Serious incident Airbus A320-211 C-FKCK,

ASN Wikibase Occurrence # 319853

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Date:	Friday 7 July 2017
Time:	23:57
Type:	Airbus A320-211
Owner/operator:	Air Canada
Registration:	C-FKCK
MSN:	265
Year of manufacture:	1991
Engine model:	CFMI CFM56-5A1
Fatalities:	Fatalities: 0 / Occupants: 140
Aircraft damage:	None
Category:	Serious incident
Location:	San Francisco International Airport, CA (SFO) - United States of America
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Toronto-Pearson International Airport, ON (YYZ/CYYZ)
Destination airport:	San Francisco International Airport, CA (SFO/KSFO)
Investigating agency:	NTSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
On July 7, 2017, about 23:56 local time, Air Canada flight 759, an Airbus A320, C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), California, but instead lined up on parallel taxiway C, where four aircraft were awaiting takeoff clearance.
At 23:55:46, when AC759 was about 0.7 mile from the landing threshold and about 300 ft above ground level (agl), the flight crew contacted the ATC tower, mentioned seeing lights on the runway, and requested confirmation that the flight was cleared to land.
At 23:55:52, the airplane flew too far right of course to be observed by the local controllers ASDE-X/ASSC and was not visible on the ASDE-X/ASSC display for about 12 seconds.
Four seconds later, when AC759 was about 0.3 mile from the landing threshold, the local controller confirmed and recleared AC759 to land on runway 28R.
The flight crew of the first airplane in queue on taxiway C (UA1) transmitted statements regarding AC759, one of which mentioned the alignment of AC759 with the taxiway while AC759 was on short final. The flight crew of the second airplane in queue on taxiway C switched on their airplanes landing lights as the incident airplane approached.
The incident pilots advanced the thrust levers when the airplane was about 85 ft agl. FDR data indicate that the airplane was over the taxiway at this time, approaching the vicinity of taxiway W.
At 23:56:04, AC759 reappeared on the local controllers ASDE-X/ASSC display as it passed over the first airplane positioned on taxiway C. About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.
At 23:56:10, the local controller directed AC759 to go around. The airplane had already begun to climb at this point.

At the time of the incident, runway 28L was closed to accommodate construction; its approach and runway lights were turned off, and a 20.5-ft-wide lighted flashing X (runway closure marker) was placed at the threshold. Construction on runway 28L was part of a project that started on February 21, 2017, and notices to airmen were issued to alert operators of its operational status. The closure was also mentioned on the ATIS.
In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.

The aircraft lined up on taxiway C were:
1. UA1 SFO-SIN, Boeing 787-9 Dreamliner, N29961
2. PR115 SFO-MNL Airbus A340-313, RP-C3441
3. UA863 SFO-SYD, Boeing 787-9 Dreamliner, N13954
4. UA1118 SFO-MCO, Boeing 737-924ER N62895

Probable Cause:
The NTSB determines that the probable cause of this incident was the flight crews misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing.
Contributing to the incident were (1) the flight crews failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canadas ineffective presentation of approach procedure and NOTAM information.

METAR:

05:56 UTC / 23:56 local time:
KSFO 080556Z 29012KT 10SM CLR 17/09 A2993 RMK AO2 SLP135 T01720094 10244 20172 51010

Accident investigation: