Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!

[peekay4]

Unfortunately, Canada has yet to adopt modern flight/duty time rules as contemplated in ICAO SARPs.

Updated Canadian fatigue management rules were proposed in 2014 (same time FAR 117 went into effect) but their implementation was postponed following a huge industry backlash. Updated draft rules were finally published just a few weeks ago in the federal register (Canadian Gazette) but the draft rules will not become law until late next year, at the earliest.

So due to severe incompetence of the crew they decided not to secure the CVR in direct contradiction to Canadian law.

Securing the CVR/FDR after a reportable event is a shared responsibility -- not just the responsibility of the cockpit crew.

E.g., after being informed by the crew, it's also the responsibility of Air Canada management to ensure that any evidence is secured.

And, at the FAA and/or NTSB -- after being informed of the incident possibly by various parties -- it is the responsibility of the duty investigator to immediately work with the operator (including the operator's maintenance personnel) to again ensure that all evidence are immediately secured.

On most modern aircraft the CVR automatically stops recording shortly after engine stop, and I believe this aircraft sat on the ground for an extended period before its next flight. If the CVR was not secured, then there's plenty of blame to go around.

But we don't actually know at this point if the CVR recording has been lost. Plus there have been incidents where the crew / maintenance did pull the CBs but the CVR recording wasn't accessible anyway due to technical failures.

[RAT 5]

It brings around, once again, the debate about updating the rules for CVR/FDR to at least 24hrs or a taper proof live data recording back at home base. Technologically I'm sure it's not difficult. Compressed data transmission would not use too many bites or band width. I'm a dinosaur about such electronic matters, but I'm sure there are some clever bods who have a solution, if the authorities are so minded. When you consider the sophistication of modern fly-by-wire a/c and the computer power they have; and then you consider you can use Netflix almost like an HDD recorder with millions of others at the same time, it does seem daft that a battery powered 2 hour chip is all a $60m-$250m a/c has got onboard: and that may end up 6000' high in a mountaintop jungle or 6000' on the ocean bed.
If this had been the case the MH370 would not be such a mystery; and what has that cost so far to achieve zero? I think the cost of that search alone could pay for the development of live data transmission technology.
One aspect of the process is that no solution will be found until the powers acknowledge there is a problem. It might be they need a kick up the jacksie.

[Ian W]

The technology not only exists for live streaming Qatar is apparently already doing so https://runwaygirlnetwork.com/2015/1...lack-box-data/

'Always on' broadband links to aircraft are available that would allow continual streaming of DFDR and CVR data. As soon as the aircraft plugs in at the gate the stored FOQA, DFDR and CVR plus any maintenance data could be transferred over terrestrial links.

It is not a technical issue, it is a human issue. There is considerable pressure to not allow access to recordings especially from the cockpit. Misgivings become even more pronounced when video recordings of the cockpit are proposed. These misgivings are given a significant boost by company managers and beancounters perusing FOQA data to try to identify supposed flight crew short comings. So flight crews 'know' that they cannot trust management.
Who knows; if this distrust in airlines was not there MH370 may not be missing.

A sad state of affairs

[gus320]

This is a preliminary Bow-Tie analysis of the recent Air Canada 759 Severe Incident at SFO.

From the preliminary NTSB Report (DCA17IA148 web available) and audio file, we can only assume which was the possible scenario.

Considering that:
1 - We do not know yet if any Notams were active at SFO;
2 - WX was certainly not a factor;
3 - Flight Crew deliberately chose a Visual approach by night;

the most probable causes of the "Undesidered event" have to be found in the failing of Causal Barriers B2, B4, B5, B6 (almost all Human Factor related).

Fortunately Consequential Barriers C1 and C2 worked properly, although we strongly believe also C3 would also have.

Standing by for final report.
Any comments welcomed.

https://www.facebook.com/photo.php?f...type=3&theater

[underfire]

I would have thought that one of them would have needed to return to the gate for a seat cover change, at the least...

In the recording, it is obvious it was UA1 that made the on taxiway call. Would be interesting to get his take on events.

http://www.mercurynews.com/2017/07/1...sfo-near-miss/

[Airbubba]

Originally Posted by peekay4

On most modern aircraft the CVR automatically stops recording shortly after engine stop, and I believe this aircraft sat on the ground for an extended period before its next flight. If the CVR was not secured, then there's plenty of blame to go around.

