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

[Airbubba]

Like I said... ;)

[DaveReidUK]

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

Yes, but that quote is just plain wrong.

The TSB's initial report said the opposite, making it clear that the ACA was already climbing and had overflown all 4 aircraft on the ground by the time the controller instructed the GA. If that report has been contradicted by any subsequent update from the TSB, I haven't seen it and there has certainly been no reference to it on here.

See also my previous comments about that graphic that crudely attempts to synchronise the ADS-B plot and the LiveATC recording. FlightAware should know better than to try to do that, though to be fair their analyst does caveat his analysis with "if everything lines up with my data and the timestamp from the audio" (it clearly doesn't).

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.

No argument there.

[peekay4]

Yes, but that quote is just plain wrong.

The TSB's initial report said the opposite, making it clear that the ACA was already climbing and had overflown all 4 aircraft on the ground by the time the controller instructed the GA. If that report has been contradicted by any subsequent update from the TSB, I haven't seen it and there has certainly been no reference to it on here.

You may be confusing TSB's initial report with FAA's. TSB estimated that ACA759 overflew Taxiway C for approximately 0.25 miles when ATC instructed the go around. That's about halfway between Whiskey and November, so at that point ACA759 had not overflown all four aircraft on the ground yet.

It's possible that the go around was already initiated by the time ATC chimed in, but the TSB report doesn't state that.

[aterpster]

there are two, BOTH in the FMS database

Two FMS Visuals to 28R?

[RAT 5]

Two FMS Visuals to 28R?

Children of the magenta line comes to mind with these 2 words in the same sentence.

[peekay4]

Nav providers including Jeppesen will code visual approaches -- in addition to RVFPs -- into the database, when possible. So it would not be surprising to see both FMS Bridge and Quiet Bridge visual procedures in some databases.

(There are visual approaches which cannot be coded into the database due to lack of individual landmarks or waypoints).

[underfire]

SIMO FMS QUIET BRIDGE VISUAL RY 28R AND ILS OR RNAV RY 28L IN USE.
LNDG RWYS 28L, 28R. DEPG RWYS 1L, 1R.

They need to get it together. I have also seen RNAV Bridge visual, I have also seen simply Visual 28R

Per a question on previous post, RWY 28L is at 284 and RWY 28R is at 281(per the RNP plates)

[West Coast]

Only one FMS bridge visual in my database. You'd have to build the quiet bridge visual yourself.

[underfire]

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

ummmm...try flying the FMS Bridge visual without DME/DME/IRU or GPS.
First, RVFP developed under this guidance are for use only by pilots of aircraft equipped with Instrument Flight Rules (IFR)‑approved RNAV systems.

[peekay4]

That doesn't make it an instrument approach.

If FMS Bridge is an instrument approach, tell us:

What are the approach minimums?
Where's the initial approach fix? Final approach fix? Missed approach point?
Why must pilots confirm visual sighting of the airport environment / preceding traffic?
Why must the the aircraft remain clear of clouds?
Per 8260.55, why is the procedure only authorized in VMC?
Per 8260.55, why may ATC offer RVFPs only when visual approaches are in use?

And again, why is it not in 8260.3, the standard for all instrument approach procedures?

aterpster gave some good insight earlier on why RVFPs are the way they are and how FAA AFS feels about them.

[porterhouse]

Wrong Mr. peekay4

CVFP (Charted Visual Flight Procedure) are considered instrument approaches per FAA rules. This is the relevant FAA document which states:

Despite the fact that both types of Visual Approaches are conducted in VMC, they are considered IFR procedures. As such, the pilot must comply with all applicable IFR rules when conducting them. ....... CVFPs differ from
normal Visual Approaches in that they require a pilot to have a charted landmark, rather than the airport, in sight (AIM 5-4-22/23).

https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2011/InFO11003.pdf

[peekay4]

Yes are conducted under IFR, but they are not instrument approach procedures, they are visual approach procedures.

Hence, the name. :)

From AIM:

"e. A visual approach is not an IAP and therefore has no missed approach segment."

(although they can have standard missed approach instructions)

Anyway between 8260.55 and 8260.3 it's pretty clear already.

[West Coast]

AIM isn't a definitive document. I'll stick with FAA 82XX orders for differentiating between and Instrument approach, a RVFP and otherwise.

[underfire]

http://avherald.com/img/afr_a320_f-hepe_tel_aviv_120403_1.jpg

[peekay4]

I don't know what the point is. You can't compare RVFPs from different countries.

In fact one of the primary objections against RVFPs is exactly that they are completely non-standardized between countries, which can create a lot of confusion. Hence IFALPA, etc., recommend pilots do not fly RVFPs and I know some within CAAs would like to seem them go away. (On the flip side, orgs like NBAA want to see them expanded.)

Anyway, time for me to move on from this silly topic.

[porterhouse]

I don't know what the point is.
The point is that stay away from FAA terminology/definitions if you know little on the subject. Maybe it is time to leave this 'silly' topic behind however it was you who started this silliness.

[galaxy flyer]

The approach in question is NOT a standard approach, it's a SPECIAL.

GF

[cappt]

there are two, BOTH in the FMS database

Just one, the RNV28R in our FMS.

[aterpster]

Wrong Mr. peekay4

CVFP (Charted Visual Flight Procedure) are considered instrument approaches per FAA rules. This is the relevant FAA document which states:

Despite the fact that both types of Visual Approaches are conducted in VMC, they are considered IFR procedures. As such, the pilot must comply with all applicable IFR rules when conducting them. ....... CVFPs differ from
normal Visual Approaches in that they require a pilot to have a charted landmark, rather than the airport, in sight (AIM 5-4-22/23).

"IFR Procedure" does not equate to IFR approach. Note the highlighted language in the attached. There are no standard instrument approach procedure (SIAP, FAR 97) criteria for charted visual procedures nor for FMS RVFPs.

[underfire]

My god I hope that ends this madness.

(although it was AC that provided all of the entertainment) Peekay, do you work for AC?

[rog747]

not sure why there seems so much confusion over whether ATC called for GA first or not

in the play back of the ATC tape the United flight on taxiway C end waiting for his take off clearly calls (at 15.5 seconds after AC759 queries some lights on 'his runaway') ''wheres this guy goin'' then 3.5 seconds later United calls again ''he's on the taxiway''
(this is now about 20 seconds after AC759 first questions the lights he sees ahead)

then 4.5 seconds later ATC calls for AC759 to go around,
and AC759 immediately replies (now 29 seconds after his first query of lights ahead) ''IN the go around'' - the word IN and his tone implying I am already doing this (supposition on my part)


that implies to me he was already overshooting - if he was not already then I think he would have hit the aircraft waiting - that's my tuppence and I heard that the first day of the released tape which is on Page one of this thread.

in the 29 seconds of tape recording (and 29 seconds seems quite a long time to me) from AC759 first query of lights ahead to him calling 'in the go around'

how far do you fly and descend in that time ?

[RAT 5]

Just to drift away from the circular discusssion a little, I wonder what was the effect on those a/c, waiting innocently on the taxiway, of the thrust pouring out of the rear end of rapid full umph GA. I'd expect 'storm force a lot' buffeting those beasts, and scaring the poo out of the pax who could see & hear nothing. Well, up to that point anyway. I guess they heard it. If they did get a ground based ride in a washing machine I wonder what the capatins said by way of explanation.

[underfire]

Rat 5,

That is a very good point, United looked to be about 45 to the flightpath, so the pax got a real good view, the other acs, especially #2, had a very, very good view of an ac less than 50 feet above them, heading to the windscreen...damn, that must have been quite the experience.
Funny how it is always the lowest common denominator that exposes the weaknesses in a system.

Many discussions in the ATM circles on this with the move to automation of towers and remote towers. Especially how worthless ADSB is on final.

[aterpster]

Looks good in Aviation Leak (Week). As you suggest, not nearly ready for prime time.

We (as in the U.S.) haven't really solved the problem of a 737 landing atop a commuter carrier at LAX, or, for that matter, assuring the runway is clear at an LAX when I am making a CAT III autoland in RVR 600 conditions.

[underfire]

I have been looking at multiple 'tower' setups from different suppliers in the last few days, I just wonder how this has gotten so much traction, while some of the basics have lanquished.
ADSB mandate is going to be delayed yet again in the US, so while that is not really a viable method of tracking in the terminal environment, there is no other solution being looked at.

[BluSdUp]

Hi All.
Been away , doing some semi longhaul with fuelstop and a 180. Been without my prune code and just taken in all the latest ANTSB analysis . ( A= armchair).
Also did the sim and reviewed the different GPS based approaches we can and can not do.

Considering some companies do not let you do a visual at night and in some country it is prohibited, I think it is fair to propose that if a visual is executed, the ILS must be tuned idented and briefed.I dont much care how that is done in a stoneage non GPS A320, just do it!


So for the 4 time from me, to avoid making the biggest airline accident EVER:
A KISS at night, Eh!
The last S beeing the most important!

[Ian W]

Looks good in Aviation Leak (Week). As you suggest, not nearly ready for prime time.

We (as in the U.S.) haven't really solved the problem of a 737 landing atop a commuter carrier at LAX, or, for that matter, assuring the runway is clear at an LAX when I am making a CAT III autoland in RVR 600 conditions.

On the contrary, the problem has been solved in different ways several times. I have worked with one that was a distributed radar systems that could show and track individual pedestrians and the display was set up like a full airport simulator allowing the ground controller to zoom a point of presence anywhere on the airport and aircraft and vehicles were shown as 3D models of the aircraft/vehicle being picked up and tracked by the radar.
But as it would never happen that an aircraft could land on an occupied runway or taxiway :rolleyes: - it wasn't seen as something necessary :ugh: . Out of some of that research came Aerobahn by SAAB/SENSIS

Aerobahn Now Available for iPad and Android Tablets (http://www.prnewswire.com/news-releases/aerobahn-now-available-for-ipad-and-android-tablets-169160186.html)

[underfire]

Ian, how can you say that the problem has been solved, when you also say that it was not necessary to include provisions for tracking the ac to prevent landing on the taxiway? The information provided by the FAA's Surface Movement Event Service showed the ac was lined up with the taxiway, along with the altitudes, yet this system provided no alert, nor did the systems it feeds data to, ASDEX or in this case, ASSC? How can one provide runway conflict warning when incoming ac are not tracked?

Care to guess who provides these systems? (and the one at SFO?)
U.S. Federal Aviation Administration selects Saab Sensis for Airport Surface Surveillance Capability Program (http://saabgroup.com/sv/Media/news-press/news/2012-01/US-Federal-Aviation-Administration-selects-Saab-Sensis-for-Airport-Surface-Surveillance-Capability-Program/)

The Saab/Sensis system does not appear to have provisions for tracking which runway or taxiway the ac is landing, and alert/prevent. As far as I can tell, the Sensis system is really for ground ops, not a combination. How can one provide runway conflict warning when incoming ac are not tracked?


The system at SFO was supposed to be tracking inbound ac to 5nm with option for 20nm, yet it failed to alert the controller. For all we know, the ac could have been lined up on 28L instead of the taxi, what is, or even, is there an alert algorithm?

It was the prototype, and is supposed to be deployed at other airports in the US. Again, it is good that we had a lowest common denominator (airline with history of landing on taxiways) test of the system so that it is fixed and not deployed throughout the network.

It is interesting because NAVCANADA has an ATM ground track management system for tower ops that does track inbound aircraft when the threshold is obscured from tower.

[peekay4]

NTSB Issues Investigative Update on San Francisco Airport Near Miss

Summary of new / confirmed details:


The National Transportation Safety Board (NTSB) was notified of the incident on Sunday, July 9 [two days after the incident]
The NTSB investigator-in-charge has formed the following groups: Air Traffic Control (ATC), Operational Factors, Human Performance, Airports, and Flight Data Recorders (FDR)
The incident airplane’s cockpit voice recorder had been overwritten, so NTSB investigators did not have that data.
The captain was the pilot flying ACA759, and the first officer was the pilot monitoring. Both pilots held Canadian airline transport pilot certificates.
The captain had over 20,000 total flight hours, of which about 4,797 hours were as captain in Airbus A320‑series airplanes. The first officer had about 10,000 total flight hours, of which over 2,300 hours were in Airbus A320-series airplanes.
At 2349 PDT (7 minutes before the incident), all positions in the ATC tower (controller-in-charge local control, local control assist, ground control, flight data, and clearance delivery) were combined at the local control position.
As ACA759 approached SFO, at 2355:52 PDT, the airplane flew too far right of course to be observed by the local controller’s ASDE-X/ASSC and was not visible on the ASDE-X/ASSC display for about 12 seconds.
At 2355:56 PDT, when ACA759 was about 0.3 mile from the landing threshold, the local controller confirmed and recleared ACA759 to land on runway 28R.
The flight crew of the first airplane in queue on taxiway C (UAL1) transmitted statements regarding ACA759, one of which mentioned the alignment of ACA759 with the taxiway while ACA759 was on short final (see figures 2 and 3). The flight crew of the second airplane in queue on taxiway C switched on their airplane’s landing lights as the incident airplane approached.
The incident pilots advanced the thrust levers when the airplane was about 85 ft agl. FDR data indicate that the airplane was over the taxiway at this time, approaching the vicinity of taxiway W.
At 2356:04 PDT, ACA759 reappeared on the local controller’s ASDE-X/ASSC display as it passed over the first airplane positioned on taxiway C.
About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.
At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point
In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.


https://ntsb.gov/investigations/PublishingImages/dca17ia148-fig3.jpg
NTSB narrative: Figure 3 shows UAL1’s transmission at 2356:04 and ACA759’s position as it overflies the first airplane waiting on the taxiway; note that the second airplane has turned on its landing lights.

Links:
https://www.ntsb.gov/news/press-releases/Pages/pr20170802.aspx
https://ntsb.gov/investigations/Pages/DCA17IA148.aspx
NTSB finds 'blind spot' in SFO radar after Air Canada event (http://www.mercurynews.com/2017/08/02/ntsb-finds-blind-spot-in-sfo-radar-following-air-canada-near-disaster/)

[underfire]

As ACA759 approached SFO, at 2355:52 PDT, the airplane flew too far right of course to be observed by the local controller’s ASDE-X/ASSC and was not visible on the ASDE-X/ASSC display for about 12 seconds.
As stated before, they could have been trying to land on 28L and the system would not have known, or it appears alerts to the issue.

[/I]The incident pilots advanced the thrust levers when the airplane was about 85 ft agl. FDR data indicate that the airplane was over the taxiway at this time, approaching the vicinity of taxiway W.[/I]
What time were the levers advanced?

[/I]At 2356:04 PDT, ACA759 reappeared on the local controller’s ASDE-X/ASSC display as it passed over the first airplane positioned on taxiway C.[/I]
Because now you have an aircraft on the taxiway so the system finds it?!?!?

[/I]About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.[/I]
Again, a time is missing... 26 feet momentary descent! PAL was an A343 with a tail height of 56 feet...

3 feet from disaster?

So much for the afterglow...

[BluSdUp]

The CVR is overwritten and the crew can not recall overflying 4 aircraft!
WOW!

[Ian W]

Ian, how can you say that the problem has been solved, when you also say that it was not necessary to include provisions for tracking the ac to prevent landing on the taxiway? The information provided by the FAA's Surface Movement Event Service showed the ac was lined up with the taxiway, along with the altitudes, yet this system provided no alert, nor did the systems it feeds data to, ASDEX or in this case, ASSC? How can one provide runway conflict warning when incoming ac are not tracked?

Care to guess who provides these systems? (and the one at SFO?)
U.S. Federal Aviation Administration selects Saab Sensis for Airport Surface Surveillance Capability Program (http://saabgroup.com/sv/Media/news-press/news/2012-01/US-Federal-Aviation-Administration-selects-Saab-Sensis-for-Airport-Surface-Surveillance-Capability-Program/)

The Saab/Sensis system does not appear to have provisions for tracking which runway or taxiway the ac is landing, and alert/prevent. As far as I can tell, the Sensis system is really for ground ops, not a combination. How can one provide runway conflict warning when incoming ac are not tracked?


The system at SFO was supposed to be tracking inbound ac to 5nm with option for 20nm, yet it failed to alert the controller. For all we know, the ac could have been lined up on 28L instead of the taxi, what is, or even, is there an alert algorithm?

It was the prototype, and is supposed to be deployed at other airports in the US. Again, it is good that we had a lowest common denominator (airline with history of landing on taxiways) test of the system so that it is fixed and not deployed throughout the network.

It is interesting because NAVCANADA has an ATM ground track management system for tower ops that does track inbound aircraft when the threshold is obscured from tower.

