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An 'almost' accident case study: Air Canada Flight 759 near miss

Flight Chain App - NTSB Aviation Accident Reports - Helping pilots learn from accident chains By Dan Sobczak
September 2020

Editor's note: This content does not constitute flight instruction. Consult a certified flight instructor in your area for proper flight instruction.



On the night of July 7, 2017, a passenger jet came within feet of causing what could have been the worst aviation accident in history, when it attempted to land on the taxiway at San Francisco International Airport.

What happened in the chain of events that led to such an obvious mistake?

Equally important, what caused this evolving accident chain to break so that the worst aviation accident in history never happened?

It's an intriguing story with important lessons for pilots about fatigue, expectation bias, and taking action when something wasn't right.

This video clip is from San Francisco International Airport, showing Air Canada Flight 759's final approach and go-around above taxiway Charlie, just above the vertical stabilizer of Philippine Airlines Flight 115. The airport surveillance camera is looking east from the terminal across the airport. There are four passenger jets on taxiway Charlie directly in front of Air Canada Flight 759. Source: NTSB.

This video clip is from San Francisco International Airport, showing Air Canada Flight 759's final approach and go-around above taxiway Charlie, just above the vertical stabilizer of Philippine Airlines Flight 115. The airport surveillance camera is looking east from the terminal across the airport. There are four passenger jets on taxiway Charlie directly in front of Air Canada Flight 759. Source: NTSB.



Background of the Air Canada Flight 759 incident


Air Canada Flight 759, an Airbus A320-211, Canadian registration C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (KSFO).

However, Flight 759 lined up with the parallel taxiway C, where four passenger jets were awaiting clearance to take off from runway 28R.

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As Flight 759 descended to an altitude of 100 feet above ground, it overflew the first airplane on the taxiway.

As it approached the second airliner on the taxiway, Flight 759's crew initiated a go-around as they reached a minimum altitude of about 60 feet, passing directly over the second airliner within mere feet before starting to climb.

With that background, let's look at the near crash of Air Canada Flight 759, and its 'almost' accident chain. The descriptions in the 'almost' accident chain outline below are taken from the NTSB's final report on this incident.

C-FKCK, the Airbus A320-211 involved in the incident, in June 2007. Source: NTSB.

C-FKCK, the Airbus A320-211 involved in the incident, in June 2007. Source: NTSB.



Air Canada Flight 759's 'Almost' Accident Chain


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PILOT RELATED: Prior to flight, Captain's sleep schedule - On the day before Flight 759's near miss incident, the Captain, a reserve pilot for Air Canada, reported for duty between 16:00 and 17:00 EDT and flew to LaGuardia Airport, New York, and then back to YYZ (Lester B. Pearson International Airport) in Toronto. He went off duty at 23:13 EDT and drove home. He stated that the flight from New York, because of its arrival time, affected his sleep cycle "a little bit." The Captain went to sleep between 02:00 and 03:00 EDT on July 7 and awoke about 07:45 EDT.

On July 7, the Captain's reserve duty period began at 11:13 EDT. About 11:49 EDT, crew scheduling called the Captain to notify him of a round-trip flight assignment from YYZ to SFO. The Captain did not take any naps that day and reported for duty by 19:40 EDT. The Captain considered himself to be rested before the flight but reported that he started feeling fatigued midway through the flight, just after the airplane maneuvered through an area of thunderstorms.

At the time of the incident, the Captain had been awake for more than 19 hours.

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PILOT RELATED: Prior to flight, First Officer's sleep schedule - On July 5, the First Officer awoke about 08:00 EDT and took a nap in the afternoon for 90 minutes. He was a flight crew member (pilot flying) that night for a flight to SFO, which landed at 23:05 (02:05 EDT on July 6). The First Officer went to sleep about 04:00 EDT on July 6 and awoke about 10:00 EDT. He took a 1-hour nap in the afternoon and flew back to YYZ that night. The flight arrived on July 7 about 00:30 EDT, and the First Officer went to sleep about 03:00 EDT. He awoke about 09:00 EDT (the day of the incident flight), took a 90-minute nap about 13:00 EDT, and reported for duty at 19:10 EDT. The First Officer stated that both he and the Captain began to feel "very tired" during the incident flight between 23:30 PDT and 00:00 PDT (02:30 and 03:00 EDT on July 8).

