Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO! [Archive] - Page 2

ShyTorque

16th Jul 2017, 09:42

A few thoughts from someone who, as a helicopter pilot (ex-fixed wing) flies to very poorly lit sites by night (in the past I sometimes had to land at totally unlit sites). For people doing this job, a lit runway or any sort of approach aid is a luxury.

I've flown to airfields where the runway lights are set far dimmer than the taxiway lighting...not a good idea. Over bright lighting on a taxiway can easily hide large objects, even lit ones e.g. the lights of very large aircraft sitting thereon. I'm not saying this happened on this occasion, but it can happen.

When approaching visually by night, it's of paramount importance to keep an open mind. What you're "seeing" might not be what you ought to be looking at. When approaching a night landing site, do NOT commit yourself to "having found it" because lighting can give you a false impression of what you're looking at. Once that mindset is there, other cues, even very obvious ones, might be totally missed, or ignored. This is why the requirement exists to dial the ILS on a visual approach. The ILS is generally less likely to be "tricked" by false cues. The earlier the false visual cues are picked up, the less likely it is that a pilot will be able to give them up and correct the mistake.

One story about false visual "cues" that always sticks in my mind is that of an RAF Wessex carrying out night flying training on Salisbury Plain, at a field location. Although the weather had earlier been very suitable for night flying training, fog suddenly came in at the base field (RAF Upavon, no navaids, no tarmac runway only a NATO 'T' of lights to land at on the grass field). The aircraft were recalled. The last aircraft back had to recover the training underslung load (a couple of barrels of water in a net). They were both experienced pilots and possibly a little over confident. They came in from the east, saw what they took to be the NATO T on the airfield and made an approach to it, obviously with the underslung load dangling below the Wessex.

When they got to the hover at what should have been the middle of the airfield, they realised the lights they had made an approach to was the "Welcome to RAF Upavon" sign outside the camp gates. They were hovering over the main road and had flown between two tall hangars, which they hadn't seen, to get there. The NATO T lights on the airfield were still on, but they had "locked on " to the incorrect visual cues because they were brighter and were seen first.

ironbutt57

16th Jul 2017, 11:01

but they had "locked on " to the incorrect visual cues because they were brighter and were seen first.

very likely scenario in this instance

BusAirDriver

16th Jul 2017, 11:42

helicrazi

16th Jul 2017, 11:44

@ShyTorque - I think alot can be taken away from that and I suspect you are very close to the truth.

Also in the helicopter world, I've been 'plugged in' in the back listening to the discussion in the front about the crew deciding if they had the right visuals for a Nato T, listening to this I decided to to turn around and see what was going on poking my head through to the cockpit, both crew totally fixated on the lights outside, no one monitoring the instruments, airspeed washing off rapidly and rate of decent rapidly increasing, neither crew aware, I called the go around. The crew were getting confused with brighter lights nearby which were much clearer than the Nato T.

Slightly different scenario but I think it goes to highlight the night environment can catch you out very quickly as you become fixated.

underfire

16th Jul 2017, 12:20

Are you sure? The FMS Bridge Visual to 28R is an Authorization Required (AR) approach procedure but not, as far as I can see, an AR RNP (Required Navigation Performance) instrument approach.

Never said it was an RNP AR approach. It is a tailored approach to approved operators, hence the AR. It is the same approach as the visual quiet bridge, but adds ARCHI, and F101D, which doglegs it back to extended centerline, and adds the stepdown fixes as named waypoints for the database. (UAL also is approved for this procedure, I dont know who else)

The FMS Bridge Visual Approach 28R is a version of the Quiet Bridge Visual Approach 28R which is coded with GPS coordinates and can be included in an FMS database for approved operators. This allows the procedure to be used when the SFO VOR is out of service, and also gives ATC additional flexibility by allowing them to clear pilots direct to any of the fixes without needing to intercept the radial on the standard arrival.

ironbutt57

16th Jul 2017, 12:21

"ACMS"

Many times when you are flying a Visual approach, there is a reason for this, generally it is that the ILS is unserviceable.

If the the ILS not working, or you are told to NOT use this NavAid, and make a visual approach, you would most certainly NOT tune in the ILS for any kind of reference, as it would be unreliable.

This is BASIC stuff.

And for "ratpackgreenslug" - The Airbus have NO MAGENTA LINE.

There are certain tools that could have been used, example extended centre line and various fixes, to establish current position for the approach to assist with SA.

the visual approach they were flying is an FMC approach, therefore it is in the database, and when selected provides all the information you need to fly..the autopilot system does a very nice job on these approaches...some here seem to think they were eyeballing seat of the pants approach flying, not the case, or wasn't supposed to be anyway..

aterpster

16th Jul 2017, 13:47

Airbubba, that particular procedure is with waypoints and is AR. The ac would have had to be GPS to get the AR approval to use the procedure

I hadn't previously heard the term "FMS Approach" but I am familiar with "RNAV Visual Approach," which are issued only to air carriers. Business aviation cannot have access to them, not even the high-end jets.

Technically, these RNAV visual approaches are not "AR' in the sense that RNAV RNP AR or CAT II or III ILS approaches are. Everyone has the charts for those AR approaches, but in the case of RNP AR they won't be in the FMS database unless qualified.

With these RNAV visuals neither the chart nor the database procedure are available publicly. But, nowhere on the chart does it state "authorization required," per se. At least it doesn't on the SFO charts for one major carrier that I have seen.

Interestingly, the "FMS Bridge Visual Rwy 28R" has an IFR missed approach procedure, which is contrary to the usual FAA policy for visual approaches.

Brain Potter

16th Jul 2017, 13:59

In the A320 the display of ILS GS and LOC symbology on the PFD is incompatible with using the autoflight system to fly a non-precison approach. The ILS may be hard-tuned but the crew will not see the data unless they select the LS pushbutton or switch the Nav Display over to ROSE LS mode. If they do press the LS pushbutton after loading an approach with vertical guidance, they will get a flashing amber V/DEV message on the PFD to highlight the incompatible selection. I do not have experience of any 'FMS coded' visual approaches (RNAV visuals in other parlance?) but I expect that the FMGS behaviour is the same.

In the case of a classic visual approach, with just the runway selected in the FMGS, the ILS will have auto-tuned (the FMGS will know that it is an ILS runway) and the data can be displayed on the PFD without any advisory messages; the selections are compatible. However, by coding the visual approach trajectory into the FMGS it has effectively been transformed into a non-precison approach, and the selection of supporting ILS information is not as straightforward.

Bearing in mind the above information, just try writing a procedure to turn what may sometimes be a valid technique into a SOP. You would have to decide at what point it would be safe for the crew to start making fundamental changes to their EFIS set-up in order to discard the FMGS guidance and switch to ILS data. You would also need to consider if your procedure is robust enough to cope with the different cases of a non-ILS runway, ILS not available and a full-up ILS.

I also think it is worth pointing-out that hard-tuning the ILS requires manual entry of data from a different approach and introduces the chance of incorrect data entry. What if the FMS Quiet Bridge approach to 28R had been selected, but going to a different plate to obtain the ILS ident resulted in the tuning of the ILS for 28L? The technique is valid, but it is not a completely threat/error free.

Perhaps this particular occurence has found the flaw in FMS coded visual approaches? Rather than just censure the crew, the industry needs to look at what lessons we can all learn from this. Would the inclusion of runway lighting configuration on the ATIS at airports with close parallel runways be worthwhile?

underfire

16th Jul 2017, 14:25

I hadn't previously heard the term "FMS Approach" but I am familiar with "RNAV Visual Approach," which are issued only to air carriers.

It does remind me of the current RNAV visual approach procedures, but the AR is due to the 'tailored' approach part of the adventure.
The waypoints are at setpdown fix locations, with at/abv designators, which appears to add a quasi vnav to the RNAV approach.

With RNAV visuals, the FMS auto computes a straignt line VNAV path. I think that the legs may too short and outside of the FMS ability, especially the dogleg at ALPHI for the FMS to keep up with a VNAV solution. Perhaps this is why it is considered a tailored approach requiring approval to use?

I have also encountered differences in the ac/FMS performance with AT/ABV altitudes on waypoints on final. Another good reason for the tailored designation on the procedure.

I seem to remember in AUS, the international crews are/were not authorized to use the RNAV visuals.

ironbutt57

16th Jul 2017, 14:45

aterpster

16th Jul 2017, 15:19

Perhaps this particular occurence has found the flaw in FMS coded visual approaches? Rather than just censure the crew, the industry needs to look at what lessons we can all learn from this.

Absolutely! I'm confident the NTSB and their Canadian counterpart will be looking looking quite closely at all aspect of these database FMS "visual" procedures.

aterpster

16th Jul 2017, 15:39

I seem to remember in AUS, the international crews are/were not authorized to use the RNAV visuals.

Thinking about your comment, perhaps Air Canada wasn't authorized the FMS Visual. If so, seems like they would have been flying the plain vanilla Quiet Bridge 28R Visual.

Zeffy

16th Jul 2017, 15:54

Thinking about your comment, perhaps Air Canada wasn't authorized the FMS Visual. If so, seems like they would have been flying the plain vanilla Quiet Bridge 28R Visual.

Didn't the ATC recording include a clearance to TRDOW and the FMS Bridge visual for AC 759?

aterpster

16th Jul 2017, 16:25

Didn't the ATC recording include a clearance to TRDOW and the FMS Bridge visual for AC 759?

I only looked at the tower transcript. If they were cleared for the FMS Visual, in some ways that deepens the mystery.

underfire

16th Jul 2017, 17:36

I only looked at the tower transcript. If they were cleared for the FMS Visual, in some ways that deepens the mystery.

I listened to the recording, they specifically asked for FMS Bridge vsual 28R, and were cleared to land.

Interesting, when you listen (to the recording in post #4 of this thread) you hear different requests coming in.
at 1430 you have a delta request 28R visual;
at 1705 someone requests FMS 28R, bridge visual;
at 1942, a delta asks for RNAV bridge visual 28R;
at 2110, you have air canada 759 request FMS bridge visual 28R.

Interestingly, the "FMS Bridge Visual Rwy 28R" has an IFR missed approach procedure, which is contrary to the usual FAA policy for visual approaches.

True for the US on public procedures, but as a tailored approach, it makes sense to have that in the design? That may be another reason that this is a special, because you would have to include VFR and IFR waypoints in both of the databases.

TLV and BOD have published missed approaches on their RNAV visuals.

ironbutt57

16th Jul 2017, 17:53

both are the FMGS database

underfire

16th Jul 2017, 18:05

From ICAO guidance:

An RNAV Visual Approach is comprised of a flight path requiring an FMS and use of ground based, space based or onboard navigation aids, followed by a visual track to landing.
These are very specific procedures which require the operator to obtain Civil Aviation Authority approval before its pilots can fly an RNAV Visual.

■Your airline is required to be CAA approved for RNAV Visual approaches. Note that it is possible for an airline to be authorized to fly RNAV approaches, but not authorized to fly RNAV Visual approaches.
■ If your airline is not approved, you should not have the RNAV Visual charts, however, reports indicate that some crews have had these approaches included in their onboard chart library even though neither they nor their airline was authorized.

From FAA:

In 2010 the FAA issued Order 8260.55 allowing the development of RNAV Visual Flight Procedures (RVFPs) that capitalize on the capabilities of RNAV systems to provide repeatable flight paths, reduce pilot-controller communications and enhance safety through the use of vertical guidance during visual approaches. These RVFPs are not “Public” procedures. Instead, they are approved by a process similar to “Special” IFPs and are only available to part 121 and part 135 operators through OpSpec approval.

https://www.faa.gov/documentLibrary/media/Order/8260.55.pdf

Yes, it does deepen the mystery...

both are the FMGS database

Yes, they may be. As noted, an airline can be approved, but the crew must also be appoved to use them.

underfire

16th Jul 2017, 18:16

Airbubba

16th Jul 2017, 21:16

It does remind me of the current RNAV visual approach procedures, but the AR is due to the 'tailored' approach part of the adventure.
The waypoints are at setpdown fix locations, with at/abv designators, which appears to add a quasi vnav to the RNAV approach.

Airbubba, that particular procedure is with waypoints and is AR. The ac would have had to be GPS to get the AR approval to use the procedure

But I still don't believe the AR necessarily means that GPS is required. You certainly don't need GPS to fly a procedure with waypoints in all cases.

As the FAA document Special Area Navigation Visual Flight Procedures you cited in your previous post says:

RNAV Equipment Requirements and Procedure Flyability. Only RNAV systems compliant with AC 90-100, using distance measuring equipment (DME)/DME/Inertial Reference Unit (IRU) and/or global positioning system (GPS) sensor inputs, are acceptable for use on an RVFP.

After the release of the YHZ accident report, Air Canada has committed to upgrading their narrowbody fleet with GPS by the end of this year but there is a good chance that C-FKCK had not yet been upgraded. If didn't have GPS it might have made a difference in matching the picture on the screen with the view out the window when they were lining up on final.

I listened to the recording, they specifically asked for FMS Bridge vsual 28R, and were cleared to land.

Interesting, when you listen (to the recording in post #4 of this thread) you hear different requests coming in.
at 1430 you have a delta request 28R visual;
at 1705 someone requests FMS 28R, bridge visual;
at 1942, a delta asks for RNAV bridge visual 28R;
at 2110, you have air canada 759 request FMS bridge visual 28R.

You might want to listen to that recording again. ;) I don't think any of these folks are requesting the FMS Bridge Visual 28R from the tower controller on the link posted by that smart feller in post #4. They are reporting their assigned approach procedure to the tower. You probably do that when you switch to tower, don't you?

They were already cleared for that approach by the previous controller.

As I posted earlier:

You can hear AC 759 cleared for the FMS Bridge Visual at about 15:45 into this approach control clip (the time seems to be different depending on the .mp3 player used):

http://archive-server.liveatc.net/ksfo/KSFO-App-28LR-Jul-08-2017-0630Z.mp3

Thinking about your comment, perhaps Air Canada wasn't authorized the FMS Visual. If so, seems like they would have been flying the plain vanilla Quiet Bridge 28R Visual.

Didn't the ATC recording include a clearance to TRDOW and the FMS Bridge visual for AC 759?

Yep, I agree, their clearance for the FMS Bridge Visual RWY 28R is in the approach control clip linked again above. And there still is no runway 28C...

