- [Narrator] It is almost midnight at San Francisco International Airport as Air Canada Flight 759 is approaching. Just one more easy landing, and the pilots can call it a day. What they are not aware of is that the airport looks quite a bit different than usual.
They are clear to land on runway 28 right, located next to 28 left. However, due to maintenance, the runway 28 left is closed that night and the lights had been turned off. But as the pilots who both have landed at this airport before were expecting to see two parallel runways, they make a mistake.
Thinking that the center runway is 28 left, they confuse the taxi way on the right to be runway 28 right. On that very taxi way, four other flights are lined up for departure. United One, a Boeing 787; Philippine Airlines 115, an Airbus 340; and two more United flights.
In total over 1,000 passengers, and the Air Canada flight is heading straight towards them all. The information about the runway closure was listed in a so-called NOTAM. These are notices to airmen which summarize any exceptional details regarding the flight.
But these lists are quite long, typically several pages, and it's not easy to pick out the details that are actually relevant for the flight. The flight crew missed the runway closure. The pilots had been cleared for a so-called visual approach.
This means that they can line up with the runway manually, steering the aircraft according to what they see. Considering the clear weather conditions, the visual approach is the normal procedure. But as landings on false runways or even taxiways have occurred before, careful pilots usually back up their approach with instrument guidance.
In this case, they could have used the instrument landing system, ILS for short, of runway 28 right to confirm that they really were on the right path. In order to activate this system, a frequency corresponding to that runway has to be dialed into the navigation receiver. Modern flight management computers usually do this automatically, but in this case, it had to be dialed in manually, and for some reason the first officer didn't do that.
The cockpit crew has had a long day. Coming from Toronto, Canada, their inner clock is already at three past midnight, and overconfidence and fatigue have been attributed to these mistakes. Canadian pilot fatigue rules were less stringent than US regulations, and the flight's captain had no significant rest period for the last 19 hours.
As no one recognized that the airplane is lined up for the taxiway, Air Canada heads closer and closer to disaster. The ideal flight path for the visual approach at this airport comes in at a slight angle from the right. This was done in order to have incoming planes stay further away from the west shore of the bay, reducing noise pollution.
Therefore, it is not unusual that from the tower perspective airplanes appear a little offset to the left of the runway center line. Air Canada further closes in on the runway, about to crash into the parked planes. And as they notice that something seems off, they reassure themselves.
- [Pilot] And Tower, just wanna confirm. It's Air Canada 759, we see some lights on the runway there. Please, confirm we are cleared to land?
- [Narrator] At this moment, the tower voice recording shows that it took the tower controller about five seconds to answer the call. - [Tower] Air Canada 759, confirm. Cleared the land runway 28 right.
There is no one on 28 right but you. - [Narrator] There was only one controller managing the traffic at this time. Normally, an additional ground controller is responsible for handling the ground traffic, but during the less busy night hours, the tower controller often works both frequencies.
The pilots of United Flight One, waiting as first in line on taxiway Charlie were listening in on this exchange with Air Canada. They probably were wondering why Air Canada was still so far to the left of the center line. When it became obvious to them that the plane was heading for the taxiway, they spoke up quickly, not even mentioning their own call sign in order to save any second.
- [United Pilot] Where is this guy going? He's on the taxiway. - [Tower] Air Canada, go around.
- [Pilot] In the go round, Air Canada 759. (suspenseful music) - [Narrator] What we just witnessed could have been the largest accident in general aviation that ever happened. Air Canada 759 missed the tail fins of the waiting aircraft only by a few meters.
- [Tower] 759, looks like you were lined up for Charlie there. Fly heading 280, climb and maintain 3,000. - [Pilot] Heading 280, 3,000, Air Canada 759.
- [United Pilot] United 1, Air Canada flew directly over us. - [Tower] Yeah, I saw that, guys. (suspenseful music) - [Narrator] This real footage of the incident shows just how close the planes were.