At the time of the incident, the First Officer had been awake for more than 12 hours.

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PILOT RELATED: Prior to departure, NOTAM received about SFO runway closure - Before the flight's departure, the flight crew received a NOTAM about SFO's runway 28L closure, which would begin at 23:00 PDT that night and last until 08:00 PDT the next morning. Construction crews would be working to resurface the runway and install new lighting. This work was being done at night when air traffic was low.

The First Officer stated that he could not recall reviewing the specific NOTAM that addressed the runway closure.

The Captain stated that he saw the runway closure information, but his actions (as the pilot flying) when aligning the airplane with taxiway C instead of runway 28R demonstrated that he did not recall that information when it was needed.

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PILOT RELATED: During flight, pilots experienced fatigue - The flight crew reported that they started to feel tired just after they navigated through an area of thunderstorms about 21:45 PDT (00:45 EDT). This is important to note because the near miss incident occurred at 23:56 PDT, which was 02:56 EDT according to the flight crew's normal body clock time.

Thus, part of the incident flight occurred during a time when the flight crew would normally have been asleep (according to post-incident interviews) and at a time that approximates the start of the human circadian low period described in Air Canada's fatigue information (in this case, 03:00 to 05:00 EDT).

At the time of the incident, the Captain had been awake for more than 19 hours, and the First Officer had been awake for more than 12 hours.

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PILOT RELATED: During approach briefing, pilots missed NOTAM for closed runway - A second opportunity to recall the runway closure NOTAM occurred when the the flight crew reviewed SFO's ATIS information, which included the NOTAM about the runway 28L closure.

Both crew members recalled reviewing the ATIS, but could not recall reviewing the specific NOTAM that described the runway closure.

As part of the approach briefing, Air Canada's procedures required the flight crew to discuss any threats associated with the approach. The Captain stated that they discussed as threats the night-time landing, the traffic, and the busy airspace. The Captain also reported that he and the First Officer discussed that "it was getting late" and that they would need to "keep an eye on each other." The First Officer stated that the threats were the mountainous terrain, the night-time conditions, and both flight crew members' alertness.

The Captain and the First Officer could not recall whether they discussed the runway 28L closure during the approach briefing.

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PILOT RELATED: During approach, pilots did not enter ILS frequency - The procedures for the approach to runway 28R required the flight crew to manually tune the ILS frequency for runway 28R, which would provide backup lateral guidance (via the localizer) during the approach to supplement the visual approach procedures.

When the First Officer set up the approach, he missed the step to manually enter the ILS frequency.

The Captain was required to review and verify all programming by the first officer but did not notice that the ILS frequency had not been entered.

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PILOT RELATED: During approach, pilots did not see runway closure indicators - A runway closure marker with a flashing white "X" was placed at the threshold of runway 28L to indicate its closure. However, the flashing "X" would not have been in the flight crew's direct field of view because the "X" was oriented toward the runway 28L final approach corridor and the airplane was not aligned with runway 28L.

Runway 28R, which was still in use, was parallel to runway 28L, which was now closed, did not have its runway lights on, and showed only the flashing "X", along with the lights of construction vehicles. To the right of runway 28R was taxiway C. By design, the lights on runway 28R were much brighter than the lights on taxiway C.

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PILOT RELATED: Visual illusion for the previous flight crew - About four minutes before Air Canada Flight 759's near miss incident, Delta Air Lines Flight 521 (a Boeing 737), landed on runway 28R.

During post-incident interviews, Flight 521's flight crew reported that, after visually acquiring the runway environment, they questioned whether their airplane was lined up for runway 28R.

