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.