The problem - tracking aircraft, on the ground and close in on approach to identify which runway (taxiway) they were lined up for etc., has been solved it can be done and it has been demonstrated several times with live aircraft on a live airport. Nevertheless, the people who decide what goes operational thought that this was not a problem that needed a solution - even though it would have been ideal for so called virtual control towers. A version without some sensors and with different plan view displays rather than 3D virtual reality was what went ahead. So technically solutions are available and probably significantly cheaper than the cost of a crash into a line of widebodies - the problem is with bean counting. You persuade the beancounters and the system could be rolled out.

[momo95]

How is it that only UAL 1 said anything? There's some fair distance between them and the PAL A340 ... surely they too must have noticed something amiss? I mean a massive jet heading directly at you is not what you expect waiting on a taxiway!

[Smott999]

Do we know if CVR recovery is possible? Or being attempted?

[DaveReidUK]

At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point

At least that finally settles the debate about which came first: the crew's decision to go around or the controller's instruction to do so.

[Jet Jockey A4]

@ DaveReidUK...

Does it matter if the pilots applied power for the go around first or that the tower told them to go around afterwards?

In the grand scheme of things it doesn't really matter because they were going to land on Taxiway C if it wasn't for the actions of UAL 1's and PAL 115...

To me this statement is the most important clue as to why a major accident was avoided...

"The flight crew of the first airplane in queue on taxiway C (UAL1) transmitted statements regarding ACA759, one of which mentioned the alignment of ACA759 with the taxiway while ACA759 was on short final (see figures 2 and 3). The flight crew of the second airplane in queue (PAL 115) on taxiway C switched on their airplane’s landing lights as the incident airplane approached."

Without the actions of both these aircrafts, especially PAL 115's landing lights being turned on, it's almost 100% sure that AC759 would have landed on Taxiway C and collided with PAL 115 and perhaps the other 2 aircrafts following it on the taxiway.

The experience level of both pilots is high enough to conclude inexperience is not a factor... I would really like to know what was the major factor that created this incident in the first place... Unbelievable.

[aterpster]

Do we know if CVR recovery is possible? Or being attempted?

CVRs are intended for accident investigation, usually when there is a hull loss.

In this case, the crew is alive and well and probably subject to "endless" interrogation. And, the FDR is obviously intact. And, all the data from many points on the airport are intact.

The UAL captain was undoubtedly interviewed.

[Jet Jockey A4]

It's possible that English Language Fluency played a role that night at SFO. The AC759 crew were fully fluent in english, and as such were able to both understand and act immediately to UA01's radio transmission. What if the crew had not been fluent in english? What if this had been a foreign (no disrespect, simply a fact considering the numbers of asian airliners flying into SFO) airliner flown by foreign pilots that were NOT FLUENT IN ENGLISH? Keeping all other approach factors the same as AC759's were that night, the delay in understanding, by even a few seconds, the importance of what UA01 had said over the radio and acting on the information might very well have resulted in a Tenerifesque collision.

Personally I believe the UAL 1 call to tower was perhaps at best a first wake up call to the AC crew but they still continued in their landing phase past UAL 1 because go around trust was only applies at 85 feet AGL (past UAL 1).

What I believe saved the day was PAL 115 turning on their landing lights. They must have been scared sh!less at the approaching aircraft!

[Jet Jockey A4]

CVRs are intended for accident investigation, usually when there is a hull loss.

In this case, the crew is alive and well and probably subject to "endless" interrogation. And, the FDR is obviously intact. And, all the data from many points on the airport are intact.

The UAL captain was undoubtedly interviewed.

I'm sure they interviewed the PAL 115 crew too... They had the best view in the house!

[underfire]

In the grand scheme of things it doesn't really matter because they were going to land on Taxiway C if it wasn't for the actions of UAL 1's and PAL 115...

it notes they moved throttles forward at taxiway W. not beginning the climb for 2.5 seconds (until after PAL...)

Yes, certainly seems UAL 1 woke them up. In the image, not only does PAL have landing lights on, so does the next ac inline.

That is a very frightening read.

[Airbubba]

Yes, certainly seems UAL 1 woke them up. In the image, not only does PAL have landing lights on, so does the next ac inline

And, some pilot stuff, those may be taxi lights on one or both of the planes in line, not the much brighter landing lights. Also, does the last aircraft in line have the logo lights off perhaps?

Either way, it is customary to have those taxi and landing lights off while you are parked with the brakes set waiting in the queue for a night departure. The taxi lights would normally be on while the aircraft is moving, back off when you stop. Also, if there is an aircraft on short final, most folks turn off the taxi lights even if moving to avoid blinding the landing crew. Until it looks like they are landing on top of you that is. :eek:

The CVR is overwritten and the crew can not recall overflying 4 aircraft!
WOW!

Yep, act surprised. ;)

As we discussed earlier here:

My guess is that after midnight Friday evening you're not going to have a lot of feds in the SFO office even if a report was immediately filed. The tower probably filled out an incident report but it may not have been seen until Monday morning when the media started calling about reports of the incident based on radio transmissions monitored by 'ham radio operators'. [looks like the NTSB was actually notified on Sunday, but after the AC 759 crew was long gone - Airbubba]

United 1 may have typed up a report on the way to SIN and filed it with the company but I would be surprised if it got much attention outside the airline over the weekend.

The Air Canada 759 pilots may have called ops, grounded themselves, fessed up to a near horrific mishap and waited to be deadheaded back to base on another carrier. Or, they may have filled out a couple of CYA safety reports and operated back to YYZ over the weekend before anyone noticed.

The AC crew probably has a policy to pull the Cockpit Voice Recorder circuit breaker and make a logbook entry for maintenance to remove the CVR after a 'reportable' incident. Did they? I wouldn't be surprised if they 'forgot' to do this based on some other incidents of this type.

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

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. ;)

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.

[Ambient Sheep]

https://ntsb.gov/investigations/PublishingImages/dca17ia148-fig3.jpg


Wow!

Good job this was all just "breathless nonsense" and "certainly wasn't anything close to a disaster", isn't it?

[rog747]

At least that finally settles the debate about which came first: the crew's decision to go around or the controller's instruction to do so.

Dave - indeed but IMHO
if anyone had listened to the ATC tape on page 1 of this thread and read that of my post just above on this matter I personally had no doubt from the tape that AC759 was already IN the go around when ATC called for him to do it - so most fortunate for all that the AC crew realised they were in the wrong place eventually and got out of there (just)

one may read my post here
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-27.html#post9849003

Rog

[DaveReidUK]

Dave - indeed but IMHO
if anyone had listened to the ATC tape on page 1 of this thread and read that of my post just above on this matter I personally had no doubt from the tape that AC759 was already IN the go around when ATC called for him to do it - so most fortunate for all that the AC crew realised they were in the wrong place eventually and got out of there (just)

one may read my post here
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-27.html#post9849003

Rog

Quite so, as indeed I said three weeks ago:

it's clear that the GA was instigated by the pilot before the ATC instruction was given. That's consistent with the ATC recording:

SFO Tower: "Air Canada, go around."

ACA759: "In the go around. Air Canada 759."

[rog747]

Quite so, as indeed I said three weeks ago:

actually i think i do recall reading your post and thought someone else was on the same page as me (and probably the NTSB were as well)

the AC759 pilots' tone implied to me 'We are on it' and 'we are already IN the GA'

any investigator should pick that up and pick it to pieces for clarification

[GMC1500]

when this first happened, some of my ac friends on fb clearly thought this was being overblown by the media. clearly it was not. This was way too close, somebody needs to figure out why.

[underfire]

The pilot may have been in the GA, but not by much, as the GA did not begin until after the ac passed UAL 1.

Time to use radio while missing parked ac by 3 feet.....

actually, this is different from other events as the press has not rooted out every passenger to detail their harrowing near death experience.

[BluSdUp]

It is a shame the CVR can not be recovered as it is essential to understand what happened.
The crew has conveniently developed amnesia.
Thinking that 28L was still active when it was on the NOTAM and ATIS Q is to lame.
Not noticing ANY aircraft on the taxiway after passing Uniteds wopping big tail litt with logolight broadside AND the second aircraft suddenly lighting up their aiming point for touchdown , and then claim they saw no aircraft.
That is called selective memory , at best!

Another detail:
There was only one TWR controller, as per procedure. Did he let ground and Clerance Delivery still operate on Ground and then switch you to TWR frequency only when holding short of 28R? One man two frequencies.
This is done some places to avoid congestion on frequency . Is this the case here. That would explain why the second aircraft did not scream blue murder on the frequency. ( Mind you the report would have mentioned if he did call out on ground frqz I suppose )

I suspect had he not put on the landing lights, he would have been dead.
If on Twr , why did he not call out?

Situational awareness is the key , perhaps?
One to land , you are nr two holding short. Relax a bit, all is 100% safe!
To process and comprehend the unlikely picture that someone is about to land on you on your taxiway needs a bit of time and reality checks.
Especially if they did not pay attention to AC last query.

If they just clued in when United piped up and then froze in his landinglights and decided to return the favor and light up their own , then man. was it close.

Funny thing AC pilots claim they did not see this.

Again, we are going to learn a lot from this, I shure have so fare, but it would be great to have the CVR to confirm how it came so close with such an experienced crew.

[underfire]

In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.


Much more detail here in the NTSB link: https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx

[RobertS975]

It is commonplace for the pilots in aircraft lined up for takeoff on a taxiway parallel to the active runway to douse their landing lights to reduce glare for the oncoming landing aircraft. Fortunately, that did not seem to be the case here, or did crews on the taxiway sense what was happening and then turn on landing lights?

[roybert]

I'm sure they interviewed the PAL 115 crew too... They had the best view in the house!



Jet Jockey


Not sure watching an aircraft trying to land where your parked is the Best View in my books

[feueraxt]

It is commonplace for the pilots in aircraft lined up for takeoff on a taxiway parallel to the active runway to douse their landing lights to reduce glare for the oncoming landing aircraft. Fortunately, that did not seem to be the case here, or did crews on the taxiway sense what was happening and then turn on landing lights?

From the NTSB update linked by underfire:

The flight crew of the first airplane in queue on taxiway C (UAL1) transmitted statements regarding ACA759, one of which mentioned the alignment of ACA759 with the taxiway while ACA759 was on short final (see figures 2 and 3). The flight crew of the second airplane in queue on taxiway C switched on their airplane’s landing lights as the incident airplane approached.

[Jet Jockey A4]

Jet Jockey


Not sure watching an aircraft trying to land where your parked is the Best View in my books

Well, I do hope you realize I was being extremely sarcastic in my comment.

[Jet Jockey A4]

From the NTSB update linked by underfire:

Quote:
The flight crew of the first airplane in queue on taxiway C (UAL1) transmitted statements regarding ACA759, one of which mentioned the alignment of ACA759 with the taxiway while ACA759 was on short final (see figures 2 and 3). The flight crew of the second airplane in queue on taxiway C switched on their airplane’s landing lights as the incident airplane approached.


Exactly... PAL 115 most likely by their action saved the day.

[rog747]

re CVR lost: has crew conveniently developed amnesia.?

well no, but this whole incident (very serious as it was, almost a Tenerife x 2) I reckon will see findings to be mainly down to Circadian low effects and v.v time zones rosters commuting etc etc (IF we are ever told and shared this info)
This is causing fatigue, mind fixations, - ie: I'M VERY TIRED

maybe the CVR was wiped or simply got forgotten to be saved as implied by my above comment(s)

just my 2p

[deSitter]

Why didn't the first two planes bail off the taxiway? I can't imagine I'd just sit there and let someone land on my nose. What are your driver's instincts here? When Bob Bragg's captain saw KLM he firewalled it sideways and saved at least some of his passengers' lives. That no one even seemed to get excited, much less take some action, is as strange as the errant line-up.

-drl

[rog747]

Why didn't the first two planes bail off the taxiway? I can't imagine I'd just sit there and let someone land on my nose. What are your driver's instincts here? When Bob Bragg's captain saw KLM he firewalled it sideways and saved at least some of his passengers' lives. That no one even seemed to get excited, much less take some action, is as strange as the errant line-up.

-drl

the front a/c United was angled holding at about 30-40 degrees ready to line up to take off (not facing AC 759 straight on) - his tail was in jeopardy to be hit but not the rest of him by the look of the photos

the 2nd a/c was PAL an A340 who was actually the first a/c to be head on to him (AC759) and frankly in the few seconds he had where would he have gone? the sea was on one side and the live runway the other?
it seem PAL did have his landing lights on so that's all he could do maybe - ghastly scenario avoided by a few seconds and feet

the United guy at the holding point certainly needs to be bought a few beers for speaking up (twice) his voice was quite excited BTW
listen to the recordings

[Jet Jockey A4]

re CVR lost: has crew conveniently developed amnesia.?

well no, but this whole incident (very serious as it was, almost a Tenerife x 2) I reckon will see findings to be mainly down to Circadian low effects and v.v time zones rosters commuting etc etc (IF we are ever told and shared this info)
This is causing fatigue, mind fixations, - ie: I'M VERY TIRED

maybe the CVR was wiped or simply got forgotten to be saved as implied by my above comment(s)

just my 2p

Fatigue and/or Circadian effect is perhaps the only logical explanation for this near disaster.

I'm sure the authorities will look into this when writing their report.

[aterpster]

In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.


Much more detail here in the NTSB link: https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx

The NTSB is treating it like an accident. The lack of the CVR is not going to let the crew have a pass; not even close.

[rog747]

Fatigue and/or Circadian effect is perhaps the only logical explanation for this near disaster.

I'm sure the authorities will look into this when writing their report.

I am almost certain JJA4 -
I'm not a safety ''expert'' but since commencing my career in civil aviation in 1971 all air safety its causes and findings immensely interest and fascinate me and I made it part of my work - I worked for BMA and knew the Kegworth skipper well.

and perhaps I had a lean towards investigative work who knows.....
hey ho but i was no good at maths or physics for a degree lol

[deSitter]

Nice sim - gulp

https://www.youtube.com/watch?v=ydUqfhNqUIc

[hitchens97]

*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.

Huh? This looks pretty damn close to a disaster.

[galaxy flyer]

Adoption of Forward Looking IR (Enhanced Flight Visibility Systems, EFVS in FAA speak) and Synthetic Vision Systems (SVS) would go a long way to eliminating night visual problems. The EFVS view, especially in a HUD, would have shown the line up planes as four large signatures and the lighting clearer, assuming it hadn't been converted to LED. The SVS would have shown the runway off line-up to the left in a daylight view and the taxiway in front of them. SVS is good enough to show you taxiing across a runway and the view on the PFD or MFD is identical to the outside view.

[DaveReidUK]

The NTSB is treating it like an accident.

Per Annex 13, it will be categorised as a Serious Incident: "An incident involving circumstances indicating that there was a high probability of an accident ..."

Annex 13 goes on to explain, rather chillingly, that "The difference between an accident and a serious incident lies only in the result".

[underfire]

Adoption of Forward Looking IR (Enhanced Flight Visibility Systems, EFVS in FAA speak) and Synthetic Vision Systems (SVS) would go a long way to eliminating night visual problems.
The damn AC aircraft likely did not even have GPS.....

Annex 13 goes on to explain, rather chillingly, that "The difference between an accident and a serious incident lies only in the result".

If what the report states is true, that the AC drivers did not even recognize the taxiway was full, that implies they did not see the landing lights, nor hear UAL 1. (or are not telling the truth) There is enough intent in their statement alone, (forget the lack of CVR data) to prevent those 2 from rotating again.

Time to stop making excuses for the airline, the ac, and the crew. Let DHS get the true story out of them.

[Jet Jockey A4]

The damn AC aircraft likley did not even have GPS.....

The 320 in question did not have GPS but is that really an excuse for a VFR approach at night under good visual conditions?

Besides that, not having GPS, the FMS would have used DME/DME for updating which is extremely precise enough to get you to the threshold of a runway.


If what the report states, that the AC drivers did not even recognize the taxiway was full, there is enough intent in that statement alone to prevent those 2 from doing that again.

I totally agree...

What bothers me is the fact they allowed the CVR to be over written perhaps purposely to cover their mistake(s).

Then in there statement to the NTSB they claim they never saw any aircrafts on taxiway C, so why did the initiate a "GO Around" at 85 feet AGL if they absolutely thought they were landing on RWY 28R?

Sounds to me like they are covering up, in other words lying about the whole incident, if so they should to be fired.

[galaxy flyer]

Does AC have the authority to use the special "FMS RNAV Quiet Bridge" procedure? I've not seen anyone post that bit of info--maybe they don't.

[Jet Jockey A4]

Maybe I am wrong but I believe that is not the approach they were cleared for.

[underfire]

Yes, it is clear in the audio, requested and cleared for FMS Bridge Visual. Some call it FMS Bridge visual, others call it RNAV bridge visual , some call it simply 28R visual in the ATC tape. Pretty loose given there is a Quiet Bridge Visual and Tipp Toe visual to 28R.