Flight 521's Captain stated that he could see lights (but no airplanes) on taxiway C and that those lights gave the impression that the surface could have been a runway.

Flight 521's First Officer reported seeing a set of lights to the right of runway 28R but that he "could not register" what those lights were. Flight 521's First Officer also reported that there were "really bright" white lights on the left side of runway 28R (similar to the type used during construction), but both he and the captain knew that runway 28L was closed.

Flight 521's pilots were able to determine that their airplane was lined up for runway 28R after cross-checking the lateral navigation (LNAV) guidance. Flight 521's Captain stated that, without lateral guidance, he could understand how the runway 28R and taxiway C surfaces could have been confused because the lights observed on the taxiway were in a straight line and could have been perceived as a centerline.

Flight 521's Captain and First Officer later provided written statements to Delta Air Lines that were subsequently provided to the NTSB. The Captain stated, "had the runway sequenced flashing lights been on it would have defined the landing runway or had we flown the ILS [approach] we would have had precision course guidance which would have eliminated the illusion that we were not lined up on runway 28R." The First Officer stated, "the pilot flying stayed on the LNAV guidance all the way to the runway which mitigated the confusion we experienced from the lighting and non-normal airport configuration at SFO that night."

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EXTERNAL FACTOR: ATC Controller's recuperative break - SFO's ATC tower was staffed with two controllers for the midnight shift, which began at 22:30 PDT and ended at 06:30 PDT the next day. Before the incident occurred, the controllers evaluated the traffic complexity and determined that the traffic volume would allow tower staffing to be reduced to a single-person operation (which was authorized for midnight shift staffing), with one controller working all positions in the tower cab and the other controller taking a recuperative break in the tower building.

All control positions and frequencies were combined and operated from the local control position starting about 23:49 PDT, seven minutes before Flight 759's near miss incident occurred.

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PILOT RELATED: Expectation bias by pilots - As Flight 759 received its landing clearance for 28R from the controller and proceeded with its final approach, the Captain lined up with what he thought was runway 28R.

However, as he was expecting to see two parallel runways, he was faced with the illusion of two parallel runways. Since 28L was closed, and 28R was operating, and taxiway C had lights on it from the four aiplanes lined up, Flight 759 instinctively lined up for the "runway" on the right -- what the flight crew perceived to be as 28R -- but was actually taxiway C.

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PILOT RELATED: First Officer's head down - The First Officer was focusing inside the cockpit programming the missed approach altitude and heading (in case a missed approach was necessary) and was setting (per the Captain's instruction) the runway heading, which reduced his opportunity to effectively monitor the approach.

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PILOT RELATED: First Officer questions ATC - The Captain asked the First Officer to contact the controller to confirm that the runway was clear, at which time the First Officer looked up.

By that point, the airplane was lined up with taxiway C, but the First Officer presumed that the airplane was aligned with runway 28R due, in part, to his expectation that the Captain would align the airplane with the intended landing runway.

The controller confirmed that runway 28R was clear, telling the flight crew that "there's no one on two eight right but you."

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PILOT RELATED: First Officer feels something isn't right - The First Officer later stated during post-incident interviews that, when he looked up after the captain asked him to contact the controller to verify that the runway was clear, he thought that something was not right but could not resolve what he was seeing.

Not only was this moment an opportunity to speak up, it was the pilots' last opportunity to take action that could have broken this chain of events.

However, the First Officer simply assumed that the Captain would proceed with the approach correctly.

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THE ACCIDENT CHAIN BREAKS: Pilots on the ground see the potential disaster unfolding in front of them and take action - There were four airplanes lined up on taxiway C at the time of the incident. The captain of the first airplane, United Airlines Flight 1 (a Boeing 787), stated that he had a clear view of arriving traffic. He stated that he first saw Air Canada Flight 759 when it was about one to two miles away because its landing lights were pointed directly at the United Airlines Flight 1 airplane. He said he thought that Air Canada Flight 759 would correct its course and align with the runway. When that did not occur, he transmitted on the radio "where is that guy going" and "he's on the taxiway" on the tower frequency.

