Originally Posted by
DaveReidUK
Includes a 37-page submission from Air Canada:
Air Canada Submission to the NTSB in the Investigation of the Overflight of a Taxiway at San Francisco International Airport on July 7, 2017
ACA-determined Probable Cause:
"The Probable Cause of the ACA759 overflight incident was the flight crew’s misperception of SFO Taxiway C as Runway 28R during the approach. Contributing to the incident were: (1) San Francisco International Airport’s inadequate lighting of the runway environment, including lighting of the ongoing construction, to distinguish the normally-configured parallel runways from runway 28R and Taxiway C given the closure of runway 28L; (2) failure of the sole, combined local controller/controller-in-charge (LC/CIC controller) in the KSFO tower to provide any direction or information to the flight crew, following the flight crew’s request, until after the flight crew had already initiated the go-around; and (3) insufficient training and knowledge by the combined LC/CIC controller on use of available lighting resources and ADSE-X/ASSC capabilities."
If ACA really believes this, one wonders why they are still choosing to fly into SFO, especially at night. Indeed, of ACA's
26 points of proposed findings of the causes of this incident,
24 of them are attributed to SFO, the FAA and the ATCO, while only
2 of them are levied against ACA.
5.1.14. The ACA759 flight crew were likely affected by some degree of WOCL/Fatigue.
5.1.22. The lack of onboard GPS, HUD or software tools to assist with alignment placed the crew in a position where they would be susceptible to illusions and biases.
Including erasing the CVR, it would appear that safety culture deficiencies are present up to the very top at ACA.