CurtainTwitcher

16th Jul 2017, 21:19

Perhaps this particular occurence has found the flaw in FMS coded visual approaches? Rather than just censure the crew, the industry needs to look at what lessons we can all learn from this. Would the inclusion of runway lighting configuration on the ATIS at airports with close parallel runways be worthwhile?
Thank you Brian Potter! We have a crazy policy recomendation to de-tune the ILS for an RNP approach when the runway is equiped with an ILS, why? Because of occasional GPWS glideslope alerts if the ILS is tuned! The GPWS is valid, but because some approaches are 2.8 degree (due hot weather), if it is cold and with enough barometric error you are actually low on path compared to the ILS. Better to turn the noise off than acknowledge the issues. Reminds me of "Shut up Gringo".

It goes against all instincts to deliberately hide a piece of potentially extremely valuable information, especially at night or in marginal weather.

aterpster

16th Jul 2017, 22:41

terpster, a few years ago, the FAA was looking at RNP AR to visual approach procedure concepts with Naverus. Are you aware if they were working on this concept with anyone else? Naverus was looking at this to get below the 250 HAT.

I haven't heard of that. If could still be in-house though. That would require some changes to criteria.

MITRE has been looking at RNP AR to LPV. That's been going on for several years.

West Coast

16th Jul 2017, 23:45

Originally Posted by underfire View Post
terpster, a few years ago, the FAA was looking at RNP AR to visual approach procedure concepts with Naverus. Are you aware if they were working on this concept with anyone else? Naverus was looking at this to get below the 250 HAT.
I haven't heard of that. If could still be in-house though. That would require some changes to criteria.

MITRE has been looking at RNP AR to LPV. That's been going on for several years.

Naverus is no more, they were bought out a few years ago by General Electric, Flight Effeciency services is the new name under GE.

MITRE for lack of a better term has licensing authority over FAA software called TARGETS that is the basis for building RVFPS. This is often issued to airlines who build them for their needs, SWA being one of the more aggressive ones.

Ian W

17th Jul 2017, 00:00

TARGETS was actually developed by MITRE CAASD an interesting and useful tool to use that may need more work to support curved RNP final approaches such as 'Greener Skies' Report Shows Benefits of ?Greener Skies? approaches at Sea-Tac Airport (http://www.prnewswire.com/news-releases/report-shows-benefits-of-greener-skies-approaches-at-sea-tac-airport-300106956.html)

aterpster

17th Jul 2017, 00:46

TARGETS is certified for RNAV but not RNP AR. It can be used to develop an RNP AR approach, but only for preliminary work. RNP AR is too critical to be left to TARGETS.

RAT 5

17th Jul 2017, 06:57

The GPWS is valid, but because some approaches are 2.8 degree (due hot weather), if it is cold and with enough barometric error you are actually low on path compared to the ILS.

If this is true it sounds scary. I've not flown RNP approaches, nor an Airbus, but any IFR approach system that brings you below the ILS GP sounds dodgy to me. Please give more info.

As well as the Gringo event remember the Air Inter A320 at Strasbourg that made a smoking hole on the rushed VORNPA. Due to various nuisance warnings Air Inter had disabled the GPWS systems as it was not yet mandatory, only advisory. By not selecting the ILS you remove the "Below G/S" alerts. As I've mentioned previously, a/c have been designed with back-ups in nearly every system, including 2 pilots, but when on approach to terra concrete SOP's can dilute you down to only 1 nav system. Seems to go against the basic philosophy of back-ups and needs justifying by the SOP scribes. It reminds me of one operator who removed the SBY ILS from their approach Cx list. Why? I've no idea; and indeed no-one ever published why. The result was that some captains taught that it was no longer necessary to select it ON during approach. OMG. Trained monkeyness gone mad.

CurtainTwitcher

17th Jul 2017, 07:36

It's true, in high temp environments (ISA+30), a 2.8 degree path will actually give you close to a 3 degree path at those higher temps (the column of air expands with increasing temp). However, the problem is when the temp is low, it is back to a 2.8 degree path and if the ATIS QNH hasn't been updated for a while you can get on the slightly lower angle than the 2.8 (we only get 15 minutes from receipt of the ATIS for a valid QNH).

The RNP already has an allowed vertical error (ANP) of 125'. We also go to RNP 0.1 which can have minima around 370' / 2200m so you can be close to the hard stuff with some degree of uncertainty. If you then get a little low on that path...you are starting to get closer to the weeds than is comfortable.

So, rather than accept a G/S warning (and QAR flag) saying "Hey Gringo, you really are low", just turn the off the warning system and remove perfectly valid, usable, independent and rock stable path indication! Really, although not everyone follows the recommendation :ok:

RAT 5

17th Jul 2017, 08:16

Thanks. I know about temp corrections, especially the cold stuff. I thought FMS altitude data was supposed to be corrected for cold temp' so that you did not become dangerously low on path. But I've only flown VNAV/LNAV approaches with raw data backup and not the new fangled RNAV GNSS thingies.

It reminds a little of a mate, in his very old car some decades ago, who had an annoying low oil pressure light keep coming on. (no gauge) He kept checking the oil and it was full, so he disconnected the bulb. Engine seized due to broken oil pump. He had confused quantity with pressure. Duh! Now we would never do anything like that, would we? Remove the bulb, I mean.

Landflap

17th Jul 2017, 08:37

Ha ! Good start to my day Rat 5 ! Thanks. Rhetorically asked , I know, but way back, we really were taught to "think outside of the box" and get the bird home , even if it meant taking out the bulb !

AfricanSkies

17th Jul 2017, 10:02

_Phoenix

17th Jul 2017, 10:51

"... He’s on the taxiway!" cut into AC landing re-confirmation seconds before disaster, this described perfectly the conflict between "we see lights" and "28R clear" Those words were extremely effective in en-lighting the crew and initiated the go around immediately. The tower's "go around" came to late... it could be preceded by a large ball of fire.

underfire

17th Jul 2017, 13:36

Naverus is no more, they were bought out a few years ago by General Electric, Flight Effeciency services is the new name under GE

You are funny! (BTW GE calls is simply Navigation Services now, flight efficiency services has been dead for a while)

MITRE for lack of a better term has licensing authority over FAA software called TARGETS that is the basis for building RVFPS.

It can be used to develop an RNP AR approach, but only for preliminary work. RNP AR is too critical to be left to TARGETS.

They use the RNAV-Pro for RVFPS and RNP-Pro for RNP-AR.

2) The operator, with the assistance of the regional All Weather Operations (AWO) and the RNAV and RNP Group personnel assigned to the OSG, must assess the capability of the local DME infrastructure to support all segments of the procedure. The operator should use “RNAV-Pro” for this assessment.

The operator must also document the RVFP procedure on FAA Form 8260-7, Special Instrument Approach Procedure, with an amended title of RNAV Visual.

The FAA then puts the completed procedures into TARGETS to verify the obstacle evaluation.

nnc0

17th Jul 2017, 14:53

Interesting explanation hereCTV News Channel: 'Situation was unusual' | CTV News (http://www.ctvnews.ca/video?clipId=1165295&playlistId=1.3497833&binId=1.810401&playlistPageNum=1&binPageNum=1)

DaveReidUK

17th Jul 2017, 15:11

Already discussed several days ago.

The guy was being interviewed the morning after the incident, before many of the facts had emerged, so "explanation" is a bit of an exaggeration.

aterpster

17th Jul 2017, 15:48

They use the RNAV-Pro for RVFPS and RNP-Pro for RNP-AR.

I'm not sure which "they" you are referring to. I am referring to the FAA, not third-party developers.

I don't know anything about the development of RVFPS, which is not an instrument flight procedure.

Just to be certain I submitted the following question To my FAA procedures manager contact about FAA-developed RNP AR IAPs:

My question:

Which system or tool do your folks used to design FAA-developed RNP AR approaches?

His answer:

We use IPDS and IAPA. Eventually we will be using TARGETS for everything.

Airbubba

17th Jul 2017, 17:57

For every approach put the relevant ILS frequency in the box. Identify said ILS (dits and dars) and fly said ILS as presented by wondrous displays on the panel within 18 inches of one's nose.

This cock up is what happens when children of the Airbus magenta line look out the window and decide to go for it. Wonder where they would have ended up on the Quiet Bridge Visual.

In the A320 the display of ILS GS and LOC symbology on the PFD is incompatible with using the autoflight system to fly a non-precison approach. The ILS may be hard-tuned but the crew will not see the data unless they select the LS pushbutton or switch the Nav Display over to ROSE LS mode.

Thank you Brian Potter! We have a crazy policy recomendation to de-tune the ILS for an RNP approach when the runway is equiped with an ILS, why? Because of occasional GPWS glideslope alerts if the ILS is tuned!

The ILS to 28R was apparently working just fine. TACA 560, another A320, was cleared for the ILS 28R a few minutes before the AC 759 flyby. Sure looks like most A320 operators don't bother with tuning the ILS with a non-ILS FMS approach and it is awkward to view the raw data while getting guidance from the FMS profile.

Listening to the approach control audio in the link posted a couple of times above, AC 759 was coming in on the DYAMD3 arrival, they checked in with NOCAL descending through FL250. They were given at ARCHI join the FMS Bridge Visual 28R. The subsequent controller told other planes to join the FMS Bridge Visual 28R, routing only (I like her style a little better since a couple of planes incorrectly read back the first controller's clearance as 'cleared for the approach').

AC 759 was given depart CEDES heading 270, vectors for spacing. After some vectoring with altitude and speed changes, they were given direct TRDOW, cleared for the FMS Bridge Visual Approach Runway 28R.

Obviously some button pushing to re-intercept the approach at TRDOW, some chances to inadvertently delete a constraint or heal a discontinuity in the wrong place. Still, nothing uncommon at a busy international airport even at midnight in my experience.

MATELO

17th Jul 2017, 17:58

HUD's should eradicate this, just line her up with the green box directly in front of you.

underfire

17th Jul 2017, 18:19

We use IPDS and IAPA. Eventually we will be using TARGETS for everything.

We are speaking the same thing.

The difference here is that IPDS is simply the FAA's acronym Instrument Procedure Design System, but its parts are supplied by a 3rd party contractor. Just as TARGETS is supplied by MITRE. Instrument Approach Procedure Automation (IAPA) is the old version of the system being replaced by IPDS.

I was working with ATSI when the FAA was using SAAR-Pro (I called it RNP-Pro) to design and validate RNP-AR procedures, and helping with the data port to TARGETS. Check with the guys at AFS-460/420 for how they use RNAV-Pro and SAAR-Pro..

That is why the FAA requires operators to use RNAV-Pro, because in reality, that is IPDS and already part of TARGETS.

This is TARGETS: Data file exchange is supported between TARGETS and the Total Airspace and Airport Modeler (TAAM®), the Sector Design and Analysis Tool (SDAT), RNAV Pro™, and MapInfo®

While MITRE has the development contract for TARGETS, MDA had the development contract for IPDS (although I am not certain they still have that)

JumpJumpJump

17th Jul 2017, 18:41

We were parked on a taxiway once and an aircraft was clearly lined up on the taxiway to land. The pilot also told Tower that she sees lights and aircraft on the runway, tower also told her the runway is clear.

For us to have transmitted at that stage ala "where's this guy going? He's on the taxiway" would have risked blocking a vital transmission, either from landing aircraft or from Tower to Go Around, at a critical point. We put all our lights on and waited.. Tower told aircraft to go around, she didn't miss us by far.

It's one of those situations where interference can save you, or it can seal your fate.

"Air Canada go around" from one of the waiting aircraft would have been a far better (and briefer) call than the one made.

I have often considered under which circumstances at a controlled airfield a pilot could/should tell another aircraft to go around. Certainly if I saw landing lights coming from the sky in front of me when rolling for take off, I think tha this would be the correct course of action. In this case, from what we know, I also think that it would have been justifiable.... What do other people think? What possible outcomes could there have been for the pilot on the taxiway had he have called the go-around.... in this situation it looks like he may have been justified in doing so.... has anybody else considered this course of action in the past? would anybody here consider following that course of action in the future?

underfire

17th Jul 2017, 19:10

well 3J, it looks like just that will be looked at in this case.

you have radio traffic between ac and tower which question runway clear
You had an unknown person, a pilot, radio the ac was on the taxiway
then ATC issues go around
the pilot almost instantly responds go around. (100' or less from the ground facing other aircraft, initiating GA, and one has time to use the radio?)

lots of questions on this one.

you are questioning if you as a pilot should call a GA to another ac, that is all good.

on the flip side, if you were the pilot, and heard go around on radio that was obviously not ATC, what would you do?

On a related note, at YMML, there was recently a case where an unauthorized person on ac band radio in a car called a GA (and the ac responded with a GA)....

JumpJumpJump

17th Jul 2017, 19:30

"If you were a pilot, and heard go around on radio that was obviously not ATC, what would you do?"

UF

At that height, most likely go around, I think it would be hard to distinguish whether or not it was ATC, obviously if the message was transmitted with my callsign, I would do around immediately without thinking about it... Likewise with a part of the callsign, at that height, I would most likely go around, if it was, for example... "air canada" go around. If it were something a little more non-standard, "landing aircraft, go around" "aircraft on short final... go around" Again, at that height I would almost defiantely follow the instruction (assuming a normally operating aircraft, wings attached and not on fire, etc) as somebody has likely seen something that I hadn't be it whether I am not aligned with the runway, gear up, something else) probably one of the few situations where I would prefer to be in the air, wishing I was on the ground.... If after asking questions to establish what had happened it turned out it was some ******** hijacking the frequency, I would consider diverting as the information at the airfield at that time would be hard to consider reliable... however, back to the point... I think that the part of any message there that would stick out would be the term "go-around".... no?

WillowRun 6-3

17th Jul 2017, 19:42

lots of questions on this one. ...
Acknowledging that both the NTSB and the TSB (CA) will conduct their typically exacting inquiries, still, it may be worth noting the categories into which some, at least, of those "lots of questions" will fall within.
1. Factually, who exactly called "Where's this guy going? He's on the taxiway"? And was there a decisive cue for the pilot who did so? (The controller's answer to AC 759's inquiry about lights on the runway, across the runway, in transcript, is "There's no one on 2-8 right but you" - but when played, there is a tone of definiteness in the controller's diction. Did this grab the other pilot's attention? - and what does this all say about RT procedures?)
2. The physics of the situation. How close was the AC aircraft to a collision? Was it approaching a physical state in which a collision was unavoidable? (Yes, no aviator would try to land an aircraft on a runway [taxiway, either] after seeing other aircraft lined up on it - but the issue here is how long it took for that "seeing" to occur and how it occurred.)
3. Did AC 759 initiate the GA prior to the tower calling a GA?
4. Lighting configurations and types, and visual fixating.
5. Approach design and its evidently many technical and varied subparts (instruments and data used in particular approaches, database alignment with particular types of approaches, carrier operational procedures which may vary, whether the "Quiet" aspect of the approach in this incident is a factor, and others as well).
If the impression the thread has given, namely that the AC aircraft had very little margin left in terms of position and momentum, is correct, then at the risk of being charged with excitability, I would advise the safety enquiry authorities to view this as an instance when the Cheese was a bit more viscous or impervious than usual, and precisely how something this close happened must be understood.

