From the abstract..
1. None of the following were factors in this incident: (1) flight crew qualifications, which were in accordance with Canadian and US regulations; (2) flight crew medical conditions;(3) airplane mechanical conditions; and (4) airport lighting, which met US regulations.
2. The first officer did not comply with Air Canada’s procedures to tune the instrument landing system (ILS) frequency for the visual approach, and the captain did not comply with company procedures to verify the ILS frequency and identifier for the approach, so the crewmembers could not take advantage of the ILS’ lateral guidance capability to help ensure proper surface alignment.
3. The flight crew’s failure to manually tune the instrument landing system (ILS) frequency for the approach occurred because (1) the Flight Management System Bridge visual approach was the only approach in Air Canada’s Airbus A320 database that required manual tuning of a navigation frequency, so the manual tuning of the ILS frequency was not a usual procedure for the crew, and (2) the instruction on the approach chart to manually tune the ILS frequency was not conspicuous during the crew’s review of the chart.
4. The first officer’s focus on tasks inside the cockpit after the airplane passed the final waypoint reduced his opportunity to effectively monitor the approach and recognize that the airplane was not aligned with the intended landing runway.
5. The flight crew-initiated, low-altitude go-around over the taxiway prevented a collision between the Air Canada airplane and one or more airplanes on the taxiway.
6. The controller responded appropriately once he became aware of the potential conflict.
7. Errors that the flight crewmembers made, including their false assumption that runway 28L was open, inadequate preparations for the approach, and delayed recognition that the airplane was not lined up with runway 28R, reflected breakdowns in crew resource management and led to minimal safety margins as the airplane overflew taxiway C.
8. The flight crewmembers’ lack of awareness about the runway 28L closure and the crewmembers’ previous experience seeing two parallel runways at San Francisco International Airport led to their expectation to identify two runway surfaces during the approach and resulted in their incorrect identification of taxiway C instead of runway 28R as the intended landing runway.
9. Although the notice to airmen 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.
10. The cues available to the flight crewmembers to indicate that the airplane was aligned with a taxiway were not sufficient to overcome their belief, as a result of expectation bias, that the taxiway was the intended landing runway.
11. Multiple salient cues of the surface misalignment were present as the airplane approached the airport seawall, and one or more of these cues likely triggered the captain’s initiation of a go-around, which reportedly occurred simultaneously with the first officer’s call for a go-around.
12. The captain and the first officer were fatigued during the incident flight due to the number of hours that they had been continuously awake and circadian disruption, which likely contributed to the crewmembers’ misidentification of the intended landing surface, their ongoing expectation bias, and their delayed decision to go around.
13. Current Canadian regulations do not, in some circumstances, allow for sufficient rest for reserve pilots, which can result in these pilots flying in a fatigued state during their window of circadian low.
14. Flight safety would be enhanced if airplanes landing at primary airports within class B and class C airspace were equipped with a cockpit system that provided flight crews with positional awareness information that is independent of, and dissimilar from, the current instrument landing system backup capability for navigating to a runway.
15. Although the investigation into this incident identified significant safety issues, cockpit voice recorder information, had it been available, could have provided direct evidence regarding the flight crew’s approach preparation, cockpit coordination, perception of the airport environment, and decision-making.
16. Once the flight crewmembers perceived lights on the runway, they decided to contact the controller to ask about the lights; however, their query was delayed because of congestion on the tower frequency, which reduced the time available for the crewmembers to reconcile their confusion about the lights with the controller’s confirmation that the runway was clear.
17. Although the use of line up and wait (LUAW) procedures during single-person air traffic control operations was not a factor in this incident, the tower controllers should have delayed consolidating local and non-local control positions until LUAW procedures were no longer needed.
18. If an airplane were to align with a taxiway, an automated airport surface detection equipment alert would assist controllers in identifying and preventing a potential taxiway landing as well as a potential collision with aircraft, vehicles, or objects that are positioned along taxiways.
19. Increased conspicuity of runway closure markers, especially those used in parallel runway configurations, could help prevent runway misidentification by flight crews while on approach to an airport.
The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information.
I'm a huge fan of the little jab at TC about fatigue rules. They've been stalling on implementing the updated rules for a long time..
"To Transport Canada:
Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low."