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

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

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Old 26th Jul 2017, 20:23
  #441 (permalink)  
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Originally Posted by Airbubba


Again, can you cite any reference to indicate that the FMS Bridge Visual 28R requires GPS? It requires radar from the old plate posted earlier on the thread.
Here is the equipment note on the current Jepp chart. As you can see, for a pre-GPS airplane DME/DME/IRU is the option to GPS.

Also, my FAA expert friend contacted his Jeppesen database expert. Jeppesen codes LNAV approach mode (RNP 0.30) at what they consider to be the "FAF."

The lack of standards is a bit appalling, though. At KLAS the FMS Visuals have a profile view. Not so at KSFO.
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Old 26th Jul 2017, 21:02
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Yep, and a pre-GPS A320 would certainly have DME/DME/IRU. Thanks.
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Old 26th Jul 2017, 21:08
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The SQ accident at TPE occurred when they were taking off at night into an approaching Typhoon. Lots of rain and wind, not so much visibility. This AC incident at SFO took place in completely clear conditions, although at night. Visibility should not have been an issue.
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Old 26th Jul 2017, 21:48
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terpster, can you provide the entire Jepp chart you have the exerpt from?

Waypoints with coordinates in the FMS, how are these coordinated with DME?

Last edited by underfire; 26th Jul 2017 at 22:16.
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Old 26th Jul 2017, 22:08
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No. It's not in the public domain.
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Old 26th Jul 2017, 23:03
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I am wondering if the chart shows the DME distance, or simply the waypoints. Quiet Bridge visual does, but I dont see them on the FMS Bridge Visual, but I only have the waypoints from the database.

Construction at SFO.

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Old 26th Jul 2017, 23:28
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Originally Posted by SeenItAll
The SQ accident at TPE occurred when they were taking off at night into an approaching Typhoon. Lots of rain and wind, not so much visibility. This AC incident at SFO took place in completely clear conditions, although at night. Visibility should not have been an issue.
I agree, the SFO incident where pilots in a 25 year-old glass cockpit plane on a clear night with light winds were unable to correctly execute a published visual approach procedure is very puzzling.

The incident databases have many reports of TCAS alerts, missed restrictions and off-profile descents on this approach. You can flip through some on this NASA site, search for quoted text "FMS Bridge Visual" in the narrative:

https://asrs.arc.nasa.gov/search/database.html

I haven't run across anything yet with lineup on the wrong runway or taxiway. A recurrent theme seems to be the casual sounding ATC clearances to join and descend via the FMS Visual Approach with crew questions over whether the aircraft are actually cleared for the approach.
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Old 26th Jul 2017, 23:40
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No. It's not in the public domain.
Can you provide a screenshot of a waypoint?
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Old 27th Jul 2017, 00:49
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Is this sufficient?
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Old 27th Jul 2017, 03:53
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Thanks, every one of the waypoints can be cross-checked with either VOR/DME or, in the case of F101D, LOC/DME if the aircraft and company procedures allow it.

Still, using raw data is considered a somewhat antiquated concept in these enlightened times of ever increasing automation.
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Old 27th Jul 2017, 11:03
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Quote:
Originally Posted by Ian W
Similarly, had ATC switched on the 28L lights the illusion would have been destroyed, had ATC added to the approach clearance 'runway 28L is out of use unlit and marked with a red cross' - the illusion would have been destroyed.

Originally Posted by Air Bubba
The big FAA L-893 'X' is not red, it's yellow, flashes aviation white lights and in my experience, you can see it for miles on a clear night. Hard to miss if anybody is looking out the window.
The Gorilla in the human factors research video is also totally impossible to miss unless your brain is told to focus its attention on something else. You will have to accept that when attentional tunneling occurs you will miss things that are in plain sight even those things that can be seen for miles on a clear night. This is a feature of the human attention system; trying to pretend it is not is dangerous.