(suspenseful music) A full investigation was launched, and the National Transportation Safety Board has released an entire list of recommendations, many of which have already been implemented. Visual approaches at night are no longer allowed at San Francisco when an adjacent runway is closed. Furthermore, two air traffic controllers are now required to be on duty until the late night arrival rush is over.
The incident became a striking reminder of the dangers of miscommunications at airports, but whether enough lessons have really been learned is increasingly being put into question, as this year saw an unprecedented amount of close calls at US airports. - [Reporter] A close call between two planes at New York's JFK Airport is now under federal investigation. - [Newscaster] In Austin, an airport crisis caught just in time.
- [Reporter] This fourth close call of the year happened at Burbank Airport on Wednesday. - [Newscaster] Well, tonight the FAA has launched an investigation into yet another near collision of two aircraft. This one at Boston Logan International Airport.
- [Reporter] This morning, another close call between two planes is under investigation. The FAA says a Republic Airways flight crossed the wrong runway at Reagan National Airport. - [Narrator] On January 13th, 2023, two airplanes almost crashed into each other at JFK Airport in New York City.
American Airlines Flight 106 was coming from the northwest along Taxiway Bravo. To get to the departure end of runway four left where they were gonna take off, they were told to taxi along Bravo and then turn onto Kilo. - [Ground Controller] American 106, Kennedy Ground, Runway 4L, taxi left Bravo, hold short of Kilo.
- [Pilot] Hold short of Kilo, American 106. - [Narrator] Note that the pilot did not read back the runway assignment but just the taxi route. This is a minor deviation from protocol, and the controller simply dismissed it, something that will prove dangerous.
At about the same time as they reached that intersection, Delta Airlines flight 1943 was ready for takeoff on runway four left and received its final clearance. - [Tower Controller] Delta 1943, wind 350, 18 gust two four, runway four left, cleared for takeoff. - [Pilot] Cleared for takeoff, runway four left, Delta 1943.
- [Narrator] Meanwhile, American Airlines 106 is continuing to taxi, and is instructed to turn at Kilo - [Ground Controller] American 106, heavy cross runway three one left at kilo. - [Pilot] Cross three one left at Kilo, (audio blurs). - [Narrator] But instead of turning right onto kilo, they taxi straight ahead onto Juliet, thereby crossing the very same runway on which the Delta flight is departing.
Why the pilots of the American Airlines flight continue taxiing straight ahead is unclear. JFK does often operate departures on runway three one left. Perhaps the pilots were so used to that taxi route that in their mind they were going to take off from there.
Another factor that might have pre-programmed them to believe they were departing from three one left was that the current winds were 340 degrees with 18 knots and gusts of 24 knots. These conditions would have favored runway three one left for departure. For operational reasons, however, the airport was using runway four left for departure.
Also noteworthy is that both flight crews could not hear each other. American 106 was on the ground frequency, while Delta 1943 was on the tower frequency. They were talking to different controllers and did not have a mental picture of what the other one was doing.
Thankfully, just seconds after the mistake, the tower controller notices what's happening and reacts extremely well. - [Tower Controller] American 106 Heavy, American 106 Heavy, hold position. - [Man] Shit!
- [Tower Controller] American 106 Heavy hold position. - [Tower Controller] Delta 1943, cancel takeoff clearance. Delta 1943, cancel takeoff clearance.
- [Pilot] Rejecting. All right, ah, whoof, Delta 1943. (dramatic music) - [Narrator] The delta plane comes to a stop about 1000 feet shy of intersection Juliet, and nobody was injured.
The US Federal Aviation Administration categorizes runway incursions by type and severity. Besides the incursions that actually result in an accident, there are four categories ranging from close calls in which a collision was just narrowly avoided to errors that at no point posed any security risks. The JFK incident was serious enough to be categorized as Category B.
