Back to Squawk list
  • 58

Editorial: Air Canada, FAA hindered investigation of SFO near-miss

The FAA, which was responsible for having only one air controller working traffic in the tower at the time, took more than 24 hours to notify the NTSB. The delay allowed Air Canada to use the plane for three flights in which the cockpit recorder was taped over multiple times. ( More...

Sort type: [Top] [Newest]

chalet 11
Given the potentially awful consequences if the Air Canada 320 crashed on top of 4 jets all of whch were fully loaded with fuel, both the NTSB and FAA should have looked into this incident right away in spite that the law requires that property or whatever sustained damages. There is one thing called "criteria" or "open mindness" and two pilots not realizing where they were going to land on was sufficient for bringing them to task. Shame on both the NTSB and FAA over this matter only, otherwise both are top flight agencies.
Although very different in cause , the near collision of a fully loaded Asia bound transport with Mt Wilson in the LA area did not require death or damage to initiate an investigation. However not much has been heard of it . Talk about a close call
milypan 0
NTSB and FAA have very different missions, at least de facto if not de jure. NTSB exists to investigate and make safety recommendation. FAA nominally cares about safety and is supposed to act on NTSB's findings when appropriate, but de facto it basically exists to accommodate the airline industry. Safety will never be a top priority for FAA.
I worked for FAA for 50yrs. As an inspector. You are talking through your__hole. You have nothing to back up your statement.
SFOBro 9
I still have a great deal of trouble understanding this type of miscommunication by any pilots going into SFO. It is one of the most important airports in the world, let alone the U.S. The approach from the head of the bay is unique. They have charts.
I mean, if you are making that approach, at ANY time of day or in ANY weather, and can't tell that you're about to drop onto 4 planes waiting for you to land on the actual runway, then there's just something really, really wrong. In a way, it kind of suggests a scenario where you'd be driving towards the oncoming headlights on the freeway.....Oops, well I was just going where it was lit.
Charts ......... pretty much gone . But there were ample displays in the cockpit . including I assume , projected course arrow. Without us knowing who was doing what it is hard to know who should have been the first to pickup the errant direction.

There is also the issue of ending a long flight, getting the cockpit cleaned up for landing and getting out of the airplane.
Kris Durbin 7
Not a bad editorial, but what isn't addressed is how the author suggests that near-misses be regulated. Another federal agency (not relating to the FAA or NTSB) defines a near miss as "an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred." A near miss would necessarily be a completely different reporting categorization from an Incident, and one that introduces a significant amount of subjectivity; and in many cases, cannot even be monitored with modern technology, processes, and regulation. It's the US Federal Government, so I know they will try, but I am curious what kind of burden these undefined, yet proposed regulatory requirements would place on the FAA and operators. Plane nearly misses a flock of geese? That's a near miss. Tail strike? Near miss. Ground traffic confusion? Near miss. ATC correction of instruction? Near miss. Where would it end?
nsandin88 6
I believe the current NASA report system is sufficient for aviation near miss reporting. Perhaps there should be more emphasis on near miss reporting through this system, but another system or set of regulations altogether would almost certainly add an unnecessary level of confusion and ambiguity to the already grey world of self reporting.
sharon bias 10
We can't have data recorders that store more than one flights information? Don't put humans as the first line of defense in this battle. Use technology for what it's good at, storing and handling data. This should be a low cost solution to this problem.
Sergey Maltsev 11
I think we already have all technologies we need. Just need to implement a 'procedure' which will automatically transfer voice recorder data to the Ground once aircraft is arrived to gate. It can be done thru mobile network (via ACARS) or wi-fi. The data then should be put in secure storage with limited access for a period, let say, 30 days.
There are fundamental issues of privacy here. Imagine that your every conversation in the workplace was recorded and kept for posterity .