They would have to have DME/DME/IRU in lieu of GPS. They would have had to have it in the FMS to be approved to use it. Both the airline AND the crew have to be apprved. It is commonly used, so it is likely they were approved.

The 320 in question did not have GPS but is that really an excuse for a VFR approach at night under good visual conditions?
The response was to someone suggesting that Heads Up would be in order, hence my response that the ac does not appear to have GPS, so it is unlikely the airline would have the wherewithall to provide HU capabilites.

[Airbubba]

Does AC have the authority to use the special "FMS RNAV Quiet Bridge" procedure? I've not seen anyone post that bit of info--maybe they don't.

Maybe I am wrong but I believe that is not the approach they were cleared for.

I agree, that was not the correct name for the approach AC 759 was given. The mixed up name on the D-ATIS doesn't help matters in my opinion. Perhaps the Quiet Bridge Visual and FMS Bridge Visual approaches were verbalized correctly on the voice version of the ATIS.

From an earlier post:

You can hear AC 759 cleared for the FMS Bridge Visual [to 28R] 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

This link will time out soon when it hits the 30-day mark so download the clip from liveatc.net if you think you might want to review it later.

[WillowRun 6-3]

Quote: various posters subsequent to the NTSB information release yesterday, professing various conclusions about crew acts or omissions, and consequences, relative to sanctions, and system component reforms, and even ... causation.
Forum 11th Commandment: Must Have investigation report and those odd, pesky things, known as facts.
There is just too much left to be uncovered by the investigation process, and then still too much needing to be done to integrate the various and several factual elements into a coherent whole picture of the incident, before many of the assertions being made here would be justified and warranted. True, compared to investigations a couple of decades or so ago, places like this forum provide lots of access to relevant information - all the more so with all the tech gizmos which can show position, time-stamp, and more. But the thread is not the investigation. And before ya'all throw FCOM books at me, just think for a minute: once the facts are indeed known and integrated into a coherent whole picture of the incident, there will be plenty, plenty of time and opportunity to discuss probably dozens of system and subsystem reforms and changes. Wasn't the point, or one of the points, of poster Ian W.'s tutorial on attentional tunneling, a/k/a target fixation, that this could happen to anyone manning the flight controls? But let's hang the crew on suppositions here, heck, it's just the internet.

[peekay4]

Agreed 100% WillowRun 6-3.

Also, we know that post-incident/accident statements are often very inaccurate -- not necessarily because anyone is lying but due to natural characteristics of human memory. Hence the lack of the CVR recording in this case is a big loss for the safety investigators.

Perhaps it's time to mandate the 25-hr CVR rule worldwide.

[Airbubba]

Yes, it is clear in the audio, requested and cleared for FMS Bridge Visual.

Again, I don't believe AC 759 ever 'requested' this approach. They were advised to expect it on the ATIS, told to join it by a NORCAL controller and later cleared for the approach by another controller. At least that's what I get off the LiveAtc.net tapes.

Can you provide a cite that says otherwise?

Your earlier post claiming planes were 'requesting' the FMS Bridge Visual 28R from the tower controller is total nonsense in my opinion:

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.

[deSitter]

Quote: various posters subsequent to the NTSB information release yesterday, professing various conclusions about crew acts or omissions, and consequences, relative to sanctions, and system component reforms, and even ... causation.
Forum 11th Commandment: Must Have investigation report and those odd, pesky things, known as facts.
There is just too much left to be uncovered by the investigation process, and then still too much needing to be done to integrate the various and several factual elements into a coherent whole picture of the incident, before many of the assertions being made here would be justified and warranted. True, compared to investigations a couple of decades or so ago, places like this forum provide lots of access to relevant information - all the more so with all the tech gizmos which can show position, time-stamp, and more. But the thread is not the investigation. And before ya'all throw FCOM books at me, just think for a minute: once the facts are indeed known and integrated into a coherent whole picture of the incident, there will be plenty, plenty of time and opportunity to discuss probably dozens of system and subsystem reforms and changes. Wasn't the point, or one of the points, of poster Ian W.'s tutorial on attentional tunneling, a/k/a target fixation, that this could happen to anyone manning the flight controls? But let's hang the crew on suppositions here, heck, it's just the internet.

As an outsider with some knowledge of aviation this real issue is possibly clearer to me than to those closer to things. The AC pilots are surely fine pilots and representative of their profession. The guys in the waiting planes, likewise. But literally everyone was asleep here. The entire system nodded off. Why?

Routine. There is so little freedom of action, and the the long day is so overgrown with necessary actions performed almost as an automaton would, that given a certain hour of the day, condition of lighting, etc. the truth can hide in plain sight. That can't be a plane coming at me - planes don't line up on taxiways! They are for taxiing! And those runway lights sure look strange - shrug. Can't wait to get down and get some sleep.

So much of the visual stimulus at night is hard to make out, even if colored like a Christmas tree. It must seem a wash of pretty lights sometimes, moving with hypnotic slowness. Every pattern has a significance, but maybe there are too many of them to keep immediately in mind because you are tired or just bored after a long day being a part of the machine. There are numerous cases of "how on Earth did they not hear that alarm? Why didn't they set the flaps? How can you mistake a frequency for an altitude?"

I don't know what you can do other than to make life more interesting for pilots so that they remain engaged. Let them - no require them - to do some hand flying. That's a start.

[underfire]

Again, I don't believe AC 759 ever 'requested' this approach.

jeeezus...listen to the tape...they requested clearance to land for that approach...correct, just like all of the others on the tape...what, you want me to type out requests clearance to land for each line? I simply typed requests, not requested as you are stuck on.
I guess you did not listen to the tape, or you would have understood what was meant....there you go....

The AC pilots are surely fine pilots and representative of their profession. The guys in the waiting planes, likewise. But literally everyone was asleep here. The entire system nodded off. Why?

The taxiway is very near the runway on an offset angle approach. While waiting in line (for what appears an extended amount of time due to 28L closure), you are staring out the windscreen trying to figure out if the other ac are on RWY?
How often do lawyers sue other lawyers?

Who were asleep, were the pilots in command of the AC jet.

As much as drivers want to claim they are solely responsible for the command of the aircraft, here is the chance to put blame exactly where it belongs.

Children of the magenta line make excuses for poor performance. As noted, there is enough intent shown by the circumstances to show that it was an accident. It should and likely will be treated as such, and the responsible ramifications should be followed through.

There are systems that warn, but the bottom line. no matter what the warnings, ATC instructions, or aircraft , it is the PIC that makes and takes the responsibility.
Bottom line, that crew drove the ac down the taxiway on a clear night. Bright and very adequate approach lights...and a big white 'X' on 28L.

"jeez, looks like there is something on the runway, but ATC says there is nothing, so I will land anyways. Oh , I forgot to turn off the CVR and it got erased...really, we dont remember seeing any aircraft on the runway, those bright lights shining at me, or hear the radio saying I was on the taxiway....we just remember seeing something odd, and decided to GA.... "

How did AC 624 A320 plow into the dirt 300m short of threshold?

FFS, make all the excuses you want...time to cull this herd, with good reason.

[Airbubba]

jeeezus...listen to the tape...they requested clearance to land for that approach...correct, just like all of the others on the tape...what, you want me to type out requests clearance to land for each line? I simply typed requests, not requested as you are stuck on.
I guess you did not listen to the tape, or you would have understood what was meant....there you go....

So now they are requesting 'clearance to land for that approach'?

Like I said...

[Havingwings4ever]

de-Sitter,

I wont comment on the "probable" causes leading to this incident, lot of speculation as usual, except for that regarding the local time this happened and how long their workday/night had been so far tiredness might have played a factor. My experience(25yr ww) is that boredom usually doesn't show up on approach and landing(complacency maybe).

Maybe it makes you feel better knowing that plenty of pilots still hand-fly, usually at lower levels and the flight departments encourage it. This depends on the(expected) workload though, flying into a challenging airport, or just a lot of traffic, weather, tiredness etc or a combination of all, yes, it can get interesting..(SEQM eg)

[peekay4]

Seems the only thing clear from this thread is who are pilots and who are not.

[galaxy flyer]

Why I asked about AC's approval is their are TWO Quiet Bridge approaches--one public visual and one private, by specific approval FMS Quiet Bridge approach. Is AC approved for the approval required FMS Quiet Bridge or where the actually flying the public visual approach?

GF

[Airbubba]

FMS Quiet Bridge approach?

Here we go again... :)

You might want to check the name of that approach.

[deeceethree]

The CVR is overwritten and the crew can not recall overflying 4 aircraft!
WOW!
If what the report states is true, that the AC drivers did not even recognize the taxiway was full, that implies they did not see the landing lights, nor hear UAL 1. (or are not telling the truth) There is enough intent in their statement alone, (forget the lack of CVR data) to prevent those 2 from rotating again.

Time to stop making excuses for the airline, the ac, and the crew. Let DHS get the true story out of them.

Whoa, hold on a mo, I think there is some fundamental misunderstanding going on here. The Air Canada 759 crew did see something on what they thought was Rwy 28R (but was actually Taxyway C), and queried it with the Tower:NTSB 2nd August 2017 Update:
At 2355:46 PDT, when ACA759 was about 0.7 mile from the landing threshold and about 300 ft above ground level (agl), the flight crew contacted the ATC tower, mentioned seeing lights on the runway, and requested confirmation that the flight was cleared to land.
The Tower replied:"Air Canada 759, confirmed, cleared to land Runway 28 Right, there is no one on 28 Right but you."
AC759 quickly replied:"Okay, Canada 759."
Consequentally, whatever the reasons for AC759 being incorrectly lined up with Taxyway C, the crew had just had their (unknowingly) erroneous visual and mental model apparently reinforced by the Tower. Neither side of that radio conversation knew yet that things were badly wrong (the 4 aircraft crews on Taxyway C may have already had hairs standing on the back of their necks). The AC759 crew did have some initial unease about their odd visual picture, and queried it, but Tower (through no fault of his own), seemingly dispelled it.

United Airlines 1, right in the 'line of fire', seemed to be the first to raise real alarm, and did so by quickly transmitting (right on the end of AC759's reply to Tower):"Wheres this guy going?"
"He's on the Taxyway!"
I believe it was those calls from UAL1 that probably then provided the serious startle factor for AC759. Very shortly thereafter they commenced a go-around, and Tower, now also aware of the potential disaster, ordered a go-around. A final report will, no doubt, clarify the precise timings and order for those latter events.NTSB 2nd August 2017 Update:
"In post incident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them."
I don't believe that the AC759 crew statements "that they did not recall seeing aircraft on taxiway C but that something did not look right to them" mean that they did not see anything on Taxyway C - they did see something there - lights - and queried it with Tower. When Tower told them the runway was their's to land on, in their mental/visual model they then had even less reason to think that the lights were aircraft.

For people here to express astonishment that the AC759 crew did not see this or that, or demand that heads roll because the AC759 crew might be lying, is really jumping the gun! AC759 did see lights, and had their verbal query apparently satisfied by Tower's reply. I suspect that it may have been UAL1's calls which suddenly brought the visual and mental models inside the AC759 cockpit into very stark focus, and the crew must have been frightened and then embarrassed in the space of a handful of seconds.

Give them some space people, for goodness sake! All we know, and they now know, is that something went terribly wrong. Only a final report will give us more insight into the reasons for AC759 lining up with Taxyway C and not the real Rwy 28R. In the latter stages there seems to have been a serious disconnect between where they thought they were and what they saw, when compared to where they actually were.

Human Factors studies are being devolped and refined all the time, and the subject is part of pilot license qualification and training. It also forms part of ongoing license requalification and retraining - we study it it because we are erring humans subject to sometimes insidious phenomena. If it wasn't important, we wouldn't need to consider the subject, would we? It could be that this incident is a variation on something already known about mental/visual pictures being mixed up, but whatever it is, quit the flipping armchair judge-and-jury nonsense. It sucks, and some of you do yourselves no favours by behaving like a lynching mob.

[SalNichols]

Dollars to donuts, the contents of the CVR following the GA weren't printable anyway.

[deSitter]

Well said.

This is so much like Comair at Lexington.

[EGLD]

*sigh*

What breathless nonsense.

http://www.airlive.net/wp-content/uploads/2017/08/Capture-1.png

[RAT 5]

There has been much 'red herring' chat about the type of approach offered/requested/accepted. IMHO that has nothing to do with this incident, and I do not wish to open that discussion again. This incident started to occur at less than 3nm visual finals to RW28R. How they arrived at that point has nothing to do with it. It is what the crew did after that point that is relevant. Please, let us see the wood for the trees.

[Smott999]

I can't help wondering that the gap after PAL and prior to the UAL 3rd in line, wound up as hugely important to the safe result? If UA had been right behind PAL....would the bottom end of that flight path during GA cleared everyone?

Terrifying to think about.

[MarcK]

Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance? That approach follows the SFO 095 radial inbound, which happens to cross the airport boundary just at Taxiway C. They would have to offset left a bit after crossing the San Mateo Bridge to line up on 28R.

[Loose rivets]

Sorry if this has been shown. Just some daytime shots of the approach.


About 7mins in.


https://www.youtube.com/watch?v=ENe89j89tBA

[SeenItAll]

Let me add another scenario. If you listen to the ATC tape, I am dumbfounded by the nonchalant transmission from AC saying that they are in the go-around. I am not sure that even then they realized what a f-up had just occurred and how close they were to disaster. At least we have the FDR. They should be able to synchronize it with the ATC tapes to see exactly when the go-around was commenced.

[Tankengine]

Good reason to stick to ILS. ;)
If ILS out of service, the RNP would line you up with the runway.

[West Coast]

Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance

Yes it is, done so many times. Workload is much lower on the FMS bridge however.

[peekay4]

The crew were cleared for the FMS Bridge but of course at this time we don't know what approach they actually flew and how they did it.

I don't see the expected turns to/from F101D in the (admittedly sparse) ADS-B data from FlightAware.

[Airbubba]

Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance?

I've also wondered if somehow they had the wrong approach in the box or were looking at the wrong one on their tablets? Did they build a path or incorrectly heal a discontinuity that gave faulty guidance on final?

Can you pull up the Quiet Bridge Visual on the A320 FMS? Will it give guidance on final?

Some earlier opinions:

there are two, BOTH in the FMS database

Two FMS Visuals to 28R?

Only one FMS bridge visual in my database. You'd have to build the quiet bridge visual yourself.

Just one, the RNV28R in our FMS.

You can see how much confusion there is on this thread about the two visual approaches to 28R with 'Bridge' in the name.

Since the dog ate the CVR tape, will the legacy FDR data show much about what was in the FMS?

Why didn't the first two planes bail off the taxiway? I can't imagine I'd just sit there and let someone land on my nose. What are your driver's instincts here?

Actually there was an accident three decades ago where an airliner taxiing for takeoff did swerve when seeing a commuting Eastern captain in an Apache coming out of the fog lined up on the taxiway. The Pan Am 727 moved enough to avoid a direct hit and took a glancing blow. The Apache was totaled with fatal results but everybody in the 727 evacuated successfully and the plane was repaired and flew again.

Jet at Tampa Airport Hit By Small Plane

By Bill McAllister November 7, 1986

A small twin-engine plane, flown by a senior airline pilot, crashed into a taxiing Pan American World Airways jet in dense fog at Tampa International Airport yesterday morning, killing the small-plane pilot as his aircraft broke apart in a fireball.

Officials said the death toll in the Florida accident would have been higher if the pilot of the Pan Am 727 had not spotted the approaching plane seconds before impact and swerved to avoid a head-on collision.

"That maneuver . . . prevented what could have been a much more serious accident," Pan Am spokesman Alan Loflin said. Two of the jet's 17 passengers and one of its six crew members suffered minor sprains sliding down the aircraft's emergency chutes.

https://www.washingtonpost.com/archive/politics/1986/11/07/jet-at-tampa-airport-hit-by-small-plane/ff70bb0a-6c0a-40f3-928d-a816b4be707d/?utm_term=.a2fbba62c493

[EcoFox]

Sorry if this has been shown. Just some daytime shots of the approach.


About 7mins in.


https://www.youtube.com/watch?v=ENe89j89tBA
I think the approach is actually this one: https://www.youtube.com/watch?v=LO12oGJPrPY

[peekay4]

You can see how much confusion there is on this thread about the two visual approaches to 28R with 'Bridge' in the name.
Seems they did select the correct approach, flew direct TRDOW to join before being cleared for the visual. This waypoint doesn't exist on the Quiet Bridge.

[West Coast]

Seems they did select the correct approach, flew direct TRDOW to join before being cleared for the visual. This waypoint doesn't exist on the Quiet Bridge

yup, not sure how one could confuse the two when they went to TRDOW. Non player to me.

