Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
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This crew will be able to tell the investigators all they want to know.
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Pukingdog, Brilliant!
Portmanteu:
Indeed, the CVR is primarily the voice of the dead.
Secondarily used for cases like this.
(Mr CEO in Quatar has other plans for the future that he has experimenting with, but lets leave that one for later, but it is relevant!)
As NTSB goes , yes they shall indeed ask a lot of questions!
But do not for one second assume that they get the correct answers in a proper timeline.
I shall back off on my rather harsh description of the crew, but once parked and debriefed OPS AC should have told them to secure the CVR.
When debriefing the Crew and later the wet debrief at the hotel, after a quick call to the Union boss, I think the gravity of the case starts to sink in.
If OPS did not just DH them back to base the next day, they flew active.
Regardless, would you not think they spent a minute or 3 to go over what happened?
If the standard 2 hrs CVR was saved NTSB has a starting point at least 30min before TOD , possibly more than 1 hr. The brief would have been there.
Now they have a crew that have had a week or more to communicate to interview. With no facts to back it up.
I am not saying the crew will come with false statements or keep important details to them selves if not asked.
After all this is NTSB not the Police. And they do not know if NTSB can recover
some or all of their last conversations ( unlikely, but).
I rest assured that their right are taken care off by AC and their union.
Now , there is monumental events in aviation that leads to positive improvement or re -focus on basic skills.
This is one of them.
Portmanteu:
Indeed, the CVR is primarily the voice of the dead.
Secondarily used for cases like this.
(Mr CEO in Quatar has other plans for the future that he has experimenting with, but lets leave that one for later, but it is relevant!)
As NTSB goes , yes they shall indeed ask a lot of questions!
But do not for one second assume that they get the correct answers in a proper timeline.
I shall back off on my rather harsh description of the crew, but once parked and debriefed OPS AC should have told them to secure the CVR.
When debriefing the Crew and later the wet debrief at the hotel, after a quick call to the Union boss, I think the gravity of the case starts to sink in.
If OPS did not just DH them back to base the next day, they flew active.
Regardless, would you not think they spent a minute or 3 to go over what happened?
If the standard 2 hrs CVR was saved NTSB has a starting point at least 30min before TOD , possibly more than 1 hr. The brief would have been there.
Now they have a crew that have had a week or more to communicate to interview. With no facts to back it up.
I am not saying the crew will come with false statements or keep important details to them selves if not asked.
After all this is NTSB not the Police. And they do not know if NTSB can recover
some or all of their last conversations ( unlikely, but).
I rest assured that their right are taken care off by AC and their union.
Now , there is monumental events in aviation that leads to positive improvement or re -focus on basic skills.
This is one of them.
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Even when the pilot's report is identical to the CVR, the CVR is a better source to cite when arguing for changes in regulations, procedures, equipment, etc.
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I notice an interesting pattern in the second-by-second analysis shown in earlier posts. The pattern may indicate that the AC pilot(s) may have initiated the go around before the time stamp indicated.
Elevation above ground has already flattened out near 130 feet as the plane overflew UAL1. The next five seconds of data would be consistent with the plane's nose beginning to lift and the tail continuing to drop. For about four seconds there is more tail drop than nose lift, presumably, then the full climb is achieved about two seconds after the indicated marker.
Elevation above ground has already flattened out near 130 feet as the plane overflew UAL1. The next five seconds of data would be consistent with the plane's nose beginning to lift and the tail continuing to drop. For about four seconds there is more tail drop than nose lift, presumably, then the full climb is achieved about two seconds after the indicated marker.
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PukinDog,
Very well detailed and thought out post.
To add to this, 28R has the FMS/RNAV visual, but it also has a pure visual approach, (that does not align with centerline) which several other aircraft preceeding them had used.
Should the FMS on the ac be off, the visual approach is still there, if nothing else, as you very well illustrated, the visual clues to back up the automation.
With the FMS visual procedure, the airline and the individual crew must be authorized to use, so there is a bit more involved in training, and hopefully the briefing.
That big white cross at threshold, that is not difficult to miss...
Looks like we also need this on the taxiway.
Very well detailed and thought out post.
To add to this, 28R has the FMS/RNAV visual, but it also has a pure visual approach, (that does not align with centerline) which several other aircraft preceeding them had used.
Should the FMS on the ac be off, the visual approach is still there, if nothing else, as you very well illustrated, the visual clues to back up the automation.