If we really wanted to use recorders to improve flight safety they would be installed in congressional and bureaucratic offices.
Billy Koskie 4
There is a missing point here. The NTSB and FAA have been constant adversaries on aviation safety. It's no surprise the FAA doesn't notify the NTSB of an incident. It's well documented that NTSB recommendations arising from an incident or accident is either delayed or completely ignored by the FAA. I think they should be combined with a mandate of cooperation.
James Derry 4
They must never be combined and are not in any country I know of, for good reason. Where ATC responsibility is related to a CAA (FAA in this case) they may be a part of an investigation and therefore the NTSB must be apart. It also checks other types of transport accidents.
SFOBro -2
The FAA can't even figure out at what height we're allowed to shoot a spy drone out of the sky above our houses, nor the opposite; telling us what's safe. Federal Academy of Aha! Big Guv at your service.
I am Canadian and I posted a comment on this 'near miss' and I said that Air Canada would blame everyone but the flight crew for this; ATC lights etc. There has been nothing in any media here about this. These guys as I mentioned should have been fired, or a least demoted and retrained. A friend of mine a now retired ACA 340 captain commented to be following the Air France over shoot at Toronto several years ago was a 'no brainer' pilot error after AF tried to blame ATC for the almost disaster. All airlines seem to choose to deny pilot error to protect themselves from law suits. In the Air France incident they landed on third down the runway took 6 seconds to activate the reversers and then wondered why the run out of runway especially when it was wet.
Dave Fisher 2
@Terry McKinney "There has been nothing in any media here [Canada] about this."

that is utter nonsense. nothing in the media here?

fact check:
If you look at some of the Amereican Airlines training films including Children Of The Magenta you's see the airline learning from mistakes made in the field.

Perfection is seldom found in places other than the personal mirror.....
D Chinn 2
Very early newspaper accounts of this incident DID report that one runway was closed at the time. I read about it within hours of the near-miss (or whatever you want to call it). I consider this a serious incident, and if there are no recordings left and no consequences for anyone, this is a really bad situation. It's as if it never happened, and as a frequent passenger in and out of SFO, I am really angry about that. At the very least, the pilots should have to be re-trained even more rigorously than usual and the ATC staffing situation changed.

Yes, SFO is a very important and busy airport. Yes, it was nighttime. And the taxiway IS close to the runway 28L, probably two plane lengths, I'd guess—not much. And with only one controller, that doesn't sound good at SFO that night. Aren't there different colored lights for each type of lane?

The separation between 28L and 28R is already too close for modern comfort. In inclement weather—fog, rain (lots of it at SFO, the frequency of flights in and out is cut by about half because of that (lack of) separation. Heaven forbid you should have to land in inclement weather or land with one runway closed—that means one landing runway ONLY for SFO. (The other two runways are take-off only, from my experiences as a passenger.) Most people don't appreciate or know about the problems at SFO, even as it gets busier and busier.
Geoffrey Lang 2
Up until yesterday, there was no widely-circulated reporting that, in fact, runway 28L was actually closed (and apparently, has been for a while due to construction / repair)on the night of the incident, which MIGHT explain - sort of - why the pilots would assume that taxiway C was actually 28R.

However, one would also have to ASSUME that the runway closure wasn't a secret, and that information would have been communicated and confirmed by ATC at SFO to the crew of AC759 early on during their approach.

There's obviously a lot more to this...which will be difficult to reveal given the absence of CVR records, and the seeming reluctance for both the FAA and Air Canada to divulge information.
How could the NTSB not know about this near miss? Apparently, everyone in the free world knew about the San Francisco near miss except the NTSB. We are now being fed a bunch of excuses to ensure that no one is held accountable and the truth is never known. Certainly, the pilots are not talking and I believe Air Canada is doing all it can to obfuscate the facts. Two pilots nearly kill 1000 people and no drug testing, no voice recorder and no flight recorder? Impossible. We criticize some third world airlines for low standards when in fact Air Canada has established a new low in corporate integrity. We need to know how this could happen, who was responsible and what is being done to preclude a recurrence. The bureaucrats should be fired and the NTSB should be shut down.
Torsten Hoff 9
I agree with most of what you wrote, with the exception of shutting down the NTSB -- it performs a crucial and invaluable service in investigating accidents and improving aviation safety.