Looking at the statistics, it can be observed that the number of serious incidents over the past two decades has been going down. While there were 22 category A incidents in 2007, there have never been more than nine such incidents per year in the past decade. As far as category B incursions are concerned, a similar trend is visible.
- If you look at the last decade or so, you would see between 10 and 20 times a year typically that this would happen. This year we're on track to have more than 20, and even one is one that I would not like to see happen. - [Narrator] The JFK incident has put a large media spotlight on airport safety, but still it will just take three weeks until the next close call, this one perhaps the most scary one.
Flight FedEx 1432, a Boeing 767 cargo plane, was coming from Memphis and arrived in the early morning hours in Austin. As happens so often in Austin, the ground is covered with a thin layer of fog, just about a thousand feet thick, but very dense. They are still high above that fog layer enjoying a clear sky, but they will have to dive through it for their landing - [Pilot] Austin Tower, FedEx 1432, heavy passing 5.
4 for that Cat three ILS one eight left. - [Narrator] Due to the low visibility, FedEx 1432 had to execute what is called a category three instrument approach, a procedure applied at very low visibility and clouds reaching almost to the ground. For such approaches, the auto land system of the airplane is used, and the flight crew only monitors the correct operations of all systems.
This in itself is just routine for the flight crew and nothing unusual. - [Tower Controller] FedEx 1432 heavy Austin tower, one eight left, RVR touchdown 1,400. Midpoint 600, rollout 1,800.
One eight left clear to land. - [Narrator] The RVR value given by the tower controller denotes the visibility in feet at three different points along the runway, near the touchdown point, the middle, and the end. The phrase passing 5.
4 means that they are 5. 4 miles away from the ILS transmitter, which sits at the end of the runway. At just this moment, Southwest 708 calls in.
- [Southwest Pilot] Tower Southwest 708. We're short of one eight left, and we're ready. - [Tower Controller] Southwest 708, Austin Tower.
Runway one eight left, 1200. Midpoint 600, rollout 1600. Fly heading 170, runway 18L, cleared for takeoff.
Traffic three miles final is a heavy 767. - [Southwest Pilot] Okay, fly heading 170, cleared for takeoff, one eight left. Copy the traffic, Southwest 708.
(dramatic music) - [Narrator] The tower controller's intention is to have the Southwest flight take off on the same runway before the FedEx lands. Three miles is usually a comfortable spacing to let a departure slip in front, and the phrase traffic on three mile final is a heavy 767 is to inform the Southwest crew about the incoming FedEx plane which requires them to do a speedy departure, but things take longer than expected. Time is ticking as the FedEx is entering the fog layer not able to see anything out of their cockpit windows anymore.
Their distance to the runway has now shrunk to merely 1. 2 miles, and they are becoming nervous about the Southwest still sitting on the runway - [FedEx Pilot] Tower confirm, FedEx 1432 heavy cleared to land on one eight left. - [Tower Controller] FedEx 1432 heavy, that is affirmative, runway one eight left.
You are cleared to land. Traffic departing prior to your arrival is a 737. - [FedEx Pilot] Roger.
- [Narrator] 60 seconds have now passed since the tower gave Southwest 708 the take off clearance, and apparently they are still standing at the threshold. Although there is no fixed time limit for starting the takeoff roll, it is expected that pilots perform the takeoff in an expeditious way. - [Tower Controller] Southwest 708, confirm on the roll?
- [Southwest Pilot] Rolling now. - [Narrator] Meanwhile, FedEx is descending through the fog layer and highly concentrated to look for the approach lights that show up. At about 150 feet above the ground, the fog clears up a bit, and they can make out the lights of Southwest 708 still on the runway rolling, but yet very slow.
They immediately initiate a go around, and they address the Southwest crew directly. - [FedEx Pilot] Southwest, abort. FedEx is on the go.
