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Accidents · NTSB DCA17IA148 · Final report

Airbus A320-211 incident near San Francisco, California, July 8, 2017

On July 8, 2017 at about 6:56 am local time, a 1992 Airbus A320-211, registered CFKCK, was involved in an incident during approach near San Francisco, California (San Francisco International airport). It was flown under foreign airline rules (Part 129). The NTSB record does not give the injuries. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

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 notice to airmen (NOTAM) information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew's failure to tune the instrument landing system frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in crew resource management and (2) Air Canada's ineffective presentation of approach procedure and NOTAM information.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
July 8, 2017 · about 6:56 am local time
Place
San Francisco, California · San Francisco International · map
Type
Incident
Injuries
The NTSB record does not give the injuries.
Weather
visual conditions (good weather)
Aircraft
Airbus A320-211 211, built 1992 · all A320-211s on the register
Registration
CFKCK · no longer on the register · serial 265
Damage
Not recorded
Flight
Flight · foreign airline rules (Part 129)

The NTSB's narrative final · quoted from the NTSB record

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft incident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Incident Report number is NTSB/AIR-18/01. On July 7, 2017, about 2356 Pacific daylight time, Air Canada flight 759, an Airbus A320-211, Canadian registration C-FKCK, was cleared to land on runway 28R at San Francisco International Airport, San Francisco, California, but instead lined up with parallel taxiway C. Four air carrier airplanes (a Boeing 787, an Airbus A340, another Boeing 787, and a Boeing 737) were on taxiway C awaiting clearance to take off from runway 28R. The incident airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before starting to climb. None of the 5 flight crewmembers and 135 passengers aboard the incident airplane were injured, and the incident airplane was not damaged. The incident flight was operated by Air Canada under Title 14 Code of Federal Regulations Part 129 as an international scheduled passenger flight from Toronto/Lester B. Pearson International Airport, Toronto, Canada. An instrument flight rules flight plan had been filed. Night visual meteorological conditions prevailed at the time of the incident.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Wrong surface or wrong airport during approach defining event

The NTSB's findings

  • cause Personnel issues › Action/decision › Info processing/decision › Identification/recognition › Flight crew
  • cause Environmental issues › Operating environment › Airport facilities/design › Runway/landing area condition › Awareness of condition
  • cause Personnel issues › Task performance › Use of equip/info › Use of available resources › Flight crew
  • factor Personnel issues › Task performance › Use of equip/info › Use of equip/system › Flight crew
  • factor Personnel issues › Action/decision › Info processing/decision › Expectation/assumption › Flight crew
  • factor Personnel issues › Physical › Alertness/Fatigue › Circadian rhythms or jetlag › Flight crew
  • factor Personnel issues › Physical › Alertness/Fatigue › Lack of sleep › Flight crew
  • factor Personnel issues › Task performance › Communication (personnel) › CRM/MRM techniques › Flight crew
  • factor Organizational issues › Management › Policy/procedure › Adequacy of policy/proc › Operator
  • Aircraft › Aircraft systems › Navigation system › (general) › Design
  • Aircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) › Capability exceeded

The aircraft

  • Airframe total time: 82,427 hours
  • Last inspection: approved inspection programme, June 25, 2017
  • Maximum gross weight: 166,449 lb
  • Seats: 154
  • Landing gear: retractable
  • Engine 1: Cfm CFM56-5A! (turbofan); 79,303 hours total
  • Engine 2: Cfm CFM56-5A1 (turbofan); 69,225 hours total
  • Operator: Air Canada

The flight

  • Departed from: YYZ Toronto OF
  • Destination: SFO San Francisco CA
  • Flight plan: IFR
  • Runway 28R, 11,870 ft by 200 ft
  • A second pilot was aboard

Weather at the time

  • Light: night, dark
  • Wind: from 290° at 9 knots
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 61°F (16°C), dew point 48°F (9°C)
  • Altimeter: 29.92 inHg

Documents from the investigation the NTSB's docket: the evidence folder behind the report

53 documents, released by the NTSB on May 2, 2018. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