[Johnny Albert]

New images of Air Canada near miss (https://www.liveleak.com/view?i=218_1501760697)

[deeceethree]

Let me add another scenario. If you listen to the ATC tape, I am dumbfounded by the nonchalant transmission from AC saying that they are in the go-around. I am not sure that even then they realized what a f-up had just occurred and how close they were to disaster. At least we have the FDR. They should be able to synchronize it with the ATC tapes to see exactly when the go-around was commenced.
Dumbfounded? I have listened, and am not dumbfounded.

You assert that you are "... not sure that even then they realized what a f-up had just occurred and how close they were to disaster" but are also surprised they made a supposedly nonchalant transmission? If, and this is a big 'if', it is true that the AC759 crew were still unaware of the disaster that had just been averted, why would you expect them to be anything other than calm? They can't be frightened by something they don't know has happened, surely? But I sincerely don't think that is going to be the case uncovered here.

As I indicated in my earlier post (http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-15.html#post9851253) (#584), it is highly likely that UAL1's calls of "Wheres this guy going?" and "He's on the Taxyway!" brought things back into focus for AC759, with fear and embarrassment in equal measure in the following seconds. The radio conversation that ensues is:Tower: "Air canada, go-around."
AC759: "In the go-around, Air Canada 759"
"In the go-around ..." implies that AC759 has already begun his go-around (as you state, the NTSB will undoubtedly be able to pinpoint precisely what was done and what was said, to the fraction of a second ...). If you currently believe AC759's reply transmission as "nonchalant", would you be willing to alternately consider it might be that, having been startled by UAL1s calls, the crew realised the enormity of what was unfolding, and were now working extremely hard not to let the emotions, fear almost certainly being one of them, overwhelm their recovery from the near disaster? They were 'boxing the chimp' and hanging on to their sensibilities - try a websearch for Dr Steve Peters and 'The Chimp Paradox' if you are not familiar with the term.

Whilst AC759's go-around reply is short and crisp, I beg to differ about it being at all "nonchalant"! I believe we will eventually learn that by then the crew did realise that a disaster had only just been averted, by the narrowest of margins, and they were desperately trying focus on recovering as calmly and professionally as they could, not making things any worse whilst they did so. Throughout the go-around and beyond, a nagging thought of "What the hell just happened?" would likely have been distracting them.

Despite the CVR loss, we are fortunate that there is still plenty of data available for the NTSB to reconstruct this serious incident, and we will learn in fine detail what went on and, hopefully, why. It seems clear that the crew of AC759 had a mental/viusal model that was disparate from what others involved could see, so it really is important to learn how and why they got there. As I declared in my earlier post, stop with the unnecessary character-bashing and rush to judgement - it isn't seemly without all the facts to hand. The NTSB final report will give us those.

If anyone is concerned I might be biased in favour of the AC759 crew, I am happy to openly declare my position:
1. I have no connection with Air Canada, or the crew members involved, whatsoever.
2. Neither do I have any connections to any of the other crew, SFO ATC, or the investigators.
3. I fly longhaul passenger aircraft, and have 38 years of professional flying experience.
4. I have operated in and out of SFO.

Now, stop being so bloody judgemental of the AC759 crew!

[framer]

This incident started to occur at less than 3nm visual finals to RW28R.
If I had to bet I would say that this incident started well before that. There is only one way that I can see that this occurred. The expectation of both pilots had to be that there would be a runway to the left of their final approach track and that they wanted the second one in. This expectation had to be pretty strong in order for "expectation illusion" to 'overpower' what they actually sensed when looking out the window.
It could have been a strong expectation because they had both flown into that airport at night from the East on many occasions, or because they briefed that that is what they would see, or both. Either way I can't see how it could have been such a strong expectation in both of them if they had read and understood the notam and the ATIS.
So when the report comes out ( and I may be wrong of course) , I think we will read that the nuts and bolts of this incident are to be found a long way prior to 3nm final.

[Contact Approach]

Well said Deeceethree.

[Stuart Sutcliffe]

New images of Air Canada near miss (https://www.liveleak.com/view?i=218_1501760697)
JA, you may wish to know that the images in your link were highlighted earlier in post #552 (http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-28.html#post9850817), which itself led to this NTSB page (https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx) where the images were first publicised, I believe.

[Loose rivets]

My few posts have mostly been concerned with the psychology of the incident.

The tiniest hint of disbelief by the PNF when assured the runway was clear, is I feel, a very significant point. What they were perceiving has been well covered: a runway to their left and a set of lights that didn't look quite right - ringing an alarm bell in the mind of one pilot if not both.

Then there's the RT.

"Were going in the Hudson." is a sentence probably buried in the memory of every pilot in the Western World. As we all know, it did not convey the magnitude of the emergency and certainly not the intention.

"Wheres this guy going?" and "He's on the Taxyway!" brought things back into focus for AC759,

Without a second-by-second time-line into the thinking of the flying pilots, I rather think it didn't. Neither statement made the extent of the emergency totally clear - and from the holding pilot's viewpoint it was an imminent catastrophe.

If I'd been presented with that image, I like to think I'd have made it very clear - the very least, Landing aircraft. You are lined up with, or You are landing on the Taxiway. And yes, there would have been a lot of !!!!!!! to emphasise the point.

We know what was meant by He's on the Taxyway, but that was background noise in the ears of the flying pilots who were already presented with something that simply did not look right. Again, if I'd been presented with that image . . . well, I have no idea what I would have done. If the rows of lights fooled two experienced pilots, they may well have fooled me.

If we are to truly learn from this incident, the entire thing should be re-enacted, though I hasten to add I'd not have the camera aircraft overfly the holding hardware! Expensive, but it's vital to know how pilot perception can be slewed so dramatically.

N.B. I had a Boeing trundling towards me while at about 6 miles finals at night. I watched bemused as it seemed to be gathering extraordinary taxiing speed. When it rotated I asked if they'd like me to move out of the way. All good humoured. The point being, it was all so clear. I could even identify the aircraft. What was it about the row of holding aircraft that looked so different?

[aterpster]

Whilst AC759's go-around reply is short and crisp, I beg to differ about it being at all "nonchalant"! I believe we will eventually learn that by then the crew did realise that a disaster had only just been averted, by the narrowest of margins, and they were desperately trying focus on recovering as calmly and professionally as they could, not making things any worse whilst they did so. Throughout the go-around and beyond, a nagging thought of "What the hell just happened?" would likely have been distracting them.

If your premise is correct, then the crew had a subsequent lack of ethics and integrity by failing to secure the CVR and so advising their flight management at the end of the flight.

Now, stop being so bloody judgemental of the AC759 crew!

Why, given your premise and their failure to secure the CVR?

[WillowRun 6-3]

. . . . . . their failure to secure the CVR?

I'd like to be able to articulate a view which gives the AC crew some degree of credit for having flown the approach well enough - minus the misalignment obviously - so that the physical separation margin of error turned out to be enough. It might turn out to be shown that it was, mathematically and in terms of the physics of the situation, the minimum separation that could have existed, but we do not know that. And to be blunt, it can't really be said validly at this juncture, on the facts that are pretty much given, that the approach was operated in such a way so that what might have been a lower crossover of the threshold did not materialize. I sure can't say that, as much as I might want to.
But maybe there is another factor which should serve here to pull back on the reins dragging two fine aviator careers toward a rush to judgment. Specifically, that CVR content might have been pretty darn scary for the traveling public to hear. I have no idea what actually was on that segment. But it seems neither unrealistic nor unreasonable to include, as a possibility, that the segment no longer available was some pretty unnerved stuff. Now, that is not a reason for not preserving the CVR (double-duh!) in the eyes of the law. But before canards about ethics get taped to someone's jacket, should not reasonably possible mitigating factors be given their due?

[Airbubba]

Seems they did select the correct approach, flew direct TRDOW to join before being cleared for the visual. This waypoint doesn't exist on the Quiet Bridge.

Actually a waypoint at the same position is designated as the SFO 095/20 on the Quiet Bridge approach. But you are right, if it is in the box it probably would be named with the FMS alphanumeric coding scheme.

[aterpster]

I'd like to be able to articulate a view which gives the AC crew some degree of credit for having flown the approach well enough - minus the misalignment obviously - so that the physical separation margin of error turned out to be enough. It might turn out to be shown that it was, mathematically and in terms of the physics of the situation, the minimum separation that could have existed, but we do not know that. And to be blunt, it can't really be said validly at this juncture, on the facts that are pretty much given, that the approach was operated in such a way so that what might have been a lower crossover of the threshold did not materialize. I sure can't say that, as much as I might want to.
But maybe there is another factor which should serve here to pull back on the reins dragging two fine aviator careers toward a rush to judgment. Specifically, that CVR content might have been pretty darn scary for the traveling public to hear. I have no idea what actually was on that segment. But it seems neither unrealistic nor unreasonable to include, as a possibility, that the segment no longer available was some pretty unnerved stuff. Now, that is not a reason for not preserving the CVR (double-duh!) in the eyes of the law. But before canards about ethics get taped to someone's jacket, should not reasonably possible mitigating factors be given their due?

The CVR is for the serious purpose of investigation. It is not for the public's entertainment. Only this crew could have preserved the tape.

[peekay4]

On the CVR:

I believe the incident aircraft was C-FKCK, msn 265 delivered in 1992 -- so it may only have a 30 minute CVR installed in compliance with Canadian regulations.

The go-around happened by 02:56 UTC. After the circuit, AC759 then landed at 03:11 and arrived at the gate at 03:15. That's 19 minutes.

So unless the pilots pulled CBs within 10 minutes of the gate arrival (while passengers were still disembarking), the CVR might have been completely overwritten in any case.

And I'm not even sure it's standard procedure for AC pilots to pull CBs on their own after every possible reportable incident. Probably the pilots were told to "call the tower" at this point and were still wondering / discussing what had just happened amongst themselves.

25-hr CVR rule would have made a difference here.

[DaveReidUK]

Specifically, that CVR content might have been pretty darn scary for the traveling public to hear. I have no idea what actually was on that segment. But it seems neither unrealistic nor unreasonable to include, as a possibility, that the segment no longer available was some pretty unnerved stuff.

Are you seriously suggesting that would justify a conscious decision (if such was made) to allow the CVR to be overwritten?

[aterpster]

I would have thought by 1992 that solid state CVRs were being installed. The solid state units record two hours.

[Ian W]

Adoption of Forward Looking IR (Enhanced Flight Visibility Systems, EFVS in FAA speak) and Synthetic Vision Systems (SVS) would go a long way to eliminating night visual problems. The EFVS view, especially in a HUD, would have shown the line up planes as four large signatures and the lighting clearer, assuming it hadn't been converted to LED. The SVS would have shown the runway off line-up to the left in a daylight view and the taxiway in front of them. SVS is good enough to show you taxiing across a runway and the view on the PFD or MFD is identical to the outside view.

Unfortunately, HUDs and Synthetic Vision bring their own attentional tunneling effects which have been repeatedly demonstrated in human factors experiments in high fidelity simulations. You cannot 'cure' a feature of the human brain by adding more devices; except perhaps by automating out the crew entirely.

[peekay4]

I would have thought by 1992 that solid state CVRs were being installed. The solid state units record two hours.

No even brand new solid state CVRs today come with 30-minute and 120-minute options from the manufacturer.

FA2100 (http://www.l3aviationproducts.com/products/fa2100-series-cockpit-voice-and-data-recorders/#1441874218832-398800e3-835ed211-c946):

http://i.imgur.com/mSHOiBx.png

[WillowRun 6-3]

Are you seriously suggesting that would justify a conscious decision (if such was made) to allow the CVR to be overwritten?
No. A mitigating factor is one which tempers a sanction, typically in support of reducing a sanction (but sometimes only in a pro forma manner). Not justification. And secondly, here the inquest is intended (or should be intended) to extract as much information as is relevant to the sequence of events. Asking what possibly could have caused one of those events is an established means of assuring that an investigation process does not gloss over or miss anything (as much as this can be assured).

[Ian W]

Let me add another scenario. If you listen to the ATC tape, I am dumbfounded by the nonchalant transmission from AC saying that they are in the go-around. I am not sure that even then they realized what a f-up had just occurred and how close they were to disaster. At least we have the FDR. They should be able to synchronize it with the ATC tapes to see exactly when the go-around was commenced.

You are approaching what you are convinced is the runway you have been cleared to land on. As you reach short finals you see lights on 'the runway' you tell ATC who tell you there is nothing on the runway you are clear land. But you _still_ see those lights and think I am going around there _is_ something on the runway. Just as you start to go around tower tells you to go around. You say to Tower "In the go around" and you are thinking those guys in the tower screwed up! There _were_ vehicles on the runway! ....

Perhaps the illusion that the taxiway was the runway actually lasted all the way around the circuit after the go around until a straight in approach made them realize that their first approach had been to the taxiway.

Just a thought.

[standbykid]

Now, stop being so bloody judgemental of the AC759 crew!

They seemed to have performed very well when they realized what was going on.
It's the fact they nearly thumped it into a crowded taxiway that is the issue.

The error was rectified, but whatever caused the initial problem needs to be fixed.

[SeenItAll]

DC3: If you read carefully my post, you will note that I drew no conclusions as to what actually did happen. All I did was propose another possibility. And as I noted, whether or not this possibility is correct will come out as the investigation continues. While I cannot opine as to the composure that these pilots might have been able to muster in the face of a situation that 3 or 4 seconds prior was going to be beyond catastrophic, I know that I (and I think most people, even pilots) would have been a little rattled.

Further, I can't recount the number of times I have asked my kids to come home for dinner, and received a response that "I am on my way," even when they had not started or were only beginning this process. It's a face-saving response to which many (myself included) are prone.

Again, I do not know what exactly did happen and I apologize if you thought that my raising of this possibility was disrespectful. In any event, you may wish to reread your post and decide whether it needs to be scrubbed of some judgements.

[Airbubba]

So unless the pilots pulled CBs within 10 minutes of the gate arrival (while passengers were still disembarking), the CVR might have been completely overwritten in any case.

And I'm not even sure it's standard procedure for AC pilots to pull CBs on their own after every possible reportable incident. Probably the pilots were told to "call the tower" at this point and were still wondering / discussing what had just happened amongst themselves.

At many U.S. carriers the CVR circuit breaker is on the shutdown checklist and should be pulled in the event of an NTSB Part 830 reportable incident or an accident. That procedure has been in place in the U.S. for several years, I'm sure someday it will be SOP in Canada as well if it is not already.

But, as you can see from my earlier comments, I'm not too surprised that the CVR recording was somehow unavailable for the NTSB investigation of an incident that occurred around midnight on a Friday evening.

[DType]

Having lived in the same house for 54 years, and having parked outside it some 50,000 times, I recently parked outside the wrong house. Excuse was a defunct street light, plus I "latched" on to the wrong facade, which I thought looked slightly "funny". 1 in 50,000 is AOK for a parking location error, but totally unacceptable for a life threatening error.
HOWEVER
F Type pretty soon put me right.
Which means that the probability of two pilots getting it wrong is not my 1 in 50,000, but 1 in 50,000 squared, or 1 in 2,500,000,000. Which is much better, but still a bit scary.
A good argument for having two pilots.

[TRW Plus]

As a non-pilot, this intrigues me and I would like to know what pilots think about this situation -- it appears obvious from the discussion that one of two things is true, either

(a) the pilots did not receive the NOTAM concerning runways in use, or

(b) the pilots forgot the information from the briefing presumably four to six hours earlier.

Either way, is there no system in place to remind pilots of NOTAM information at a useful time such as 30 minutes before arrival?

If not, should there not be one? Just some sort of computer-generated message like reminder of NOTAM of closed runway at SFO, with the actual details in the message. This would avoid both possibilities above.

[West Coast]

Either way, is there no system in place to remind pilots of NOTAM information at a useful time such as 30 minutes before arrival?


Possibly. Many airlines make a checking NOTAMS a part of the approach briefing.

[sleeper]

Even better, notams are checked before flight including the arrival airport and it is good practice to check again before starting the arrival/approach. There is no excuse for not knowing about arrival notams except when they are issued after departure which is possible given the long haul flight times.

[BRDuBois]

No even brand new solid state CVRs today come with 30-minute and 120-minute options from the manufacturer.

FA2100 (http://www.l3aviationproducts.com/products/fa2100-series-cockpit-voice-and-data-recorders/#1441874218832-398800e3-835ed211-c946):

http://i.imgur.com/mSHOiBx.png

They could be recording essentially unlimited times, given the cost of storage chips now. This is totally amazing. 30 minutes appears to be the capacity of the first CVR from 1961, if we can trust Wikipedia.

[aterpster]

TWA installed them in 1964. Tape recorder, 30 minute loop. That 30 minutes was invaluable in the 1974 TWA 514 CFIT investigation. Much more so than the FDR.

