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This phenomenon can be attributed to a psychological process known as pattern recognition. Given that the crew was trained to recognize certain lights and layouts in an airport environment, their brains began to categorize the taxiway lights as runway lights due to the expected visual patterns they anticipated.
The Near Miss
With both the Captain and First Officer now executing their final approach, they sought confirmation of their landing clearance from air traffic control. Despite their erroneous alignment, air traffic control assured them that the runway was clear. Consequently, the aircraft proceeded dangerously low over Taxiway Charlie, where it narrowly avoided colliding with a United Airlines aircraft preparing for takeoff.
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Analyzing the Air Canada Flight 759 Incident
On July 7, 2017, a critical aviation incident occurred involving Air Canada Flight 759 during its approach to San Francisco International Airport. This article will dissect the details of the event, the crew's decisions leading up to it, and the subsequent investigation by the National Transportation Safety Board (NTSB).
Overview of the Incident
The episode began with a routine approach aligned for landing on Runway 28R. However, the flight crew found themselves lined up with Taxiway Charlie instead, leading to a dangerous situation where the aircraft nearly landed on another taxiing plane. The essence of the incident revolves around several contributing factors, including fatigue, miscommunication, and procedural errors.
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Flight Crew Background
The flight had a highly experienced crew: the Captain, 56 years old with over 20,000 hours, and the First Officer with more than 10,000 hours. They had been on standby and were called in relatively late for the flight, departing from Toronto approximately an hour late due to thunderstorms and other delays.
Initial segments of the flight were routine, aside from concerns about inclement weather. However, fatigue began to set in as they neared San Francisco, particularly as the flight crossed into the early morning hours of their local time. This factor is crucial, as fatigue can seriously impair cognitive function and decision-making for pilots.
The Approach to San Francisco
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As they approached San Francisco, the crew prepared for a visual approach, a method that carries particular challenges, especially at night. Although the crew was accustomed to flying the route, problems arose when they failed to correctly tune the Instrument Landing System (ILS) frequencies necessary for backups during their approach.
The complications increased when the crew began their descent. The Captain switched from managed descent mode to open descent mode to gain better control. However, this change added confusion for the First Officer, who felt uncertain but did not communicate his concerns.
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The crew began their visual approach, thoroughly expecting to align with Runway 28R. Nonetheless, a key detail was overlooked: a NOTAM (Notice to Airmen) indicated that Runway 28L would be closed for maintenance. This essential information was buried deep in the lengthy briefing documents and was not sufficiently emphasized to the crew.
Misperceptions and Visual Cues
As the pilots neared the runway, visual cues became increasingly misleading. Runway 28L had been closed, and its lights were turned off, replaced by construction lights that mimicked taxiway lights. Thus, in the dark conditions, the pilots mistook the taxiway for an active runway.
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Significantly, moments before the Air Canada aircraft's landing, the Captain of the United Airlines plane recognized the imminent danger and reported, “Where is this guy going?” This alert transmitted to the Air Canada crew shortly before they executed a go-around maneuver.
Investigation Findings and Recommendations
The NTSB conducted an extensive investigation into this near-disastrous incident, calling attention to multiple operational failures. They provided recommendations aimed at improving the safety protocols and systems in place.
Key recommendations included:
- Runway Awareness and Advisory Systems: The installation of systems that alert pilots if they are misaligned with the correct runway.
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Enhanced NOTAMs: Emphasizing critical information such as runway closures more prominently in briefing materials.
Visual Cues for Closed Runways: Better illumination systems that would still signal to pilots that a runway is closed.
Fatigue Management: Recommendations for airline authorities in Canada to review regulations regarding pilot duty times, especially with respect to circadian rhythms affecting alertness.
The NTSB's findings revealed no gross negligence on the part of the flight crew. Instead, they identified systemic issues and procedural oversights that contributed to the incident's occurrence.
Conclusion
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While the Air Canada Flight 759 incident revealed serious lapses in communication and adherence to procedures, the NTSB's approach emphasizes learning from mistakes rather than merely assigning blame. The recommendations put forth are meant to enhance the future safety of air travel by preventing occurrences that compromise pilot decision-making during critical flight phases.
This incident serves as a significant reminder of the many variables affecting aviation safety and illustrates the complex interplay between human factors, technology, and operational standards.