RAT 5

17th Jul 2017, 20:01

AC 759 was given depart CEDES heading 270, vectors for spacing. After some vectoring with altitude and speed changes, they were given direct TRDOW, cleared for the FMS Bridge Visual Approach Runway 28R.
Obviously some button pushing to re-intercept the approach at TRDOW, some chances to inadvertently delete a constraint or heal a discontinuity in the wrong place. Still, nothing uncommon at a busy international airport even at midnight in my experience.

I understand there are the 'new boys on the block' with their toys, and there are 'the old farts' from the days before toys. People talk about button pushing and FMS guidance and programming for a visual approach where you slide pass the bridge in silent mode and intercept a well lit runway with approach lights & PAPI. It strikes me that all these 'bells & whistles' have made an easy job difficult. A B732 or B727 would have had no problems with this, or properly trained/experienced crews would not have. This may open an old discussion that has been going round in circles for a few years, and I don't want to do that; but, it does seem as if people are trying to blame new technology and operating techniques as being at fault. Perhaps they are correct, and that is where I'm wondering if we have just over complicated things on what should be the most basic of manoeuvres; a visual approach.
I know of one erstwhile operator who has a mandatory VNAV/LNAV FMS WPT programmed visual circuit profile for a basically equipped airfield. It's been there a longtime, and I flew into it with B732. Somehow, 35 years later in a more sophisticated jet, it needs magenta lines, both later & vertical, to fly a visual circuit.
The world has gone mad, and I enjoy my stressless retirement. I got out just in time. Straight jackets & handcuffs are useless in a cockpit, sometimes.

EGLD

17th Jul 2017, 20:26

According to AvHerald, they overflew the first two aircraft by 100 feet, the third by 200 feet and the fourth by 300 feet. That is astounding, if true.

81 feet

Federal investigators on Monday revealed startling new information about the July 7 close-call at SFO. The Air Canada pilot that mistook a crowded taxiway for his approved runway actually flew over at least one plane on the ground before aborting his landing.

National Transportation Safety Board investigators said in an initial report that Air Canada flight 759 from Toronto descended below 100 feet and aborted the landing “after overflying the first airplane on the taxiway.”

New data show that the Air Canada plane was just passing over a second aircraft – Philippine Airlines jet – at 106 ft in the air and continued his descent when an SFO air traffic controller finally warned him to abort his landing.

The Transportation Safety Board of Canada said in their initial report that the Air Canada pilot did not begin his “go-around” until the air traffic controller told him to pull up.

The plane continued to drop to as low as 81 feet, as aviation experts say such a late aborted landing takes a moment to stop the jet’s inertia and climb again.

post too short

SeenItAll

17th Jul 2017, 20:51

See more detailed discussion of fly-over heights and when the go-around was ordered. It gets even more frightening. Although given the positions and heights involved, AC would not have hit first two aircraft, only numbers 3, 4 and 5.:ugh:
SFO near-miss: Air Canada flew over plane before aborting (http://www.mercurynews.com/2017/07/17/ntsb-air-canada-pilot-actually-flew-over-plane-before-aborting-landing/)

underfire

17th Jul 2017, 20:58

3J, I know, it was a thought question, not a question...

Aside from that, its looking worse all the time...

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!

http://i65.tinypic.com/2r44r3s.jpg

DaveReidUK

17th Jul 2017, 21:12

That contradicts both the TSB and FAA accounts, and of course assumes accurate time synchronisation between FlightAware and (presumably) LiveATC.net.

underfire

17th Jul 2017, 21:19

Dave, it is a datapoint. FA has been getting pretty good these days, and has quite the offering for tracking, I would not discount the accuracy.
The GA call is one thing, and the driver may have not reacted to the call, but still, the altitude track is damning. PAL must have had quite the ringside seat....

underfire

17th Jul 2017, 21:35

Perhaps they are correct, and that is where I'm wondering if we have just over complicated things on what should be the most basic of manoeuvres; a visual approach.

This is a basic procedure, and was used by quite a few operators just preceeding these guys. With all of the angle points/stepdown fixes on the approach, it actually is easier for everyone involved.

It is a RNAV visual approach, and visual from 4 DME. The driver even questioned if there were aircraft on the runway, and still decided to land. From what everyone is saying, this is an old A320 that may have not been GPS capable, so it appears they werent relying on the automation anyways...

Kentot Besar

17th Jul 2017, 22:26

Those sky gods advocating tuning the ILSs when given a non precision or charted visual approaches clearly do not understand the policies of modern major air operators where big aunty FOQA is sifting through post flight data.
Also it is mandatory in some operators' policies to execute an unnecessary go around if the glide slope GPWS warnings are triggered.

Damn, it is a night landing and you are a dot right of localizer at 999ft AGL..and you didn't go around? Gee, auntie FOQA will get you taken off the roster, get to the safety office to explain. All your very convincing explanations will be met by very sceptical and cynical interruptions, the so called FOQA gatekeeper will let you stew before s/he let it on that you indeed did no wrong. Your week or days is already ruined, your blood pressure up and you probably pissed off more nincompoops inadvertently with your enthusiastic defence of your actions. You know now that more eyes are now watching you, waiting for your next social or technical faux pas.

Small hassle? Yes or no. Go figure.

rotornut

17th Jul 2017, 22:34

Just heard on the radio that the NTSB is going to release a video of the incident.

What will happen to the pilot at AC?

Airbubba

17th Jul 2017, 22:37

Although given the positions and heights involved, AC would not have hit first two aircraft, only numbers 3, 4 and 5.:ugh:

Before we get too far with this one, weren't there only four aircraft holding short of 28R on C?

It is a RNAV visual approach, and visual from 4 DME. The driver even questioned if there were aircraft on the runway, and still decided to land. From what everyone is saying, this is an old A320 that may have not been GPS capable, so it appears they werent relying on the automation anyways...

And it appears that the A320 will give you path guidance all the way to touchdown in this case, even if the nav is not accurate due to a map shift of some sort. But you are absolutely right, this is a visual approach with a four mile line up, they should not have relied on the FMS for anything more than advisory guidance on the visual segment.

Perhaps they are correct, and that is where I'm wondering if we have just over complicated things on what should be the most basic of manoeuvres; a visual approach.
I know of one erstwhile operator who has a mandatory VNAV/LNAV FMS WPT programmed visual circuit profile for a basically equipped airfield. It's been there a longtime, and I flew into it with B732. Somehow, 35 years later in a more sophisticated jet, it needs magenta lines, both later & vertical, to fly a visual circuit.
The world has gone mad, and I enjoy my stressless retirement. I got out just in time. Straight jackets & handcuffs are useless in a cockpit, sometimes.

Years ago I flew for an airline that wore white hats and had acquired a regional carrier to provide a domestic feed to their legendary international routes. Folks from the domestic carrier weren't too keen on book learning but they had honed their flying skills doing several sectors a day around the southeastern U.S. in a 727 or L-188. The pilots from the international airline could quote chapter and verse of all the manuals but didn't do that many landings flying long haul. The domestic airline types joked that the other folks would someday write a book called The Dreaded Visual Approach.

Three decades of glass cockpit flying has probably made us ready for that bestseller. ;)

Airbubba

17th Jul 2017, 22:57

Just heard on the radio that the NTSB is going to release a video of the incident.

From today's Mercury News article, looks like it will be a while before the video is released in the NTSB incident docket:

According to the NTSB initial findings, federal investigators interviewed the Air Canada captain on Friday and will interview the first officer on Tuesday. Air traffic controllers were interviewed at SFO and Northern California TRACON, the regional hub, on Sunday and those will continue through Wednesday.

Federal officials have recovered the aircraft’s flight data recorder and security camera video from SFO of the incident approach. The NTSB says that video will be released once the public docket for this incident is opened in the next several months.

SFO near-miss: Air Canada flew over plane before aborting (http://www.mercurynews.com/2017/07/17/ntsb-air-canada-pilot-actually-flew-over-plane-before-aborting-landing/)

Conspicuously absent is any mention of the cockpit voice recorder, my guess is that the crew 'forgot' to pull the circuit breaker. An honest mistake. ;)

What will happen to the pilot at AC?

Far as we know there were at least two pilots. If their union dues are up to date they probably will get some extra sims and a line check and resume their scheduled trips. If the CVR is missing they can't gig them for missing checklists and callouts, right?

underfire

17th Jul 2017, 23:36

Far as we know there were at least two pilots. If their union dues are up to date they probably will get some extra sims and a line check and resume their scheduled trips. If the CVR is missing they can't gig them for missing checklists and callouts, right?

As an international carrier from a bit of an unfriendly nation these days, IF the airline was not authorized to use that procedure, and/or if that ac was not authorized, and/or if that crew was not authorized to use that procedure, I am afraid the ramifications will be a bit more than a few extra sims.

As a driver sitting in that lineup, what would you want for that crew, see them on the next rotation and hope? When AC aircraft are around will SOP be "cabin crew prepare for impact"?

Is this per chance, the same AC crew that tried to land in the water a while back?

SeenItAll

17th Jul 2017, 23:54

Conspicuously absent is any mention of the cockpit voice recorder, my guess is that the crew 'forgot' to pull the circuit breaker. An honest mistake. ;) ...
If the CVR is missing they can't gig them for missing checklists and callouts, right?

While we don't know yet whether the CVR was preserved, not pulling the CVR circuit breaker seems often to be item #1 on the After F*ck Up checklist. While I understand the motivation, the only real solution appears to be the installation of memory chips that hold 24+ hours -- rather than the 30 minute or 2-hour jobs that are now relics of the magnetic tape era.

Derfred

18th Jul 2017, 00:47

Conspicuously absent is any mention of the cockpit voice recorder, my guess is that the crew 'forgot' to pull the circuit breaker. An honest mistake.

I'm fascinated by this.

Pulling the CVR circuit breaker following an incident is not procedure in my jurisdiction, nor in my airline.

Is it really policy in that part of the world?

CVRs were introduced for accident analysis. Not for incident blame game.

What is USALPA's position on this?

Jet Jockey A4

18th Jul 2017, 01:18

Is this per chance, the same AC crew that tried to land in the water a while back?

No, if you are referring to the Sint-Maarten incident... That would have been WestJet.

Airbubba

18th Jul 2017, 02:38

Pulling the CVR circuit breaker following an incident is not procedure in my jurisdiction, nor in my airline.

Is it really policy in that part of the world?

The NTSB has lobbied for a couple of decades for turning off the power to the CVR after a 'reportable' incident or accident.

See:

THE NTSB RECOMMENDS THAT THE FAA: REQUIRE ALL AIRLINES TO REVISE THEIR PROCEDURES TO STIPULATE THAT FLIGHTCREWS TURN OFF POWER TO THE COCKPIT VOICE RECORDER AS PART OF THE ENGINE SHUTDOWN PROCEDURE IN THE EVENT OF A REPORTABLE INCIDENT/ACCIDENT.

https://ntsb.gov/safety/safety-recs/_layouts/ntsb.recsearch/Recommendation.aspx?Rec=A-96-170

Several airlines have put the CVR breaker on the shutdown checklist ('as required') so if the pilots 'forget' to pull it in case of a safety related event, the feds can go after them for not properly completing the checklist. Or, maybe it's just a memory aid. :)

§ 121.359 (h) mentions NTSB part 830, if you don't hit anything and no one swerves out of the way, you might be OK buzzing four planes holding short of the runway and not pulling the cb:

(h) In the event of an accident or occurrence requiring immediate notification of the National Transportation Safety Board under part 830 of its regulations, which results in the termination of the flight, the certificate holder shall keep the recorded information for at least 60 days or, if requested by the Administrator or the Board, for a longer period. Information obtained from the record is used to assist in determining the cause of accidents or occurrences in connection with investigations under part 830. The Administrator does not use the record in any civil penalty or certificate action. [trust me, we're here to help you etc. - Airbubba]

https://www.law.cornell.edu/cfr/text/14/121.359

On the Canadian side it looks like the CVR is supposed to be disabled after an accident or incident. Again, maybe AC 759 could claim they didn't hit anything so they didn't know the cb was supposed to be pulled:

3.0 BACKGROUND
Following recent incidents, flight crews have either disabled the wrong circuit breaker or neglected to pull the circuit breaker for a CVR, resulting in the loss of critical information. The Transportation Safety Board (TSB) has recommended that steps be taken to ensure that the necessary information and guidance is made available to flight crews to properly safeguard on-board recordings following an occurrence.

4.0 REQUIREMENTS
Subsection 605.34(2) of the CARs states: No person shall erase any communications pertaining to the flight being undertaken that have been recorded by a cockpit voice recorder.

Paragraphs 725.135(i), 724.121(i), 723.105(1)(aeroplane) 723.105(j)(helicopter) of the CASS require the inclusion of FDR and CVR procedures in the Company Operations Manual. It is expected that the appropriate steps for disabling of a FDR and/or CVR following an accident or incident will be included in these procedures.

Clauses 705.124(2)(a)(iv)(C), 704.115(2)(a)(v)(C), and subparagraph 703.98(2)(c)(iii) of the CARs require that an air operator’s training program include initial and annual training on emergency procedures. This training should include procedures for disabling the FDR/CVR following an accident or incident, and must be provided to flight crew members and ground personnel.

https://www.tc.gc.ca/eng/civilaviation/opssvs/managementservices-referencecentre-acs-700-700-013-131.htm

ironbutt57

18th Jul 2017, 04:28

RAT 5

18th Jul 2017, 08:22

The old adage of "when there's doubt there is no doubt" comes to mind. That helps you decide that if you are not 100% certain you really are where you want to be, when close to damaging concrete, it is a good idea to get the hell out of it and start again.
This incident raises many issues from technology to human behaviour, both that of the individual and as a team; and local airport procedures. These events rarely happen in isolation. They will repeat until they are fully understood and mitigated against. May be not in the exact same place or circumstances; could be elsewhere, but Murphy is always sniffing around.
This event requires much more than just a few extra sims: it also has to include local airport & ATC procedures, plus AC's own. This occurrence might well have contributing parameters outsides the flight-deck.