[BRDuBois]

I'd give a body part to have had one in my dad's plane. It would have kept the CAB from making such a hash of their investigation.

http://www.pprune.org/accidents-close-calls/571018-help-researching-1961-electra-crash.html

[SalNichols]

Not that you guys and gals need more crap to look at, but why not put a big illuminated yellow X at the ends of Txwy C...out in front of the seawall?

Yeah, GenDynamics actually paid me a lot of $ for ideas like this.

[underfire]

https://i.imgur.com/DMA9sC2.jpg

[BluSdUp]

NTSB states in preliminary report.:

Atis info Q active, stating standard stuff, PLUSS : Runway 28L Closed, approach lights and runway lights OFF.

So if they forgot the Notam they read i Canada X hrs earlier, there is no excuse now.

[galaxy flyer]

Unfortunately, HUDs and Synthetic Vision bring their own attentional tunneling effects which have been repeatedly demonstrated in human factors experiments in high fidelity simulations. You cannot 'cure' a feature of the human brain by adding more devices; except perhaps by automating out the crew entirely.

IanW,

First, I completely agree with your post 616--whatever illusion in both pilots view could have been confirmed by the ATC comment and remained until the second approach. Anyone who's been thru visual illusion training knows how diificult it is "break" the illusion and how compelling it is.

WRT, HUD/EFVS/SVS, I haven't seen the studies you mention but a couple thousand hours using the equipment demonstrates its value. Yes, initially it is very compelling and causes tunneling of attention, but with experience it becomes another firm information that requires the pilot to properly channel his attention.

[framer]

I think it is worth remembering that what we perceive, and what we sense, are two different things.
If you think that you percieve things exactly as they are seen ( sensed) , then you are wrong, and you are more susceptible to this kind of illusion than those who understand that the human brain has a particular area of weakness here. I say weakness but 99.99% of the time when your brain takes the visual information sensed and modifies it prior to presenting it to you, it works to your advantage. Your brain is quite capable of adding things that don't exist to a picture prior to presenting it to you.
These guys had a lot of successful flying experience, we should assume that a combination of factors came together which resulted in them both developing a mental picture that was different from reality and search for each of those factors. We should determine how we can reduce the likelihood of this combination of factors aligning again.
Notams are good if you read and understand them, ATIS information is good if you read and understand it. A shared mental model is good if it is correct. We will never 'fix' the trait that caused this incident, but we might guard against further mishaps if we educate about the importance of having more than one source of information, about the susceptibility of the brain to these illusions, and research how circadian lows and busy rosters affect our susceptibility to them.

[Raingear]

Good day all, I'm an AC ramp employee and new to this board.
I've become fascinated with this incident and all the possible explanations as to why it occurred.

I've seen the pictures of what a nighttime approach into SFO looks like, and it seems to me that with the runway approach lights extending well out into the water, it should be pretty obvious to see where the runway is...but the crew lined up with the taxiway instead and the still unanswered question is why?

Here's a theory I'll throw out for consideration..
Assuming the crew had forgotten about the closure of 28L, they would be expecting to see two parallel sets of approach lights; so I wonder if the light from the nose gear of the aircraft first in line on the taxiway, pointing straight out into the bay, may have been mistaken for the approach lighting for 28R from a couple of miles out?

If this was the case, then the lights from the other aircraft on the taxiway could have been what prompted the AC crew's query to ATC about traffic on the runway.
I'd be curious to hear feedback from the professionals on this board if this is a plausible explanation. It's definitely disappointing that we will never hear what was actually said in the flight deck that night.

[aterpster]

Had they been coupled to the FMS28R "George" would have prevented all those variables.

[tubby linton]

I disagree. At some point an approach has a visual segment unless you are going to autoland in low visibility. Airbus has recently changed the minimum height for autopilot disconnection after a non-precision approach but on a cavok night the temptation would be to disconnect the autopilot, select the Bird ,align with the runway centreline and fly the papis by looking out the window. The problem is that if the visual picture is confusing with lots of lights on the airfield environment and the lights of the city beyond, there will be nothing inside the aircraft to tell you as the ILS will not have been tuned by the aircraft.
With a non-gps aircraft the map on the ND would could also have a small error.
Perhaps as part of the approach briefing the threats of the runway closure and what the correct visual picture will be for landing could have been discussed.
Gatwick has two strobes on the runway threshold when the standby runway is in use, and nobody is allowed to occupy the parallel taxiway.

[aterpster]

This entire approach was a visual segment, albeit one with guidance that provides 3D alignment almost 4 mile out. If there was a map shift, which hopefully will come out in the investigation, then D/D/I should be prohibited from FMS Visuals.

The standards folks in the FAA have not been exactly fond of these FMS Visuals.

[Jet Jockey A4]

https://i.imgur.com/DMA9sC2.jpg

Underfire...

Who made this cross section diagram and how accurate is it?

[peekay4]

Which means that the probability of two pilots getting it wrong is not my 1 in 50,000, but 1 in 50,000 squared, or 1 in 2,500,000,000. Which is much better, but still a bit scary.
I've been thinking about the above... I'm not sure it's accurate, partly because wrong info from one pilot can affect the judgement of the other pilot, and from that point forward the two pilots may actually reinforce & amplify each other's incorrect perceptions.

Scenario fulfillment can happen to entire crews. The most extreme example is perhaps the shooting down of Iran Air 655 by USS Vincennes.

[West Coast]

Even better, notams are checked before flight including the arrival airport and it is good practice to check again before starting the arrival/approach. There is no excuse for not knowing about arrival notams except when they are issued after departure which is possible given the long haul flight times.

Not better, rather in conjunction to reading them prior to departure. Easy to overlook something you read many hours before which is why you do it as a part of the approach briefing.

[wiedehopf]

@Raingear

not only has this theory been posed on the first page of this quite long thread, also it's been confirmed by interviews with the pilots:

"The NTSB reported that in post flight interviews both pilots of AC-759 reported they were convinced the lighted runway to their left was runway 28L and they were lined up with runway 28R. They did not recall seeing aircraft on taxiway C, however, something did not look right to them."

[harpf]

Our airline has HW RASS system when they close a runway open new one etc we get false alarms until the data base is fixed, That said it will advise if you attempt to land or depart on a taxi way

[Exnomad]

Oh for the old days, with a runway caravan, and someone to fire off a few reds is something looks wrong.

[underfire]

Who made this cross section diagram and how accurate is it?

I made it using the NTSB image and altitude information in the NTSB report. It includes the information from the 3 images, the altitude data at several points on the profile, which correlates very well with the 2.5 seconds at around 140 kts distance.
Aircraft images are to scale with the profile and altitude information.

PAL 115 A340 tail is 56.5' tall, and the AC ac descended to 59 feet. Where that altitude provided is measured from, I am not certain, so the profile is the best scernario at bottom of wheel.
If this is measured from a different point on the ac, then the situation becomes worse.

I have the 3D aircraft for a profile, with the fligthpath, and can do a fly thorough, like a desktop sim, but just did not want to spend the time to generate that.

http://i.imgur.com/Qu66Mlk.jpg

[underfire]

"The NTSB reported that in post flight interviews both pilots of AC-759 reported they were convinced the lighted runway to their left was runway 28L and they were lined up with runway 28R. They did not recall seeing aircraft on taxiway C, however, something did not look right to them."

They did let the CVR go, and certainly had time to rehearse the story.

How can this be in anyway mistaken?

http://i.imgur.com/qrnsIIg.jpg

FMS Bridge Visual Approach:

https://i.ytimg.com/vi/rNMtMYUGjnQ/maxresdefault.jpg

AC FMS Bridge Visual Approach Taxiway C variant.
Hmmmm...something doesnt seem right here...oh well, lets land anyways...

http://i.imgur.com/pyuByXC.jpg

[b1lanc]

Interesting paragraph in the AC624 AIR Section 2.5 cited as a cause/contributing factor. Who knows what an individuals "salient triggers" are. Replace "too low" with "lined up on taxiway" and the paragraph fits.

[Loose rivets]

How can this be in anyway mistaken?

Well, of course it can't. The only way to truly assess the slewing of their perception would be the re-enactment I mentioned. Sadly, I feel this would be deemed seriously OTT, given 'that's no excuse' outcome where there is still a major difference between 28R and C even with the taxi lights of the holding aircraft. And that's another point: most crews would turn off any light that might be distracting for a landing aircraft. Is there any information about the real quantity of the 'mass of lights' on C?

IMHO, this aberration is only bewildering because, as far as we know, both pilots were affected.

Of course, it may turn out that there was a much greater stream of protests on the flight deck than we know about.

[DaveReidUK]

Of course, it may turn out that there was a much greater stream of protests on the flight deck than we know about.

No it won't, because the only conclusive evidence of that would have been the CVR.

[framer]

How can this be in anyway mistaken?

If you think that you percieve things exactly as they are seen ( sensed) , then you are wrong, and you are more susceptible to this kind of illusion than those who understand that the human brain has a particular area of weakness here

IMHO, this aberration is only bewildering because, as far as we know, both pilots were affected.
That both pilots were affected is the greatest clue that whatever programming of their expectations that had occurred prior to turning final was strong enough to influence both of their perceptions.
On a different tack, have you ever been so knackered that you slur your speech and can't construct sentences properly? I wonder if we will find out that the combination of rostered duties and the individual home lives of these two meant we had two fatigued pilots up front.
I know I'm not the only one to wonder.

[underfire]

No it won't, because the only conclusive evidence of that would have been the CVR.

Concur.

Take them both off line, they will turn on each other, that is the only way.

I wonder if we will find out that the combination of rostered duties and the individual home lives of these two meant we had two fatigued pilots up front.

more excuses....

[tubby linton]

Underfire, can you send your contact details to your president as he doesn't need the expemsive NTSB when he has you. You have solved what has happened , I am just waiting for the report. Also call the chiefl pilot at AC and have both pilots sacked based on your testimony and investigation.Perhaps you would like to do their dismissal hearings. Don't bother looking at any of the contributing causal factors which may have contributed to this.In your eyes they are guilty and should never fly again.Have you ever heard of Swiss cheese?
You probably don't remember this incident, but the Captain committed suicide after his trial. He certainly hadn't started his day thinking I must try and land on a road.
https://aviation-safety.net/wikibase/wiki.php?id=147119

[framer]

Underfire, wondering if the pilots cognitive performance was reduced due to their workload and hours of wakefulness and sleep history and the stage of their circadian rhythms isn't an excuse, it is common sense. The job they were doing at the time of the incident requires a certain rate of cognitive processing, any neuro scientist will tell you that the rate of processing can be affected by the above factors.

We have an incident where the cognitive process clearly failed, to not look at something that is known to affect the process is irresponsible.

[deSitter]

@Raingear

not only has this theory been posed on the first page of this quite long thread, also it's been confirmed by interviews with the pilots:

"The NTSB reported that in post flight interviews both pilots of AC-759 reported they were convinced the lighted runway to their left was runway 28L and they were lined up with runway 28R. They did not recall seeing aircraft on taxiway C, however, something did not look right to them."

That is the essential point. Considering Western at Mexico City, the lesson to be learned is how to close a runway in a way that is utterly obvious and clear.

[Ironman1331]

Huh? This looks pretty damn close to a disaster.
I strongly dislike commentators stating this could have been "the worst aviation disaster in history", hyping for dramatic effect, BUT, one of the aircraft on the taxiway turned on his landing lights!!! as the errant aircraft approached, the aircraft approaching asked about lights on the runway, reports said the aircraft was down to 100 feet, others said lower.

[Ironman1331]

*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.
There was a fair amount of hype from commentators, BUT, said the approaching airliner was down to 100 feet OVER the taxiway, incorrect, as to planes on the ground were ear the threshold. There were five large airliners, one of whom turned on his landing lights as the aircraft approached. The incoming pilot re-checked for clearance to land and said there were lights on the runway. To not be there or see it yourself, and state it wasn't close, and state the aircraft were clearly visible is faulty. The approacing aircraft was, reported, 100 feet above the AC on the taxiway, some said lower, hito evidence seen, pilot asked about his cleared to land status, said there were LIGHTS, not that he saw aircraft. There was clise proximity w AC at 150 knits 100 feet over other AC. I don't like the dramatic statements of worse accident in history, but you are dismissing this incident carelessly.

[West Coast]

the lesson to be learned is how to close a runway in a way that is utterly obvious and clear

To clarify, are you inferring the current process isn't sufficient? in this case, NOTAMs, runway lights off, a lighted X on the closed runway, a clearance to land on the lighted proper runway, an instrument procedure that provides positive lateral and vertical course guidance to the runway in conjunction with an approach lighting system, differing colored lighting between runways and taxiways. likely a lot more safety nets as well. We should always focus on improving the system, but somewhere we need to focus on the most fallible part of the entire system, the humans.

I'm sympathetic to the AC crew and hope much is learned from this and that there's no negative long term consequences to their careers.

[underfire]

Don't bother looking at any of the contributing causal factors which may have contributed to this.In your eyes they are guilty and should never fly again.Have you ever heard of Swiss cheese?

Guilty with an explanation is still guilty.

They allowed the CVR to be erased, and from the preliminary NTSB statement, both denied seeing any aircraft on the 'runway' , but simply did a GA because "something didnt look right"

While those two may have suicidal tendencies, it is not fair to take out 400 others.

Yes, I feel very strongly they should be removed.

In aviation, we deal with the Swiss Cheese model all of the time. You just had 2 idiots drive over the cheese, not through the holes.

http://i.imgur.com/pyuByXC.jpg

[WillowRun 6-3]

underfire, when you get a chance, you *could* look up and read NTSB Chair Hersman's separate statement which they made part of the Board report on the Colgan accident. It was linked in a prior post in this thread. Then again, it makes a pretty articulate case for fatigue, when fairly raised by facts, to be a contributing factor. Facts, underfire, are not so easily swept away, as mere excuses. Then too, perhaps the Chair of the NTSB just plain ol' didn't know what they were writing about?

[underfire]

As a professional, is it not your responsibility to deal with the conditions and recognize issues such as fatique? This is the same for any high risk profession.

Look what they do to the train drivers in accidents where fatique was blamed, or truck drivers? Why is it that pilots feel they are exempt from punishment?

Does anyone assume that the pax expect a disaster because the driver has to commute or works too many hors and is tired? What about the other drivers sitting on the ground, are they responsible for being on the taxiway the AC was trying to land on?

If you cannot handle the job, then move on. If you dont move on, you should be removed.

[Loose rivets]

Well, not having a long term consequences will have a lot to do with the Feds having some sympathy with the reasoning - which surely has to be based more on imagery rather than electronics.

Me:
Of course, it may turn out that there was a much greater stream of protests on the flight deck than we know about.

Dave Reid
No it won't, because the only conclusive evidence of that would have been the CVR.

The overall time bracket wasn't very long, so yes, 'stream of protests' was too strong a statement but I suspect there may have been a mounting 'realization differential' and doubt both then realised the truth at the same instant.

I for one hope there is an agreed visual trap that will to some degree mitigate this puzzling incident. I re-read the 747 incident and recall how sad I felt at the time for the skipper.

[llondel]

As a professional, is it not your responsibility to deal with the conditions and recognize issues such as fatique? This is the same for any high risk profession.

OK, so you're half an hour from landing, you realise you're dog-tired, you're not in a position to stop. Sure, you can try to double-check everything from then on, but that just slows everything down, including the thought processes and decision-making. They were on final, realised something wasn't quite right but failed to understand exactly what, so they called ATC and found a solid piece of cheese as a result.

In the absence of the CVR and with a consistent story from the pilots, that's probably about the best you'll get. NTSB has come up with a good reconstruction of what happened, but 'why' is going to take a lot longer and may never yield a verifiable answer.

[galaxy flyer]

Underfire, can you send your contact details to your president as he doesn't need the expemsive NTSB when he has you. You have solved what has happened , I am just waiting for the report. Also call the chiefl pilot at AC and have both pilots sacked based on your testimony and investigation.Perhaps you would like to do their dismissal hearings. Don't bother looking at any of the contributing causal factors which may have contributed to this.In your eyes they are guilty and should never fly again.Have you ever heard of Swiss cheese?
You probably don't remember this incident, but the Captain committed suicide after his trial. He certainly hadn't started his day thinking I must try and land on a road.
https://aviation-safety.net/wikibase/wiki.php?id=147119

Tubby,

I've read of that BA incident, he should never have been tried. Would you agree?

Underfire,

The pics from the sim, I presume, make it look ridiculously obvious, but it can't be as simple as shown. Surely, two highly experienced pilots didn't suddenly decide to land on the taxiway, there must be much more to it--illusion, both very fatigued, etc. 3 am body time is tough and, despite it being and everyday schedule, sometimes things just go wrong.

[underfire]

All these excuses, and for both drivers!

No incident =no drug or alcohol test?

What about opinion of the UAL 1 driver, he did not appear too impressed?

