ACA, that is an unfortunate submittal to the NTSB investigation. The runway still had a full set of runway lights and approach lights, and a LLZ, GS etc. The crew presumably had a RWY 28R position on the ND, but of course that may be subject to position errors depending on the status of the MMR/GPS equipment, although the aircraft is presumably fully compliant with ADSB out/in GPS position accuracy. 10 out of 10 for supporting your flight crew, but it is a poor response. Suspect the NTSB will be more supportive of the flight crew and the constraints on human perception that exist.
It is understandable that the crew may have an expectation of the visual cues that differs from reality when the configuration of the runways is changed. The NOTAM itself may assist in ensuring that does not occur, but it is not a direct defence against misperception by the flight crew. The crew would eventually detect the differences in observed features as they approached the assumed runway end, but there are common cues that occur on every approach, and these were perceived late in the sequence, and apparently simultaneously by the Captain and the FO. The error appears to have been perceived earlier by the crew in the aircraft on the taxiway, which is also understandable, they are stationary and at a reasonably low level of cognitive load at that time, just observing a mess developing. Intervention by the flight crew on the ground is fraught with delay and confusion, and at 200FPS, that translates to quite a potential for the aircraft to get close to the taxiway before taking any action.
The controller had a pretty high workload, and appears to have never comprehended what the issue raised by the AC A320 crew really meant; the process of assimilating the A320 info, ascertaining the implications and responding takes time, probably much more than selecting TOGA on the ATS would have done. Even with multiple ATC officers, it is going to be an open question whether the interrogative from the A320 is going to trigger suspicions with the ATC officer that the flight crew have a S.A. error and are heading towards the weeds (and aluminium tubes).
Upgrading EGPWS systems is a possibility, with the improved accuracy of the nav systems that is associated with ADSB, that could give improved cueing to the flight crew of alignment. You get better information from FOREFLIGHT than the ND on the Boeings or Airbus aircraft at this time. The technology certification cycle and cost is close to being a negative to flight safety as much as it ensures safety through compliance.
Notice on the ATIS on the NOTAMS is of limited value, it may provide a cue to the visual aspect expected to be seen, but it is also subject to being lost in the noise of the rest of the operational information.
The AC submission makes the case for continued ground based nav aids to be maintained, which would be nice to have, but is opposite to the trend of progressing towards SBAS approaches. A RNP-AR type approach would have given adequate guidance to the actual runway, at least to the same level of reliability as a LLZ which is subject to its own errors and interferences. ASDE would assist, but it needs to be alerting the ATCCO in such instances, or it is a passive tool only.
Collectively, we as a group have been dealing with KSFO and it's oddities for a long time. While we appreciate the geographic issues that exist for this airport, it is remarkable how many bandaids exist in giving approaches to the airport. As much fun as Quiet Bridge and similar approaches are to fly, I'm not sure that they are collectively in the best interest of the public, they provide expediency but with a substantial increase in complexity of the task the crews face. At what point do the airlines and flight crew call it quits with dealing with simops, dependent parallel non aligned approaches, etc? Operating a cross runway for departure and two non compliant spaced parallel approaches and departures at the same time suggests it's time to get a new airport. This is not the first incident that came close to crews sharing cockpits, and it is unlikely to the the last at this airport. As much as I like Lefty O'Douls, the fare payers probably deserve a better infrastructure, or one that manages the operating tempo with more margin for error.
Last edited by fdr; 28th Sep 2018 at 02:03.