Midnight Close Call: How Fatigue Nearly Caused a Catastrophe at SFO

## Almost Midnight at SFO: A Near-Miss 😱

It was almost midnight at San Francisco International Airport when **Air Canada Flight 759** was approaching for its final landing of the day. The pilots, eager to call it a day, were unaware that the airport was different from usual. They had been cleared to land on **runway 28R**, located next to **28L**. However, due to maintenance, runway **28L** was closed, leaving its lights turned off.

### The Mistake: Confusing the Taxiway for the Runway 🎭

Both pilots, familiar with the airport, expected to see two parallel runways. They mistook the center runway for **28L** and confused the taxiway on the right to be **runway 28R**. On that very taxiway, four other flights were lined up for departure:

In total, more than **1,000 passengers** were at risk as the **Air Canada flight headed straight towards them**.

### The Role of NOTAMs 📜

The runway closure was listed in a NOTAM (Notice to Airmen), which contains exceptional flight details. However, these lists are typically several pages long, making it difficult to pick out the relevant details. The flight crew missed this crucial information.

### Visual vs. Instrument Approaches 🛬

Cleared for a visual approach due to clear weather conditions, the pilots relied on their sight. While visual approaches are typical, careful pilots usually back up their approach with instrument guidance. They could have used the **Instrument Landing System (ILS)** of runway 28R to confirm their path. In this instance, the first officer had to dial in the frequency manually but failed to do so.

### Fatigue and Human Error 🥱

The cockpit crew was exhausted, having flown from Toronto. Their inner clock read past midnight. The flight’s captain had not had significant rest for the last 19 hours, contributing to the errors. Overconfidence and fatigue clouded their judgment.

### Moments Before Disaster ⏳

The ideal approach path at SFO comes in at a slight angle from the right to reduce noise pollution, often appearing offset from the centerline. As **Air Canada Flight 759** closed in on the taxiway, the pilots became suspicious.

### A Close Call: United Pilot’s Intervention 🚨

United Flight One, first in line on **taxiway Charlie**, noticed the deviation and intervened:

The **Air Canada flight** narrowly missed the tails of the parked planes by just meters. This incident could’ve been the largest accident in general aviation.

### Immediate Reforms and Recommendations 📝

A full investigation by the National Transportation Safety Board led to immediate changes:

### Rising Concerns in Aviation Safety 🚥

Despite reforms, the year saw an unprecedented number of close calls at US airports, highlighting ongoing concerns about aviation safety. Incidents at JFK, Austin, Burbank, Boston Logan, and Reagan National have all shown just how easily near-misses can occur.

### The JFK Incident: A Dangerous Intersection 🗽

On January 13, 2023, at JFK Airport, **American Airlines Flight 106** taxied onto a runway that had been cleared for **Delta Flight 1943’s** takeoff. Miscommunication and incorrect taxiing routes led to a serious close call, narrowly avoided by quick-action from air traffic controllers.

### The Austin Incident: Visibility Challenges 🌫️

In Austin, foggy conditions led to a near-midair collision between **FedEx Flight 1432** and **Southwest 708**. Due to low visibility and delayed takeoff, FedEx initiated a go-around just in time, avoiding disaster by 100 feet.

### The Takeaway: The Need for Vigilance and Coordination 🛡️

These incidents are stark reminders of the importance of vigilance and effective communication in aviation. The industry continues to adapt and implement necessary safety measures, but each close call is a reminder of the margin for error.

In conclusion, the series of events highlight critical aspects of aviation safety, reinforcing the need for stringent guidelines and clear communication to prevent potential disasters. 🛬