NTSB · Safety Recommendation
Safety Recommendation A-18-028
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Conduct human factors research to determine how to make a closed runway more conspicuous to pilots when at least one parallel runway remains in use, and implement a method to more effectively signal a runway closure to pilots during ground and flight operations at night.
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
July 31, 2024 · NTSB Correspondence · FAA
We note that you are continuing your human factors-based research and development project to investigate the effectiveness of novel lighting systems making closed parallel runways more conspicuous to pilots. We also note that, in 2023, the FAA evaluated customized X runway closure markers and is now focusing on the human factors aspect of those findings.
We look forward to reviewing the findings from this research. Pending completion of this research and a plan for developing and implementing any solutions that are identified, Safety Recommendation A-18-28 remains classified OPEN-- ACCEPTABLE RESPONSE.
August 23, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) continues to advance a human factors-based research and development project to investigate the effectiveness of novel lighting systems making closed parallel runways more conspicuous to pilots. Previously described field evaluations of customized lighted-X runway closure markers, which make up the first part of the study, will continue into the summer of 2023. This date was extended from the summer of 2022 due to testing facility delays.
Following the completion of the field evaluations, the FAA will design the second part of the study, which will focus on human factors and incorporate findings from the field evaluations.
I will keep the Board informed of the FAA’s progress on Safety Recommendation A-18-28 and anticipate providing an update by July 31, 2024.
October 21, 2022 · NTSB Correspondence · FAA
We note that, although your human factors-based research and development project was delayed due to issues finalizing the original contract, you have awarded the contract to another contractor and anticipate publishing the report in the first part of 2023. We look forward to reviewing the findings from your human factors research on novel lighting systems and their effectiveness in making closed parallel runways more conspicuous to pilots. Pending completion of this research and a plan for developing and implementing any solutions that are identified, Safety Recommendation A-18-28 remains classified OPEN--ACCEPTABLE RESPONSE.