- [Tower Controller] Southwest 708, roger, you can turn right when able. - [Narrator] The tower's transmission is the result of a misunderstanding as he assumed the abort message had come from Southwest which was informing them about aborting their takeoff run. - [Southwest Pilot] Negative.
- The Southwest crew, however, was probably already beyond their V1 speed, and rejecting the takeoff would've been dangerous. As they were busy, they simply answered negative. This exchange shows just how confusing things can get very quickly.
Both planes come within 100 feet of each other, but the FedEx is able to out climb the departing Southwest plane. Normally, one aircraft is not allowed to give instructions to another. The fact that the FedEx crew did shows the severity of the situation.
After the tower controller got things sorted out, he takes active control again and gives instructions to both airplanes that keep them separated. - [Tower Controller] FedEx 1432, climb and maintain 3000. When able, turn left heading zero eight zero.
- [FedEx Pilot] With turn to zero eight zero, FedEx 1432 heavy. - [Tower Controller] Southwest 708, you can turn left heading one seven zero. - [Southwest Pilot] One seven zero.
(dramatic music) - [Narrator] Two airplanes should never come this close in such a situation. At the same time, the sequence of events also shows that several procedures did work in avoiding a collision. Whether by directly seeing the Southwest on the runway or a warning of the Tikka system the FedEx crew took timely action to stay separated from the other aircraft.
- [Tower Controller] FedEx 1432 heavy, roger, sir. You have our apologies. We appreciate your professionalism.
- [FedEx Pilot] Thank you. - [Narrator] Was it a wise decision to let Southwest go in front of FedEx while they were on a three mile final? In hindsight, the answer is probably no, particularly not at a time of very low traffic where a short two minute delay for Southwest 708 would've taken all the stress and risk out of the situation.
On the other hand, Southwest pilots are known for their proficiency and expeditious takeoffs. Thousands of other times such a takeoff clearance has already worked just fine. When it comes to the ultimate question of responsibility, the full NTSB investigation will decide about that.
Since the beginning of the year, eight cases of one way incidents have been reported, three of which have already been classified as Category B. At what point it is no longer a statistically plausible accumulation but a serious problem is difficult to say. At least to some degree, the current media attention is highlighting something that has always happened.
All of this is to prevent a repeat of history. If you look at a list of the deadliest aviation accidents that ever happened, the number one spot isn't a high altitude crash but rather two planes colliding on the runway. This accident occurred in 1977 between a KLM and a Pan-American flight.
Both planes were 747s, at the time the largest passenger plane in the world. In the cockpit of the KLM sits one of the airline's most experienced pilots who even appears in the company's advertising. The weather had deteriorated massively, and the two planes did not see each other nor could the tower controller see the aircraft.
While the PanAm is taxiing down the runway, the KLM is lining up for their departure and with the pilot under the wrong assumption that the runway is clear, they start rolling. (dramatic music) How it came this far is a fascinating story which is why I have produced another full length video about this crash, creating detailed models and mapping out where exactly things went wrong. - [KLM Pilot] The KLM 4805 is now ready for takeoff.
And we're waiting for our ATC clearance. - [Narrator] This video is part of my ongoing Nebula original series "Under Exposure" in which I explore topics that could not work on YouTube. That is because on one hand, they are violent subject matters that would get demonetized or perhaps even age-restricted.
For example, I produced a video about the investigation into flight MH17 that was shot down over Ukraine. Or another video about the Bin Laden raid, following the operation that stormed his compound. The other reason why these videos couldn't work on YouTube is because they are made for the big screen.
Videos that are not made for the YouTube algorithm, but unrushed storytelling. And since Nebula is a subscription service, I get to put higher budgets into the production of this series. Nebula is a creator owned streaming service, and besides my videos, you can watch exclusive videos from lots of other independent creators.
So go to nebula. tv/neo and make sure that you use that very link so that you get 40% off on an annual plan. All my exclusive videos are up there, so thanks for the support.
And thanks so much for watching this video.