Moments later, as Air Canada Flight 759 got closer to the ground and the airplanes on taxiway C, the flight crew of the second plane in line on taxiway C, Philippine Airlines Flight 115 (an Airbus A340), switched on its landing gear lights and nose lights so that Air Canada Flight 759's flight crew could recognize that they had aligned their airplane with a taxiway.

The Captain of the third airplane on taxiway C, United Airlines Flight 863 (a Boeing 787), later stated that he turned on all airplane lights before Air Canada Flight 759's flight crew performed a go-around.

Air Canada Flight 759 continued to descend, heading straight for the third airplane on taxiway C, United Airlines Flight 863. When Air Canada Flight 759 finally advanced its throttles to initiate a go-around, its altitude above ground was about 84 feet, coming very close to clipping the vertical stabilizer of Philippine Airlines Flight 115.

The controller heard the transmission indicating that an airplane was over the taxiway. The controller stated that he had never seen an airplane line up with taxiway C and that there was no indication that Air Canada Flight 759 was misaligned until he observed the airplane looking "extremely strange" on short final, which was about the time when he decided to instruct the flight crew to perform a go-around.

Four seconds after Air Canada Flight 759 initiated its go-around, the controller ordered a missed approach. By this time Flight 759 was already climbing.

This video clip is from San Francisco International Airport, showing Air Canada Flight 759's final approach and go-around above taxiway Charlie, just above the vertical stabilizer of Philippine Airlines Flight 115. The airport surveillance camera is looking east from the terminal across the airport. There are four passenger jets on taxiway Charlie directly in front of Air Canada Flight 759. Source: NTSB.

This video clip is from San Francisco International Airport, showing Air Canada Flight 759's final approach and go-around above taxiway Charlie, just above the vertical stabilizer of Philippine Airlines Flight 115. The airport surveillance camera is looking east from the terminal across the airport. There are four passenger jets on taxiway Charlie directly in front of Air Canada Flight 759. Source: NTSB.


Top image: Air Canada Flight 759 passing over the top of United Airlines Flight 1 (a Boeing 787), the first airliner on taxiway C, 100 feet above ground. Bottom image: Air Canada Flight 759 passing over the top of Philippine Airlines Flight 115 (an Airbus A340), the second airliner on taxiway C, 60 feet above ground, coming within mere feet of its vertical stabilizer. Had Flight 759 not performed a go-around, it might have clipped the vertical stabilizer of the second airliner Philippine Airlines Flight 115, and its descent path would have taken it straight into the third airliner, United Airlines Flight 863 (a Boeing 787). Source: NTSB.

Top image: Air Canada Flight 759 passing over the top of United Airlines Flight 1 (a Boeing 787), the first airliner on taxiway C, approximately 100 feet above ground. Bottom image: Air Canada Flight 759 passing over the top of Philippine Airlines Flight 115 (an Airbus A340), the second airliner on taxiway C, approximately 60 feet above ground, coming within mere feet of its vertical stabilizer. Had Flight 759 not performed a go-around, it might have clipped the vertical stabilizer of the second airliner Philippine Airlines Flight 115, and its descent path would have taken it straight into the third airliner, United Airlines Flight 863 (a Boeing 787). Source: NTSB.



Air Canada Flight 759's Final Report


As stated in the incident's NTSB report, the investigation determined the probable cause of Air Canada Flight 759's near miss incident was:

"...the flight crew's misidentification of taxiway C as the intended landing runway, which resulted from the crew members' lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing.

Contributing to the incident were: (1) the flight crew's failure to tune the instrument landing system frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in crew resource management; and (2) Air Canada's ineffective presentation of approach procedure and NOTAM information."


How was this near miss incident possible?


