NTSB · Safety Recommendation
Safety Recommendation A-18-024
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Establish a group of human factors experts to review existing methods for presenting flight operations information to pilots, including flight releases and general aviation flight planning services (preflight) and aircraft communication addressing and reporting system messages and other in-flight information; create and publish guidance on best practices to organize, prioritize, and present this information in a manner that optimizes pilot review and retention of relevant information; and work with air carriers and service providers to implement solutions that are aligned with the guidance.
Safety Issue and Context
This report discusses the July 7, 2017, incident involving Air Canada flight 759, an Airbus A320-211, Canadian registration C-FKCK, which was cleared to land on runway 28R at San Francisco International Airport, San Francisco, California, but instead lined up with parallel taxiway C. Four air carrier airplanes were on taxiway C awaiting clearance to take off from runway 28R. The incident airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before starting to climb.
None of the 5 flight crewmembers and 135 passengers aboard the incident airplane were injured, and the incident airplane was not damaged.
Safety issues identified in this report include the need for consistent flight management system autotuning capability within an air carrier’s fleet, the need for more effective presentation of flight operations information to optimize pilot review and retention of relevant information, the need for airplanes landing at primary airports within Class B and Class C airspace to be equipped with a system that alerts pilots when an airplane is not aligned with a runway surface, the need for modifications to airport surface detection equipment systems to detect potential taxiway landings and provide alerts to air traffic controllers, the need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use, and the need for revisions to Canadian regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low.
As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the Federal Aviation Administration and Transport Canada.
Response History
September 29, 2023 · NTSB Correspondence · FAA
We note that the FAA’s Air Traffic Organization and Civil Aerospace Medical Institute are continuing to determine the most critical information for each phase of flight, as well as when and how that information should be delivered to pilots. Specifically, the controller surveys have been developed and the pilot surveys are being finalized. We also note that, although you anticipate completing the controller surveying by the end of fiscal year 2023, the schedule for surveying pilots cannot be determined until after you have complied with the Paperwork Reduction Act and coordinated with pilot labor groups.
You also reported plans to switch to a single notice-to-air-mission (NOTAM) system with improved search capabilities.
Although we continue to believe the multilevel review that you are conducting is responsive to this recommendation, we are concerned because this recommendation is almost 5 years old, and you have not finished developing the surveys. In addition, we are curious why the FAA has decided to distribute hard copies of the pilot surveys instead of a web-based version.
Pending our review of the requested information, the development of guidance based on the findings from the completed review, and a plan to ensure that this guidance is used by air carriers and service providers, Safety Recommendation A-18-24 remains classified OPEN-- ACCEPTABLE RESPONSE.
May 5, 2023 · Recipient Response · FAA
-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) continues to advance the human factors research project addressing this safety recommendation. Researchers from the FAA’s Air Traffic Organization and Civil Aerospace Medical Institute have successfully coordinated the development of surveys for the air traffic controller population since our last update to the Board.
We anticipate completing surveying this population by the end of Fiscal Year 2023. Researchers are finalizing the coordination of the development of surveys for the pilot population, and the schedule for surveying this population will be determined by approvals needed to comply with the Paperwork Reduction Act and successful coordination with pilot labor groups.