NTSB · Safety Recommendation
Safety Recommendation A-18-026
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with aircraft and avionics manufacturers and software developers to develop the technology for a cockpit system that provides an alert to pilots when an airplane is not aligned with the intended runway surface, and, once such technology is available, establish a requirement for the technology to be installed on airplanes landing at primary airports within Class B and Class C airspace.
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
March 3, 2025 · NTSB Correspondence · FAA
On November 5, 2024, former FAA Administrator Michael G. Whitaker informed us that the agency is continuing the work described in its previous letter regarding Safety Recommendation A-18-26. We look forward to receiving your next update.
November 5, 2024 · Recipient Response · FAA
-From Michael G. Whitaker, Administrator: In the Federal Aviation Administration’s (FAA) previous response dated September 27, 2023, we indicated that we had begun collecting data related to Safety Enhancements (SE) 231, Approach and Landing Misalignment – Aircraft-Based Technologies, and SE 235, Approach and Landing Misalignment – Aircraft Based Technologies (Research and Development), from the Commercial Aviation Safety Team’s Approach and Landing Misalignment Joint Safety Analysis and Implementation Team’s final reports.
The reports determined the extent that approach and landing misalignment technologies are currently available, eligibility for incorporation of the technologies on the existing transport category aircraft fleet based on current equipage, and current original equipment manufacturer efforts to incorporate the technologies on new transport category aircraft.
The FAA CAST Safety Enhancement Plan is available at the following website: https://skybrary.aero/enhancing-safety/cast-safety-enhancements/cast-safety-enhancements-plan
Both SE 231 and SE 235 have now been merged with the activities of the FAA’s chartered, Investigative Technologies Aviation Rulemaking Committee (InTech ARC), which is tasked with providing recommendations on how to require cockpit alerting technologies designed to reduce runway safety events. These technologies alert flight crews to take corrective actions when the aircraft is aligned to a surface that is not a runway, is aligned with the incorrect runway, or when a runway is too short. The InTech ARC will also provide quantitative benefit and cost estimates, qualitative benefit-cost description, and compliance impacts for any recommendation that proposes changing regulatory requirements.