Too Close for Comfort in San Francisco

By Bruce Landsberg, Vice Chairman

On March 27, 1977, two Boeing 747s collided on a foggy runway in Tenerife, Spain. The crash took 583 lives, marking it as the deadliest aviation accident in history. Although commercial airline safety has made huge strides since then, a disaster potentially twice as deadly as Tenerife was recently averted by only about 13 feet.

In the late evening hours of July 7, 2017, an Air Canada Airbus A320 inbound from Toronto almost collided with four jetliners awaiting take off at San Francisco International airport (SFO). The night was clear and calm, with no weather to obscure the visual approach to Runway 28 Right.

The Air Canada pilots, not realizing the parallel runway (28 Left) was closed, lined up on a nearby taxiway rather than their assigned runway. As the waiting airliners flashed their landing lights to alert the errant Airbus, one of the pilots on the control tower frequency ground broadcast can be heard saying “Where’s this guy going?” and “He’s on the taxiway!” In the last few seconds, the Air Canada crew recognized their error and aborted the landing.  Simultaneously, the tower controller ordered the Airbus to go around.

Upon landing, the captain called the tower to discuss the incident, and then went to bed. It was 3 am by his body clock and he was exhausted. Although he was required to do so as soon as possible, the captain did not inform Air Canada’s dispatcher about the incident until 16 hours later, by which time the aircraft had already departed on a morning flight, resulting in the required 2-hours of cockpit voice recorder (CVR) data being overwritten.

With all the equipment, training, and safety management systems implemented since Tenerife, it’s astonishing how a near miss like this could happen. But as our investigation revealed, a long and intricate chain of events was to blame. We clearly understand now what happened, but, because the CVR data was lost, we only know part of the why.

We made several recommendations to address the safety issues our investigation uncovered. The incident report, which is available at ntsb.gov, should be required reading for pilots of both large and small aircraft. Here are some of the most important takeaways.

Knowing what to expect. Before flight, all pilots are required to check for Notices to Airmen (NOTAMs), which inform them of anything unusual that has recently changed at the departure or arrival airport, as well as navigational outages along the way. In practice, 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.

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. This Air Canada crew missed two warnings about the closed runway at SFO, first in predeparture, and then via datalink before landing. Had they been aware of the closure, the pilots almost certainly would’ve suspected an unusual airport configuration with changed lighting patterns.

The current NOTAM system lists everything that could, even under the most unlikely circumstance, affect a flight. It lays an unnecessarily heavy burden on individual pilots, crews, and dispatchers to sort through dozens of irrelevant items to find the critical and important ones. When an important item is missed—as is common—and a violation or incident occurs, the pilot is blamed for not finding what amounts to a needle in a haystack.

Further, NOTAMs are published in hard-to-read codes. Using plain language and conventional date and time configuration in both local and universal (UTC) time could go a long way toward making flight safety information easier to understand. The Federal Aviation Administration (FAA) has been aware of the NOTAM problem for more than 15 years. In 2012, Public Law 112-153 (Pilot’s Bill of Rights) gave the FAA 1 year to fix the problem. The incident at SFO makes it clear that there is still much more work to be done. This is a safety issue that calls for urgent action.

The fatigue factor. Fatigue continues to be a recurring factor in accidents and incidents. The Air Canada captain had been awake for 19 hours at the time of the incident. It’s estimated that he awoke around 0800 eastern time (ET); the incident occurred at 0300 ET the following day. 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.

During postaccident interviews, the captain said he did not make a timely incident report to Air Canada’s dispatch after landing because it was “very late” and he was “very tired.” If the captain is too tired to make a phone call to report an incident, should the rules allow him to fly a challenging night approach with the lives of 139 passengers and crew in the balance? 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.

Cockpit voice recorders and beyond. The Airbus’s CVR would have provided much more information on what happened, but it was overwritten during the first flight following the incident (current CVRs are only required to store a minimum of 2 hours of audio). Without the CVR data, we may never understand all the reasons behind the numerous procedural failures, but we know one thing for sure: the CVR would have provided a much better picture of just how this incident came close to being a catastrophic accident.

Cockpit image recording could provide a much richer source of critical information. We initially issued an image recorder recommendation as long ago as 2000.

We have had far more success with image-recording technology in every mode of public transportation except commercial aviation. Some pilot groups are concerned about the flight crew’s right to privacy and that the information gathered will be used punitively. Workplace right to privacy has been extensively debated, but for employees in safety-critical positions, privacy should take a backseat to human life.

Unlike written transcripts, cockpit audio and video recordings are protected by federal law and never released by the NTSB. Likewise, video recordings are protected by law from being released. Over-the-air transmissions, such as communications between a pilot and air traffic controllers, are in the public domain, by definition, but in-cockpit audio and video recordings are protected by the NTSB against public disclosure.

More importantly, image recorder data gathered routinely before an accident will be invaluable in preventing the next tragedy. This approach has been highly effective in flight operational quality assurance (FOQA). This approach may pose some technical challenges, but it will significantly increase safety and accountability.

Learn and forgive. One of the best practices used in aviation is the concept of “just culture,” or nonpunitive corrective action. Most people put their best foot forward and attempt to minimize a critical error when they make one, which is perfectly understandable. Yet, some supervisors want to mete out sanctions to “teach a lesson” or to make an example of a crew. Unless someone is habitually error prone or intentionally ignoring safety procedures, a punitive response is completely inappropriate to critical performance environments in all modes of transportation.

This Air Canada flight crew will almost certainly never make such a mistake again, and my hope is that they will continue to fly to the normal end of their careers.

We gain much more from being introspective rather than judgmental about this incident. We should celebrate when someone confesses a mistake and learns from it. This is one of the key factors in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to recur. Let’s not squander it.

 

Reduce Fatigue-Related Accidents and Expand Recorder Use to Enhance Safety are topic areas on the NTSB 2017-2018 Most Wanted List.

 

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