What about the PAL drivers?

OK, so you're half an hour from landing, you realise you're dog-tired, you're not in a position to stop.

As professionals, you are both so dog tired after a 6 hour flight that you are incoherant to land the aircraft? What part of being a professional is that?

Forget about the 400 pax, right? They all have the expectation that the people driving will get them there and are professionals. According to all the posts with excuses, the drivers were tired because it is such a lousey profession, great excuse. Its okay, just like the one who drove it into the mountain on purpose, he was real tired too.

[WillowRun 6-3]

No don't fret, that header was just an attention-getting device.
underfire, I think everyone concerned with safety and its improvement where and when improvement is shown to be needed agrees: excuses have no place. But you're reaching for the disciplinary rod before enough facts have been determined. Again, after Colgan, the Board chairman strongly advocated for recognition of fatigue as a contributing factor. Obviously the Colgan crew paid a kind of disciplinary penalty of the ultimate kind. But you seem to be saying, "to identify all the facts and to find all the causal links and causal factors is the same as just sloughing off crew responsibility". You didn't use those words of course, but why the insistence that relentlessness in finding all the facts means anyone wants to shrug off the crew's responsibility?

[underfire]

But you're reaching for the disciplinary rod before enough facts have been determined.

On direct:
If the NTSB report is correct, in essence;
the crew has denied being on the taxiway,
denied seeing aircraft on the taxiway, and
denied outside input that influenced their decision to go around. (UAL 1 saying they were on the taxiway, nor PAL turning on their lights)

On cross:
The crew then exaserbated the situation by not securing the CVR, which could have substantiated their "story".

To date, the crew has not stated they were tired, have not claimed anything other than they went GA because it didnt look right.

You make the call, and stop putting words in their mouths as they have already spoken.

[PuraVidaTransport]

Flying a night visual approach, wouldn't the lack of PAPI lights on the "runway" while looking to the left and seeing PAPI for the "other" runway, be a rather large clue? And by the time the AC pilots got to the gate, they knew they had lined up on the taxiway and overflown at least one aircraft from the radio traffic alone. UA1 reported it (both 'on the taxiway' and 'right over us'), tower acknowledged it AND tower told AC they'd lined up on Charlie. To not immediately secure the CVR and notify the proper authorities seems a major misjudgement. And why not allow a small commercial drone to "fly" and video that night approach with similar aircraft on the taxiway, the last 3 miles or so? It could provide crucial evidence at minimal risk.

[tubby linton]

Galaxy flyer, He should not have been tried . If you search for topics about it on here, there was a lot more to the incident

[slast]

The underlying reason for the trial was that the event came close to being a "worst ever transport disaster" (full 747 impacting a full hotel, wreckage path would have taken out the airport rescue, firefighting, emergency communications and police facilities and hit the the access routes to the airport which were full of rush hour traffic etc.) Normally the UK AIB would have investigated it but they were fully occupied with dealing with the PanAm Lockerbie bombing plus British Midland. Kegworth crash, so since there were no injuries and no damage it was left to a internal investigation.

Powers that be in the CAA felt (quite rightly IMHO) that this was severely flawed and resulted in little effective action to prevent repetition. They then pursued the prosecution route which in itself only succeeded in proving what an inadequate tool criminal prosecutions are for investigating complex matters like this.
(See event 3 on this link which also links to a substantial article on the event)
Appendix: Internal culture and resistance to change. | PicMA (http://www.picma.info/?q=content/appendix-internal-culture-and-resistance-change)

Also well covered in Matthew Syed's book "Black box thinking".

[WHBM]

AC759: "Tower, just want to confirm. This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?"

SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."
I wonder why the tower just nonchalantly said there's nothing there if a crew reports seeing unexpected lights. How did they know a runway incursion, even by a vehicle, had not taken place ?

It's the old adage "If it doesn't look right, assume it's wrong".

[DIBO]

To not immediately secure the CVR and notify the proper authorities seems a major misjudgement.Well, they were requested to contact an FAA supervisor, and even given the phone no., before switching off. When did they call the FAA supervisor? What was discussed?
Not implying anything, but looking at the 'EK / Seychelles' incident, where it was discussed something in the line of "we don't file a report, if you don't either", we simply don't know what the AC crew and FAA super. discussed and what actions followed from that discussion.

[DIBO]

I wonder why the tower just nonchalantly said there's nothing there if a crew reports seeing unexpected lights. How did they know a runway incursion, even by a vehicle, had not taken place ?
Well, because their tower is full of the latest, fancy equipment, so the single, very busy controller handling both GND and TWR, with 2 crossing active rwy's in use and a lot of activity going on even that late at night, will most likely has checked the rwy "incursion status" on his fancy equipment and seen that all was as it should have been. And visual checking at night, at a 30-40° angle to the centerlines, would not have helped him easily spotting the misalignment... until AC actually overflew the acft's on C. And the fancy equipment 'loosing sight' of AC for about 15 sec's, surely won't have helped him either.

[Loose rivets]

And why not allow a small commercial drone to "fly" and video that night approach with similar aircraft on the taxiway, the last 3 miles or so? It could provide crucial evidence at minimal risk.


I suggested this, albeit not with a drone*, some posts back. The problem is, all the expenditure of an exact simulation would be expensive and - in the minds of the funders - primarily for a defence argument**. Also, how does one achieve an exact simulation? Every aircraft would have to be very near to the same place and have precisely the same lights on. I gather one at least put on main landing lights. Could all the crews remember their light settings at any given moment?

I can't express how strongly I feel about the RT wording used. A clear, addressed, and forceful message would have been a much better tool to warn that a major mistake was being made. But then, the issue of disbelief is as true for the crews in the firing line as it is for the landing pilots.

Tiredness. I can't count the times I've felt miserably tired during a flight - especially in the days before a quick shut-eye was allowed - but always the approach and landing were so stimulating, so much the absorbing part of why I was in the profession, that the tiredness was put on hold by brain chemistry.


*A camera aircraft with a couple of Fed guys on board is the only way.

**While it would seem primarily a flight for defence mitigation, the all-important learning issue is still valid and I feel this case is so important because it is so unexplainable.

[AerocatS2A]

They did let the CVR go, and certainly had time to rehearse the story.

How can this be in anyway mistaken?



Well, obviously it can. Or are you suggesting that they correctly identified the taxiway and decided to try and land on it anyway?

If the NTSB report is correct, in essence;
the crew has denied being on the taxiway,
denied seeing aircraft on the taxiway, and
denied outside input that influenced their decision to go around.

Not at all. If the NTSB report is correct then they didn't recall seeing aircraft. That doesn't mean they saw no aircraft, it just means that what they did see didn't look like aircraft, it probably looked like a bunch of confusing lights. Obviously they didn't think they were on the taxiway because if they did they wouldn't have been there :ugh:. No doubt they realised afterwards they were on the taxiway, but hindsight is an awesome thing.

As professionals, you are both so dog tired after a 6 hour flight that you are incoherant to land the aircraft? What part of being a professional is that?

Forget about the 400 pax, right? They all have the expectation that the people driving will get them there and are professionals. According to all the posts with excuses, the drivers were tired because it is such a lousey profession, great excuse. Its okay, just like the one who drove it into the mountain on purpose, he was real tired too.

Obviously we don't know if this crew were tired or fatigued or whatever, however, your statements on the issue betray a large amount of ignorance on the subject. Fatigue is not black and white. You are not either fatigued or not fatigued. Likewise with being tired or just having low arousal levels. If pilots refused to fly whenever they were the slightest bit fatigued, tired, or in a low point in their circadian rhythm, half the flights in the world would be grounded.

We must accept some deterioration in our performance on a regular basis otherwise we would all stay home and the aviation industry would stop. The question then is how much fatigue/tiredness/etc is acceptable? There are no hard and fast rules, everyone is different, and a big problem is that it is very difficult to predict at the start of a duty, how you will feel by the end of it.

I fly back of the clock freight all of the time and know my personal signs of fatigue. Things like asking for a checklist associated with the last type I flew rather than the current one, being slower, having a narrower focus on a task leading to poorer situational awareness, and being less critical of my own performance and that of my colleague. I do my very best to only work if I believe I am fit for duty but I don't have a crystal ball and cannot predict my future performance with 100% accuracy. One consequence of fatigue of course is a decline in the ability to make good decisions. The fatigued pilot is therefore more likely to make a poor decision about whether they are in fact fit to fly.

I am not making excuses for the AC crew, I don't know how they mistook a taxiway for a runway any more than you do, but I'm pretty sure they didn't deliberately attempt to land on a taxiway. I'm also pretty sure that if this crew were told about this incident happening to someone else they'd be just as disbelieving as we are. Something screwed up their mental model and it is much more valuable to be open to explanations (not excuses) so that we can learn something from it, rather than just sitting back, pointing, and saying "you screwed the pooch!"

[AerocatS2A]

*A camera aircraft with a couple of Fed guys on board is the only way.


The real problem with doing this is that it doesn't simulate the mental state of the pilots. It would be like watching the gorilla video when you know the gorilla is there.

[WillowRun 6-3]

. . . You make the call, and stop putting words in their mouths as they have already spoken.
1. underfire, let's assume your factual picture is painted with complete accuracy. Nonetheless, it is based only on what has emerged in the preliminary phases of the investigation. Further assume that the severity of sanction you evidently believe is deserved by the AC crew is in fact justified and deserved. Nonetheless, AC could be due for sanction too, and so could FAA if a more damaging event had occurred which fortunately it did not. So, in at least hurrying if not rushing to judgment about crew responsibility, you are short-circuiting the full process. The disagreement is not with your conclusion that the crew, if erring the way you state they erred, is due for sanction (or will be due, once all the facts are known). Nor is it necessarily with your assessment of their errors. The brutal truth is, though, we do not yet know all the facts, and the process for finding those facts has been derived over time and proven more reliable than short cuts. It's about the process. And that's for the sake not just of a decent and reasonable result for crew (and other involved parties, if any), it's also about two other factors. (AerocatS2A in #671 seemed to be making a similar kind of point.)
2. No one taking the time to write posts on this forum (posts of any seriousness, that is) fails to hold a strong desire to know the WHY: why did this sequence of events, acts and omissions, take place, and how did it all take place, as exactly as possibly determined afterwards. But preliminary - or less nicely, half-baked - conclusions about responsibility based on a very early stage of factual development strikes this poster as a good way to interfere with defining and understanding the why and the how.
3. And then there's the "what needs to be changed" discussion. One can anticipate the NTSB issuing a pretty lengthy list of stuff that needs to be changed (probably some pretty complex stuff, too). Again, premature conclusory assertions as to crew culpability and the clarity with which they deserve to be tarred and keel-hauled is a good way to interfere with attaining the necessary clarity about system modifications and the broad understandings needed to restructure system elements, if any need to be restructured (like approach airspace architecture, and runway and taxiway lighting, just to name two candidates).
4. I really don't think reference to an aviator who "drove it into the mountain" adds much here, underfire. But, it's free expression.
5. Once upon a time, a lawyer had a case in which a client had re-enacted an alleged safety violation (not involving airliners, alas). The re-enactment went very well, so the lawyer was told, in establishing the wrong-doing of the dismissed employee. Ah, but the notes taken by some of the participants....which led to the lawyerly wisdom, "you think I'm putting words in someone's mouth? Actually, they teach that art, in law school - take the course in Evidence and find out!"

[fjordviking]

@underfire.
I`ve love to have the opportunity to work alongside such a flawless individual as yourself. I Would just sit in amazement and watch and Learn from the skygod never making mistakes and never having to mitigate.

[DIBO]

The real problem with doing this is that it doesn't simulate the mental state of the pilots. It would be like watching the gorilla video when you know the gorilla is there.A re-enactment of the approach will not have the simulation of the mental state as goal, but will look and try to find other clues besides the gorilla aka twy C. You can't miss the gorilla once you know it's there, so nobody will mistake C for 28R no matter how many simulation or re-enactment flight are done. But maybe, just maybe, other factors will be discovered, by the human eye on board of an investigation plane. That's why drone camera's or simulators won't be do the job. Many post back, I mentioned differences in 'perception' of classic and LED lighting. At that time I thought LED were at a disadvantage, after updating my knowledge, it's LEDs that are better in this case, the twy centerline greens, remain 'greener' at long distance compared to classic bulbs. Not sure what twy C is equipped with (seem to remember somebody mentioning LED's), but classic bulbs in the twy centerline, might have appeared less green/more white from a distance, and maybe the AC pilots locked their minds on "visual with a white centerline" (although, knowing the gorilla, it's remains hard to comprehend that all the rest of available lighting didn't give the right clues). If twy C is already equipped with LEDs however, then one less argument in favor for the AC pilots...

[BluSdUp]

To accuse the crew of flying fatigued is serious stuff today. And for Aircanada.

Some of you confuse pure tired with fatigue, different animal.
They most likely did only one sector before this one ,if any at all.
That is as easy as it gets.
Anyway, we know NOTHING about their personal state,so fare.

My money is on complacency , a common thing after 30 and, or 10 000hrs.

So that is always in my Threat and Error Brief.

I trust that The Union and AirCanada is taking proper care of the crew.
I would imagine the Crew contacted their Union and AirCanada asap after deboarding.
Someone wrote they were told to contact a FAA rep asap.
I shure as **** would pull that CVR Cb to prevent it being over written, if I got that message. Can always push it in if all are happy.

Now, that is Company procedure were I work.

Not in AirCanada as we have seen. It is going to be most interesting to see what communication took place between the different partys that evening , and morning. Before someone clued in and phoned NTSB.

Every year I write a handfull of reports, and never hear a thing back.
No news is good news.

In this case it was uttered at least 3 times on an open channel, full of nerds listening,that he was about to land on Taxiway C.
Did they think it was going to go away, seriously dude!

Gather the facts, call the Boss , tea no crakkers! Or not!

For now, if You are tired:
Fly the ILS

[aterpster]

For now, if You are tired:
Fly the ILS

You simply cannot do that when cleared for the FMS Bridge Visual 28R. When 28L is open that would have the tower screaming at you.

[Carbon Bootprint]

It's the old adage "If it doesn't look right, assume it's wrong"

Indeed, much like "Whenever there is any doubt, there is no doubt"

(Which has probably been posted already in this thread, sorry if it's redundant.)

I'm just glad this turned out the way it did.

[BluSdUp]

Hey, Not even I fly approaches I am not cleared for!

On first contact with Approach I request vectors for ILS 28R, negative visual.

On another note, You mention in post #635 map shift etc.
I have been thinking about this.

Is it possible they had a slight MFD drift to the right. The A320 they flew not having GPS, we are looking at DME DME VOR triangulation.
The IRS being off by at least a mile after 5 hrs, how does the A320 mix the position presented and flown on the MFD ?With the FMS (visual Bridge)28R in?

If the track presented was off by just 100 meters right, they would think they were on CL.

I most certainly see FAA not loving some of these money saving , half baked so called procedures.

[WHBM]

Well, because their tower is full of the latest, fancy equipment, so the single, very busy controller handling both GND and TWR, with 2 crossing active rwy's in use and a lot of activity going on even that late at night.
AS I understand it, neither of the crossing runways were active, nor was 28L. Only 28R was in use, hence they were landing on it (with several having just preceded them) with four to depart. This is why there were so many holding to depart.

For now, if You are tired:
Fly the ILS
You simply cannot do that when cleared for the FMS Bridge Visual 28R.
So how was it that when they came round again for their second approach they could be cleared for the ILS without issue.

[DaveReidUK]

AS I understand it, neither of the crossing runways were active, nor was 28L. Only 28R was in use, hence they were landing on it (with several having just preceded them) with four to depart. This is why there were so many holding to depart.

No, there were also departures from 1L immediately prior to the incident.

[DIBO]

And also after the incident 'crossing' departures 28R / 1L continued.

And a while later, this created the recipe for a new swiss cheese on the table, with already one hole lined up. But luckily this cheese was countered as quickly as it appeared...

[Carbon Bootprint]

So what difference does it make who is departing from where? Another distraction from what could have been a huge mess, judging from the photos, animations and other resources that have sought to illustrate this incident.

[Airbubba]

So how was it that when they came round again for their second approach they could be cleared for the ILS without issue.

More nonsense :=, AC 759 was vectored for a visual approach to 28R the second time around. A visual approach is not the same as an ILS (although I'm sure some folks on this thread would argue otherwise). They were given a heading of 310 to join the final and cleared for a visual approach behind an AA 777 who was on the FMS Bridge Visual Approach 28R. It's on the tape at liveatc.net

Well, they were requested to contact an FAA supervisor, and even given the phone no., before switching off. When did they call the FAA supervisor? What was discussed?

