NTSB announces findings and recommendations regarding Air Canada near miss at SFO

On July 7th of last year, an Air Canada plane with 140 on board, after a long flight from Toronto, attempted to land at San Francisco Airport just before midnight. Before making a last second go around, it almost landed on a taxiway on top of four airliners waiting to depart, containing a total of 1,100 passengers and crew. NTSB Chairman Robert Sumwalt said, "This was a very close call."

Now, fourteen months later, the NTSB, the National Transportation Safety Board unanimously announced numerous findings and recommendations. The NTSB found the pilots were fatigued due to long hours without sleep; the captain awake for 19 hours. They failed to see closed runway markers despite warnings of the closed runway given in advance. "A Notice to Airmen, or NOTAM, advised of the runway 28 Left closure. The flight crew has received this information in a flight release hours before the incident and, then again, in flight before the descent from cruise altitude," said Chairman Sumwalt.

As a result, the pilots erroneously identified the taxiway as the runway. In addition, the pilots failed to turn on the readily available runway alignment equipment. Just before slamming into the waiting aircraft, the pilots sharply pulled up, averting disaster.

"The distance between aircraft was about thirteen, thirteen feet," said the NTSB's John Lovell. "The was no indication that the crew was aware that they had overflown four air carrier aircraft on the taxiway," said NTSB Vice Chairman Bruce Landsberg.

The NTSB did not like the fact that, though legal, only one air traffic controller was on duty at midnight with another on a rest period. Many changes in SFO's closed runway procedures and control tower staffing have already been instituted. The NTSB also criticized the FAA, especially the fact that truly critical safety information, such as the closed runway, though disclosed in a NOTAM, Notice to Airmen, is not highlighted.

"And that's what NOTAMs are; they're just a bunch of garbage that nobody pays any attention to," Chairman Sumwalt.  "We just get pages and pages and page of irrelevant material. The important stuff gets buried," said Vice Chairman Landsberg.

The slew of new recommendations remain just that, recommendations that airlines, airports, aircraft makers and the government itself can either accept or reject.