The NTSB incident report noted some external factors that, had they been present, could have helped Flight 759 avoid the near miss incident from ever happening. Two examples include:

  • the airplane's 'Enhanced Ground Proximity Warning System' had an optional feature called SmartLanding that was not installed, which would have sounded a warning that the plane was attempting to land on the taxiway; and,

  • the limitation of ground radar installed at SFO could only warn the controller of potential collisions between aircraft and vehicles on the ground -- it could not make a controller aware of a possible collision involving a landing aircraft.

However, to help pilots of all experience levels learn from this incident, the lessons learned focus on the pilot-related and human factors that led to this near crash incident, since these same factors can affect any pilot, regardless of experience.


Air Canada Flight 759 Lessons Learned: The pilot-related factors


As noted earlier, Air Canada Flight 759's near miss incident is an intriguing story with important lessons to learn about fatigue, expectation bias, and taking action when something wasn't right.

"This incident report should be required reading for all pilots. Only a few feet of separation prevented this from possibly becoming the worst aviation accident in history."

- Vice Chairman Bruce Landsberg, NTSB Final Incident Report

In examining more closely the lessons learned, much of the text outlined below is taken from the NTSB's final report on this incident.

1) "Failure to tune the instrument landing system frequency"
(a pilot-related contributing factor, as ruled by NTSB)

It's very likely that, had the crew tuned to the ILS frequency for their approach to SFO, Air Canada Flight 759's landing may very well have been a normal event, and this 'almost' accident case study would never have been written.

The second page of the approach chart was in text format and indicated that Airbus A319/A320/A321 pilots should tune the ILS for runway 28R, which would provide flight crews with backup lateral guidance (via the localizer aligned with the runway heading) during the approach. This lateral guidance would supplement the visual approach procedures.

The First Officer stated that, when he set up the approach in the FMC, he missed the step in the procedure to manually tune the ILS frequency. It's possible fatigue may have contributed to the First Officer missing the step to tune the ILS for runway 28R for the "Quiet Bridge" approach they were flying into SFO.


2) "Fatigue due to circadian disruption"
(a pilot-related contributing factor, as ruled by NTSB)

The crew's sleep times and alertness may have contributed to the incident, as the Captain and First Officer both reported feeling late in Flight 759's flight to SFO.

With the Captain being awake for 19 hours and the First Officer being awake for 12 hours (as described in the NTSB report), the flight crew's alertness could have been compromised enough for them to not realize they were making their final approach to land on taxiway C.

The incident occurred at 23:56 PDT, which was 02:56 EDT according to the flight crew's normal body clock time. Thus, part of the incident flight occurred during a time when the flight crew would normally have been asleep (according to post-incident interviews) and at a time that approximates the start of the human circadian low period described in Air Canada's fatigue information (in this case, 03:00 to 05:00 EDT).

These sleep times are important to note because of the human body's circadian rhythm. Air Canada's Flight Operations Manual provided information regarding the development of fatigue and fatigue management, stating that humans "have an internal circadian clock that regulates physiological and behavioural functions on a 24-hour basis" and that "the clock coordinates daily cycles of sleep/wake, performance, physiology, mood, and other functions."

The manual also discussed circadian disruption by stating that "the circadian clock cannot adjust immediately when a person suddenly changes schedule (e.g., by flying into a new time zone or changing to a new work/rest schedule)." The manual further stated that flying into a new time zone produces "a challenge to the circadian clock" because "it can take several days or weeks for the clock to get into step with the new local time." In addition, the manual stated that, between 03:00 and 05:00 (body clock time zone), "physiological sleepiness peaks, and virtually all aspects of alertness and performance slow and can be reduced."

It was at this point, near the end of Flight 759, when the pilots would have been in their circadian low and could experience a reduction in alertness and performance.


3) "Expectation bias"
(a pilot-related contributing factor, as ruled by NTSB)

Air Canada's training programs defined expectation bias as "when someone expects one situation, she or he is less likely to notice cues indicating that the situation is not quite what it seems."

Because the pilots of Flight 759 were not aware of the runway 28L closure, apparently having forgotten about it from the NOTAM they received earlier, they were not mentally prepared to see only one runway.

