U.S. accident investigators probing a San Francisco incident last year in which a jetliner was mere feet from landing on top of at least one other plane are poised to recommend new automated safety warnings and better pilot-fatigue protections.
An Air Canada flight mistakenly tried to touch down on a taxi strip where four other jetliners were awaiting takeoff. Both pilots told investigators that they were tired as they neared the airport at almost midnight. Because they lived in Toronto, it was the equivalent of 3 a.m. on their body clocks.
The National Transportation Safety Board on Tuesday is scheduled to adopt its findings and make recommendations on the July 7, 2017 incident that could have become one of the worst airline disasters in decades if the Air Canada plane had descended just a few feet more.
Investigators have concluded that the tired pilots erred by failing to identify the runway and hadn’t adequately reviewed pre-flight warnings about potentially confusing construction at the airport, according to a person briefed on the proposed findings. The action was described by a person familiar with the agency’s work who wasn’t authorized to speak publicly.
Instead of aiming for a runway, the captain, who was at the controls, flew on a parallel path toward a taxiway, where the other jets were idling.
“Where is that guy going?” a pilot on a United Continental Holdings Inc. jet radioed as the Air Canada plane approached. “He’s on the taxiway,” the United pilot said three seconds later as the other plane passed just overhead.
10 to 20 Feet
The Air Canada pilots eventually aborted the landing and climbed, but it was so late that they were still descending when they passed above the United plane and flew just 10 to 20 feet (3 to 6 meters) over a Philippine Airlines Inc. jet, according to the NTSB’s review of flight data and surveillance video.
While the NTSB’s findings are subject to change at the meeting, the staff has proposed citing pilot actions as the cause of the incident, with the flight crew’s fatigue and other issues as factors, said the person. The NTSB is also preparing to ask Transport Canada, that nation’s aviation regulator, to adopt stricter rules for pilots who fly in the U.S., according to the person.
Air Canada didn’t respond to a request for comment.
Canada’s rules governing how many hours a day a pilot can fly haven’t been changed since 1996, according to a 2014 advisory by Transport Canada. Since that time, many other nations have adopted new regulations as the science of sleep has shown the dangers of fatigue. Canada announced its intent to bring its rules more closely in line with U.S. and European standards in a 2014 advisory.
Transport Canada intends to finalize its updated regulations as soon as this year, it said in an emailed statement. The agency referred questions about the San Francisco episode to the NTSB, which makes safety recommendations but has no regulatory power.
The U.S. Federal Aviation Administration adopted new pilot work rules in 2011 that limited how long crews on passenger planes could fly during the wee hours and increased the minimum rest period between shifts from 8 hours to 10. The rules only apply to U.S.-registered airline crews.
The issue of pilots inadvertently landing on taxiways, wrong runways or even the wrong airports has been a concern in recent years. The NTSB is also preparing several recommendations to the FAA seeking more research on the issue and better technological safeguards.
One of the NTSB’s proposed recommendations would call on the FAA and aircraft manufacturers to develop technology that would automatically warn pilots when they’re not flying toward the proper runway.
It would also ask for the FAA to adapt current radar systems that monitor planes on the ground to track aircraft as they arrive and warn air-traffic controllers when one is lining up to land on a taxiway. The agency said a year ago it was planning to make such changes.
There have been 596 instances of aircraft landing on the wrong runway or at the wrong airport — or almost doing so — in the past two years, according to the FAA. The vast majority of those cases involve smaller private planes, such as when actor Harrison Ford landed a small plane on a taxiway in February 2017 at John Wayne Airport in California.
However, there have been a troubling number of large airliners on which pilots made similar blunders. The NTSB is also investigating a Dec. 29 incident in Pullman, Washington, when a Horizon Air plane operated by Alaska Air Group Inc. landed on a taxiway. A Delta Air Lines Inc. plane came within 60 feet of the ground in Atlanta before climbing as pilots mistook a taxiway for a runway on Nov. 29.
Since the San Francisco episode last year, the FAA has taken several steps to address the issue in addition to the ground radar adaptation. It held a forum on the issue in August and is also exploring whether it can use other radars to create a more comprehensive warning system, the agency said in an emailed statement.
The NTSB has raised concerns about collisions on the ground for decades. A collision on a runway in Tenerife, Canary Islands, between two Boeing Co. 747s in 1977 killed 574 people, according to the NTSB, making it the deadliest airline accident.
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