#DocumentWhat it is
1 Security Camera Video File PDF, 1 page View Download
2 Operational Factors/human Performance Factual Report PDF, 102 pages View Download
3 Operational Factors/human Performance Group - Attachment 1 - Flight Crew Interview Summaries PDF, 34 pages View Download
4 Operational Factors/human Performance Group - Attachment 2 - Air Canada Personnel Interviews PDF, 73 pages View Download
5 Operational Factors/human Performance Group - Attachment 3 - Airplanes on Taxiway C Crew Statements PDF, 12 pages View Download
6 Operational Factors/human Performance - Attachment 4 - Preceding Flight Crew Statement PDF, 10 pages View Download
7 Operational Factors/human Performance Group - Attachment 5 - Dispatch Release PDF, 28 pages View Download
8 Operational Factors/human Performance Group - Attachment 6 - Acars Traffic Log PDF, 24 pages View Download
9 Operational Factors/human Performance Group - Attachment 7 - FAA Notams for Sfo PDF, 5 pages View Download
10 Operational Factors/human Performance Group - Attachment 8 - Ramp Reconciliation Report PDF, 4 pages View Download
11 Operational Factors/human Performance Group - Attachment 9 - Canadian ATP Requirements PDF, 3 pages View Download
12 Operational Factors/human Performance Group - Attachment 10 - Air Canada Pilots Contractual Pairing and Reserve Rules PDF, 24 pages View Download
13 Operational Factors/human Performance Group - Attachment 11 - Sfo Runway 28R Approach Charts PDF, 20 pages View Download
14 Operational Factors/human Performance Group - Attachment 12 - Route Briefing - the Americas [excerpt] PDF, 8 pages View Download
15 Operational Factors/human Performance Group - Attachment 13 - Air Canada Threat Briefing Reference Card PDF, 2 pages View Download
16 Operational Factors/human Performance Group - Attachment 14 - Air Canada Nav Tuning Guidance PDF, 2 pages View Download
17 Operational Factors/human Performance Group - Attachment 15 - Air Canada Non-precision Approach Procedure PDF, 6 pages View Download
18 Operational Factors/human Performance Group - Attachment 16 - Air Canada's Simulator Evaluation PDF, 19 pages View Download
19 Operational Factors/human Performance Group - Attachment 17 - QRH Normal - Controlled Rest on the Flight Deck PDF, 2 pages View Download
20 Operational Factors/human Performance Group - Attachment 18 - Canadian Aviation Regulations Advisory Council on Flight Crew Fatigue Management PDF, 34 pages View Download
21 Operational Factors/human Performance Group - Attachment 19 - Incidient Crew Schedule Preceding 90 Days PDF, 9 pages View Download
22 Operational Factors/human Performance Group - Attachment 20 - Incident Crew Training Records PDF, 5 pages View Download
23 Operational Factors/human Performance Group - Attachment 21 - NTSB Email Correspondence with Air Canada Regarding Acars, CRM Training, and Fatigue Policies PDF, 12 pages View Download
24 Operational Factors/human Performance Group - Attachment 22 - Previous Captain and Duty Pilot Interview Summaries PDF, 11 pages View Download
25 Operational Factors/human Performance Group - Attachment 23 - North Platte Neberaska Weather radar Data PDF, 2 pages View Download
26 Operational Factors/human Performance Group - Attachment 24 - Air Canada Autopilot Limitation PDF, 2 pages View Download
27 Operational Factors/human Performance Group - Attachment 25 - Air Canada Email on Captains Reserver Duty Day PDF, 3 pages View Download
28 Operational Factors/human Performance Group - Attachment 26 - Email from Honeywell PDF, 6 pages View Download
29 Operational Factors/human Performance Group - Attachment 27 - Only Manual Tuned Approach for A320 PDF, 2 pages View Download
30 Operational Factors/human Performance - Errata 1 PDF, 1 page View Download
31 Air Traffic Control Factual Report PDF, 16 pages View Download
32 Air Traffic Control Factual Report - Erratum and Addendum PDF, 2 pages View Download
33 Air Traffic Control Factual Report - Attachment 1 Interview Summaries PDF, 18 pages View Download
34 Air Traffic Control Factual Report - Attachment 2 Previous Safety Recommendations PDF, 7 pages View Download
35 Air Traffic Control - Attachment 3 - Mandatory Occurence Report PDF, 8 pages View Download
36 Air Traffic Control - Attachment 4 - Daily Record of Facility Operations PDF, 5 pages View Download
37 Air Traffic Control - Attachment 5 - radar Data PDF, 16 pages View Download
38 Air Traffic Control - Attachment 6 - Position Logs PDF, 5 pages View Download
39 Air Traffic Control - Attachment 7 - Memorandum for Combining Positions PDF, 3 pages View Download
40 Air Traffic Control - Attachment 8 - Memorandum for the Record Asde-x Testing at Sea PDF, 2 pages View Download
41 Flight Data Recorder Specialist's Factual Report Attachment 1 data file Download
42 Aircraft Performance PDF, 17 pages View Download
43 Flight Data Recorder Specialist's Factual Report PDF, 14 pages View Download
44 Pilot/operator Aircraft Accident Report, NTSB Form 6120.1 PDF, 11 pages View Download
45 Airports Specialist Report PDF, 12 pages View Download
46 Airports - Attachment 1 - Sfo Airport Inspection Logs PDF, 3 pages View Download
47 Airports - Attachemnt 2 - Sfo Airport Lighting Logs PDF, 9 pages View Download
48 Aircraft Performance Erratum PDF, 1 page View Download
49 Aircraft Performance Erratum 2 PDF, 1 page View Download
50 Party Submission PDF, 37 pages View Download
51 Honeywell EGPWS Smart Landing Simulation Report PDF, 3 pages View Download
52 Correspondence PDF, 3 pages View Download
53 NTSB - Adopted Board Report, AIR-18/01 PDF, 93 pages View Download

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.