Instead, they were likely expecting SFO to be in its usual configuration, which would include runway 28L being open for departures and arrivals and airplanes using taxiway F to reach the departure end of runway 28L. Because of the runway 28L closure on the night of the incident, airplanes were using taxiway C to depart from runway 28R.

San Francisco International Airport (KSFO) layout. Source: NTSB.

San Francisco International Airport (KSFO) layout. Source: NTSB.


During post-incident interviews, the two pilots reported that the taxiway C surface resembled a runway, which they believed was runway 28R. A cue supporting their perception was the lighting from the airplanes on taxiway C. Specifically, the airplanes' wingtip navigation lights would have partially resembled (width-wise) runway edge lighting.

Also, the airplanes' flashing red beacon lights would have been consistent with features associated with approach lighting.

Another cue that would have supported the pilots' perception was the presence of runway and approach lights on runway 28R, which would also have been present on runway 28L when open. However, the runway and approach lights on runway 28L were off, and the construction lighting that was reported on the runway 28L surface had features that were consistent with ramp lighting.

Although multiple cues were available to the pilots to distinguish runway 28R from taxiway C, sufficient cues also existed to confirm the crew's expectation that the airplane was aligned with the intended landing runway. As a result, once the airplane was aligned with what the pilots thought was the correct landing surface, they were likely not strongly considering contradictory information.

The NTSB concluded that, as a result of expectation bias, the cues available to the pilots that indicated the airplane was aligned with a taxiway were not sufficient to overcome their belief that the taxiway was the intended landing runway.


4) "Taking action when something wasn't right"
(a pilot-related action that broke this accident chain)

This incident had all the hallmark signs of an accident chain in progress that was proceeding to its inevitable deadly conclusion.

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The pilots of the four aircraft on taxiway C certainly noticed that something didn't seem right.

Instead of assuming that the pilots of Flight 759 would correct its misaligned approach, the pilots on the ground finally took action to successfully break this accident chain from proceeding further, by questioning over the radio to call additional attention to what Flight 759 was doing, and switching on additional airplane lighting to alert the pilots of Flight 759.


Additional Resources


For more on the Air Canada Flight 759 near miss during its taxiway overflight at San Francisco International Airport, be sure to check out the following links.


Stay sharp!
The Flight Chain App team




Flight Chain App - NTSB Aviation Accident Reports - Helping pilots learn from accident chains Dan Sobczak is the founder of www.FlightChainApp.com, a mobile app that helps pilots learn from accident chains by making NTSB reports more convenient and easier to digest. Dan received his private pilot certificate in 2003.


Flight Chain App and its companion blog www.AheadOfThePowerCurve.com are committed to reducing general aviation accidents, helping improve aviation safety, and growing the pilot population.


Ahead Of The Power Curve
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2020


September 2020:
An 'almost' accident case study: Air Canada Flight 759 near miss
August 2020:
Accident case study: Cory Robin's crash into a river in Ohio
July 2020:
Accident case study: Air Florida Flight 90 - Crash into the Potomac River
June 2020:
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May 2020:
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April 2020:
NTSB report released detailing Roy Halladay accident; was there faulty ADM involved?
March 2020:
Keeping your real-world flying skills sharp with a home-based flight simulator
February 2020:
NTSB preliminary report: Thoughts on the helicopter accident involving Kobe Bryant
January 2020:
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2019


December 2019:
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November 2019:
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October 2019:
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September 2019:
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August 2019:
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July 2019:
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June 2019:
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May 2019:
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April 2019:
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March 2019:
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February 2019:
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January 2019:
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2018


December 2018:
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November 2018:
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October 2018:
Flight Chain App releases new NTSB accident trends feature in latest update
September 2018:
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August 2018:
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July 2018:
Accident case study: Create your personal minimums checklist for flying
June 2018:
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May 2018:
Fighter pilot skills every aviator needs to have to fly safe
April 2018:
The meaning of 'Ahead of the Power Curve'
March 2018:
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February 2018:
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January 2018:
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