffic Controller was working at the time of the incident, the other was on a previously scheduled break.

6. Only having one controller working slowed down response time, and made it harder to recognize what was happening.

7. The crew initiated the go-around before they were ordered to do so.

8. The air traffic controller could have employed "sequence strobes" to light runway 28R, that simple tool would "have all but eliminated the possibility of misalignment"

9. The flight crew was likely affected by some degree of fatigue.

10. The airport failed to conduct a hazard assessment of the closure of runway 28L and the impact construction lighting would have on pilots.

RELATED: FAA investigates another questionable Air Canada landing at SFO

3 Key Recommendations:

1. The FAA conduct a study analyzing runway closure lighting and taking night approaches into account.

2. Based on that study-- the FAA implement appropriate measures to enhance runway identification at night.

3. SFO establish a requirement that a minimum of two controllers be on duty at all times.

SFO on Tuesday released a statement on the incident.

"We appreciate the detailed investigation conducted by the NTSB into the incident involving Air Canada 759. We have the utmost respect for both the in-depth analysis conducted by the NTSB and the recommendations put forth to enhance the safety of air transportation.

While there were no findings specific to our airport, we appreciate the recommendations put forth today by the NTSB on how to reduce the risk of wrong surface alignment. These items align with our own proactive measures taken following the incident, which include:
Postponing overnight runway maintenance closures until midnight or later; Expanding the use of remote gate operations to reduce aircraft waiting on taxiways; Convening a special Runway Safety Action Team (RSAT), in partnership with the FAA, to discuss the Air Canada incident directly with airline pilots who fly into SFO; and Funding and implementing a Ground Based Augmentation System (GBAS), which offers a greater level of precision to flight crews than the current Instrument Landing System (ILS).

We appreciate the engaged participation by so many sectors of the aviation community in these enhancements, and we look forward to continuing in this proactive partnership to ensure the very best set of safety standards are always in place at SFO.

The report noted that the flight crew utilized missed approach procedures, commonly referred to as 'go-arounds', as part of their standard safety protocols. This measure is a critical safeguard at any airport, and we appreciate the attention the NTSB has given it."

See the full text of the Air Canada's pilots' interviews with the NTSB here.
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