Air Canada’s Aborted SFO Taxiway Landing
A Working Hypothesis Until the Investigation is Completed
- Anyone, who has spent much time in the cockpit of a commercial airliner flying through complex airspace to a multi-runway airport at night, knows that the pilots must be well prepared and have focused attention on the demanding task at hand.
- Anyone, who has participated in an accident or incident investigation, will acknowledge that the process involves reviewing and eliminating scenarios, that as the exercise develops the number of alternatives to be examined may actually expand to capture constructs not initially included and that the determination of a final cause must involve a slow, careful series of iterations.
- Anyone, who has covered one of the NTSB investigations (like David Koenig for almost 20 years), is aware that the fecund false information environment surrounding an NTSB case, a publicity magnet, requires careful parsing of sources.
- Everyone, who comments on such situations, should not be given equal weight as to their expertise. There is a community of “talking heads”, who know how to spin a yarn which improves ratings; others are able to articulate a set of facts attractive to those who may have been harmed.
- One of a few people whose opinions are likely to be carefully selected and whose insights are based on real experience is Steven Wallace, the former Director of the FAA Office of Accident Investigation, where he was responsible for FAA accident and incident investigation activities. Mr. Wallace was one of thirteen members of the independent board that led the investigation into the February 2003 loss of the Space Shuttle Columbia. Previously, he was Manager of the Standards Staff in the FAA’s Transport Airplane Directorate in Seattle. That experience provided a great education for the airworthiness aspects of investigations. Wallace also was an attorney in the agency’s Eastern Region counsel’s office in New York, then at the Northwest Mountain Region counsel’s office. Steve earned a commercial pilot’s license with multiengine, instrument, seaplane and glider ratings.
That’s a very long introduction to verify the following statement made by Mr. Wallace in Mr. Koenig in the AP article:
The Air Canada plane with 140 people aboard came within 100 feet of crashing onto the first two of four passenger-filled planes readying for takeoff.
Runways are edged with rows of white lights, and another system of lights on the side of the runway helps guide pilots on their descent. By contrast, taxiways have blue lights on the edges and green lights down the center.
“The lighting is different for good reason,” said Steven Wallace, a former director of accident investigations at the Federal Aviation Administration. “Some of these visual mistakes are hard to believe, but a crew gets fixated with thinking ‘That’s the runway,’ and it’s not.”
And later in the same story, Wallace is quoted:
Throughout aviation history, deadly accidents have led to safety improvements. As fatal crashes have become rare, “the only way to get better is to learn from close calls and incidents,” Wallace said.
To reiterate an earlier point, as credible as these comments may be, there have been many NTSB cases in which such preliminary theses have been replaced by another probable cause. The iterative process frequently defines overlooked faults in the system. As with all NTSB investigations, it is advisable to hold this as a working hypothesis until the process is completed; it is too early to assume that corrective action based on this incident’s early informed judgment will fix the problem.