It sounded to me like AC 759 called ground on 121.8 while everyone else had been switched to tower freq on 120.5. Sounded like AC 759 said 'What is the phone number where we could reach you? The captain's going to give you a call.' The controller said 'sure' and gave the phone number over the air. It will indeed be interesting to hear what was discussed since ATC phone lines are usually recorded from what I've seen in NTSB reports. Or, were they doing midnight maintenance on the phone recorder and the tape is regrettably not available? ;)

The old 30 minute CVR's used to have a union-mandated bulk erase button. And inevitably somehow this bulk erase button would often seem to 'accidentally' get pushed after an incident. As the NTSB put it in a famous 1979 upset investigation:

We believe the captain's erasure of the CVR is a factor we cannot ignore and cannot sanction. Although we recognize that habits can cause actions not desired or intended by the actor, we have difficulty accepting the fact that the captain's putative habit of routinely erasing the CVR after each flight was not restrainable after a flight in which disaster was only narrowly averted.

Our skepticism persists even though the CVR would not have contained any contemporaneous information about the events that immediately preceded the loss of control because we believe it probable that the 25 minutes or more of recording which preceded the landing at Detroit could have provided clues about causal factors and might have served to refresh the flightcrew's memories about the whole matter.

https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8108.pdf

[peekay4]

The old 30 minute CVR's used to have a union-mandated bulk erase button.
The rules are a bit different in Canada... erasing the CVR is a big no-no and on most Canadian aircraft the bulk erase function is disabled.

[Ian W]

Routine deletion of CVR moves things more and more toward an automatic downlink of CVR if not in flight (and yes the bandwidth is enough) then it could be automated as soon as the aircraft plugged in at the gate for every flight. The 'system' could delete CVR data if there is no requirement for the data after 28 days, in the same way as most ATM recordings.

[RAT 5]

When did they call the FAA supervisor? What was discussed?

Has this guy been identified & interviewed? From previous posts I've gleaned that the '28R Bridge approach' is used when 28L is in use so as to provide increased separation during the initial approach. Is that correct, or is it purely noise abate reasons? If the former is true, and 28L was closed, why give a more difficult visual approach at night than a simple straight forward ILS?

It has been agreed that this incident started many miles and minutes before; in the cruise, when the NOTAMS had not been reviewed and not included in the brief, apparently. There is much talk about the confusion created by what kind of approach was given. Possible. There is speculation about tiredness/fatigue, but then it was countered by the natural kick-in of stimulation by a challenging visual approach. Been there done that many times: it is correct. (We do not yet know at what point the A/P was a disconnected). What ever the approach given & flown it still remains that the route was to bring you onto a visual finals that is defined by lots of well known and often experienced lights. IMHO the type of 'Bridge' approach is a red herring. Green lights DO NOT = runway. Never and nowhere in the world. The confusion over the landing area started inside 4nm. The root cause lies well before that, but after the FMC brought them on to a visual finals 2 sets of eyes & brains managed to become confused.
I'd love to hear the CVR from 10nm out. "can you see the runway? yeah it's over there. Oh yep, go it." a few nm later. "do we land over the lights or on the right? Er, left is closed, I think, so over to the right." "You sure? I think so." etc. etc. all the way down to 100'.
GREEN lights DO NOT equal runway. Saying there are lights? on the runway, are we cleared to land is just astonishing. Lights on the runway or not, GREEN lights do not equal a landing area. And 2 pilots. Where was PM looking. Who was PM, LHS/RHS, and when were they under manual control?

[aterpster]

The old 30 minute CVR's used to have a union-mandated bulk erase button. And inevitably somehow this bulk erase button would often seem to 'accidentally' get pushed after an incident. As the NTSB put it in a famous 1979 upset investigation:

https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8108.pdf
From what I can determine FAR 91.609 (g) wasn't enacted until 10 years later. And, how would it apply to Air Canada? Are they bound by Part 91 when operating in the U.S.? Seems they would be, but I don't know.

[Ian W]

RAT you really need to do a visual perception course to see how easy it is for _your_ cognition to deceive you. Aircraft landing on taxiways is not uncommon despite all the green center lines and blue edge lights - and the pilots often high hours professionals, were all convinced they were landing on the runway. It would be better to work out why these cognitive misperceptions occur rather than question the capability of the crews involved.

Also the idea that suddenly being stimulated is a way to avoid cognitive issues has been shown to be wrong since 1908 in Human Factors research. Two psychologists Yerkes and Dodson developed a theory that has been continually shown to be true since then that both little stimulation and high stimulation can lead to errors in attention, It is often called the inverted U theory as performance is best at a median level of stress/stimulation.

From Yerkes Dodson Law - AviationKnowledge (http://aviationknowledge.wikidot.com/aviation:yerkes-dodson-law)
When arousal is high the quality of performance is expected to decline with load shedding, and tunnel vision symptomatic of attention narrowing. An experience Wickens and Hollands (2000, p. 484) describe as “stress produced perceptual tunnelling” directly resulting in a reduction in the standard of performance. (my underline)
There are many more references on inverted U and Yerkes Dodson if you do an internet search. Being at the wrong part of the circadian cycle and fatigue will exacerbate these effects.

[Sea Eggs]

Missed by 4 feet?

Air Canada Flight Misses By Four Feet
By Geoff Rapoport
https://www.avweb.com/eletter/archives/101/3762-full.html?ET=avweb:e3762:231676a:&st=email#229456

New flight recorder data says Air Canada flight 759 (ACA759), an Airbus A320, descended as low as 59 feet above ground level and the 55-foot tall 787 on Taxiway C before beginning to climb out on its go-around—coming potentially as close as four feet from a collision. At four minutes to midnight on July 7, ACA759, which had been cleared to land on Runway 28R at San Francisco International, instead lined up on Taxiway C, on which three aircraft were holding for takeoff. After prompting by one of the pilots of United Flight 1 (UA1), the first in line for takeoff on Taxiway C, who was well positioned to see that ACA759 was not headed toward a runway, the tower controller instructed ACA759 to go around. After advancing the thrust levers at 85 feet above ground level, the aircraft continued to sink to a minimum altitude of 59 feet, before overflying at least two more aircraft. Altitude figures in the NTSB report are likely based on the A320’s radar altimeter, according to an A320 pilot who spoke with AVweb about the incident. The extent to which the accuracy of the radar altimeter may have been influenced by extremely close proximity to aircraft underneath has not yet been reported by the NTSB.

According to initial interviews with the flight crew, both pilots appear to have been confused by the absence of lighting on Runway 28L, which had been closed for construction. Its lights were turned off at the time of the incident, and a 20.5-foot wide flashing X had been placed near the threshold. The Air Canada pilots reporting believing that Runway 28R was actually 28L and they therefore believed that Taxiway C was Runway 28R. According to the NTSB, the pilots “did not recall seeing aircraft on Taxiway C but that something did not look right to them.” At 0.7 miles from the runway, the Airbus crew had asked the tower to confirm there were no aircraft on 28R and that they were cleared to land. The NTSB only learned of the incident two days after the fact, at which point the cockpit voice recorder had been overwritten by subsequent flights.

[pilot9249]

uhRAT you really need to do a visual perception course to see how easy it is for _your_ cognition to deceive you. Aircraft landing on taxiways is not uncommon despite all the green center lines and blue edge lights - and the pilots often high hours professionals, were all convinced they were landing on the runway. It would be better to work out why these cognitive misperceptions occur rather than question the capability of the crews involved .

At some point, the relentlessness with which you pursue this single line of argument becomes comparable to the relentlessness with which the incident crew lined up on the taxiway.

Nothing more or less than a human frailty.

Since we were in caves, progress has been marked by two endeavours

1. Making it easier for the human to do what they do
2. Removing the human from having to do anything at all

Any argument that doesn't balance these is flying in the face of logic.

Any argument that doesn't give primacy to the second answer is flyng in the face of history.

[JammedStab]

So what are the official reasons in Air Canada's ops manual for saving a CVR recording. If not available, what about at your airline?

[framer]

but then it was countered by the natural kick-in of stimulation by a challenging visual approach.
A brain that is processing information at a reduced rate because it has been awake for many hours doesn't suddenly become able to process information faster because you're excited. You may start processing faster than you were ten minutes ago, but it is still slower than you would process if you were well rested.
It is all a matter of degrees.
If you had been awake for 200 hours would your processing rate be slow? Yes.
If you had been awake for 100 hours would your processing rate be slow? Yes.
If you had been awake for 50 hours would your processing rate be slow? Yes
If you had been awake for 25 hours..........
If you had been awake for 12.5 hours........
When does the answer become No Rat?

[peekay4]

So what are the official reasons in Air Canada's ops manual for saving a CVR recording. If not available, what about at your airline?
I've been made aware that since 2010, Canadian pilots and ground personnel must review rules and procedures re: FDR/CVR deactivation on equipped aircraft -- at least annually -- as part of their recurrent training. And the Commercial Air Service Standard (CASS) requires inclusion of the deactivation procedures in the Operations Manual.

More info: Transport Canada AC No. 700-013: Procedures and Training for the Preservation of Aircraft Recorded Data (https://www.tc.gc.ca/eng/civilaviation/opssvs/managementservices-referencecentre-acs-700-700-013-131.htm)


Air operators are requested to review their training programs to ensure all flight crew members and ground personnel receive adequate training with regard to the proper procedures to safeguard on-board recorded data following an occurrence. In order to meet the above stated requirements of the CARs and the CASS, the following training should be provided to the flight crew members and ground personnel during initial and recurrent training sessions:



Initial and annual recurrent training that addresses the importance of preserving information held on a CVR and/or FDR;

Initial and annual recurrent training that addresses the proper procedures for disabling a CVR/FDR following an incident or accident;

Awareness of the consequences of incorrectly disabling a CVR and/or FDR following an incident or accident; and

The Air Operators training program should contain a provision that ensures all flight crew members and ground personnel are trained regarding any specific aircraft differences or procedures concerning the disabling of a CVR and/or FDR.

[Ian W]

uh

At some point, the relentlessness with which you pursue this single line of argument becomes comparable to the relentlessness with which the incident crew lined up on the taxiway.

Nothing more or less than a human frailty.

Since we were in caves, progress has been marked by two endeavours

1. Making it easier for the human to do what they do
2. Removing the human from having to do anything at all

Any argument that doesn't balance these is flying in the face of logic.

Any argument that doesn't give primacy to the second answer is flyng in the face of history.

The difference between your claim and mine is that professional crews repeatedly land on taxiways. It is not uncommon. What these incidents have in common is that each crew were convinced they were landing on the runway they were cleared to land on.

The way flight safety works is not to crucify each crew with the hope of 'encourager les autres'; it is to examine each incident and try to find why these landings (and in some cases take offs) on taxiways takes place. Then attempt to prevent that happening. Human factors research shows that attentional (aka cognitive) tunneling is one reason, that is then supported by confirmation bias. The same research shows that once an individual has been shown what can happen in their heads then they are less likely to have the same tunneling. Note that is less likely not impossible.

Trying to pretend that it is just that particular crew will. inevitably, only lead to another crew perhaps actually landing on a taxiway with several widebodies queued on it. Identifying what the reason was for misidentification and finding a method of mitigating it is far more productive; and is the way flight safety has been improved in the past.

[787PIC]

*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.

When I started this thread the above was the first response to my comment.
I would like to remind the Gentleman, "What is 4 Feet between friends?":cool:

[WHBM]

More nonsense, AC 759 was vectored for a visual approach to 28R the second time around ... They were given a heading of 310 to join the final and cleared for a visual approach behind an AA 777 who was on the FMS Bridge Visual Approach 28R. It's on the tape at liveatc.net

I gladly accept your correction to what I had seen written elsewhere.

However, one then has to ask, what on earth in the SFO procedures allows an aircraft, which has had difficulties with a visual approach to a fully ILS capable runway, to be brought around and given just a visual, not an ILS-guided, approach again. I hope the FAA/NTSB really take them to task on this.

According to initial interviews with the flight crew, both pilots appear to have been confused by the absence of lighting on Runway 28L, which had been closed for construction. Its lights were turned off at the time of the incident, and a 20.5-foot wide flashing X had been placed near the threshold. The Air Canada pilots reporting believing that Runway 28R was actually 28L and they therefore believed that Taxiway C was Runway 28R.Seems just the same, along with the NOTAM that 28 approach lighting was unserviceable, as the two Gatwick taxiway landing incidents, which I hope the enquiry examines closely for common factors. Bear in mind that one of the two Gatwick incident crews were actually based there.

[ElectroVlasic]

Post #4 includes a good audio of ATC, at about 25:45:
“There's no one on 2-8 Right but you!”
“OK, Air Canada 75/Where's this guy going? He's on the taxiway!”
Fortunately, there was a guy more alert than AC flight deck and ATC, all together. He cut off the AC re-confirmation. Hundreds of souls are still with us today because of this guy. Congratulations, well done, unknown hero! :D
However, had the holes in the swiss cheese lined up differently and there were two heros reporting the problem at the same time (shades of Tenerife) the transmission would have been garbled and perhaps not understood.

Near miss, says I.

[PaxBritannica]

Humble pax here who doesn't get to see out the front. Everyone has talked about the green centreline lights on the taxiway. How many of them would have been visible, with four large aircraft lined up on top? Is it possible that only fragments of green line would have been discernible?

At night, with less visual information, the brain has to extrapolate from the visual clues it has, and wrong patterns can be made. I've certainly misinterpreted the road ahead when driving at night.

[.Scott]

There was still a good amount of green line left in front of the closest aircraft on the taxiway.
Obviously, it was still possible to miss that cue. Without an actual (not simulated) photo of that approach under those conditions, it would be hard to judge how conspicuous the color was.

[aterpster]

I gladly accept your correction to what I had seen written elsewhere.

However, one then has to ask, what on earth in the SFO procedures allows an aircraft, which has had difficulties with a visual approach to a fully ILS capable runway, to be brought around and given just a visual, not an ILS-guided, approach again. I hope the FAA/NTSB really take them to task on this.

You're not an airline pilot, are you.

[cappt]

There was still a good amount of green line left in front of the closest aircraft on the taxiway.
Obviously, it was still possible to miss that cue. Without an actual (not simulated) photo of that approach under those conditions, it would be hard to judge how conspicuous the color was.

My opinion based on 17K hours of experience. From a distance (6-8 miles out) the dimmed whites and bright greens look similar. Not like the sim picture above from short final with all the runway lights on high. This is also the distance where pilots flying a visual have already identified the runway and in their mind have shifted focus from runway identification to landing the A/C on the runway, I.E. airspeed, descent, final configuration. Throw in some circadian rhythm effects and tiredness and the holes begin to line up.
Without mentally forcing yourself to backup and reconfirm your earlier decisions one can become focused on the task at hand and prior mistakes will go unchallenged.

[EEngr]

From a distance (6-8 miles out) the dimmed whites and bright greens look similar.

And color vision at low light intensity suffers as well. Lighting/marking systems need to be based on patterns more than colors particularly at night.

[Zeffy]

...This is also the distance where pilots flying a visual have already identified the runway and in their mind have shifted focus from runway identification to landing the A/C on the runway, I.E. airspeed, descent, final configuration...
Without mentally forcing yourself to backup and reconfirm your earlier decisions one can become focused on the task at hand and prior mistakes will go unchallenged.

Good points...

Brings to mind the C-17 wrong airport (http://www.pprune.org/military-aviation/491076-c17-lands-wrong-3600-foot-runway.html) landing near MacDill AFB.

Once the target landing area had been identified (incorrectly) crew attention was focused solely to flight path and airspeed to the (wrong) TDZ.
Ironically, due to the precise flight path and airspeed guidance inherent in the HUD guidance, they got the beast stopped OK.

[aterpster]

Wasn't that during the daytime? And, I don't believe there were any other airplanes on the runway.

There is a wealth of incidents of pilots landing on the wrong runway and even at the wrong airport. But, I don't recall a case with the instant essentials where a pilot attempted to land on a taxiway occupied by well-lighted other large airplanes.

[Heathrow Harry]

firsttime for everything I guess.........

[framer]

As long as we approach the event with the assumption that these two pilots didn't do it on purpose ( I think we can all agree that is the case), and keep in mind that there have been many incidents of experienced and competent pilots landing, attempting to land, taking off, and attempting to take off on taxiways, then we must accept that the human brain is susceptible to creating the wrong patterns ( as mentioned by humble pax) if the stimulus presented is incomplete or differs from that expected.
What we do next is important, do we change the stimulus presented ( difficult in the real world but synthetic vision etc may help), or do we work on expectations? ( ATC required to transmit phrase " Runway 28R is unlit" on first contact) Or both?
If closely parallel runways had a lit orange circle or cross as part of the 1000ft markers and on a visual it was a requirement to have it in site and have a landing clearance to touch down, would that make a difference? On a PRM it wouldn't matter as the guidance is there.
Thinking out loud.