With the FMS visual procedure, the airline and the individual crew must be authorized to use, so there is a bit more involved in training, and hopefully the briefing.
That big white cross at threshold, that is not difficult to miss...
Looks like we also need this on the taxiway.
Last edited by underfire; 20th Jul 2017 at 14:11.
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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.
Similarly had the Tower (or a previous arrival controller) just added runway 28L is out and unlit, expectations would have changed.
But all the holes in the cheese lined up. Including worst circadian time at the end of a long day.
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I am inclined to think they were not aware it was out of service. This led them to think the lit runway on their left was 28L and 28R had to be further over to the right which was where they headed. How they could do that in the absence of any approach lighting is the mystery yet to be solved.
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Is AC 'dispatched' with a briefing or is it where the crew print out an armful of paper, have a coupe of minutes to review the salient items, load fuel and blast off. During the cruise they have time to read through the NOTAMS. How are they in Canada? Is it easy to pick out these critical items or are they hidden in the acres of garbage we are often presented with in Europe? Either way it was not a short flight. Only the crew will know.
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From the FAA:
SMES (Surface Movement Event Service): ASDE-X/ASSC data, OOOI events (Spot Out, Off, On, Spot In), Category 11/Category 10 position reports.
ASSC improves surface surveillance and situational awareness in all kinds of weather. ASSC is similar to a prior system deployed in the U.S. called the Airport Surface Detection Equipment, Model X (ASDE-X), which is deployed at 35 airports.
In October 2016, ASSC will be operational at San Francisco airport. Over the next few years, it will be implemented at:
https://www.faa.gov/nextgen/programs/adsb/atc/assc/
It appears that the system referenced for the aircraft location and altitudes was the first of its type installed by the FAA.... Did this new system provide warnings of the conflict?
Since the new and improved system does not appear to have detected the conflict, what about its predecessor which is deployed a minimum of 35 airports in the US, and an unknown number of airports worldwide?
here we go, a few more holes in the Swiss Cheese ...
EDIT: 35/36 airports for ASDE-X.... http://saab.com/saab-sensis/air-traf...gement/asde-x/
Following the success of the ASDE-X program that covers 35 airports in the USA, the FAA decided to extend the technology to nine additional airports: Anchorage, Andrews Air Force Base, Cincinnati/Northern Kentucky, Cleveland, Kansas City, New Orleans, Pittsburgh, Portland, Ore and San Francisco.
The ASSC system deployment includes multilateration sensors, data fusion, conflict detection and alerting, and the same HMI already in use at the 35 ASDE-X sites.
SMES (Surface Movement Event Service): ASDE-X/ASSC data, OOOI events (Spot Out, Off, On, Spot In), Category 11/Category 10 position reports.
ASSC improves surface surveillance and situational awareness in all kinds of weather. ASSC is similar to a prior system deployed in the U.S. called the Airport Surface Detection Equipment, Model X (ASDE-X), which is deployed at 35 airports.
In October 2016, ASSC will be operational at San Francisco airport. Over the next few years, it will be implemented at:
https://www.faa.gov/nextgen/programs/adsb/atc/assc/
It appears that the system referenced for the aircraft location and altitudes was the first of its type installed by the FAA.... Did this new system provide warnings of the conflict?
Since the new and improved system does not appear to have detected the conflict, what about its predecessor which is deployed a minimum of 35 airports in the US, and an unknown number of airports worldwide?
here we go, a few more holes in the Swiss Cheese ...
EDIT: 35/36 airports for ASDE-X.... http://saab.com/saab-sensis/air-traf...gement/asde-x/
Following the success of the ASDE-X program that covers 35 airports in the USA, the FAA decided to extend the technology to nine additional airports: Anchorage, Andrews Air Force Base, Cincinnati/Northern Kentucky, Cleveland, Kansas City, New Orleans, Pittsburgh, Portland, Ore and San Francisco.
The ASSC system deployment includes multilateration sensors, data fusion, conflict detection and alerting, and the same HMI already in use at the 35 ASDE-X sites.
Last edited by underfire; 20th Jul 2017 at 17:23.
Still does not explain where this "to the foot-precise" altitude or height comes from. ADS-B/mode S rounds to the nearest 25-feet, surfaces movement radars are primary/2D radars. FDR - RadAlt seems a very likely source, but this data shouldn't be available to Flightaware and neither so soon ...