I believe that on most U.S. aircraft these days the CVR is running whenever there is power on the aircraft to cover the requirement for recording the final checklist at the completion of the flight. There is still an erase button but it does not erase the final 30 minutes of a two hour recording in compliance with the CVR FAR:

§ 121.359 Cockpit voice recorders.

(f) In complying with this section, an approved cockpit voice recorder having an erasure feature may be used, so that at any time during the operation of the recorder, information recorded more than 30 minutes earlier may be erased or otherwise obliterated.

Some of the old boilerplate verbiage from the 30 minute recorder era seems to remain in airline aircraft, systems and ops manuals but I'm sure it will eventually be revised out.

AC 759 apparently wasn't required to have a modern CVR so it may have indeed had the last 30 minutes of the flight recorded ending with the engines shutdown. But, as I observed earlier, it was after midnight Friday night at an out station and nothing was bent, maybe preserving the CVR recording was 'overlooked'.

Or perhaps, as we speak, the legacy CVR is sitting on a workbench at the Quantico lab undergoing data recovery. The NTSB says they were notified on Sunday, perhaps the CVR was recovered but overwritten a few times.

Originally Posted by gus320

Considering that:
1 - We do not know yet if any Notams were active at SFO;

We do know there were NOTAMS for the closure of 28L, as I posted here earlier:

Originally Posted by Airbubba

Here's a couple of possibly pertinent SFO Notams in the traditional cryptic format:

SFO 07/026 SFO RWY 10R/28L CLSD 1707080600-1707081500
SFO 06/017 SFO RWY 28L ALS OUT OF SERVICE 1706021357-1707211500

[Loose rivets]

The cockpit voice recording.

There have been numerous posts about the psychology involved. Learning from this is vital because at face value the event seems bewildering.

One issue is about denial. #322 Portmantau's post included:

3. AC 759 believes what ATC tells him and prepares to land.

I suggested in an early post that the PNF doesn't quite believe what he's being told. The question mark hanging over his reply is clearly discernible.

I think it's important to know if the part of his brain processing that vital issue emphasised the point with the PF. Verbal exchange between pilots the moment after that call is of the utmost importance. So yes, the voice recording couldn't be more important.

[Bergerie1]

Here are two more TED Talks on perception. It is pity the quality of the video in the first one is a little blurred:-
https://www.ted.com/talks/al_seckel_...wired#t-571278

And here is another which is fairly mind blowing:-
https://www.ted.com/talks/donald_hof...t_is#t-1264332

In flying such illusions do occur, usually when only limited visual information is available but also when we have very strong expectations of what we want to see - not unlike what may have happened on your early map reading exercises when you erroneously fitted what you saw to what you hoped to see from the map.

These things do happen, even to experienced pilots, which is why we should always back up our visual flying with as many radio aids as possible.

BUT, sometimes, despite this, we can find ourselves overwhelmed by the power of the illusion.

[WillowRun 6-3]

Question (probably not illusory) & a second question . . .

I've read somewhere that actual incidents or accidents are the best sources of inputs for improvement in safety systems and even larger upgrades in system architecture - and even more so where the incident did not result in significant property damage or loss of life, but accurately is categorized as "way too close for comfort." So, piling on to the CVR discourse . . .


At ICAO's Second High-Level Safety Conference (Feb. 2-5, 2015), one of the topics was Safety Information Protection (Topic 2.2); and Working Paper 4 was presented, "Balancing the use and protection of safety information" (HLSC/15-WP/4, ICAO Secretariat: https://www.icao.int/Meetings/HLSC20...ingPapers.aspx).
Question: was the discussion in Feb. 2015 the most recent gathering of its type on these issues, or has something as "high-level" and inclusive of a broad (possibly comprehensive) range of industry viewpoints, taken place since that time? (The WP may not mention CVR intricacies in direct fashion but - unless I missed the boat - the need for such data, the issues of crew worries over airline management pin-headedness, and so on, are clearly the framework for the WP and the Topic 2.2 overall.)


Separate question. What would your typical line pilot, experienced grizzled drivers and so on, react with, if a law firm sprung up, quite suddenly, ready, willing, and more than merely able, to stop pin-headed airline management in its tracks in courtrooms anywhere where courtrooms exist, when pinheads try to micro-manage pilot safety decisions based on FOQA and CVR data? The present state of affairs is unsatisfactory - looking for logjam breakers - saddlin' up some hard-headed litigators in the model of Melvin Belli-crossed with-Julius Lucius Eccles just might redress the balance. Not a criticism of existing airline pilot union counsel; just asking about adding to their bench, so to speak.

