Virgin America A320 and Compass E175 at San Francisco on Feb 15th 2017, operational error leads to runway incursion

Last Update: March 31, 2021 / 22:03:52 GMT/Zulu time

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Photo of Virgin America N627VA, Airbus A320 — Virgin America N627VA, Airbus A320 (Photo credit: airlines470 / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Feb 15, 2017

Classification
Incident

Airline
Virgin America

Flight number
VX-920

Departure
San Francisco, United States

Destination
Las Vegas, United States

Aircraft Registration
N627VA

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A Virgin America Airbus A320-200, registration N627VA performing flight VX-920 from San Francisco,CA to Las Vegas,NV (USA), was cleared to line up and wait runway 28L and was taxiing into position.

A Compass Airlines Embraer ERJ-175 on behalf of American Airlines, registration N214NN performing flight CP-6081/AA-6081 from Los Angeles,CA to San Francisco,CA (USA), was on final approach to San Francisco's runway 28L at about 20:00L (04:00Z Feb 16th) when tower received an ASDE-X alert and instructed the Embraer to go around. The crew complied and went around from about 450 feet MSL. The aircraft positioned for another approach and landed safely on runway 28L about 12 minutes later.

On Nov 18th 2017 the NTSB reported night visual meteorological conditions prevailed. The occurrence was rated an incident and is being investigated.

On Mar 31st 2021 the NTSB released their final report concluding the probable cause of the incident was:

The local controller's issuance of a landing clearance for runway 28L to the ERJ170, and the subsequent issuance of line up and wait instructions to the A320 for runway 28L, resulting in a runway incursion.

The NTSB analysed:

The Boulder sector approach controller was the first controller the pilot of CPZ6081 contacted when entering NCT airspace. The controller informed the pilot that the ATIS was "tango" and to expect a visual approach to runway 28L.

Aircraft arriving from the south of SFO were routinely assigned runway 28L on initial contact; however, when noise abatement procedures were in effect, runway 28R was the preferential runway.

When the Boulder controller realized that CPZ6081 would arrive at SFO during noise abatement hours, he informed the Woodside controller that he would change CPZ6081 to runway 28R. The Boulder controller subsequently changed CPZ6081's data tag on the radar display from runway 28L to runway 28R and electronically handed the airplane off to the Woodside controller.

The Boulder controller did not inform the pilot of CPZ6081 about the runway change to 28R and did not inform the Woodside controller that he had not passed that runway change information to the pilot.

CPZ6081's data tag indicated runway 28R when the Woodside controller accepted the airplane.

When the Woodside controller cleared CPZ6081 for the visual approach to runway 28R, that was the first mention of runway 28R to the pilot. The pilot read back "runway 28R," however, continued to prepare for the runway 28L approach. The flight crew had briefed for a visual approach to runway 28L with a backup ILS to runway 28L and thought they had been cleared for the runway 28L approach.

The Woodside controller electronically handed off CPZ6081 to SFO ATCT, and the SFO local controller accepted the handoff; the data tag on the tower radar display indicated runway 28R.

The pilot of CPZ6081 contacted SFO tower and reported they were on a visual approach to runway 28L. The local controller issued the wind and cleared CPZ6081 to land "runway 28L," which the pilot read back correctly.

When the local controller instructed VRD920 to LUAW on runway 28L, she visually scanned the approach corridor and saw CPZ6081 on final approach, and then scanned the tower radar display and saw that CPZ6081's data tag indicated runway 28R. She stated that although it was difficult to visually discern which runway (28L/28R) an aircraft was lined up for, especially at night, she expected CPZ6081to land on runway 28R, and thought she had cleared the flight to land on runway 28R.

The local control audio revealed that the local controller had been consistent in providing traffic information to a pilot when she put an airplane into LUAW when another airplane was on the approach for that runway; however, in this case she had not provided traffic information to VRD920 or CPZ6081.

The airport surface surveillance capability (ASSC) system functioned as designed and produced the appropriate alert when CPZ6081 was approximately .85 nautical mile final runway 28L. The local controller took timely and appropriate action when the ASSC alerted and issued go-around instruction to CPZ6081; the pilot adhered to the go-around instruction.