I am beginning to think that rather like the decompression and hypoxia training that is done so crews recognize it, there should be some attentional training done so pilots can understand when they are likely to have cognitive issues. Unfortunately, the natural response to a stressful task with fatigue/circadian stress is to try to concentrate more and that is the classic way to initiate attentional tunneling ("count the passes by the white team" in the gorilla video)
If it is simple to ensure against the illusion by a few words on each transmission then it blocks that hole in the cheese at low cost.
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Old 27th Jul 2017, 13:44
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Is this sufficient?
Yes, thank you very much. Now I can see that the waypoints also have the DME information, makes more sense now for a non-GPS equipped ac.

I also thought that FMS Bridge visual did align with extended runway, but I see this is not the case.

Also, my FAA expert friend contacted his Jeppesen database expert. Jeppesen codes LNAV approach mode (RNP 0.30) at what they consider to be the "FAF."
What does Jepp consider as the FAF on this chart?

When we were testing the RNAV Visuals, on the Bus, we would have the #1 set to RNAV solution using the waypoints (GPS) and the #2 set to ILS as a check. Seems reasonable to do this operationally, not sure why one could not, (I am sure you guys will let me know)
Thanx

Ian, note 'X' on post #448

EDIT: Given what happened, this would seem to raise concern on the remote tower operations. In many ways, listening to radio, you could imagine this senario. Runway appears occupied, no its clear, and no apparent warnings from any ground based system that the ac was landing on a taxiway, occupied or not.
Seems to be a failure of several systems already in place. How would remote tower operations fare?

Last edited by underfire; 27th Jul 2017 at 14:08.
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Old 27th Jul 2017, 14:29
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The Gorilla in the human factors research video is also totally impossible to miss unless your brain is told to focus its attention on something else. You will have to accept that when attentional tunneling occurs you will miss things that are in plain sight even those things that can be seen for miles on a clear night.

Yes but; NOTAM said that 28L was closed and approach light were off. Therefore you land on 28R which has all the usual lights. You should not have focus on landing on the right most set of lights that you see. The airport chart shows 28L - 28R - taxiway. You read the NOTAMS and construct a picture in your mind that 28R is the left most set of lights you will see. Indeed you will see only 2 sets of lights, and they will be very different. There will be only 1 set of approach lights and one set of white runway lights. That's the one that is open for use.
I'm beginning to think the gorilla comparison is not apples & apples. It is a scenario of complicated multi-item moving targets that you've never seen before. If there were strobe lead-in lights, and the a/c was on auto flight, and the crew had been instructed to count how many strobe flashes there were in 2 mins, I can almost guarantee they would not see the regional jet lining up ahead of them; especially at night. But this was not the scenario.

When the crew have been debriefed, which must have happened already, we might learn if this was a case of failing in the 6P's when planning the arrival into SFO.

Last edited by RAT 5; 27th Jul 2017 at 14:58.
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Old 27th Jul 2017, 15:06
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Originally Posted by underfire

I also thought that FMS Bridge visual did align with extended runway, but I see this is not the case.
I believe alignment occurs flying by F101D.

What does Jepp consider as the FAF on this chart?
Don't know. I'm trying to find out. Anyone here who flies this RVFP should be able to tell us.

I have no doubt this procedure works great when competently flown in an airplane with a GPS FMS. I have to wonder about D/D/IRU, though. The industry learned the hard way to require GPS for TSO-C-129 RNAV instrument approach procedures.
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Old 27th Jul 2017, 15:42
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Yes but; NOTAM said that 28L was closed and approach light were off. Therefore you land on 28R which has all the usual lights. You should not have focus on landing on the right most set of lights that you see. The airport chart shows 28L - 28R - taxiway. You read the NOTAMS and construct a picture in your mind that 28R is the left most set of lights you will see. Indeed you will see only 2 sets of lights, and they will be very different.
I am hoping that the report will go into detail around why the crew didn't read/brief the notams that applied to their time of arrival. ( if that is the case)
Will it go into detail surrounding their sign on time and the time they were expected to be at the aircraft? How long did it take them to get through security? Was there sufficient time to read all the notams and briefing documents prior to walking to the aircraft ?
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Old 27th Jul 2017, 15:46
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Was there sufficient time to read all the notams and briefing documents prior to walking to the aircraft ?

