Too bad the CVR was conveniently overwritten. If it weren't, investigators would know if what should have occurred before this approach began actually occurred, including the crew using the primary, fundamental tools one does in order to plan/know what to expect; bookwork like we're paid to do, planning, and a proper briefing as dictated by Company SOPs. As it is, nobody knows if they followed any or conducted an approach briefing, or even if they used checklists appropriately or observed a sterile cockpit. We do know this, however;
The NOTAMS re the closure of 28L and 28Ls Approach Light System were both published. AC OPs Specs would dictate they were disseminated to the crew.
The ATIS received by the crew before the approach also notified them that 28L was closed and the Approach Light System for 28L was out of service. Company SOPs would dictate this be reviewed by the crew prior to the approach and ATC would expect acknowledgment it had been received.
The publications/Airport Diagram the crew had on hand showed the parallel runways with Approach Light Systems installed on each, and details or each installation plus runway lighting and PAPI. They also show Taxiway C running parallel to 28R.
The crew told the investigators that they thought 28L was 28R. That is admitting they didn't either read the NOTAMs or listen to the ATIS, or means they did but never talked about it/ignored what would could be an operational concern (runway closure).
It also means they were unaware of what they should be seeing for miles before they attempted to land on Taxiway C; an Approach Light System and a PAPI.
A proper approach briefing of any type identifies the primary guidance to be used, and most Company SOPs dictate their review and inclusion. This was a visual approach, at night, over water where any licensed pilot should be well-aware of possible black hole effect which makes the vertical guidance all the more critical to identify. Runway 28R has a diagramed and functioning Approach Light System (ALSF-II) stretching out into the water for lateral guidance. 28R has a PAPI located on the LH side of the runway for vertical guidance. These are ground-based, visual approach light systems that lead directly to the runway and Touchdown Zone of the correct runway. Those are the primary aids for the approach, not the FMS.
How hard is it to brief (and it makes no difference which FMS procedure got them to the point or what green taxiway lights look like from a distance) "the visual segment for 28R will be over water, we'll align with the ALSF-II and follow the PAPI located on the LH side"?
That's what a briefing is all about. To create a picture of what is known and printed right there in our faces about where we're going, and what to look for out the windscreen when the time for looking is at hand.
Briefings, SOPs, and checklists are there to backstop performance, especially when tired, etc. because they focus attention on where it needs to be focused. Even the well-rested pilot that does no bookwork, planning, or briefing will stuff things up a thousand times more often than a tired pilot that does all the above.
One can go around and around about FMS procedures, lack of EVS, "Tunneling" and circadian rhythms, but those aren't going to prevent stuff-ups of this nature if the crew didn't bother with fundamentals and basic adherence to procedures already in place.
Does anyone actually think a detailed, proper briefing that reviewed the primary guidance aids (ALSF-II and PAPI) to be followed for this visual approach was conducted in this case?
The statements by the crew and convenient overwriting of the CVR lead me to suppose this approach wasn't stuffed-up on short final, or 4 miles out due to an illusion, but long before when no attention to detail to what was published and/or briefed regarding the upcoming visual approach to the runway they were (supposed to be) landing on. If they had briefed the critical details of primary guidance aids just like everyone does for an ILS etc, this wouldn't have happened. The aids were right there, yet they never looked for them or (obviously) used them until the 2nd time around. Bear in mind that 2 crew with separate sets of eyeballs missed the same things.
I don't believe there's any big mystery or highly-unusual Human Factors, super-illusion boogeyman at work here. We deal with many all the time, usually by preventative measures. Until it can be shown that this crew followed those time-proven, fundamentals that prevent this sort of thing from happening I'm not going to assume it.
Last edited by PukinDog; 13th Aug 2017 at 10:52.