CurtainTwitcher

18th Jul 2017, 09:25

Rat5, confusion is what we humans will always do!

Another way of looking at it, cognitive biases and heuristics are the mental equivalent of the way a lens bends light. Our mindis the lens, it literally bends what we see based on our preconception. Stated another way, our perception is dependant upon what we believe. We process randomness until we "understand" the chaos AND THEN STOP PROCESSING, and move on to the next task. We superb pattern recognition machines, and we will always attempt to make sense and interpret what we perceive. Watch the short video below.
8FIEZXMUM2I

Did you attribute intention and make up a story to go along with these geometric shapes moving around a board? That is our faulty cognitive machinery at work.

A smart guy once remarked that the first impulsive thought to a GPWS "PULL UP" is likely to be utter disbelief, followed by "nah, its spurious" because by definition we are confused about where the aircraft is if we get this warning.

Our mental model says we are one place, the aircraft knows we aren't. We would not be in the approaching terrain willingly, so we are confused! Our instinctive response is to blame the machine for it's confusion, we aren't confused! I suspect this is the case with most CFIT, the crew are very happy with where they think they are, until they aren't

I made a similar post over on the Dubai B777 accident, post#1371 (http://www.pprune.org/rumours-news/582445-emirates-b777-gear-collapse-dxb-35.html#post9502897) with some more thoughts on confusion. I don't believe this mental state is well understood or researched.

A soft entry into this is Michael Lewis's recent book, "The Undoing Project". If you like this, then move onto Daniel Kahneman's "Thinking Fast and Slow" and even Nassim Taleb's "Fooled by Randomness". Those books are the more general cases, not aviation specific, however there is lots that we can take away as pilots.

DIBO

18th Jul 2017, 09:43

... SFO TWR with all its equipment could also have picked up the misalignment much earlier. Not required to, but could/maybe should have...
Nope, they should NOT have noticed the misalignment.
Having listened to comm's before and well after the incident, he (as in only one) was too d#mned busy handling arriving/departing traffic 28R, interleaved with many departures 01L, combining GND/TWR positions, explaining to people he was the only one up there, getting everybody over and over again on TWR freq., handeling gate position not yet free, people uncertain about their gate having to call OPS, people messing up taxi instructions, English procifiency levels with room for improvement, .... Well the usual stuff...but all this with still a lot of traffic, enough to keep one person very busy.
Contributing factor maybe? ATCO staffing levels not allowing an extra pair of eyes to monitor things and even for visual approaches to do a spot check on the radar screen, knowing that the rwy config (dark 28L) was not 100% "as usual"?
I know, keep on dreaming, we are in the age of cost cutting...

portmanteau

18th Jul 2017, 09:53

1. AC 759 queries lights on runway.
2. Atco, no matter how busy he was would have looked along runway before reassuring aircraft it was safe to land. ( Atco doesn't say, by the way you are lined up on the taxiway because that fact is not apparent to him. It's night remember).
3. AC 759 believes what ATC tells him and prepares to land.
4. AC 759 gets the shock of his life when he realises that the lights he saw actually WERE aircraft, pours on the power and narrowly gets away with it. i.e. he was right and so was ATC. They were just talking about two different "runways".

5. I am a bit puzzled about the almost light-hearted " he's on the taxiway" which suggests 759 still had some way to go and therefore time to correct his error. ( I doubt if the 759 PF needed any prompting from anybody. It must be possible that he didn't even hear it, what with the flight deck suddenly becoming a hive of activity).
6. Is there not a case for wondering if Visual approaches AT NIGHT to several close parallel runways and taxiways such as occurs at SFO are a suitable option when accurate instrument aids are available? Distance between 28R and taxiway C for example is only around 480 feet (centreline to centreline).

ZOOKER

18th Jul 2017, 10:13

Anyone controlling arrivals and departures on 2 runways, (crossing, or otherwise), should not be doing GMC.

Ian W

18th Jul 2017, 11:12

As I said way back this was a cognitive misperception - expecting an approach to the rightmost of 2 runways the pilot sees two rows of lights and his brain says that is the right hand runway. From then on that is what he sees a runway. if you don't think that is possible and didn't read my post before - consider this your vision cannot see a ball in flight as it is not seeing for much of the time - your brain fills in where that ball is. It is why you have to teach children to catch balls. However, you will claim you watched it all the way as your brain makes you think that you did.

So visual spatial cognitive channel is showing the taxiway as a runway and the anti-collision lights were perceived as traffic on the runway. Instead of a voice call - that worked but might not have, one or more of the aircraft putting on all their landing lights would have destroyed the illusion immediately far faster than the R/T call.

For those who are blaming all the in-cockpit entertainment toys available these days, these kind of misperceptions were happening back when those toys were not available. It is unfortunately part of the way our brains work. Knowing that these cognitive issues arise there are better ways of ensuring people do not land on a parallel taxiway than switching off all the lights on one of the runways (red cross there or not) as pilots looking for two runways see a runway and a taxiway and some will see two runways as that is what they expect to see. It would have been better if 28L had remained lit and ATC had reminded everyone that 28L was out of service.

glofish

18th Jul 2017, 11:16

For those who are blaming all the in-cockpit entertainment toys available these days, these kind of misperceptions were happening back when those toys were not available

... thus lots of these toys are not necessary, even somewhat of an unnecessary distraction. :ouch:

SeenItAll

18th Jul 2017, 12:15

DIBO

18th Jul 2017, 12:25

Atco doesn't say, by the way you are lined up on the taxiway because that fact is not apparent to him. It's night remember.That's why they have radar screens installed even in VCR's, with a perfect straight radar trail of AC's final approach, aligned parallel next to 28R extended centerline. But the sole ATCO with his high workload, especially with all those ground and crossing rwy movements, in VMC, with visual approaches, had to keep his eyes outside. A second pair of ATCO eyes might have caught more/earlier...

RAT 5

18th Jul 2017, 13:02

A friend has just bought a new Tiguan with lots of bells & whistles. He's fawning over the reactive braking system so that you can not have a smash up with an object in front of you. He's wowing over the lane assist control if you cross the white line on the motorway. He, or his wife is, wild about the automatic park assist.
Now they're researching all these self-drive cars with auto-nav systems. Add in all the auto-brake, crz control, auto-park etc. and they are turning manual cars into an Airbus. Well let's just see where that has got us. The carnage on the roads will mean I'm staying home with everything delivered and virtual holidays via i-phone goggles and greek takeaways sitting in the Jacuzzi at 25c with a sun lamp & cold domestica to hand. One day Greece, the next Spain, the next Italy. Better sell my TUI shares.

I hope the preliminary report will be soon then we can discuss something factual.

underfire

18th Jul 2017, 13:27

I must have missed the bit about the AC crew asking ATC if the runway was clear because they could see lights on it...

Yes, look at when they asked, and they still tried to land. Seems like if you did see aircraft lights on the runway, and had to ask someone about it, that is a failure it itself?

aterpster

18th Jul 2017, 13:50

The fact that 28L and 28R are closer together than is desirable is well known. But this seems gratuitous. Taxiway C is to the right of 28R. While it would be a big construction project, why isn't Taxiway C converted into a new 28R, and the current 28R converted into a taxiway? It would seem to be a quick way of gaining another 400-500 feet of separation between 28L and 28R.

The cost would be huge. And for what gain? Unless they are spaced far enough part for simultaneous, independent parallel instrument approaches, what would be the point?

Perhaps 15, 20 years ago, there was a well-designed plan to fill in a portion the bay to make the airport area sufficiently large to have simultaneous, independent parallel instrument approaches. (May have included such spacing for19L/R as well as 28L/R, I don't remember.) The proposal included dredging an equivalent area in a different part of the bay so the total water area would net out the same. That replacement was to satisfy the "greens." The locals would have no part of the plan, so it died.

That's California in general and the Bay Area in particular.

ZOOKER

18th Jul 2017, 14:44

Pukin'
If the airport had been "well lit, fully NOTAMed" etc, then PIA, AC or BA, this probably wouldn't have happened.

And for those who have listened to the various ATC recordings, don't forget that, unlike the actual 'ATC tapes', they don't include all the telephone conversations that may/may not have been taking place from the operational position.

sb_sfo

18th Jul 2017, 15:03

Aterpster,
As I recall, those plans would have killed tidal movement in much of the bay south of the airport, turning it into a pond with little water movement. They deserved to be shelved in that case (and I am pro-airport, having worked there for nearly 40 years).

peekay4

18th Jul 2017, 15:55

As I recall, those plans would have killed tidal movement in much of the bay south of the airport, turning it into a pond with little water movement. They deserved to be shelved in that case (and I am pro-airport, having worked there for nearly 40 years).
The expansion into the bay was envisioned when SFO's saw crazy growth rates during the dot-com days.

But subsequently the dot-com bubble burst, 9/11 happened, and United went into bankruptcy. SFO passenger traffic plunged, and the expansion plans were shelved.

Of course today SFO sees more traffic than ever before...

BluSdUp

18th Jul 2017, 16:22

I just read the NTSB official info. It did not mention the CVR. The FDR read out was provided by Canadian TSB, ergo I dare conclude the CVR was not secured.
They would have mentioned it.

So due to severe incompetence of the crew they decided not to secure the CVR in direct contradiction to Canadian law.
NTSB will find out exactly what happened here, but not nesesserely how and why.
The CVR is worth gold in this case , and the crew knew it.

On the matter at hand!
How to prevent this ever happen again:
Tune and follow the ILS inside 4 miles. And get new glasses!

DIBO

18th Jul 2017, 16:27

One aspect that I don 't expect to be covered in the NTSB report and given all the psychological insights given in this thread, how might this incident impact the front row witnesses. The PIL crew sitting in their big lame duck, nowhere to go or move, within seconds being blinded by big, bright landing lights coming straight at them. Depending on how much they saw this coming, it was all over in seconds (or a few dozen of it). How would they have keept their calm afterwards. Would you have kept your calm?
Ages ago, I had a very close call, near midair in a glider. All I could do was slam the stick and duck my head. Seconds later I was regaining control (plane & myself), but my knees kept shaking uncontrollably, until after landing safely (and without a scratch). But it took some hours on terra firma to fully regain my calm...

SeenItAll

18th Jul 2017, 17:06

I should have done my research earlier.

For simultaneous landings and takeoffs using VFR, the minimum separation between centerlines of parallel runways is 700 feet (213 m). For simultaneous IFR operations, dual simultaneous precision instrument approaches are normally approved on parallel runway centerline separation of 4,300 feet (1311 m).

Because the current separation between 28L and 28R is about 750 feet, I guess adding another 500 by swapping 28R with Taxiway C won't buy nearly enough separation to permit simultaneous IFR.

aterpster

18th Jul 2017, 17:09

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

Seems that the crew would be open to Canadian certificate action, at the least.

underfire

18th Jul 2017, 19:19

Unless they are spaced far enough part for simultaneous, independent parallel instrument approaches, what would be the point?

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.

a330pilotcanada

18th Jul 2017, 19:55

Good Afternoon All:

When I retired over 7 years ago there was absolutely no requirement to pull the C.V.R. c/b at my airline after an incident. Although the tape is continuous loop for 30 minutes and overwrites after that at an A.R.T. session many years ago we were told that the laboratory can recover up to 2 hours but it takes a lot of effort to do so.

As an aside to some of the postings written I would suggest this, wait for the report to be published read then make your "informed comments".

.

Airbubba

18th Jul 2017, 21:01

I've cited above what appears to be a Canadian requirement to pull a cb or otherwise remove power from a CVR after an incident or accident.

The two-hour CVR has been a requirement for several years in America:

§ 121.359 Cockpit voice recorders.

(i) By April 7, 2012, all turbine engine-powered airplanes subject to this section that are manufactured before April 7, 2010, must have a cockpit voice recorder installed that also -

(2) Retains at least the last 2 hours of recorded information using a recorder that meets the standards of TSO-C123a, or later revision; and

(3) Is operated continuously from the use of the checklist before the flight to completion of the final checklist at the end of the flight.

https://www.law.cornell.edu/cfr/text/14/121.359

Canada has proposed upgrading to a similar two-hour standard in future regulations:

Description of the objective

Objective: To enhance the capture of Cockpit Voice Recorder (CVR) information needed for accident investigation purposes.
Description: Proposed amendments would:

increase the duration of CVR recordings to 2 hours;

Recommendation A91-13 - Transportation Safety Board of Canada (http://www.bst-tsb.gc.ca/eng/recommandations-recommendations/aviation/1991/rec_a9113.asp)

I have heard similar claims that the older CVR technology would allow data to be recovered after several overwrites using closely held forensic techniques but I can't find much online about this other than hearsay in forums like this one.

Also, there is some question as to whether the erase function is properly implemented in current flash memory based CVR's. Is the data really gone or can it be recovered as with a camera SD card that has been reformatted but not overwritten?

It is claimed that India's DGCA has mandated removal of the erase feature from units in its aircraft, is this true?

sb_sfo

18th Jul 2017, 23:53

One aspect that I don 't expect to be covered in the NTSB report and given all the psychological insights given in this thread, how might this incident impact the front row witnesses. The PIL crew sitting in their big lame duck, nowhere to go or move, within seconds being blinded by big, bright landing lights coming straight at them. Depending on how much they saw this coming, it was all over in seconds (or a few dozen of it). How would they have keept their calm afterwards. Would you have kept your calm?

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

787PIC

19th Jul 2017, 06:41

Any Canadian airline pilots, does Canada follow any of the FAR-117 rest rules?
Thanks

peekay4

19th Jul 2017, 08:50

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

19th Jul 2017, 09:11

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

19th Jul 2017, 12:32

The technology not only exists for live streaming Qatar is apparently already doing so https://runwaygirlnetwork.com/2015/11/19/qatar-airways-ceo-says-carrier-already-streaming-black-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

19th Jul 2017, 13:26

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?fbid=10155542203673482&set=pcb.10155542208948482&type=3&theater

underfire

19th Jul 2017, 13:57

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/2017/07/18/watch-exclusive-animation-shows-air-canada-planes-sfo-near-miss/

Airbubba

19th Jul 2017, 14:20

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.