[aterpster]

Originally Posted by underfire

The FAA program, Simultaneous Offset Instrument Approaches (SOIA) allows for as little as 750 ft between runway centerlines.

The FMS Quiet Bridge visual is an example.

SOAI is a bandaid, not a solution.

Simultaneous, independent ILS approaches, both to at least CAT I (if not CAT II/III) are the only real traffic movers during the lousy weather conditions that a place, such as SFO has.

Look at ORD, then look at SFO. Look at DEN, then look at SFO. Look at ATL, then look at SFO...IAD, DFW, MCI, and so forth.

During my career with TWA, 1964-90, the worst rush-hour, non-weather delays were always at SFO. I can remember many long traffic holds at CEDES at 6:00 PM, when the weather was either good VFR or marginal VFR.

[DIBO]

Originally Posted by underfire

In the recording, it is obvious it was UA1 that made the on taxiway call. Would be interesting to get his take on events.

As they were first in the line-up sequence ready to go, they were most likely on the lookout for the no.1 on finals. But with the nose towards the holding point, only the LH seat had a clear view on the final approach area (so did the LH seat pax!) and more importantly for the scare factor, were already much out of the way, except for the tail section, no visual head-on confrontation and had things turned much more for the worse (lower vert.separ.), had a simpel escape route slamming the throttles. They must, most certainly, have had their WTF moment, but soon lost sight of the more critical phase.
The #2 in sequence, however....

[sandiego89]

Originally Posted by underfire

face it, they were landing...DAMN UAL 863 is a 789 at about 56' tall, PAL 115 is an A343 at 57' tall

Whoever said they are on the taxiway was not kidding!

Can someone help me (sorry if I missed it) with what the altitude readings such as FlightAware and other reports on this incident really indicate? I realize that such programs are not exact.
- Sea level altitude? corrected?
- What specific point of the aircraft is being measured? Pilots eye? Black box? belly of the aircraft from radar altitude? Where on the belly?


I am just trying to visualize how a reported altitude such as 106' means in real terms, as the dangly bits on the aircraft may be quite a bit lower than recorded altitude, especially at higher angles of attack. And if it is sea level, factor in the tide, runway/taxiway height....


Thank you.

[wingview]

For the issue not being able to read out a CVR or FDR, it's the same for not being able to find the location of a missing plane. This is 2017. We can track objects years out in space but we can't do that.
It's just the ignorance of the airline industry (Airliners IATA FAA with the unions all over the world and the same for the NTSB and all the colleges on this earth to change this quick.

Technology is there and should be used or better, should be mandatory on every commercial plane and also twin GA.

Like I said, this is 2017!

For the incident itself, just unbelievable this could happen at SFO and with AC!

[Airbubba]

Originally Posted by sandiego89

Can someone help me (sorry if I missed it) with what the altitude readings such as FlightAware and other reports on this incident really indicate? I realize that such programs are not exact.
- Sea level altitude? corrected?
- What specific point of the aircraft is being measured? Pilots eye? Black box? belly of the aircraft from radar altitude? Where on the belly?

Good questions. The approach end of 28R is charted as 13 feet above sea level.

Are the numbers on the plot done by FlightAware's Ryan Jorgenson above sea level or above the taxiway? The data came from the FAA's 'Surface Movement Event Service' according to the newspaper article linked earlier.

[Airbubba]

A Daily Mail article with graphics and animation supposedly derived from the FlightAware plot of the FAA SMES data:

Twenty six feet from catastrophe: Terrifying video re-enacts Air Canada plane's near-disaster at San Francisco Airport

A new animated video shows how an Air Canada plane almost hit four jumbo jets waiting on the tarmac at San Francisco Airport earlier this month

The video uses data from FlightAware to chart Air Canada Flight 759's location as it nearly landed on the taxiway instead of the runway

At its lowest, the Air Canada plane was only 26 feet above the top of United Airlines flight 863's tail

The video also includes audio from the Air Traffic Control tower, which shows just how startling the near hit was for the pilots on the ground and in the air

In total, more than 1,000 people's lives were put at risk in the incident

Animation re-enacts Air Canada plane's near disaster | Daily Mail Online

[RickNRoll]

Originally Posted by Airbubba

A Daily Mail article with graphics and animation supposedly derived from the FlightAware plot of the FAA SMES data:



Animation re-enacts Air Canada plane's near disaster | Daily Mail Online

Nearly hit four jumbo jets.

