reducing "Crew-caused"
approach and landing

Pilot-in-charge Monitored Approach

2014 B737 visual approach collision risk Fort McMurray Canada

Brief account : 

At the top of the descent, the B737 flight crew expected to be able to make, and briefed for, a visual approach with ILS/DME tuned. At approximately 4 nautical miles on final, the airport environment was visually acquired and the Captain inadvertently lined up with a parallel taxiway on which another aircraft was taxying. A go-around was initiated from below 50 feet, when when the crew realised they were not in fact lined up on the runway and a collision was narrowly avoided.

Crew-related factors : 

Based on out-of-date ATIS information, the crew expected to encounter "good weather".  However, the visibility they encountered was significantly less than expected due to smoke and the fact that they were looking into the sun. It transpired that the conditions actually being reported at the time were below limits for a visual approach.

Although the crew were cleared for an ILS, the way the visual approach actually briefed for was handled resulted in the autopilot holding an altitude significantly higher than the glideslope at the final approach fix.

At that point the taxiway was misidentified as the runway, to which the aircraft was turned. Several factors probably contributed further to visual illusions for both pilots, who did not observe the full-scale ILS deflections as a high and unstable approach ensued. 

The report noted that "Once the taxiway had been identified as the runway, both pilots focussed their attention outside the aircraft, and cues that could have alerted the crew to their error were not assimilated."  "Factors that have been shown to increase the likelihood of a continued unstable approach were present.... To overcome these factors...the use of all available cues while implementing procedures that focus the crew’s attention on those cues, such as the continuation of standard calls throughout the visual segment [is encouraged]....  "the focus of both crew members was outside the cockpit during the late stages of the approach and, therefore (instrument) deviations were not noted by the PM."

"Current defences against continuing unstable approaches have proven less than adequate. Unless further action is taken to reduce the incidence of unstable approaches that continue to a landing, the risk of CFIT and of approach and landing accidents will persist."

If PicMA had been the SOP it is more likely that 

1) an instrument approach brief would have been carried out;

2) the Captain's situational awareness would have been greater: for example of the prevailing actual visibility, from other R/T traffic;

3) the deviations from a stable approach prior to the FAF would have been less due to the F/O flying the ILS procedure as actually cleared by ATC;

4) the deviations from a stable approach below the FAF would have been less due to the F/O continuing to be instrument oriented, including awareness of the full-scale ILS deviations.


Fort McMurray
Expected weather: 
Pilot in charge: 
Early transition: 
Go-around : 
Below DH/A
Minor or none
PicMA potential: 
Vert Guidance: 
Both Head Up: 
Canadian North
Fully prepared: 
Actual Weather: 
Other vis
Autopilot :