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:

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

19th Jul 2017, 14:54

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

19th Jul 2017, 15:21

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_says_our_brains_are_mis_wired#t-571278

And here is another which is fairly mind blowing:-
https://www.ted.com/talks/donald_hoffman_do_we_see_reality_as_it_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

19th Jul 2017, 15:43

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/HLSC2015/Pages/WorkingPapers.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

19th Jul 2017, 16:03

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

19th Jul 2017, 17:42

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

19th Jul 2017, 18:58

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!

http://i65.tinypic.com/2r44r3s.jpg

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

19th Jul 2017, 19:29

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

19th Jul 2017, 20:22

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

20th Jul 2017, 01:45

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 (http://www.dailymail.co.uk/news/article-4711954/Animation-enacts-Air-Canada-plane-s-near-disaster.html)

RickNRoll

20th Jul 2017, 04:33

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 (http://www.dailymail.co.uk/news/article-4711954/Animation-enacts-Air-Canada-plane-s-near-disaster.html)

Nearly hit four jumbo jets. :E

PukinDog

20th Jul 2017, 05:17

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

20th Jul 2017, 08:00

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

20th Jul 2017, 08:39

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

20th Jul 2017, 08:45

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?

Volume

20th Jul 2017, 11:24

This crew will be able to tell the investigators all they want to know.In the way they experienced and remembered it. Which might be far from what really happened. The stress they remember and the stress their voices do show might be totally different. If they felt this was a very dangerous situation, they would have decided for a go-around. As they acted wrongly, they may remember wrongly, even if they are most sincere with the investigators. A CVR remembers accurately, neutrally and with a correct timestamp, humans don´t.

BluSdUp

20th Jul 2017, 11:47

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.

BluSdUp

20th Jul 2017, 11:54

Volume
You beat me to it!
Have done a few checklists 2 times: " Did we do XYZ Checklist?" FO:" Yes! I think so!"

.Scott

20th Jul 2017, 12:43

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

TRW Plus

20th Jul 2017, 13:33

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.

underfire

20th Jul 2017, 13:37

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...

http://i1108.photobucket.com/albums/h403/skydancer30/authcoid123151part1_zps7bd67c11.gif

Looks like we also need this on the taxiway.

Ian W

20th Jul 2017, 15:11

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.

I fully agree except the most important point has been left out. Runway 28L is NOTAMed as Out of Service. So there will only be Runway 28R available. Both crew members minds now expect only to see one runway.

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.

portmanteau

20th Jul 2017, 15:32

RAT 5

20th Jul 2017, 16:08

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.

underfire

20th Jul 2017, 16:23

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-traffic-management/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.

DIBO

20th Jul 2017, 17:42

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....

underfire

20th Jul 2017, 18:00

but this data shouldn't be available to Flightaware and neither so soon

The graphic was from FlightAware using data from the FAA's Surface Movement Event Service

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

Please read the links provided showing the capability and expectations of the system before responding. (data is used from the terminal radar system)

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.

DIBO

20th Jul 2017, 18:34

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...

Shore Guy

20th Jul 2017, 19:48

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).

underfire

20th Jul 2017, 22:53

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

21st Jul 2017, 00:05

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, ........

aterpster

21st Jul 2017, 00:47

Und

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.

So far, the FAA has no plan to decommission TRACON ASRs.

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.

neila83

21st Jul 2017, 05:09

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.

In absence of information from CVR, crew interviews etc., this seems most likely. Otherwise it's hard to see how they ignored the mass of approach lighting a few hundred feet to their left. Still leaves the question of how they approached a major international airport at night without any approach lights on the 'runway' and carried on. The circadian time seems probably very important. And as many have already alluded to, seeing what you think you should see.

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.

Bergerie1

21st Jul 2017, 07:07

Volume

21st Jul 2017, 08:37

I am inclined to think they were not aware it was out of service.
There is an important difference, between knowing it was out of service (logical level) and being aware that it would simply not be there (subconsious level). They probably knew it was out of service, their subconsious expectation however was that it still would be visible, which it probably was not. They were very well aware, that they had to use the right of the two runways, they were not aware that what they saw were 28R and Taxiway C, and not 28L and 28R.

The circadian time seems probably very important
Definitely. The more tired you are, the less you think and the more you act intuitively.

aterpster

21st Jul 2017, 12:51

"The circadian time seems probably very important."

Yes - I'm reminded of the UPS accident at Birmingham; not seeing/receiving important and normally-perceived cues.

The NTSB wasn't as sympathetic as that. See attached.

Shore Guy

21st Jul 2017, 16:39

Aterpster and all,

One of the big selling points by the FAA for ADS-B was to be able to get rid of the "expensive radars".

Not going to happen.....

Also, I believe that a backup source of navigation will ultimately be needed to provide a secure system. Enhanced Loran C comes to mind.

Imaging the consequences of a worldwide hack/shutdown of GPS......

Ian W

21st Jul 2017, 19:27

Oh but it did happen. The DoD is paying for the 'expensive radars' which are now not on the FAA books.

JammedStab

21st Jul 2017, 21:27

aterpster;
It not about the degree of sympathetic hearing, it's about the effects of fatigue that appear common to both events. There are important cues missed in both events. We have yet to learn what preceded the SFO incident and why.

The factors listed under the NTSB's Report on the UPS accident, "Probable Cause and Findings" section,

(5) the captain's performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and (6) the first officer's fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.

may or may not also apply in the SFO incident, we haven't heard from the NTSB or the TSB yet but I think the remark regarding circadian effects is a good starting point but having done these approaches into SFO over many years, I understand that there is likely more to this.

What evidence of fatigue do you have for the SFO incident. Are you aware of their schedule or sleep patterns? I think not. I suspect that you are just making an assumption based on the time that the incident happened. But perhaps the pilots were well rested prior to the flight.

There seems to be an automatic assumption by some that if any incident happens at certain times or on a long flight, that fatigue is a factor, perhaps in an attempt to deflect attention away from the possibility of crew error.

As of right now, most of us have no idea on whether the crew were fatigued so we should not be posting in a manner as if it was likely. The reality is that it is a possibility along with many other possibilities and that's all.

The other reality is that there are flights all over the world that are long haul and at strange hours. Yet they are completed without incident. Misidentification of airports and runways happen on a regular basis to fatigued and non-fatigued crews.

As we can see in the UPS cause that was posted, the captain had some deficiencies that were seen in training and resulted in the accident. I'm sure they were tired, but so were probably 25% or more of UPS pilots in the system that night and every night.

underfire

21st Jul 2017, 22:48

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

That presentation could be given today, given what was shown and what has been done. Sorry to say that was done in 2007, so in 10 years, nothing has happened.

ADSB signal consists of 112 bits, that is it, you barely get the root and the ac id in that, with coordinates, so forget about any encription, just not enough room. Even the other information is pretty granular.

ADSB may have use for ground movement, but in reality, you will never ever see ADSB-In on a commercial aircraft. Military has it, but it is built behind a very secure encryption system which is not available commercially.

DingerX

22nd Jul 2017, 00:07

Jammedstab, I think a distinction needs to be made here between fatigue and circadian rhythms. When I mentioned the "C word", I intentionally did not accuse the crew of being fatigued or even tired. They may have been, but we have no info on that.
What we do know is that it was nearly midnight local time, and the flight was originating from a place where it was then 3 AM. Contrary to your suggestion, we can guess a few things about our crew. For example, they were not based in San Francisco. Also, it was probably between 3:30 AM and midnight on their base time.

And here's the thing about Circadian lows: they're not based on fatigue, but rather what time of day your body thinks it is. Industrial accidents have their highest rates between 2-4 AM and 1-3 PM, and that's with people who are well rested, sober, and in the time zone.

Sure, most crews pull it off just fine. Most times, you'll get by without the last five minutes of final reserve fuel too.

aterpster

22nd Jul 2017, 00:36

Sure, most crews pull it off just fine. Most times, you'll get by without the last five minutes of final reserve fuel too.

Part of it is self-discipline, experience, and proficiency. I am speaking of this crew, rather the fatal UPS crew.

I flew many lousy night pairings with TWA before the duty/rest rules got a bit better.

As tired as we may have been on a multi-leg flight from LAX to the east coast on the back side of the clock, we managed to get ourselves alert for the terminal area business at hand, whether it be CAVU or bare minimums.

Don't really know. Perhaps the lack of automation forced us to be more alert. The human-factors folks probably don't have a real good handle on it.

Also, commuting from a distant location to begin a night flight should be illegal.

West Coast

22nd Jul 2017, 01:22

Also, commuting from a distant location to begin a night flight should be illegal.

Having had the domicile I lived in closed causing me to commute, I'll be happy to agree with you when the company purchases my house and provides moving expenses to a domocile within my time zone. While I'm senior enough to bid around the trips you mention, not everyone is.

aterpster

22nd Jul 2017, 12:51

I have no problem with commuting provided it is subject to FAR duty time and rest regulations.

I was forced to commute from LAX to STL for several months. I always went over the day before and spent a night in a hotel before taking my pairing the next day.

That's not the way it works for most commuters. They ride the red-eye then report for their pairing a few hours after arrival, at most. Domiciles open and close. Same happens in other industries. That's a personal/employee/employer problem that should not be transferred to the flight deck.

Also, these days many commute because they chose not to move to the domicile in the first place.

galaxy flyer

22nd Jul 2017, 16:04

There was a time living within "reasonable ground travel" of the domicile was mandatory. Why I never applied to NWA.

aterpster

22nd Jul 2017, 16:28

TWA never had that. But, before the early 1970s the jump seat couldn't be used for commuting. So, only the senior guys with term passes could commute.

Circa 1970 the LAX chief pilot issued a letter that all LAX pilots had to live within 50 miles of KLAX, The union got that rescinded in short order. We had guys driving up to 200 miles in those days.

JammedStab

22nd Jul 2017, 17:43

When I mentioned the "C word", I intentionally did not accuse the crew of being fatigued or even tired. They may have been, but we have no info on that.
What we do know is that it was nearly midnight local time, and the flight was originating from a place where it was then 3 AM. Contrary to your suggestion, we can guess a few things about our crew. For example, they were not based in San Francisco. Also, it was probably between 3:30 AM and midnight on their base time.

That is the problem, you are just guessing. How do you know that they were not Vancouver based? You don't do you.

And even if they were based in the east, how do you know that they were not well rested prior to departure? You are making an assumption(and y are making the suggestion) that this crew had to be tired. I suggest that you are just making guesses as potential excuses.

RobertS975

22nd Jul 2017, 21:21

I don't know how prevalent long distance pilot commuting is currently, but only a decade or so ago, I knew a DL pilot who would leave his home in southeastern MA (BOS pilot base had closed) about 0930 to catch an 1130 DL shuttle flight BOS-LGA, taxi from LGA to JFK to command the DL flight JFK-SVO leaving between 1600-1630. This would happen 4-5 times a month.

His landings at SVO came at 0200 or so "body clock time" after a pretty long day. There was a rest period during the TATL flight.

peekay4

22nd Jul 2017, 22:43

And even if they were based in the east, how do you know that they were not well rested prior to departure? You are making an assumption(and y are making the suggestion) that this crew had to be tired. I suggest that you are just making guesses as potential excuses.
We're still conflating fatigue with circadian rhythm. It doesn't matter if the crew was well rested. If the pilots were flying "out of sync" with their biological cycle, then their cognitive performance might be compromised.

There's a lot of research indicating that most of us cannot perform optimally past 2am unless we only work nights for an extended period of time -- e.g., doing night shifts exclusively for several weeks in a row without break.

Yet as soon as we switch to day work (even for just one day) our body clock "resets", and our night time alertness suffers again -- regardless of how "well rested" we might be.

underfire

23rd Jul 2017, 00:15

Speaking of ADSB, been hearing rumors that the 2020 mandate in the US is not going to happen, anopther delay will be announced soon (associated with the ATC privitization bill)

WillowRun 6-3

23rd Jul 2017, 02:48

Well put, peekay4. Anecdotally, a good many years ago I had a summer job assignment that led to an entire calendar month of midnight-to-8:00 a.m. shifts. Not flying anything - compiling production numbers and various numerical production reports for a BOF (Basic Oxygen Furnaces) steel-making shop. Around sun-up or so each shift, I had to drive around the massive steel mill works, in my personal car, to deliver some reports to other departments. Indeed the body clock does adjust to "steady midnights" (and some mill folk take pride in their ability, or perhaps it's only perceived ability, to adjust as necessary).But even so, driving around the sprawling Plant 2 of Indiana Harbor Works, alert for gargantuan fork-lifts carrying ingot molds for example, as the August sun was rising over Lake Michigan taxed even a 21-year-old's ability to ..... look sharp!

West Coast

23rd Jul 2017, 04:38

That's not the way it works for most commuters. They ride the red-eye then report for their pairing a few hours after arrival, at most. Domiciles open and close.

I'd say that most commuters I know haven't ever hopped an all nighter, let alone sign in for a paring after, certainly not "most" as you characterize. Perhaps in the past, not these days.
Either way, unless there's a demonstrated, continious problem, I'd prefer to avoid additional government overreach.

aterpster

23rd Jul 2017, 14:07

West Coast

23rd Jul 2017, 19:07

Colgan Air 3407 was just over 8 years ago.

It's next to impossible to gather information as to whether it is "a demonstrated, continuous problem." The commute issue of 3407's F/O was of considerable concern to the NTSB.

Given the considerable changes due to the Colgan crash along with the implementation of FAR 117, there's been ample opportunity to address it if it was deemed thst dangerous. As tragic as Colgan was, it was one accident and there are a lot of other pieces to that puzzle besides commuting.

filejw

23rd Jul 2017, 20:49

aterpster

24th Jul 2017, 00:54

As tragic as Colgan was, it was one accident and there are a lot of other pieces to that puzzle besides commuting.

I agree as to the pieces of the puzzle for that tragic crash. I didn't intend to suggest otherwise.

As to Part 117, that is speculative at best for the issue of commuting.

RAT 5

24th Jul 2017, 09:13

How did this become a thread on FTL's & commuting?

atakacs

24th Jul 2017, 11:01

Motion seconded :confused:

Probably time for a lock down until further news are available.

West Coast

24th Jul 2017, 11:36

Because the topic has run its course short of new information from the investigation.