[PukinDog]

Originally Posted by ironbutt57

crowded taxiway in a perfectly airworthy aircraft in visual conditions

an night...all aircraft stationary, most likely taxi lights off...hard to see...now not seeing runway lights , thats another human factor to be explored...it's not about the crew "blowing it", it's about WHY, so measures can be taken to minimize chances of it happening again...

A thorough briefing where both pilots pay attention to detail in order to emphasize correct and critical focal points is the primary tool/measure used by a crew to prevent blowing-it, minimize unworthy distractions, or being suckered in by illusion. Doing so purposely creates for the crew their own set of preconceived notion as to what the correct picture the approach and landing should look like. A proper briefing uses current, published information and NOTAMs, discusses what's to follow, and sets expectations/limits. It discusses what aids will be used to shoot the approach, what to expect and look for, what is to be confirmed, and limits set to wave themselves off the approach if they aren't met. SOPs are written so crews cover many of these things by following them.

We as pilots don't brief to land "at an airport". We brief the particular details for a specific approach for landing on a specific runway, and each holds it's own details to be noted and discussed. Because these details are specific, and we are talking about approach and landing, they are considered safety-of-flight critical. These specific details are published for the crew to use. Disseminated NOTAMS are likewise detailed and specific. This review and briefing is normally accomplished long before the approach begins. If time becomes an issue, pilots are still trained and capable picking out the safety-of-flight, critical items. If time doesn't allow even that, it's incumbent upon ourselves to work with ATC and create more time in order to do so.

Using Ian W's example of the gorilla not being noticed during the ball game as it pertains to this event: The ball game observers don't miss the gorilla because the brain can't handle the observation, they miss the gorilla because they were briefed only to count the number of times the ball is passed. Emphasized so during the pre-game briefing, observing the passes becomes the only focus. That's the power of a briefing. However, had the pre-game brief been "Count the number of passes, watch for a wandering gorilla, and cheer every time the blue team scores", there's no doubt that the human brain is capable of easily noticing all those things including the gorilla, and more.

So what about this approach and where did the cock-up occur that allowed the crew to be suckered in to a false illusion? Obviously, one is susceptible if they have an an erroneous (or no) preconceived notion of what they should see much like a magician uses the power of suggestion to mystify those ignorant of how the trick is performed. The crew in this case was flying an FMS approach that, miles from the threshold, transitions to a visual approach, at which time the crew visually aligns themselves with the runway, 28R.

Obviously, they didn't align themselves correctly when they transitioned. But how were they supposed to pick the correct string of lights way out there in the distance?

Well, 28R has charted, visual lighting aids specifically designed and calibrated for that purpose; ALSF-II and PAPI. They're both designed to be seen from miles away for use by a crew to 1) visually align themselves with the centerline of the runway (ALSF-II) and 2) visually join the correct vertical path that within a given distance ensures obstacle clearance down to near the Touchdown Zone (PAPI).

Given the existence of an ALSF-II and PAPI for 28R, let's start by throwing out the notion held by many that a visual approach at night to 28R is unreasonable or unsafe if it's based on the idea there's no ground-based guidance to use or back oneself up with if bog-s***t FMS equipment doesn't allow that back up to be an electronic ILS. ALSF-II and PAPI are ground-based guidance aids for 28R. Their existence should be noted, looked-for out the windscreen, and used for their intended purpose.

Even in a briefing for an Instrument approach, the type of ALS is noted and visual sighting while on the approach itself prompts a callout. Just because this was an FMS approach to a long visual segment doesn't negate the need for reviewing and emphasizing the ALS for 28R. The fact it's a visual approach segment doesn't negate the need for the crew to verbally confirm when these visual guidance aids are acquired visually. On the contrary, the fact that the FMS portion of the approach doesn't align the aircraft with the centerline should only raise awareness and emphasize the visual aids' existence and the need to notice/confirm them. Again, it's what they are for; visually acquiring and guiding oneself to the runway.