The problem here lies with there being no legal requirement to preserve evidence and ensuring timely notification of the NTSB. That should change, and there should be severe penalties for what amounts to destruction of evidence. There is no way that Air Canada and its staff did not know that the CVR data was crucial in the investigatihon that would follow.
James Derry 1
But nothing happened, except a potential accident. All the pilots needed to do was hit the event button and it would be preserved.
The article writer then says that Air Canada was somehow remise using the aircraft and the pilots(!!!?). So nothing actually happens, except that the pilots realized their mistake, initialized the missed approach and thereafter landed. I am certain they had a long talk, they might have written a company report. That IS a system. It worked. No one was injured. I have sat on a closed runway when a 747 lined up to land. I pointed out to tower, at that moment, the 747 veered over to the correct runway, tower said, I see you altering course, can you make the landing or do you need a MA? I suppose we should all have taken off for three days while the non-incident was investigated? It is aviation. We fix it before it becomes an incident or accident.
Torsten Hoff 1
You're downplaying the seriousness of this incident. Just because nobody got killed and the pilots probably had a nice long talk about it afterwards doesn't mean that the system worked and the incident doesn't need to be investigated.

Nothing happened THIS TIME, but only by the slimmest of margins. It is important to understand why a disaster nearly occurred, and reduce the chances of a future recurrence with a different outcome.
btweston 3
Lay off he pipe, mac.
Joe Birts 1
It didn't hit the local news cycle, at least in the Bay Area, for several weeks, unlike Asiana.
joel wiley 1
ACA managed to go around. At Night. Asiana didn't. In Broad daylight in time for the 5 O'clock news.
Only one controller? Hasn't the FAA learned yet....
Dan Grelinger 0
Yes, but don't stop at 2 or 3. The only way to solve any problem is... more. How about 12, that is a nice round number.
Joseph Cooney 2
I'd like to see near miss redefined as a "near collision"!
Mike Mohle 3
Exactly. A near-miss is actually a "hit"!
I agree. It should be a "near hit" NOT a "near miss" "near miss" is a political oxymoron.
paul gilpin 1
well, air canada was on their "final approach".

from the same performance.
SFOBro 1
I will NEVER understand the acceptance of that terminology! NEAR MISS, it was CLOSE TO MISSING, IT ALMOST MISSED, but it didn't. paul Gilpin, they were on their final approach alright, that is absolutely worded perfectly! But they realized that they were about to have a collision, and went around. Had they literally had a near miss, it would, in fact, have been their FINAL approach. Thank goodness they were able to correct it, that would have been horrifying. can't see what's in front of you, what, you forgot to drop the nose cone? COME ON!
Ruger9X19 1
A near-miss would be a hit. A near miss, is a miss that was nearly a hit.
Joe Birts 1
Hit, miss Or whatever- How about near catastrophe.
Dave: Do you work for ACA? None of your sites deal with what has happened to this crew. My wife and I taught at #1 fighter wing in Marville France from 65 to 67. We were members of the officer's mess and most of our friends from those years are now retired airline pilots; most with Air Canada. These guys were up front about everything thatb goes on in the industry; no BS. These guys as the editorial says flew out the next day and I guess are still flying. This crew screwed up plain and simple. I hope you are not related to Dale Fisher who flew Bristol Freighters out of our base in those years.
Yehoram Uziel 1
This is another good reason why ATC should never be privatized or handed to the control or influence of the airlines.
Maybe privitized and never handed to control of airlines would have prevented this typical government coverup for incompetence.
Highflyer1950 1
jury is still out but: 1. What was the exact approach clearance given to Air Canada.? 2. The crew did query the tower about the runway because something did not look right to them? 3. The crew had already initiated a missed approach before the tower called it. 4. The aircraft does continue to descend during the M/A and the chart procedure calls for a right turn to 310 overflying "charlie " taxiiway and the departing aircraft. 5. and whatnis that gray aircraft shadow on runway 28R during the whole thing?
Inegrity not new laws is what's needed in this and similar situations.
ABR23 1
Was an ARFF training consultant for airport in Dom Rep. A new RWY was under construction and was so much larger than old RWY that acft constantly lined up with 08 rather than 09. The airport was also too cheap to have quality X markers using old burlap sacks painted black, and held down by cinder blocks. I saw that 737 was less than 3 miles out and aligned with the closed rwy. Had the ARFF guys light all there emergency and flood lights. Plane went around, later chk with Tower pilots stated they had panel indication problem and went MA. Sen Lloyd Bentson said "Knowing human nature, one can not be surprised, but dissapointed" by those who would lie or blame others to cover their faults.
There should be plenty of data available to recreate both the visual and the instrument displays on the approach. Of course the critical cockpit voice recording no longer exist.
Ed Blanchard 1
There are a slew of well-considered thoughts on this post directly concerning the alarming report of what would have been a monumental "accident". (I use quotes there because I believe there are NO accidents). I stray from my comment: I would very much like to be able to read any of the news items on this site without having to navigate the plethora of irritating pop-ups of inane adverts. How about it FlightAware gurus- can you harness the stories without the stupid ads?
joel wiley 1
FA does not usually control the sites to which a squawk links.
LHBfans 1
In my previous industrial environment we gave emphasis to this type of incident by re-naming them "near hits". You can get a lot of useful improvement opportunities from analysis of a near hit but only if you have the data. The response to the SFO incident seems slack at best and certainly reprehensible. It should lead to some categorisation of near hits which looks at their potential consequences. Which in this case would have been be disastrous, hence a "Level 1 near hit" requiring an immediate lock down of data and personnel.
Philip Lanum 1
Why is it that journalists can't speak English anymore.