I asked if AC filters their NOTAMS to hi-light such critical items and cut out the rival. No reply. However, it was not a short flight, i.e. time enough to include a NOTAM review in the approach brief prior to TOD. That is indeed what is salient.
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Old 27th Jul 2017, 15:56
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Quote:
Originally Posted by underfire View Post

I also thought that FMS Bridge visual did align with extended runway, but I see this is not the case.
I believe alignment occurs flying by F101D.
I looked at my FMS bridge visual and this is not real clear. The course is flown 275 deg to SAMUL then a jog 267 deg to F101D then 281 deg. Nowhere does it say that F101D is the runway 28R centerline. I suspect it is supposed to be and the planview looks like it is.
More confusing is the LDA28R approach is 281 deg (a 3 deg offset) all the way in.
Also to add further confusion the RNAV app to 28R is 284 deg all the way in which coincides withe LOC 284 deg but doesn't jive with the FMS visual 281 deg from F101D?

Often the FMS course is a couple degrees off from the LOC or VOR course. I don't know what's going on here.

Last edited by cappt; 27th Jul 2017 at 16:12.
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Old 27th Jul 2017, 16:11
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These procedures are essentially coded visual approaches and therefore do not have FAFs per se, as they are not considered to be Instrument Approach Procedures. They can only be flown when there's adequate ceiling and visibility for visual approaches.

I.e., one can obviously fly the underlying visual approach without any special equipment other than mk1 eyeballs.. Hence the use of even DME/DME/IRU is acceptable as long as there's adequate DME infrastructure nearby. Otherwise the procedure will be marked "GPS only".
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Old 27th Jul 2017, 16:30
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RAT 5,

I agree, as you say, the Gorilla video is not 'apples and apples'. Nevertheless, pilots do need to be aware that the human animal is surprisingly vulnerable to various types of misperceptions either when under stress or when preconditioned by certain expectations, or when fatigued, or all of the above.

I know it seems daft - but it does happen.
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Old 27th Jul 2017, 16:41
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But can the gorilla shoot free throws?

Originally Posted by RAT 5
... I'm beginning to think the gorilla comparison is not apples & apples.
You're not alone in starting to ask about that, RAT 5. Quickly to say, there is little if any denying that what I have learned here is known as "attentional tunneling" quite likely played a large role. And being an outsider to the flight deck, I also have begun to think, . . . yes, but aren't aviators so highly trained, so polished and attuned to crisp and precise adherence to procedures, that they are expected to overcome what would otherwise afflict people in usual occupations and professions? I suppose, that could be and should be, ripped to shreds, as a point of view.
But even so, it would seem that a more relevant set of data would be some studies in simulators with well-trained senior aviators given scenarios in which attentional tunneling is, from some reasonable standpoint, expected to occur. Gorillas and basketballs, data from (I think, correct me if this is mistaken) some long time before smartphones and electronic displays in the cockpit and a strong accommodation by literally almost everyone to "screen time" and its effects on eyesight (the physical process), vision (the perceptual processing) and cognition. This is not meant to discount or denigrate the posts about the video with the gorilla, but what if we change just one little fact about it? The gorilla now looks like it is one from the 800 pound cage. But in any event, if some Transportation Research Institute pro in Ann Arbor with a budget for human factors research were to become interested, the proper scenarios could be put together in plenty of time to generate a valid data set prior to the NTSB process reaching the end of its inquiry cycles.

Last edited by WillowRun 6-3; 29th Jul 2017 at 00:05. Reason: inveterate habitual proof-reading
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