Safety Recommendation A-18-025

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.