- [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 w
ere 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 NO
TAM. 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 visu
al 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 airpl
ane 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 pla
ne 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
l
ike 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
alr
eady 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. - [Repo
rter] 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 investi
gation. 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, tax
i 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 favore
d 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 extrem
ely 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 incur
sions
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 n
ever 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 ne
xt 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 co
mfortable 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
sitt
ing 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 bo
th 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 a
t 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 r
eported, 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 run
way. 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 wit
h 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 t
hat 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 alg
orithm, 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.
(dramatic music)
Comments