How the worst airline accident in history was avoided


Sometimes the triply redundant failsafes fail four times.


The key thing here, when Air Canada says, “I see lights on the runway…”, and the tower says, “nope, there’s no one on the runway,” that should have alerted someone - probably the tower - that there was a disconnect. Instead of dismissing his “lights on the runway” as just wrong, they might have asked, “hey, are we sure we’re talking about the same ‘runway’?”



Yes and this is what scares me about automatic cars. Aviation is loaded with people who are careful, who focus on their jobs and who are very good at what they do. Road transport doesn’t have the same culture.


I have no professional junk to report here but #wrath One_Brown_Mouse got this cover


The human brain is a funny thing when it comes to spatial relatives. “I have to pick the thing on the right” … but relative to what? The right of both runways, or relative to all the runways? I am quite sure that I have made mistakes of that type. Can’t remember the circumstances, though, it certainly was not aviation :thinking:


At the time of the incident, runway 28L was closed to accommodate construction; its approach and runway lights were turned off

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.


He is Canadian, the kings of understatement. Near miss, eh?


May be worth a note, too, that SFO’s 28L and 28R are far closer than just about any other major airport, only about 750 feet apart, IIRC. With 28L closed, far easier to confuse the taxiway for the runway than would be the case at a place where the parallel runways are often separated by a mile or more.

ETA: Yeah, SFO’s runways are 750 feet apart – Heathrow and LAX, just for instance, are operating on opposite sides of the terminal at more than 3/4 of a mile. O’Hare has a couple of runways that are 1,200 feet apart, but they also have a parallel to that on the far side of the terminal. This really is particularly crowded at SFO


The pilot did sound tired to me…


Exactly. “Sorry” can come later when it won’t interfere with others getting important information over the same channel.


Okay, so:

  1. There are three strips in parallel - two runways (one closed for construction with all it’s lights off) and a taxiway.

  2. There are a bunch of planes at the closer end of the taxiway, clustered together with their lights on.

That makes it pretty simple for a tired pilot and co-pilot to look at the taxiway from long distance during their line-up, see the ground lights along it’s length and the flashing lights at the end and think “yupyup, runway there…” Good thing that illusion broke.


Yeah, but… A taxiway doesn’t have the approach lights a runway has. 28R has ILS CAT II - III lighting.
Here is what a regular approach to 28R in clear conditions looks like. Even with 28L deactivated and planes on taxiway C, the taxiway just doesn’t look like a runway, at all. How the two pilots failed to recognize this for so long is mystifying to me.


Then I hope that means no privatization of air traffic control.



Don’t forget, with 28L blacked out and a bunch of planes on the ground at the head of the taxiway, it would’ve looked more like this. After 20 hours awake (or however long it’d been) that seems pretty legit to me. But hey, no one got hurt, lessons can be learned, etc. etc.



I guess he forgot the notification, or didn’t read it in the first place, so the assumptions “there are two runways” and “I must pick the right runway” were firmly stuck in his head. Add some fatigue, et voila… But to his credit, apparently he did notice it, late, but before being told to go around by the tower.

closed #37

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