Regarding the deconflicting, depends what they had in mind when designing the system, rwy incursions, etc. yes, wings clipping at the gate, most likely not, twy incursions 'from above'... probably neither....
Regarding the deconflicting, depends what they had in mind when designing the system, rwy incursions, etc. yes, wings clipping at the gate, most likely not, twy incursions 'from above'... probably neither....
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but this data shouldn't be available to Flightaware and neither so soon
Yes, this system is designed to alert to conflicts from traffic on approach and ground operations.
Still does not explain where this "to the foot-precise" altitude or height comes from
The cost-effective alternative to the ASDE-3/AMASS capability, referred to as ASDE-X, is one of the first new runway safety program technologies aimed at improving ATCS situational awareness by providing tools to supplement their tasks (McAnulty, Doros, & Poston, 2001). The data that ASDE-X uses comes from a surface movement radar located on the airport traffic control tower or remote tower, multilateration sensors, ADS-B (Automatic Dependent Surveillance-Broadcast) sensors, terminal radars, the terminal automation system, and from aircraft transponders. By fusing the data from these sources, ASDE-X is able to determine the position and identification of aircraft and vehicles on the airport surfaces, as well as of aircraft flying within 5 miles (8 km) of the airport (selectively up to 60 nmi).
As many are aware, I have not been a proponent of the ADSB or Mode S for this type of use, due to the accuracy issues, especially on descent.
That being said, this is the data that the FAA system provides, by whatever means.
That also being said, that is my question on validity of the alert capability of the systems already in operation.
Last edited by underfire; 20th Jul 2017 at 18:14.
So you are saying terminal radars provide this accuracy? If publicly available, thanks in advance for providing souces/links so I can learn. Technology moves fast, my knowledge stops at the 25feet rouding for mode S fed SSR's or ADS-B dataframes precluding foot-precision. But as stated, always keen to learn...
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ASSC certainly looks promising but a couple of issues....
To take full advantage of it, aircraft will need both ADS-B in and out. Airlines are fighting the out mandate. No anticipated mandate for ADS-B in. That may be market driven with numerous programs for reduced separation based on having both ADS-B in and out.
Also, for maximum protection, the aircraft should be the source of any warnings. This is possible with ADS-B (I served on a ARINC/MITRE committee researching this some years back). The problem with a ground (ATC) based system is the inherent delays associated with:
(1) recognizing the issue/conflict
(2) issuing the warning to ATC
(3) delay in interpreting the warning
(4) issuing a warning to aircraft involved (with the potential for transmission being "stepped on" as in Tenerife).
To take full advantage of it, aircraft will need both ADS-B in and out. Airlines are fighting the out mandate. No anticipated mandate for ADS-B in. That may be market driven with numerous programs for reduced separation based on having both ADS-B in and out.
Also, for maximum protection, the aircraft should be the source of any warnings. This is possible with ADS-B (I served on a ARINC/MITRE committee researching this some years back). The problem with a ground (ATC) based system is the inherent delays associated with:
(1) recognizing the issue/conflict
(2) issuing the warning to ATC
(3) delay in interpreting the warning
(4) issuing a warning to aircraft involved (with the potential for transmission being "stepped on" as in Tenerife).
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Dibo, no worries, please keep in mind that is what THEY say the systems are doing.
Shore Guy. I hope you enjoyed the mind numbing experience on ADSB committees as I did. In reality, I really dont see why they are flogging this antiquated system, especially with all of the limitations. The broadcast string is too short to have a viable encription, so you will never, ever see ADSB-In. Boeing swore to that.
We trialled ADSB-In with test flights into Brisbane, and the tested many potential capabilities, and with what we were able to do, it scared the hell out of them.
The ability to input data to the FMS should scare anyone. Do it with the charecture string available in the ADSB tranmission to provide any encription, lemming talk.
That being said, the tech is going to the Ku band transmissions through uplinks to/from the ac. Many new aircraft already do this, such as the 787 variants and most new 777 variants. Boeing doesnt monitor 40,000 datapoints live on the ac through ADSB.
By the time ADSB is sorted, if ever, it will be like comparing AM radio to Broadband Wifi.
With remote tower operations, SWIMM, and other acronyms making headway, it will be interesting to see how the ASDE-X/ASSC system failed to alert an aircraft centered on the taxiway for at least 4nm affects current and near term operations.
