On July 7, 2017, an Air Canada Airbus A320, being operated as Flight 759, on final approach to San Francisco International Airport, lined up with an occupied taxiway rather than the assigned Runway 28R. The A320 descended to 60 ft above the ground and initiated a go-around after overflying the first of four airliners waiting on the taxiway for takeoff clearance.
The U.S. National Transportation Safety Board (NTSB) determined that the probable cause of the incident was the flight crew’s misidentification of Taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness — “due to their ineffective review” of notice to airmen (NOTAM) information before the flight and during the approach briefing — that the parallel Runway 28L was closed. Contributing to the incident, NTSB said, were the crew’s failure to tune the instrument landing system frequency for backup lateral guidance, expectation bias, fatigue, breakdown in crew resource management and the airline’s ineffective presentation of approach procedure and NOTAM information.
In its findings, NTSB said that although the NOTAM about the Runway 28L closure appeared in the flight release and the aircraft communication addressing and reporting system message that were provided to the flight crew, the “presentation of the information did not effectively convey the importance of the runway closure information and promote flight crew review and retention.”
At a meeting to determine the probable cause of the near miss, NTSB Chair Robert Sumwalt underscored the point even further, by referring to NOTAMs as “just a bunch of garbage that nobody pays any attention to.” This characterization resonates with many crewmembers, and his sentiments about the usefulness of NOTAMs in their current form are worth considering and acting upon.
The investigation resulted in several safety recommendations, including that the U.S. Federal Aviation Administration (FAA) establish a group of human factors experts to review existing methods for presenting flight operations information to pilots, creating and publishing guidance on best practices to organize, prioritize and present this information in a manner that optimizes pilot review and retention of relevant information, and that the FAA work with air carriers and service providers to implement solutions that are aligned with the guidance.
As NTSB and others have said, the way in which information is presented can have a significant effect on how information is reviewed and retained. More relevant information may be missed when it is presented with less relevant information. In his concurring statement on the Air Canada investigation, NTSB Vice Chair Bruce Landsberg said the current NOTAM and preflight information system “lays an impossibly heavy burden on individual pilots, crews and dispatchers to sort through literally dozens of irrelevant items to find the critical or merely important ones. When one is invariably missed, and a violation or incident occurs, the pilot is blamed for not finding the needle in the haystack!”
FAA is working on NOTAM issues and has established a task force to address stakeholder concerns. This issue has been around for a long time without satisfactory resolution. We urge FAA and other stakeholders to act to accelerate improvements to the NOTAM system to ensure that pilots have the accurate and concise information they need to safely operate their aircraft in an increasingly complex environment.