Ian W

24th Jul 2017, 13:33

How did this become a thread on FTL's & commuting?

Because cognitive misperceptions are far more likely if at the low performance end of the circadian cycle and fatigued. Often because the crew concerned are concentrating because they know they are at the low performance end of the circadian cycle and fatigued and this leads to cognitive (aka attentional) tunneling.

underfire

24th Jul 2017, 16:13

excuses without foundation.

CurtainTwitcher

24th Jul 2017, 21:39

Thank goodness they :mad: types like you out of safety departments a long time ago. If we didn't, we would still have the infallible 'Captain as God" types still flying the line, where we just sack people because they make mistakes and move on without trying to learn anything.

We are human, we are ALL screw up, and we don't get to choose when we do it. Landing on taxiways is a known phenomenon, this one just happened to be more populated than previous events.

The two guy's up the front didn't set out to screw up, the mere shame of ending up as the subject of a multi-page PPRuNe forum topic is horror enough. Let alone the true realisation of what might have been. These guys are likely to be irreparably psychologically damaged, and may even have their careers & families destroyed by this.

Aviation has moved on from previous era's of "just excuses, try harder, don't screw up", and it much safer for it. Aviation is a highly complex, stressed ecosystem with many more moving parts than just the pilots that concentrate large numbers of humans and dangerous goods into small areas at high velocity. It is a damn dangerous business, and we manage the risks exceptionally well because we have learnt that screwup can an do occur, even with the most simple and obvious task.

You can help improve the system, or you can just throw stones.

It's funny, as I am halfway through Fate is the Hunter [movie, 1964], everyone wants to hang the Captain Jack Savage out to dry...

underfire

24th Jul 2017, 22:06

The last I heard, the reasons for the incident had not been determined, hence excuses without foundation.

Time to get off that pole you are sitting on.

BRDuBois

24th Jul 2017, 22:29

I've seen quite a few suggested contributing factors. Haven't seen a single thing proposed as an excuse.

pilot9249

24th Jul 2017, 23:36

I guess I have a similar reaction to "excuse".

However that's directed at the system, not the individual.

I don't doubt the provenance of the human factors discussion above. It seems well formed.

Where I would choke is on considering those human factors a primary causal factor.

That implies we have to fix the human.

We might as well blame gravity.

We surely don't need to fix the human, and anyway let's be honest, we can't.

What we can do, and where I would hope any recommendations land, is in making circadian rhythms ever more irrelevant.

NYVR

25th Jul 2017, 00:09

I find it interesting that there is so much chat about the obvious. Poor airmanship and frankly an embarrassing moment for our profession. However I would venture a guess that these pilots where Toronto based and running on the back of the clock after a long day. AC was also involved in an incident of falling asleep at the controls only to wake up and violently manoeuvreing to avoid hitting a star. When will we band together and force laws to protect the flying public from tired pilots who are making life threatening decisions.

framer

25th Jul 2017, 01:05

Quote:
Originally Posted by BRDuBois .

Where I would choke is on considering those human factors a primary causal factor.

That implies we have to fix the human.

We might as well blame gravity.

We surely don't need to fix the human, and anyway let's be honest, we can't.
I disagree.
By identifying a human factor we don't have to fix the human, we have to fix the systems so that they are tolerant of that human factor.

BRDuBois

25th Jul 2017, 01:27

Well said.

pilot9249

25th Jul 2017, 02:14

We have a choice whether to fix the system to accommodate the human frailty, or to avoid the human frailty entirely.

History is firmly on the side of the latter.

Airbubba

25th Jul 2017, 02:27

Looks like 'the pilot' did not have the ILS tuned and displayed. This setup without the ILS would be normal for most operators on the A320 for this approach from our discussion here. Also, he went flying as scheduled the next day.

SFO close call: Air Canada pilot was not using guidance system, source says

By Matthias Gafni | [email protected] | Bay Area News Group
PUBLISHED: July 21, 2017 at 4:37 pm | UPDATED: July 24, 2017 at 4:35 am

SAN FRANCISCO — The wayward Air Canada pilot who nearly landed on a crowded SFO taxiway earlier this month did not activate his computer guidance system that would have helped guide his airplane onto the appropriate runway and not dozens of feet from a catastrophe, according to a source familiar with the federal investigation.

Preliminary findings in the joint Federal Aviation Administration and National Transportation Safety Board investigation have determined that the pilot — who flew for his carrier again the next day after his aborted July 7 landing — did not activate his Instrument Landing System during his visual approach, the source said. The Wall Street Journal, citing two unnamed sources familiar with the investigation, also reported Air Canada flight 759 attempted to land manually with no back-up.

In what experts have called a near-disaster, the Airbus 320 passed over two fully loaded airplanes on the taxiway, as close as 51 feet to one, according to flight data information analyzed by this newspaper, before finally climbing to abort the landing and traveling over two more aircraft. The NTSB and FAA have interviewed the Air Canada flight crew and SFO air traffic controllers.

With the clear weather that night, retired United Airlines pilot Ross Aimer said that, based on air traffic audio, the Air Canada pilot was approved for a Flight Management System (FMS) visual to Runway 28-Right, which would not require him to use his computer guidance system [the FMS visual didn't require him to use his computer guidance system? :confused: - Airbubba]. That is an angled approach that would require adjusting the guidance equipment if he chose to use it.

Aimer said most pilots don’t use the guidance equipment under those conditions and that type of approach.

Predictably, the union paints the AC 759 pilots as heroes for doing a go-around when told to do so by the tower :D:

Union spokesman Chris Praught said that because of the ongoing probe, he was limited in his comments, and could not comment on the pilot’s status and flight hours.

“It is a testament to the expertise and professionalism of the highly trained crew that they were able to ensure that the flight arrived safely at its destination,” he said.

SFO: Source says Air Canada pilot not using computer system (http://www.mercurynews.com/2017/07/21/sfo-close-call-air-canada-pilot-was-not-using-guidance-instruments-source-says/)

From the WSJ:

Air Canada Pilots Reportedly Didn’t Use Normal Navigation Aids in Close Call at San Francisco

Pilots of an Air Canada jet failed to use a ground-based guidance system when they nearly landed by mistake on a taxiway at San Francisco International Airport two weeks ago, potentially coming within dozens of feet of airliners on the ground, according to people familiar with the investigation.

By Andy Pasztor

Updated July 21, 2017 7:55 p.m. ET

WASHINGTON—Pilots of an Air Canada jet failed to use a ground-based guidance system when they nearly landed by mistake on a taxiway at San Francisco International Airport two weeks ago, potentially coming within dozens of feet of airliners on the ground, according to people familiar with the investigation.

As more details emerge about the incident, these people said, investigators have tentatively determined the crew didn’t utilize the available instrument landing system U.S. carriers typically require pilots to rely on for precision approaches in similar circumstances. The issue hasn’t been reported before, and it isn’t known why the crew failed to call up the instrument system for backup during the visual landing prior to breaking off the approach.

https://www.wsj.com/articles/air-canada-pilots-reportedly-werent-using-normal-navigation-aids-in-close-call-at-san-francisco-1500667932

CurtainTwitcher

25th Jul 2017, 02:42

We have a choice whether to fix the system to accommodate the human frailty, or to avoid the human frailty entirely.

History is firmly on the side of the latter.
I assume you are talking about a totally automated system, are I correct?
If that is the case, who or what is the source of such coding for the automation?

Here is an old investigation, a "computer accident" & excellent write-up by Nancy Levison: Therac-25 (http://sunnyday.mit.edu/papers/therac.pdf).

I doubt computer software is going to solve the systems problems. Sure, it will fix some obvious ones, and equally will embed new issues. There will still be human factors, however, the location of the failure will just shift from the flight deck to the coding cubicle.

Another very recent article: The Future of Artificial Intelligence: Why the Hype Has Outrun Reality (http://knowledge.wharton.upenn.edu/article/dont-believe-hype-ai-driven-world-still-long-way-off/). Soak that article up, realise the massive data acquisition & processing task we humans actually do. We are exquisitely adapted to such tasks, at cost of being 100% accurate of the time. The efficiency of our sensor bandwidth & processing vastly exceed that of current systems by a very large margin.

pilot9249

25th Jul 2017, 03:32

No. Nothing of the sort.

Full automation is a holy grail and I can only refer you to Monty Python on that.

I fully expect that increased use of existing automation would have made this incident much less likely.

Even if not, I seriously doubt that increased sensitivity to circadian rhythms would be the logical next best step that anybody could possibly invent. That would be really really sad.

Let's see the report.

skykingpilot

25th Jul 2017, 04:11

Most of my stupid mistakes have been when I was foot dragin ,eyes bleedin.dead dog tired.
Solve that problem and the safety record will soar.

601

25th Jul 2017, 05:41

I fully expect that increased use of existing automation would have made this incident much less likely.

Would a automated system be capable of conducting a visual approach?
Would an automated system ask why aircraft appear to be on the runway?

Denti

25th Jul 2017, 05:48

Even if not, I seriously doubt that increased sensitivity to circadian rhythms would be the logical next best step that anybody could possibly invent. That would be really really sad.

Let's see the report.

You mean like a FRMS (Fatigue Risk Management System)? That is already industry standard in many areas of the world, and of course takes circadian rythm, disruptions of that and effect of previous duties into account.

framer

25th Jul 2017, 08:14

An FRMS is supposed to do those things, whether it does or not depends upon the people running it. People can tick along fatigued to the point of depression within an FRMS, knowing full well that if they call fatigued one too many times it will be a mandatory visit to the company doctor. Legislated hard limits are the only real way to keep a lid on fatigue.

DIBO

25th Jul 2017, 09:53

I fully expect that increased use of existing automation would have made this incident much less likely.

Existing automation like the new, high tech 'Airport Surface Surveillance Capability (ASSC)', you mean? Less than a year operational at the pilot site SFO, which...
Provides surveillance data with an accuracy and update rate suitable for:

Situational awareness in all weather conditions
Departure queuing
Conflict detection and alerts
Taxi route conformance monitoring
but did not prevent (probably not even alert) that an airplane almost touched down on a twy full of other planes.
Still a looong way to go before automation catches most of the incidents before they become one...

Shore Guy

25th Jul 2017, 12:42

Once again, an existing product, Honeywell Smart Runway (an add on to EGPWS) would have alerted crew to a lining up on a taxiway for landing.

aterpster

25th Jul 2017, 13:44

Hasn't it been established that the flight was cleared for the FMS Bridge Visual 28R? If so, seems that would supersede using the ILS 28R, contrary to Andy Pasztor's assertion.

I believe someone stated earlier in this thread that the FMS Visual 28R could be coupled to autoflight and A/T and track a solid 3D (LNAV/VNAV) path to roll out on final at WP F101D (4.4 DME SFO VOR), which is aligned with the runway at 3.6 nautical miles.

From those of you who have flown this FMS procedure, right or wrong?

Shore Guy

25th Jul 2017, 14:07

I have not flown this specific approach, but common sense would dictate having the ILS at least tuned in for close in lateral and vertical guidance.

aterpster

25th Jul 2017, 14:28

Correct me if I am wrong, but I recall someone stating that its "either/or" with the Air Bus.

Also, I have no idea how an FMS visual is coded. If it is coded to go to LVAV approach alerting and sensitivity (RNP 0.30), perhaps at F101D, the lateral and vertical guidance should be more than adequate for the circumstances.

galaxy flyer

25th Jul 2017, 14:46

Shore Guy

25th Jul 2017, 14:54

For the controller types, would not ADSE-X or ASSC have given a warning on this event, or do these technologies work on ground traffic only. One would think combined surveillance inputs could see this developing.

Airbubba

25th Jul 2017, 15:12

I have not flown this specific approach, but common sense would dictate having the ILS at least tuned in for close in lateral and vertical guidance.

Unfortunately, it appears that on the A320 seeing ILS raw data is difficult with an FMS non-precision approach set up:

In the A320 the display of ILS GS and LOC symbology on the PFD is incompatible with using the autoflight system to fly a non-precison approach. The ILS may be hard-tuned but the crew will not see the data unless they select the LS pushbutton or switch the Nav Display over to ROSE LS mode. If they do press the LS pushbutton after loading an approach with vertical guidance, they will get a flashing amber V/DEV message on the PFD to highlight the incompatible selection.

Another workaround I'm told would be to put the ILS 28R in the secondary flight plan and toggle to it on final but that opens up a can of worms with a possibly different missed approach and non-standard procedure.

Why do I find it hard to believe that we, as pilots in clear weather, need an ILS to find a runway plainly visible? The pilots on the AC flight questioned the controller, but did not question themselves, there's the problem.

I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.

Agreed, the biggest raw data cue in this case should be visual, a bright flashing 'X' on the closed runway 28L and ALSF-II approach lights on 28R.

WillowRun 6-3

25th Jul 2017, 17:03

A set of factors led up to this incident, and obviously not all of those factors yet are identified, let alone integrated into an overall narrative - but will the end result of the Board report be fully satisfactory? To explain . . .Reference has been made by several posts to the Colgan accident, as I understood it, for context for suggestions that effects of fatigue, or circadian rhythms (or both), played a role in the SFO incident. Someone posted the NTSB report on Colgan which I took as an invitation to start reading said report. Immediately the role of probabilistic assessment leapt out from its pages:

"The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions." Report Sec. 3.2 (p. 155).

Note also, Finding no, 9, the reason the captain failed to recognize the impending onset of stick shaker “could not be determined from the available evidence”; Finding no. 15 (“the reasons the F/O retracted the flaps and suggested raising the gear could not be determined from the available information); and Finding no. 24 (“The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined”).

It seems more than just reasonable to say that the analysis of causes in the AC 759 SFO incident also will involve a set - a complex, a list - of factors. What is the standard for "probable cause" as opposed to a "contributing factor" as opposed to some factor that a large or even vast majority of ATPs will say was a relevant one but which the available evidence or information does not warrant making a firmer conclusion or finding about? More than a pedantic query, the standard for assessing causal linkage relates directly to identifying priorities for rule-making, technological system assessments, and other factors. (And is formal assessment of cause one which assumes that all of the factors would take place in the next potential incident or does the remedial and preventative effort proceed with an understanding that several different combinations of most, but not necessarily all, of the factors would result in an accident the next time?)

The glib reason for being curious about this is that as Congress and other interested parties take a shot at separating the ATC and Safety functions of FAA, the agency's ability to respond to NTSB recommendations certainly cannot be allowed to be degraded, downgraded or otherwise reduced, and should instead - in such a legislative initiative - be significantly improved.

