Investigation Summary
The incident occurred during a period of construction at San Francisco International Airport (SFO) where Runway 28L was closed. While its approach and runway lights were extinguished, a 20.5-foot-wide lighted flashing 'X' runway closure marker was active at the eastern threshold. The crew of Air Canada 759 was cleared for a visual approach to Runway 28R. Due to a combination of fatigue and ineffective review of NOTAMs (Notices to Airmen), the pilots did not account for the 28L closure. Seeing two parallel lines of lights, they assumed the left-most line (Runway 28R) was 28L and the right-most line (Taxiway C) was 28R. As they descended, the crew became uneasy because the 'runway' did not look right, prompting them to ask the tower if they were clear to land. The controller, who did not see the aircraft on his ASDE-X radar for 12 seconds because it was too far right of the approach path, confirmed the clearance. The disaster was averted by the quick thinking of pilots on the ground: the captain of United Airlines Flight 1 radioed a warning, and the crew of Philippine Airlines Flight 115 switched on their landing lights to alert the approaching A320. The Air Canada pilots initiated a go-around just as the tower controller also ordered one. Flight data showed the A320 was only 10 to 20 feet above the tail of the second aircraft on the taxiway and came within approximately 29 feet laterally of the four aircraft waiting for takeoff.
Final Conclusions
The NTSB determined the probable cause was the flight crew's misidentification of Taxiway C as the intended landing runway. This resulted from a lack of awareness regarding the parallel runway closure due to an ineffective review of NOTAM information. Contributing factors included the crew's failure to use the ILS for backup lateral guidance, expectation bias, and fatigue resulting from circadian disruption (the arrival occurred at 02:56 body time for the Toronto-based crew). The NTSB also cited Air Canada's ineffective presentation of NOTAM information and the FAA's lack of automated alerts for taxiway arrivals as contributing elements.
Video Analysis
Meters from DISASTER! - Air Canada flight 759 — A detailed breakdown of the 2017 San Francisco near-miss where an Air Canada A320 nearly landed on four other aircraft, examining the human factors and fatigue that led to the error.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
56 years old at time of incident.
First Officer
42 years old at time of incident.
Systems & Failure Modes
ASDE-X / ASSC
Airport Surface Detection Equipment, which failed to alert the controller because the aircraft was not on a surface and was outside the system's coverage area for a portion of the approach.
Instrument Landing System (ILS)
The crew did not tune the ILS frequency for Runway 28R, which would have provided a clear electronic indication that they were misaligned with the runway.
NOTAMs
The Notice to Airmen system provided the runway closure information, but it was buried within a 27-page briefing package.
Interesting Facts
- 01The aircraft reached a minimum altitude of 59 feet, while the tail of a Boeing 787-9 (two of which were on the taxiway) is 55 feet 10 inches high.
- 02The aircraft approached as close as 29 feet laterally to the four airplanes waiting on Taxiway C.
- 03Runway 28L had been closed since 23:00 local time for construction, with all lights off except a lighted flashing 'X' at the threshold.
- 04The Cockpit Voice Recorder (CVR) was overwritten because the incident was not immediately reported and the aircraft flew three more flights before the investigation began.
- 05Four aircraft were on Taxiway C: UA1 (787-9), PR115 (A340-300), UA863 (787-9), and UA1118 (737-900ER).
- 06The total number of people on the five aircraft involved exceeded 1,000.
Safety Actions & Advisories
FAA Nighttime Procedures
The FAA modified procedures at SFO to forbid visual approaches at night when an adjacent parallel runway is closed, requiring instrument approaches instead.
Tower Staffing
Requirement for two air traffic controllers in the SFO tower during late-night arrival rushes.
ASDE-X Enhancements
The FAA began testing and implementing logic changes to airport surface surveillance systems to provide alerts for aircraft aligned with taxiways.
Location
APPROXIMATE POSITION · AIRPORT LEVEL · Coordinates are the estimate published in the official investigation report. The ring shows the accuracy the record supports, not the point of impact.