On July 7, 2017, an Airbus A320 operating as a scheduled Air Canada passenger flight and conducting a night visual approach to Runway 28R at the San Francisco International Airport overflew other airliners positioned on a taxiway and awaiting takeoff clearance. As we wrote in our October 2017 issue, “Runway 28L was closed at the time; its lighting was turned off and a 20.5-ft-wide lighted flashing X (runway closure marker) was at its threshold. The Airbus lined up for its landing on parallel Taxiway C, which had four air carrier airplanes on it awaiting takeoff clearance—a Boeing 787, an Airbus A340, another Boeing 787 and a Boeing 737. Subsequent investigation reveals the Airbus crew advanced its thrust levers for a go-around when the airplane was about 85 feet above the taxiway; the minimum altitude recorded on the FDR once the go-around was initiated was 59 feet agl. The Boeing 787 is 55 feet 10 inches high.”
Understandably, the NTSB and FAA have spent considerable resources investigating this event. Among those efforts, the FAA has published a Safety Alert For Operators (SAFO 17010) it hopes will increase awareness among crews of all aircraft types of the “importance of employing best practices for successful approaches and landings to the correct airport and runway.” The SAFO highlights five basic areas it believes can not only prevent similar events but also help minimize the likelihood of landing on the wrong surface.
Best Practices
The FAA’s SAFO labels this event “an extreme example of incorrect surface approaches and landings.” In addition to the CRM resources highlighted in the text box below, the SAFO states that best practices for avoiding similar events include:
Stabilized Approach: “A stabilized approach is critical to pilots and flightcrews for maintaining situational awareness of the external environment. This means pilots and flightcrews are able to receive, process and utilize situational information to a greater affect. However, an unstable approach requires increased concentration on the performance of the airplane, by both the pilot flying (PF) and pilot monitoring (PM), to the detriment of processing other equally important situational information.”
Technology: Utilize published approaches such as VOR, localizer, ILS, RNAV, etc. “Conducting an approach in visual conditions increases the potential for confusing visual clues such as airport lighting configuration, surrounding lights, or areas that look similar to the airport.” Using a published procedure even on a visual approach will serve to support pilot and flightcrew decisions.
Cockpit/Crew Resource Management (CRM): Effective CRM is imperative because it leverages the skills of all crewmembers. If something does not look right, “the observing crewmember bears the responsibility for communicating what they see.”
Be Ready to Go Around: Crews need to be aware of the variety of reasons that a go-around may be necessary so they are ready to use it, and, if necessary, use it early, particularly during a time of confusion.
Available Resources For Identifying Correct Landing Surface
According to the FAA, effective cockpit resource management (CRM) requires the use of all available resources. When considering wrong-surface landings, those resources include but are not limited to:
• A briefing of the airfield diagram;
• A review of airport lighting including any approach lights systems (ALS);
• A review and discussion of Notices to Airmen (Notams);
• Performance of the approach and landing checklists according to approved procedures;
• Use of approach navigational aids under both IMC and VMC conditions;
• Monitoring the automatic terminal information service (ATIS) for information and changes to field conditions;
• Listening closely to all radio transmissions for pertinent information; and,
• Identification and verification of visual glide path information such as a visual approach slope indicator (VASI) or precision approach path indicator (PAPI) not only for glide path indications but also their location relative to the runway of intended landing.