Now, does anyone who actually flies such an aircraft on such an approach as was involved in this incident think that the actual physics of the situation - the amount of actual distance between two potential points of contact - was a result of some lingering doubt in the mind of the PF that maybe the approach had been screwed up, misaligned? In other words, did PF possibly fly the approach just a little bit higher, out of some kind of PF muscle memory, let's call it, just because something didn't seem quite right? The margin was so small, was it not? - but was it "enough" because the PF left a tiny bit of extra margin, subconsciously if that is what you want to call it?

Edit: Statement of Chairman Hersman, concurring (Colgan report): "We . . . do not require that any causal or contributing factor equate to a percentage or share of the cause of an accident."
(Notation 8090A, pg. 3)

ex-EGLL

25th Jul 2017, 17:07

No. Nothing of the sort.

I fully expect that increased use of existing automation would have made this incident much less likely.

Let's see the report.

I would suggest that increased use of automation may well be a contributing factor.

WHBM

26th Jul 2017, 07:26

Why do I find it hard to believe that we, as pilots in clear weather, need an ILS to find a runway plainly visible?
Given the previous incidents in this situation (night, closely parallel runways, opposite runway closed, etc), including TWO actual landings on the taxiway at Gatwick when such procedures were introduced, what is hard to believe is the authorities have not done some hard procedure about such situations.

Why on earth do the edge lights on the runway out of use have to be switched off, given they are part of the visual cues for a visual approach ?

CurtainTwitcher

26th Jul 2017, 08:27

It's not hard to image someone landing on a lit runway...

Remember the Taipei SQ accident? He used a lit runway that had construction equipment halfway down it. For every countermeasure, closing off one accident scenario seems to open up another.

As I explain to my kids, its all about identifying the failure modes and making yourself aware of the traps as best as you can. Perhaps we have got to the point where introducing more defences actually become counterproductive.

Ian W

26th Jul 2017, 10:10

Why do I find it hard to believe that we, as pilots in clear weather, need an ILS to find a runway plainly visible? The pilots on the AC flight questioned the controller, but did not question themselves, there's the problem.

I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.

First: It is easy to 'get the wrong visual picture' all of us will have had that every now and then and as references in my previous posts on this thread show even the most _obvious_ cues will go unseen indeed it seems the more obvious the cues the less likely they will be seen. The issue is how do those illusions get destroyed?

Had one of those queued aircraft switched on its landing lights the 'illusion' would have been destroyed. 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. But all the players were happy with the holes in the cheese as they were and didn't think to try to close them.

aterpster

26th Jul 2017, 11:34

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...
It's contrary to policy to turn on the runway lights on a closed runway.
As to your other point that would have been in NOTAMs and broadcast on the KSFO ATIS frequency.

RAT 5

26th Jul 2017, 11:50

This is exploding into realms that are.........

The lighting of a runway, including the approach lights is very clear, well defined and well known. The lighting of a taxiway is completely different, and there are no approach lights. The lighting systems & colours were done this way to avoid mistaken identification. Runways have white & red lights; taxiways have blue & green. Pilots have colour-blindness tests and eye-sight tests. Added to this are NOTAMS when anything is amiss.
Pilots were expected to know these things and look out of the window and use Mk.1 eyeball to determine they were landing on an OK bit of tarmac.
Now, there are techies who are designing systems to alert ATC & crews when they are lined up with the wrong bit of tarmac. Another automatic back-up to human error. Agreed, there is a system to alert the crew when they are encroaching onto an active runway. At some very confusing airfields this seems to have saved the day a few times. However, their need might have been contributed to by non-standard lighting and lack of stop bars. (it should be difficult to cross reds).
It has been surmised that over-automation might become counter productive. Humans will stop thinking, plough on regardless, and wait for the warning system alerts to wake them up. I saw this in a young company when they transitioned from B727 to B757. The instructors were scolding the pilots to "stop scanning the overhead panel. The EICAS will tell you when something is wrong." I see it in a friend's new car with lane control, reactive braking & cruise control; his attention is reduced and he says how relaxing it is. i.e. his alertness level is reduced. I look a few cars ahead to anticipate traffic flow, not at the bumper in front of me. He sets his cruise/brake control to 3 car lengths and switches off.

If a crew can not distinguish between a well lit runway & a taxiway, at night, then I'm not sure an automatic system is the answer. That is a sticking plaster on a deeper problem.

underfire

26th Jul 2017, 12:33

I believe someone stated earlier in this thread that the FMS Visual 28R could be coupled to autoflight and A/T and track a solid 3D (LNAV/VNAV) path to roll out on final at WP F101D (4.4 DME SFO VOR), which is aligned with the runway at 3.6 nautical miles.
terpster, the solution gets goofed up when the legs are too short. at/abv 1800 SAMUL to F101D may be too short for a solution. We had troubles with this at other locations, but the min length is subject to many variables, so to give a min length as a rule of thumb is difficult.
Previous comments stated that the ac may not have been GPS equipped. This would negate them even using the procedure, so who knows.

Ian W

26th Jul 2017, 12:41

Except that this experienced crew _did_ make an approach to a taxiway marked with centerline greens rather than the well lit runway alongside and with several widebodies queued on it which they also saw. Restating the reasons they shouldn't is like saying in that in the research I posted earlier the observers should have seen the gorilla. Research repeatedly shows how easy it is to get human brains to have these misperceptions.

The more this crew concentrated the more their attentional tunneling made them convinced they were making an approach to 28R. Sure we all know airport marking and lighting but once that misperception kicks in it will be difficult to remove. So the first thing is to make misperception less likely and then to break the misperception if it does occur.

WHBM

26th Jul 2017, 15:56

The lighting of a runway, including the approach lights is very clear, well defined and well known. The lighting of a taxiway is completely different, and there are no approach lights.
Don't forget they had received a NOTAM, several hours earlier in Toronto, that the Approach Lighting System on runway 28 was switched off. Sure, it was about 28L rather than 28R, but that was just one character to remember.

SFO 06/017 SFO RWY 28L ALS OUT OF SERVICE 1706021357-1707211500

I'd also suspect that the taxiway lighting at SFO is probably more brilliant from the air than the actual runway lights (with the ALS out) at various other places they go to.

Airbubba

26th Jul 2017, 16:55

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.

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.

Previous comments stated that the ac may not have been GPS equipped. This would negate them even using the procedure, so who knows.

Again, can you cite any reference to indicate that the FMS Bridge Visual 28R requires GPS? :confused: It requires radar from the old plate posted earlier on the thread.

This approach has been in use for at least 20 years, long before most A320's and B-757's had GPS. But I'm sure you knew that, right?

Remember the Taipei SQ accident? He used a lit runway that had construction equipment halfway down it.

The Y2K SQ mishap at TPE really accelerated the international implementation of improved lighting and markings to denote closed runways and taxiways from what I could see.

At the time of the SQ006 crash runway 05R was an odd pseudo-runway in my observation. It had green centerline lights since it was usually used as a taxiway. Also, the touchdown zone markings were faded and non-standard with rows of white circles instead of piano keys and solid fixed distance markers. Seems like I landed on 05R once (75 feet wide? :uhoh:) when 05L was notamed out of service for rubber removal years ago.

It appears that the edge lights to 05R were not lit when the SQ whale lined up on it by mistake:

On the night of the accident, the information available to the flight crew regarding the orientation of the aircraft on the airport was:

- CKS Airport navigation chart
- Aircraft heading references
- Runway and Taxiway signage and marking
- Taxiway NI centerline lights leading to Runway 05L
- Color of the centerline lights (green) on Runway 05R
- Runway 05R edge lights most likely not on
- Width difference between Runway 05L and Runway 05R
- Lighting configuration differences between Runway 05L and Runway 05R
- Para-Visual Display (PVD) showing aircraft not properly aligned with the Runway 05L localizer
- Primary Flight Display (PFD) information

The flight crew lost situational awareness and commenced takeoff from the wrong runway.

ASN Aircraft accident Boeing 747-412 9V-SPK Taipei-Chiang Kai Shek Airport (TPE) (http://aviation-safety.net/database/record.php?id=20001031-0)

aterpster

26th Jul 2017, 20:23

Again, can you cite any reference to indicate that the FMS Bridge Visual 28R requires GPS? :confused: 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.

Airbubba

26th Jul 2017, 21:02

Yep, and a pre-GPS A320 would certainly have DME/DME/IRU. Thanks. :ok:

SeenItAll

26th Jul 2017, 21:08

underfire

26th Jul 2017, 21:48

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?

aterpster

26th Jul 2017, 22:08

No. It's not in the public domain.

underfire

26th Jul 2017, 23:03

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.

https://photos.smugmug.com/News/72915-Tyler-Pounds-Regional/i-nwSQFJK/0/c10acb22/L/SMIL_072815_Airport_Runway_Construction_04-L.jpg

Airbubba

26th Jul 2017, 23:28

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.

underfire

26th Jul 2017, 23:40

No. It's not in the public domain.

Can you provide a screenshot of a waypoint?

aterpster

27th Jul 2017, 00:49

Is this sufficient?

Airbubba

27th Jul 2017, 03:53

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. ;)

Ian W

27th Jul 2017, 11:03

Quote:
Originally Posted by Ian W http://www.pprune.org/images/buttons/viewpost.gif (http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-post9842617.html#post9842617)
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.

underfire

27th Jul 2017, 13:44

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?

RAT 5

27th Jul 2017, 14:29

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.

aterpster

27th Jul 2017, 15:06

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.

framer

27th Jul 2017, 15:42

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 ?

RAT 5

27th Jul 2017, 15:46

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.

cappt

27th Jul 2017, 15:56

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.

peekay4

27th Jul 2017, 16:11

Bergerie1

27th Jul 2017, 16:30

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.

WillowRun 6-3

27th Jul 2017, 16:41

... 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.

FlightDetent

27th Jul 2017, 17:03

aterpster

27th Jul 2017, 17:11

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".

Nonetheless these FMS RVFPs are designed and "flight inspected" by the lead carrier. Airlines don't have the extremely sophisticated equipment that an FAA flight inspection airplane contains.

Seems to me there should be DME screening, such as the FAA does with RNAV-1 SIDs that permit D/D/IRU in lieu of GPS:

aterpster

27th Jul 2017, 17:17

I tried to search for the FAA charts of the approach procedure involved with no luck. Same result when looking into our providers' world-wide database.

There seem to be a nubmer of RNAV approaches published recently with an effective date of 20 JUL.

Any chance the FMS BRIDGE VIS is no longer a published procedure?

It's still published. Unless your provider is a commercial operator that operates into KSFO, it won't be in the charts or the database.

FlightDetent

27th Jul 2017, 17:37

FAA link... any search guru around?

peekay4

27th Jul 2017, 17:42

Seems to me there should be DME screening, such as the FAA does with RNAV-1 SIDs that permit D/D/IRU in lieu of GPS
To allow non-GPS use, DME/DME analysis is a required part of RVFP development, via RNAV-Pro plus flight testing.

aterpster

27th Jul 2017, 22:37

Yes, I learned that since my earlier posting. But, there doesn't seem to be any requirement to require use of GPS is the critical DME(s) is (are) off the air.

underfire

28th Jul 2017, 00:58

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.

Concur, why have the FMS Bridge Visual with waypoints in the FMS, and then basket case it to DME? If you dont have GPS, use the Quiet Bridge Visual.

But, there doesn't seem to be any requirement to require use of GPS is the critical DME(s) is (are) off the air.

According to the plate it is DME et al OR GPS, so if DME is down you have to use GPS.

If the DME is down, and you dont have GPS, I guess it is the 28R ILS or the 28R visual approach.

It's still published. Unless your provider is a commercial operator that operates into KSFO, it won't be in the charts or the database.

Well, yes and no, it is for approved operators only (and approved crews) It will be in your FMS if your airline is approved. As a Special Instrument Approach, it is not 'published' in the public domain. (and now not AC!)

RNAV-Pro...and not even a thank you...jeez

peekay4

28th Jul 2017, 02:21

Concur, why have the FMS Bridge Visual with waypoints in the FMS, and then basket case it to DME? If you dont have GPS, use the Quiet Bridge Visual.
The big reason is to provide an (automated) vertical path / guidance that the FMS can follow, even with older DME/DME based equipment.

At SFO especially -- with other aircraft flying "wingtip to wingtip" to you on a close parallel approach -- it's too easy for pilots busy maintaining visual with other traffic to either fly too low and bust minimums, or conversely stay too high and require high descent rates to get back on path.

With RVFP, the FMS can alleviate much of this workload and improve flight safety.

By the way, technically an RVFP is not considered a special instrument approach (visual approaches are not instrument approaches).

underfire

28th Jul 2017, 11:13

The big reason is to provide an (automated) vertical path / guidance that the FMS can follow, even with older DME/DME based equipment.

FMS Bridge visual is basically an overlay of Quiet Bridge Visual. It was supposed to provide reduced workload to the controller, as the waypoints and stepdowns altitudes are coded into the FMS.

FMS Bridge visual is considered a special procedure, (and it is an instrument approach) which the airline and pilots are required to be approved to use. This has been discussed at length in this thread.

peekay4

28th Jul 2017, 12:02

FAA 8260.55 explains why RVFPs exist and why they are NOT considered (special) instrument approach procedures.

Or you can just re-read my post above. :E

RAT 5

28th Jul 2017, 12:24

The big reason is to provide an (automated) vertical path / guidance that the FMS can follow, even with older DME/DME based equipment.

Not an AirBus guy, so some info please. The statement above would suggest an FMS guided approach. Does that need autopilot in CMD or can it feed into the FD? Is this FMS approach used to give guidance until you intercept a visual centre-line & visual glide path?

What we have not yet heard, and perhaps only the crew will know, is if they were in manual control or autopilot during the initial approach, and at what point they went manual. It is suggested that the FMS gives vertical guidance, but we are shown bright shiny PAPI's and it is a visual approach, certainly from 4nm or so. That would suggest PF would be scanning out of the window and inside to PFD in varying ratios descending below 1500'. I would have thought that from 1200' or so the PAPI would have been the primary vertical guidance aid, and I would have expected PF to be in manual control from that time, at least. Thus I am curious how the PAPI did not alert them to the active runway. The taxiway is a couple of hundred metres laterally displaced from them; and between the only PAPI visible and the taxiway is an equally bright & shiny only 1 set of approach lights. If they were following the PAPI in vertical how come they were following a flight path that would have landed them well into the taxiway, and not, seemingly, abeam the TDZ of the runway? I can't believe AirBus guys use the FMS FD guidance for vertical path below 500'.
So what might they have been using for vertical guidance below 1000' if not the PAPI?

peekay4

28th Jul 2017, 12:57

I can't believe AirBus guys use the FMS FD guidance for vertical path below 500'.