Shore Guy. I hope you enjoyed the mind numbing experience on ADSB committees as I did. In reality, I really dont see why they are flogging this antiquated system, especially with all of the limitations. The broadcast string is too short to have a viable encription, so you will never, ever see ADSB-In. Boeing swore to that.
We trialled ADSB-In with test flights into Brisbane, and the tested many potential capabilities, and with what we were able to do, it scared the hell out of them.
The ability to input data to the FMS should scare anyone. Do it with the charecture string available in the ADSB tranmission to provide any encription, lemming talk.
That being said, the tech is going to the Ku band transmissions through uplinks to/from the ac. Many new aircraft already do this, such as the 787 variants and most new 777 variants. Boeing doesnt monitor 40,000 datapoints live on the ac through ADSB.
By the time ADSB is sorted, if ever, it will be like comparing AM radio to Broadband Wifi.
With remote tower operations, SWIMM, and other acronyms making headway, it will be interesting to see how the ASDE-X/ASSC system failed to alert an aircraft centered on the taxiway for at least 4nm affects current and near term operations.
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Underfire and all,
Yes, I felt the same during my committee work. When I initially became involved, my thoughts were my kids will think this is pretty neat.
That became modified to thinking my kids kids would think this is pretty neat.
SOOO many potential downfalls to ATC using this as sole source global ATC infrastructure. It has some positives, but the FAA seems driven to hang onto this concept since (ancient history) CAPSTONE.
Does the world really want to hang the entire worldwide ATC system to a low signal/easily jammed source of navigation information (GPS, etc.) with no backup?
I think not.
And with the bad guys still out there, a ground based system (radar) will be required near population areas anyway. Whether in the US, it is budgeted under FAA or DOT, no difference. It will be necessary.
Data links, bandwidth, etc., etc. still major issues.
Remote areas (Western Australia, Hudson Bay, etc.) already using it with benefits. Worldwide satellite com will help with Oceanic applications.
Bottom line: not ready for prime time. I could go on, ........
Yes, I felt the same during my committee work. When I initially became involved, my thoughts were my kids will think this is pretty neat.
That became modified to thinking my kids kids would think this is pretty neat.
SOOO many potential downfalls to ATC using this as sole source global ATC infrastructure. It has some positives, but the FAA seems driven to hang onto this concept since (ancient history) CAPSTONE.
Does the world really want to hang the entire worldwide ATC system to a low signal/easily jammed source of navigation information (GPS, etc.) with no backup?
I think not.
And with the bad guys still out there, a ground based system (radar) will be required near population areas anyway. Whether in the US, it is budgeted under FAA or DOT, no difference. It will be necessary.
Data links, bandwidth, etc., etc. still major issues.
Remote areas (Western Australia, Hudson Bay, etc.) already using it with benefits. Worldwide satellite com will help with Oceanic applications.
Bottom line: not ready for prime time. I could go on, ........
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As to ASRSs (center primary/secondary long-range radar) those belong to the military, and will not be going away anytime in the foreseeable future.
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I am inclined to think they were not aware it was out of service. This led them to think the lit runway on their left was 28L and 28R had to be further over to the right which was where they headed. How they could do that in the absence of any approach lighting is the mystery yet to be solved.
When all is said and done, hopefully a wake up call for everyone, that any crew, from anywhere, can make potentially disastrous errors on a nice easy VFR to a big airport.
I mentioned the use of ADS-B technology in an earlier post on this thread, but didn't explain how I thought it could be used. Perhaps the presentation on Day 2 at 16.20 (ATSA-SURF - Enhanced situational awareness under adverse weather conditions) will help to explain what I mean:-
Joint Fifth ASAS-TN2 Workshop and Second FLYSAFE Forum ? ASAS TN
I know these are advanced concepts but I remain convinced that the display of other traffic using ADS-B In and Out, together with data linked warnings and taxi instructions will be the way forward as traffic levels rise and to help resolve mis-perceptions of the type that may have occurred at SFO.
One day soon I hope that a technological solution along these lines will become the norm.
Joint Fifth ASAS-TN2 Workshop and Second FLYSAFE Forum ? ASAS TN
I know these are advanced concepts but I remain convinced that the display of other traffic using ADS-B In and Out, together with data linked warnings and taxi instructions will be the way forward as traffic levels rise and to help resolve mis-perceptions of the type that may have occurred at SFO.
One day soon I hope that a technological solution along these lines will become the norm.
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I am inclined to think they were not aware it was out of service.
The circadian time seems probably very important