However, everything so far about the flight in question (ground track, altitudes, ,transmission) suggests the crew was oblivious to the existence of an ALSF-II and PAPI on 28R because, as it happened, they visually acquired, lined-up on, and overflew Taxiway C which has neither. As someone asked before, with the nearest PAPI being on the opposite side of RWY 28R from their position, what was this crew using for vertical path guidance for miles during the visual segment until reaching Taxiway C?

Also, in addition to RWY 28L's closure being NOTAMed, 28L's approach light system, a MALSR (not an ALSF-II, which is the only ALS they would have seen that night), was also NOTAMed OTS. If the crew mistook Taxiway C for RWY 28R and RWY 28R (with it's operating ALSF-II blazing away to their left) for 28L, this suggests no review of current NOTAMS that could (and did) directly affect their operation and lack of knowledge (or review) regarding Approach Light System configurations.

If the crew had no awareness to all of the above because they didn't avail themselves to information prior to beginning the approach, or didn't bother to create with any specificity or detail a notion of what they should see and use concerning ground based aids that were available to them in order to successfully transition and execute a visual approach to 28R, or didn't have any discussion that emphasized focal points and expectations based on that info, it's pretty easy to see how the lack of all those things leaves the door wide open for illusions followed by confusion to take hold.

Did this crew's briefing give short shrift to the visual portion of the approach and details of 28R itself, something along the lines of "...then pick up the visual for RWY 28R, any questions?". Or did the visual portion of the approach and runway of intended landing get briefed properly, among other things noting the existence of critical components of an ALSF-II and PAPI to the left side for guidance? I believe it's safe to assume the NOTAMs regarding outage of 28L's MALSR and 28L's closure weren't reviewed.

If the CVR was indeed overwritten then it will be left to investigators' interviews of the pilots to try and discern just how much time, effort, and detail went into the briefing and what was discussed before and during the transition to the visual segment. The devil is in the details here, and nobody knows yet if a sterile cockpit was maintained let alone a briefing conducted that included anything more than broad-brushstrokes regarding what to look for/use/how to fly the visual segment once the FMS diddling was over.

Even without the CVR, we do know 2 individual pilots in the cockpit fell for a "big picture" visual illusion where they were convinced a row of taxiway lights (it may as well have been a lighted perimeter road as is found near may airports) on the RH side of 28R "made up for" the (NOTAMed) lack of MALSR and runway lighting to the left. They fell for it despite the fact Taxiway C has green lights, no HIRLs (or other runway environment lighting), and what they should have already noticed from miles and queried the tower about, no ALS or PAPI. They also didn't notice a lighted "X" on RWY 28L.

That said, their continuation of a descent towards the imagined "runway" despite the conflict that arose between what they correctly saw (airplanes where they intended to land) and what the Tower told them ("there are no airplanes, your runway is clear") is inexplicable.

If I had to guess it's that this crew left themselves susceptible to the illusion because a proper, attention-to-detail briefing that included what lighting equipment was available and to be used for visually transitioning, approaching, and landing on 28R wasn't accomplished. With a proper briefing, normally both pilots (but if one doesn't, usually the other does and speaks up) stay on the correct page. In this case, however, both seemed to have been not on any page that reads what they should have known about RWY 28R and oblivious to it's details, and therefore let any set of lights that vaguely approximated how a runway should appear fill in the blank.

[Bergerie1]

PukinDog,
That is the most informative and best explanation I have read so far on this thread. Obviously we won't be able to put this all together until we see the results of the NTSB investigation. However, your suppositions are a very likely factor in this near accident. As I have pointed out several times before, under certain conditions as you have postulated, humans are far more susceptible to illusions than most of us are willing to acknowledge.

[portmanteau]

CVRs and FDRs are vital when no flight crew survive. This crew will be able to tell the investigators all they want to know.

[RAT 5]

As I have pointed out several times before, under certain conditions as you have postulated, humans are far more susceptible to illusions than most of us are willing to acknowledge.

Reference the above I would hypothesise that this can well be true in an unexpected situation or one with startle factor. You might revert to a comparable scenario that is in your memory data base and act according to that.
However, as PukinDog so succinctly put it, there should not have been any startle factor. There should not have been any last minute reliance on previous encounters with such a scenario because what they would see in front of them is what was NOTAM'd and thus pre-warned. Could this be where the root cause is and where the first hole was opened?