KSFO - Air Canada near disaster 7 Jul 2017 NTSB Exec Summary

[Live2Learn]

A "must read" for pilots, aircrew, Release Officers, AOBD, & IC's where fatigue or 'WOCL" could be a factor.

https://www.ntsb.gov/news/events/Documents/DCA17IA148-Abstract.pdf

While the NTSB reviewed this incident ... very nearly the largest landing disaster in history... as an air trasport problem, the error chain is filled with traps CAP and others have fallen into over the years.  The NTSB proposed several changes to procedure/communications, schedules, organizational management of fatigue, and automation (hard wired & AI) to reduce risks.  Ultimately, the near disaster resulted from human factors, fatigue, complacency, and the organizational environment.