Air Canada overflight of the taxiway, near disaster?:mindFly analysis


This incident could have been the worlds worst air disaster. The pilot of the Air Canada 759 approaching to land at San Fransisco on 02 July 2017 aligned the aircraft to land on a taxiway, which had four big jets carrying almost a 1000 passengers.  The pilot mistook the taxiway for the landing runway and continued to descend over the taxying aircraft to reach the lowest height of 60 feet before realizing the mistake and taking evasive action.  How could the pilot not see such large jet aircraft in front of him is intriguing? He could be suffering from inattentional blindness. Read my paper for more details, Inattentional blindness .

My paper on Inattentional blindness

MindFly human factor analysis

Most of the laws banning cell phone use while driving has focused inappropriately and exclusively on hand-held phones. Whether or not cell phone use while driving should be regulated is a political question, but the cause of the distraction is an empirical one. Public officials do a disservice when they fail to convey the real reasons why using a cell phone while driving is dangerous.

According to Christopher Chabris and Daniel Simons authors of the book “the invisible gorilla”, “the enforcement campaign spreads misinformation by implying that it’s the “hand-held” aspect of cell phone use that causes the problem. In reality, the real distraction has nothing to do with having both hands on the wheel — it’s the conversation itself (coupled with the challenge of communicating with someone not in the car). Using a hands-free phone doesn’t eliminate the distraction, and it might even be given people a false sense of confidence if they think that switching to a hands-free phone makes them safer”. The brain does not register the unexpected events.

Everyone is proficient in driving a car and driving with one hand on the steering wheel is not an exception.  There are times when one completes a journey and at the end of it is unable to recall the route taken to reach the destination whereas all turns and stops were executed safely.  In this scenario, the driver was lucky that another vehicle or a pedestrian did not appear unexpectedly since the brain will not register these unexpected events.   This phenomenon is called Inattentional Blindness.

Cognitive bias resulted in the pilot identifying the incorrect surface for landing instead of the runway designated to be open and cleared for operations. Expectation bias leads the crew to expect the mental image of the position of runway and taxiway to match the visually acquired image. The pilot expects to see two runways and was expecting to choose the landing surface on the right. Here the two visually acquired surfaces were the runway and taxiway. In order to align with the mental image, the crew chose the surface on the right which happened to be the taxiway.

Expectation bias leads to confirmation bias. The crew believes what they see is the correct image despite all the indications proving it to be false.

There is a cognitive phenomenon popularly known as looking without seeing. The pilot was suffering from the same. This is the reason why the pilot was unable to sight large conspicuous objects in his flight path.

Read my paper on this subject for more clarity.

Abstract from the NTSB report

National Transportation Safety Board. 2018. Taxiway Overflight, Air Canada Flight 759, Airbus A320-211, C-FKCK, San Francisco, California, July 7, 2017. NTSB/AIR-18/01. Washington, DC.

Abstract: 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.

Copyright Amit Blog post/Inattentional blindness during visual scan 2018 ©

About Capt. Amit Singh

I think therefore I am Airlines Operations and Safety balance expert. A former head of operations/training and safety of successful LCC's in India. An experienced member of the startup teams of these airlines has hands-on experience in establishing airlines systems and processes.

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