RAT_5 you may be thinking about final approach guidance, but this type of procedure isn't designed for that. Indeed the FMS Bridge procedure is meant to bring you to about <4nm from the runway threshold at 1,200ft.

But the procedure starts at ARCHI which is 25nm out at 8000ft and has many "stair-step" altitude restrictions to remain within the SFO Class B. Due to high workload during parallel approaches, pilots have been known to bust these restrictions (or conversely "dive and drive" often with high descent rates). So this is where RNAV automation can help out.

The entire procedure is still designed to be visual and you have to be clear of clouds throughout. Which means that at night the pilots should have picked up the correct runway environment from a longs ways out.

aterpster

28th Jul 2017, 13:55

FAA 8260.55 explains why RVFPs exist and why they are NOT considered (special) instrument approach procedures.

Or you can just re-read my post above. :E

Absolutely correct. They are not designed in accordance with TERPs, much less any semblance of any nstrument flight procedure (IFP) criteria. Aeronautical Information Services (AIS) that design and publish FAA public SIAPs, SIDs, STARS, and Obstacle Departure Procedures have absolutely no involvement in the development and issuance of FMS database RNAV VISUAL Flight Procedures.

They are "lead carrier" developed. In some cases they provide 3D guidance to the runway at LNAV approach sensitivity (RNP 0.30). In other cases, such as Runway 29 at KEWR, they do not.

My sources tell me that the FAA's Flight Standards Service "tolerates" RVFPs, but they don't like them. They are the product of the major Part 121 carriers and Air Traffic Services.

aterpster

28th Jul 2017, 14:08

Seems like a crew needs a Philadelphia lawyer on the jump seat to interpret/apply the "or" part of the required visibility. And, by which waypoint does the crew have to be VMC?

cappt

28th Jul 2017, 14:10

AIM
5−4−23. Visual Approach
a. A visual approach is conducted on an IFR flight
plan and authorizes a pilot to proceed visually and
clear of clouds to the airport. The pilot must have
either the airport or the preceding identified aircraft
in sight. This approach must be authorized and
controlled by the appropriate air traffic control
facility. Reported weather at the airport must have a
ceiling at or above 1,000 feet and visibility 3 miles or
greater. ATC may authorize this type approach when
it will be operationally beneficial. Visual approaches
are an IFR procedure conducted under IFR in visual
meteorological conditions. Cloud clearance
requirements of 14 CFR Section 91.155 are not
applicable, u

FAA-H-8083
A visual approach is an ATC authorization for an aircraft
on an IFR flight plan to proceed visually to the airport of
intended landing; it is not an IAP. Also, there is no missed
approach segment.

They're an IFR instrument procedure but not technically IAP's.

mixer_1979

28th Jul 2017, 14:35

I think the point RAT5 is making is AC didn't fixate on the wrong runway at 25nm but somewhere in the vicinity of the FAF at 4nm. Yes, the approach is not straight in. But I feel the thread has fixated on the approach where, all else considered, a near straight-in visual from the SE would put them in the exact same spot. Not saying I don't appreciate the discussion between the different visuals. But back to RAT5's point, from 4nm what were they using for vertical guidance to not fly red-over-red. What did they make of the PAPI and the lack of one adjacent to the pavement they almost set down on? Idea for a simple solution: turn off the runway lights (see SQ) leave the PAPI on?

peekay4

28th Jul 2017, 14:53

And, by which waypoint does the crew have to be VMC?
By the time the accept the approach, which may be well before any waypoint. Typically ATC will confirm that the pilot has the airport (or preceding aircraft) in sight before offering a visual approach.

FlightDetent

28th Jul 2017, 15:04

RAT 5

28th Jul 2017, 15:08

So is it perhaps a Jeppesen only thing?

Can that be? A few decades ago, when first starting out in airlines, I'd alway thought Jeppesen had some input into the charts data. I was told they were just publishers of AIP and airfield provided data in their own particular style. All the numbers etc were given to them.
If that is the case it follows that any publisher could have access to FMS Bridge approach with all the numbers. I don't see how it could be a 'Jeppe thing'.

Please correct me if I'm in error.

FlightDetent

28th Jul 2017, 15:41

Jepp and others do provide made-to-order tailored plates if requested. Some, I believe Jepp is one of them have the expertise to even devise the underlying procedure. http://www.asap.sk/about-us/projects-completed-by-asap-sro/united-arab-emirates/

. No trace of the procedure from FAA sources.
. No trace of the procedure from the world-wide database of Jepp's competitor.
. PPRuNe claims that the procedure exists and have Jepps pictures of it.
Where is the tie to these loose ends? Most likely I did miss something.

The FMS DB coding is provided on the same principle, it is a mere representation of data laid-out elsewhere, not a source by itself.

aterpster

28th Jul 2017, 16:11

https://flightaware.com/resources/airport/KSFO/procedures has parsed KSFO charts, FMS Bridge VIS not there.

The charting provider I have access to delivers to several large US airlines operating there, but no trace of FMS BRIDGE. So is it perhaps a Jeppesen only proc?

It was designed by the lead carrier designated by the airlines for the airport. That airline designed the procedure in an FAA design tool called TARGETS. Those data were then given to Jeppesen for both coding the procedure into the airlines' FMS and publishing a chart to be included in all the airlines' tailored subscription.

aterpster

28th Jul 2017, 16:20

By the time the accept the approach, which may be well before any waypoint. Typically ATC will confirm that the pilot has the airport (or preceding aircraft) in sight before offering a visual approach.

For sake of discussion let's say the weather is 3,000 and 10. Would NCT approve the procedure if the crew requested it on initial contact shortly after passing CEDES?

BTW, I checked the geometry.

The true bearing of 28R is 297.815. The true bearing of the 28R ILS is also 297.815. The true bearing from FD101 to 28R is 297.9 in my GIS software. The path angle from FD101D to the lead carrier's AER is exactly 3.0 degrees assuming the same TCH as the 28R ILS.

MarcK

28th Jul 2017, 16:33

FAA 8260.55 explains why RVFPs exist and why they are NOT considered (special) instrument approach procedures.
a. Operator and Pilot.
3) Pilots must request the RVFP on initial contact with the controlling agency, unless previously coordinated.

I missed the part where the pilot requested this approach.

RAT 5

28th Jul 2017, 16:41

No trace of the procedure from FAA sources.

That airline designed the procedure in an FAA design tool called TARGETS. Those data were then given to Jeppesen for both coding the procedure into the airlines' FMS and publishing a chart to be included in all the airlines' tailored subscription.

But surely the procedure would have to be FAA approved?? If it is a locally designed procedure would that limit it to US registered a/c and licensed operators?

Jet Jockey A4

28th Jul 2017, 16:46

A question... Are the centerline green taxi lights always bidirectional or are they at some airports or in some instances unidirectional?

FlightDetent

28th Jul 2017, 16:50

aterpster: that fills all the blanks, thanks. Sorry I missed it from your first posting, the idea that multiple airlines would team up for a shared tailored procedure escaped me. Thus I could not figure out how come it is not public yet at large at the same time.

Zeffy

28th Jul 2017, 17:08

Did the ATC recordings confirm/reveal that every crew cleared for the FMS Bridge visual had previously reported the airport in sight?

peekay4

28th Jul 2017, 17:30

For sake of discussion let's say the weather is 3,000 and 10. Would NCT approve the procedure if the crew requested it on initial contact shortly after passing CEDES?
Typically the crew would be directed to "expect" or "join" the RVFP at a waypoint, but this isn't clearance for the approach.

Then when closer, ATC will confirm if the pilots have the airport environment / landmark / preceding aircraft in sight, before clearing them for the visual approach.

But surely the procedure would have to be FAA approved?? If it is a locally designed procedure would that limit it to US registered a/c and licensed operators?

US RVFPs are FAA approved. As aterpster mentions, one airline (the "Lead Operator") will develop the procedure and work with ATC and FAA get it approved. After approval, other airlines (including Part 129 foreign air carriers) may then request authorization to use the procedure.

After all, Air Canada is a foreign airline. :)

I missed the part where the pilot requested this approach.

"unless previously coordinated."

I.e., if the airline is approved for the approach, then appropriate remarks may be included in the flight plan.

DaveReidUK

28th Jul 2017, 17:33

underfire

28th Jul 2017, 18:04

That airline designed the procedure in an FAA design tool called TARGETS.

mama mia....

the FMS Bridge Visual procedure was designed by a 3rd party in RNAV Pro.

8260.55

The design and implementation of RVFP differ from that of charted visual flight procedures (CVFP) in a number of regards. First, RVFP developed under this guidance are for use only by pilots of aircraft equipped with instrument flight rules (IFR)-approved RNAV systems. Second, these procedures are not “public” in nature, approved via a process similar to that of “special” instrument approach procedures (IAP). RVFP are not “special IAPs” by definition but rather are simply considered “special procedures”.

2) The operator, with the assistance of the regional All Weather Operations (AWO) and the RNAV and RNP Group personnel assigned to the OSG, must assess the capability of the local DME infrastructure to support all segments of the procedure. The operator should use “RNAV-Pro” for this assessment.

We put the final design into TARGETS to use the FAA obastacle data and to generate those damn 8260 forms!

Thus I could not figure out how come it is not public yet at large at the same time.

The FAA did not design the procedure, it is a tailored special.

The Lead operator owns and maintans the procedure, ie pays for its design and maintenence. Would you simply give it to everyone else for free? Same for the RNP AR procedures that have been developed.

b. Approval Process for Other than the Lead Operator.
1) The operator must submit a written request to use an RVFP to the regional AWO, via their POI.
2) The regional AWO will provide the operator and the POI with all applicable procedure documentation.
3) The operator must ensure the required aircraft equipage, operating procedures, and training are in place. The operator must also validate flyability of the procedure in a simulator approved for each make, model and series of aircraft intended for use of the RVFP.
4) Once satisfied with the operator’s aircraft equipage, procedures, and training program, the POI will issue written approval to use the RVFP. Appendix D contains a sample letter of approval for other than a lead operator.
5) The operator should provide the applicable AWO and ATC facility with a copy of the signed letter approving use of the RVFP.

FAA 8260.55 explains why RVFPs exist and why they are NOT considered (special) instrument approach procedures.

Or you can just re-read my post above.

OR you could read what I actually wrote

FMS Bridge visual is considered a special procedure, (and it is an instrument approach) which the airline and pilots are required to be approved to use. This has been discussed at length in this thread.

West Coast

28th Jul 2017, 18:24

Flew it today, still in use. Not requested, rather assigned by SFO ATC, advertised on the ATIS.

fantom

28th Jul 2017, 18:30

Is this still rumours and news or the inevitable PPRuNE endless thread-without-end?

peekay4

28th Jul 2017, 18:49

(and it is an instrument approach)
It is not. You will not find RVFP under 8260.3 TERPS.

peekay4

28th Jul 2017, 18:56

THE MERCURY NEWS
PUBLISHED: July 28, 2017 at 8:00 am

Did brain phenomenon contribute to Air Canada pilot’s close-call at SFO?

SAN FRANCISCO — Could the same brain phenomenon identified as contributing to today’s polarizing political climate have played a role in an Air Canada flight crew coming within seconds of landing on a row of jets awaiting takeoff at SFO? Absolutely, experts say.

The condition, known as confirmation bias, occurs when people accept or seek out evidence that confirms their expectations and ignore or avoid facts that don’t align with their expectations. Just like when a Donald Trump or Hilary Clinton supporter tunes out an opposing viewpoint, or contrary facts.

The same mental blind spot likely impacted the Air Canada flight crew on July 7 when it nearly triggered the worst aviation disaster in history by landing on four fully-loaded planes on the SFO taxiway, says Dr. Andrew Gilbey, a senior lecturer in aviation at Massey University in New Zealand.

Sidebar:
Fisher’s experiment in 1980 for NASA had pilots land on a simulator. During one landing she secretly placed an airplane in the middle of the runway. During one phase of experiment 2 of 8 pilots didn’t see the plane.

[...]

Full article and video: Did mental bias play a role in Air Canada's SFO near-miss? (http://www.mercurynews.com/2017/07/28/was-mental-bias-at-the-controls-of-air-canadas-near-miss-at-sfo/)

RAT 5

28th Jul 2017, 19:41

The Mercury News must be reading Prune?

Airbubba

28th Jul 2017, 20:56

Predictably, the union paints the AC 759 pilots as heroes for doing a go-around when told to do so by the tower

The union doesn't appear to have said that, and indeed the timeline established by the TSB soon after the event indicates that the crew were already going around at the point where ATC issued the GA instruction.

Union spokesman Chris Praught praised the AC 759 pilots thusly:

“It is a testament to the expertise and professionalism of the highly trained crew that they were able to ensure that the flight arrived safely at its destination.”

A somewhat less generous assessment of the crew performance from one of the professional pilots on this thread:

There is no excuse whatsoever for what these two chaps did and they better have preserved the CVR.
We need it to understand how it was possible and prevent other incompetent crew doing the same.
And for now : No more night visuals.
It is rather simple. They could not do the basic task of identify the rwy.
Give me a break.
They were about to possible triple the standing world record of aviation fu..ups.

Sorry for not being all cudely and understanding about this.
There has to be limits.

As for the tower calling the go-around, we'll see, as one news report put it, emphasis mine:

New data obtained exclusively by this news organization add to the picture, showing that the Air Canada plane was just flying over a second fully loaded Philippine Airlines jet at 106 feet in the air — still continuing its descent — when an SFO air traffic controller finally warned him to abort his landing. The Transportation Safety Board of Canada said in its initial report that the Air Canada pilot did not begin his “go-around” until the air traffic controller told the pilot to pull up.

SFO near-miss: Air Canada flew over plane before aborting (http://www.mercurynews.com/2017/07/17/ntsb-air-canada-pilot-actually-flew-over-plane-before-aborting-landing/)

Either way, as I said here earlier:

Whether AC 759 initiated the go around before or after the ATC call, 100 feet AGL is way too low to figure out they were over the taxiway. :=