Near-miss means that they nearly missed.
Near-collistion means they almost hit each other.

This is a so-called story about a near-collisition because they did not crash onto the four jets on the taxi-way. I remember when journalists actually used the correct set of words to describe what occured.
Dale Ballok 1
I think the news stations think the viewers like hearing someone with a different accent and colloquial phrases deliver the news.
I totally agree, Phil, that it gets confusing hearing some "foreign" phrases used to describe news details.
Jim DeTour 1
Tower didn't ask if anyone would like to file a near miss. I'm sure the airline has ideas while the pilots union has it's own of less flight hours and more pilots resulting in more money for the union. Nothing on workload of the pilots involved.
Dale Ballok 1
What the hell's going on?
Total incompetence/human error in a "near miss" airline situation.
Then the same thing on the water with a Naval warship colliding with a cargo ship!
Unbelievable, unthinkable, but true👎😩
A Gov 1
The Pilot could've at least used the ILS as guidance. Yes he was doing a visual approach but you can always tune in to the ILS and at least use it as reference
paul gilpin 0
this article is the result of "bay area" group think. just like in the tech sector, it's everyone else's fault and not ours, this article leaves out one critical piece of the puzzle. the SFO ATC obviously, according to this reporters opinion, bears no responsibility to be included in this hit piece.
in the original voice recording the air cananda crew can clearly be heard inquiring about the status of the runway, and SFO ATC says they are the only ones lined up on 28R. but they were not lined up on 28R now were they?
so let's do a hit piece on air canada and FAA to cover our bud's asses. let's lay the groundwork to discredit air canada and the FAA to de-ligitimize any findings that may come about as a result of this so-called investigation.
obfuscate the situation with this type of journalism serves no purpose, and even becomes part of the mis-handling of evidence in the investigative process.
the wheels spin. no one loses their job. let's go get a beer. wash. rinse. repeat.
nick salai 2
Have you ever heard of a tower giving approval for a landing on a taxiway?! Tower assumed the flight crew at least knew how to line up on a WELL LIT runway...

FYI... runway lights are white, taxiway lights are blue.
Joe Birts 1
#1 It was an editorial not a news article. #2 The Public didn't know about it until weeks after it happened. #3 It's hardly a "Hit" piece and I fail to see how it could be called "part of the mis-handling of evidence.
john hughes 0
Hey, Air Canada; "We To Lo" and Ho Le Phuc" are looking for jobs!

[This comment has been downvoted. Show anyway.]


Don't have an account? Register now (free) for customized features, flight alerts, and more!
Did you know that FlightAware flight tracking is supported by advertising?
You can help us keep FlightAware free by allowing ads from We work hard to keep our advertising relevant and unobtrusive to create a great experience. It's quick and easy to whitelist ads on FlightAware or please consider our premium accounts.