[OK465]

Bergstrom AFB (later Austin Intl) in the 60s:

On the parallel taxiway,

T
A
X
I
W
A
Y

(SV in the HUD will present and definitively outline the runway selected in the box and, in spite of comments about potential HUD fixation and the ever present danger of an incorrect FMS entry, I personally thought it to be extremely useful under a variety of circmstances. AFAIK it is impossible to enter a taxiway in the box as the destination runway. And then there's RAS....)

[galaxy flyer]

OK465 and Ian,

That's my experience with a SVS HUD, even if you hit fixated, the fixation is taking you to the runway. In the sim, it's pretty easy to land on the SVS 3V4Y7F and there is no taxiway, even the approach light is depicted extended out from the threshold.

[aterpster]

OK465 and Ian,

That's my experience with a SVS HUD, even if you hit fixated, the fixation is taking you to the runway. In the sim, it's pretty easy to land on the SVS 3V4Y7F and there is no taxiway, even the approach light is depicted extended out from the threshold.

Even without SVS and HUD, seems like remaining coupled up to the LNAV/VNAV FMS Bridge 28R Visual, would deliver a flight crew to the correct sight picture.

Then again, perhaps without GPS there could have been a slight map shift.

[peekay4]

Summary of other taxiway landing events I found, for comparison. Some may be similar to this latest incident at SFO.

USA

1983 Continental DC-9 landed on the taxiway at Denver (Stapleton). Frank Lorenzo, who was Continental's Chairman, was a passenger on board

2000 Harbor Air Flight 4506 (Cessna 208 Caravan) landed on Seattle's taxiway T (then called Taxiway C) instead of 16R, after a visual approach

2003 American Airlines MD-80 at Seattle landed on the same taxiway T instead of 16R, after shooting the ILS approach and transitioning to visual at 3,500ft AGL, visibility > 10nm

2004 Air Canada Jazz Dash-8 also landed on Seattle's taxiway T instead of 16R, despite the fact that a big X had been installed to mark the taxiway. Neither crew member noticed that they flew right over the X, and the pilots did not realize they had landed on the taxiway until informed by the tower.

2006 Continental 757 lands at Newark taxiway Z instead of runway 29 after a circle-to-land from the ILS RWY 22L. Night VMC conditions.

2009 Delta 767 from Rio to Atlanta landed on taxiway M instead of 27R in night VMC conditions. Fatigue was a factor as one of the three pilots became ill during the flight and the remaining two pilots had to fly the route without rest. The Captain (PF) had been awake for 22 hours when the incident occurred.

2015 Alaska Airlines 737 became the fourth commercial flight to land at Seattle's infamous taxiway T. Back in 2004 another Alaska 737 also nearly landed on this taxiway, until an FAA inspector riding in the jump seat alerted the pilots on short final.


Worldwide

1988 British Island BAC 1-11 at Gatwick landed on taxiway 2 instead of 08L after a night visual approach. A British Airway 737 was on taxiway 2 at the time, and veered off the taxiway to avoid a potential collision (but got stuck in the mud). The 1-11 stopped 190 meters short of the 737.

1993 Air Malta 737 also landed on Gatwick's taxiway 2 after a night SRA approach. The Air Malta crew thought runway 26R was 26L, and after some discussion convinced themselves that the pavement even further to the right must be 26R.

2006 TAP A320 at Sao Paulo landed on taxiway B instead of 27R (http://www.pprune.org/rumours-news/212617-did-a340-very-recently-land-taxiway-sao-paulo.html). Language may have been a factor as ATC tried to tell them to go around, but in Brazilian Portuguese.

2007 KAL 737 landed on the taxiway at Akita, Japan. Both pilots convinced themselves that the taxiway was the runway -- despite looking at the actual runway -- and concluded that the actual runway must be a "new one under construction". VMC with ceiling at 4,000ft and visibility > 10nm. Interestingly, the Captain (PF) made the approach with a HUD, but on this non-precision approach the runway was not indicated on the HUD's symbology and Captain manually aligned the Flight Path Symbol to the taxiway instead of the runway.

2009 Ryanair 737 landed on the taxiway (http://www.pprune.org/rumours-news/369682-ryr-landed-taxyway-mistake-cag.html) at Cagliari, Italy. Daytime VMC.

2011 Thomson 737 lands on the taxiway (http://www.pprune.org/rumours-news/464307-thomson-737-lands-taxiway-paphos.html) at Paphos, Cyprus.

[galaxy flyer]

Even without SVS and HUD, seems like remaining coupled up to the LNAV/VNAV FMS Bridge 28R Visual, would deliver a flight crew to the correct sight picture.

Then again, perhaps without GPS there could have been a slight map shift.

There's just something wrong about "coupled approach" and "visual". Do we know when the crew disconnected the autopilot, or more accurately, are we sure it was hand flown from earlier in the approach? I know what your saying, but at some point a visual is a hand flown maneuver.

[b1lanc]

Summary of other taxiway landing events I found, for comparison. Some may be similar to this latest incident at SFO.


I get that point and there's probably as many incidents of landing at the wrong airfield. But which one of those crews actually tried to set their aircraft down on top of other aircraft? The alarm bells in the cockpit (and maybe an understaffed tower with a gap in radar coverage) went off far too late.

[pilot9249]

The difference between your claim and mine is that professional crews repeatedly land on taxiways. It is not uncommon. What these incidents have in common is that each crew were convinced they were landing on the runway they were cleared to land on.

The way flight safety works is not to crucify each crew with the hope of 'encourager les autres'; it is to examine each incident and try to find why these landings (and in some cases take offs) on taxiways takes place. Then attempt to prevent that happening. Human factors research shows that attentional (aka cognitive) tunneling is one reason, that is then supported by confirmation bias. The same research shows that once an individual has been shown what can happen in their heads then they are less likely to have the same tunneling. Note that is less likely not impossible.

Trying to pretend that it is just that particular crew will. inevitably, only lead to another crew perhaps actually landing on a taxiway with several widebodies queued on it. Identifying what the reason was for misidentification and finding a method of mitigating it is far more productive; and is the way flight safety has been improved in the past.


You reinforce my point by continuing to pursue the same line relentlessly and regardless what the other person actually said.

While you are busy saying what you always expected to say anyway (and hence land on the taxiway) you miss my point and the runway entirely.

I never said crucify the crew.

What I said is that the human brain is so complex and on margin unpredictable, that we should do everything we can to remove the human brain from the equation, before accepting defeat and accommodating it.

And that history dictates regardless what you and I discuss, over a slightly longer arc, this approach to safety is completely inevitable anyway.

[jugofpropwash]

And color vision at low light intensity suffers as well. Lighting/marking systems need to be based on patterns more than colors particularly at night.

Haven't heard this suggested, but some people's color vision is better than others - perhaps in this case, the pilot's color vision wasn't quite 100%?

Not sure when these pilots started their day, whether they would have been up and/or flying during daylight hours? I don't usually have a problem driving at night, but if I've been driving all day in the sun, then I have trouble seeing after it gets dark.

From a distance, could the lights on the planes have drowned out the green center line lights, and seeing the lights, the assumption was made that those were the runway lights? As someone said, once fixated on the idea that "that's the runway" it could be hard to rethink that.

[DingerX]

I get that point and there's probably as many incidents of landing at the wrong airfield. But which one of those crews actually tried to set their aircraft down on top of other aircraft? The alarm bells in the cockpit (and maybe an understaffed tower with a gap in radar coverage) went off far too late.

It's harder to find information on near misses than to see the irrefutable proof rolling out on the taxiway. That said, there have been two Archie (http://www.natca.org/index.php/media-center/other-natca-awards/archie-league-awards/94-the-2014-honorees/912-new-england-region) awards (http://www.natca.org/index.php/media-center/other-natca-awards/archie-league-awards/119-the-2017-honorees/1743-ross-leshinsky-and-boston-eric-j-knight-boston) given in the last four years to Boston controllers sending around aircraft on short final to Taxiway B, in both times, much to the distress of the JetBlue passengers and crew on said taxiway.

And by the way, the human brain wrote the equation. You can't write it out, just shift the brains that enter into it and the conditions they do so.

[Volume]

Everyone has talked about the green centreline lights on the taxiway. How many of them would have been visible, with four large aircraft lined up on top? Is it possible that only fragments of green line would have been discernible? I have asked before, is SFO having "modern" LED or "traditional" light bulb lighting? LED typically have a significantly smaller angle under which they shine their light. Is green light produced by green LED or is it composed from a combination of blue and yellow? Is the colour that clear from any angle? After all the center lights are designed for the aircraft on ground, not for those on approach. Only the approach lights are supposed to be seen from the 3° ILS path.

[DaveReidUK]

I get that point and there's probably as many incidents of landing at the wrong airfield. But which one of those crews actually tried to set their aircraft down on top of other aircraft?

Albeit not involving a wrong runway/airfield or taxiway, the crew of US1493 (https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9108.pdf) (through no fault of their own) ended up doing exactly that.

[DingerX]

Well, if you include wrong runways, this nearly happened at SFO in VFR one fine afternoon in April, 2015 to an American 767 that, when told change to/clear to land 28L, readback but continued to 28R (https://www.youtube.com/watch?v=pZut0eBRVQY). A United 320 bailed out to C in a hurry. That crew was at the end of a long trip; just after leaving DFW, they had to return with a medical emergency; two hours later, they left again. That one didn't make the news either.

[aterpster]

There's just something wrong about "coupled approach" and "visual". Do we know when the crew disconnected the autopilot, or more accurately, are we sure it was hand flown from earlier in the approach? I know what your saying, but at some point a visual is a hand flown maneuver.



If you go back through this thread (yeah, right) someone who currently operates into KSFO and who has used this FMS 28R database visual approach stated how nicely the airplane flies the approach, with auto-throttles.

I have the source. It aligns with the Runway at FD101, or about 3.6 miles from the threshold, and on a 3.0 degree VNAV path. Jeppesen codes these types of FMS database visuals to switch from terminal to LNAV/VNAV approach sensitivity (RNP 1.0 to RNP 0.30) at what Jeppesen considers to be the "FAF."

So, when are you supposed to disconnect? I don't know. I hope the carriers provide some type of training for commercial crews to use this non-public FMS visual procedure.

So far as where the visual segment begins, that would have to be at the point the clearance for the visual is issued. And, how close in should this procedure be disconnected from autoflight? 500 feet?

We don't know whether AC was coupled to the procedure.

What concerns me beyond this incident is that at least some portion of this procedure is being flown in IMC as a de facto instrument approach. I suppose the vertical path is above the applicable ATC MVAs until 1,600, which is the lowest MVA over the water east of 28L/R.

[peekay4]

What concerns me beyond this incident is that at least some portion of this procedure is being flown in IMC as a de facto instrument approach.

Not sure what you mean there... when flying a visual approach procedure, one cannot be in IMC by definition, i.e., must remain clear of clouds and maintain visual with the airport environment and/or preceding aircraft.

[testpanel]

IMC vs IFR (again)?

[aterpster]

Not sure what you mean there... when flying a visual approach procedure, one cannot be in IMC by definition, i.e., must remain clear of clouds and maintain visual with the airport environment and/or preceding aircraft.
The weather minimums:

WEATHER MINIMUMS
SFO Ceiling 2100'- VIS 5
OR SFO Ceiling 1000' - VIS 3 With VIS 5 in Eastern Quadrant (030^ Clockwise 120^) and San Mateo AWOS Ceiling 2400' - VIS 5 [San Mateo AWOS info available from SFO Tower. If San Mateo AWOS inop, use San Carlos (KSQL) ceiling of 2400'-VIS 5; San Carlos ATIS on 125.9]

Let's say the weather is 2,800 overcast, visibility 8 miles. ACME AIR checks in passing CEDES and requests the FMS visual. The clearance, "Descend via the track and altitudes of the FMS visual. Expect clearance for the visual passing JANYY."

Why else would they have weather minimums well below the altitude at ARCHI?

Pure speculation on my part. :-)

[aterpster]

IFR is a flight plan and a clearance. It provides authorization to operate in instrument meteorological conditions (IMC) But, often on an IFR flight plan there isn't either a cloud or restricted visibility anywhere along the route being flown.

[Zionstrat2]

I've read the entire thread and think I understand most of the cheese holes including night vfr risks and ils not aligned with this approach.

But can someone explain to us GA folks why the FMS isn't always in use as an extra precaution?

I thought that FMS had dbase access that could load up everything, vor, dme, ils etc and GPS when available.

So am I misunderstanding the potential ability of fms to provide a backup for vfr or do airlines simply not use fms as backup?

Probably missing something obvious so please don't toast me;)

[peekay4]

Let's say the weather is 2,800 overcast, visibility 8 miles. ACME AIR checks in passing CEDES and requests the FMS visual. The clearance, "Descend via the track and altitudes of the FMS visual. Expect clearance for the visual passing JANYY."
Technically you're not on the procedure until you're cleared for the visual and fly it.

At SFO they may tell you to "join the FMS Bridge visual for routing only". But this isn't clearance to fly the FMS Bridge visual approach. You're simply flying a set of waypoints at that point (possibly in IMC) and provided all the usual IFR protections / separation by ATC. Nothing of concern here.

But you can't fly the visual approach procedure in IMC. ATC must confirm with the pilot if the airport environment is in sight before issuing the clearance. And the pilot cannot accept the visual approach unless he/she can execute it without going back into IMC.

Once you accept the visual approach, different rules apply, e.g., you're responsible for separation from the aircraft you're following, etc. However, there's no "hybrid" situation where you're somehow flying a visual procedure but in IMC with less protections than other IFR segments.

[glofish]

But can someone explain to us GA folks why the FMS isn't always in use as an extra precaution?


The FMS is basically always set up and active in modern airliners, because it does exactly that: Manage the flight. This includes a lot more than the navigational part.

Concerning this particular flight, there would have been multiple possibilities to put the intended flight path, or an aide to it, into the FMS. What happens quite often during programmed approaches with a visual final part is, that the pilots, when they transition to this visual phase, no longer follow the programmed FMS magenta line and fly ..... visually. For one reason, the visual part might not be displayed/programmed entirely, or pilots divert intentionally due to approach paths not aligned with the runway.
What i am trying to point out: Even if the flight path is partially or entirely programmed in the FMS and displayed on the PFD, many pilots switch to complete visual paths for many reasons.
Therein lie the traps. In not doing so regularly (children of the magenta), they might then screw up ......

The easiest way to get some valuable help would be to program the landing runway into the FMS as the last waypoint, with an extension on the aligned bearing. Most modern FMS allow that with a 5nm final displayed as a magenta line on the PFD. This allows a nice line up for the visual final part, some 2nm before impact.

At this stage we do not know what was programmed and displayed in the AC 320.

[aterpster]

Technically you're not on the procedure until you're cleared for the visual and fly it.

At SFO they may tell you to "join the FMS Bridge visual for routing only". But this isn't clearance to fly the FMS Bridge visual approach. You're simply flying a set of waypoints at that point (possibly in IMC) and provided all the usual IFR protections / separation by ATC. Nothing of concern here.

That's what I meant by my hypothetical clearance:

"Descend via the track and altitudes of the FMS visual. Expect clearance for the visual passing JANYY."

Later, I am going to plot the FMS28R on the NCT MVAs.

[Zionstrat2]

The easiest way to get some valuable help would be to program the landing runway into the FMS as the last waypoint, with an extension on the aligned bearing.
At this stage we do not know what was programmed and displayed in the AC 320.

Glofish, thanks so much! This helps tremendously.

So if this form of VFR backup is readily available, why isn't it SOP? Is it the pilots personal preference or varies airline to airline?

Again this may be stupid, but it seem that other than the time to enter an extra waypoint, the only other problem possible would be last minute changes- ie, if we're VFR and controller moves from us LRWY to RRWY, the final waypoint doesn't line up-

But that would be the exception and most of the time the magenta line would still support what we are seeing?

Thanks again-

[wiedehopf]

@zionstrat2

i assume you have not read the whole thread?

a much better approach is to overlay the localizer from the ils, but that is not done because deviations from the glideslope trigger an automated warning requiring to go around.
also the fms is just not set up to do it. why not? i don't know because aircraft computers need to be programmed and apparently it has not been done.

as you might have read the a320 in question did not have GPS.
dme/dme/iru accuracy is not good enough to give a safe differentiation of runway vs taxiway. (or maybe i am mistaken?)

it has already been proposed to only perform ILS-approaches at night or ever ...

well there are always pros and cons as you can also read in the rest of the thread.
as to why isn't everything done for safety? well you need some people to die to change things up most of the time.

things are also already changing with newer versions of aircraft having hopefully better FMS systems.

but for approaches like this it wouldn't be a bad thing to have the localizer programmed in as a reference for the final lineup with the runway.

[ZOOKER]

An even better approach would have been to have all the proper lights on.

[Zionstrat2]

@zionstrat2
but for approaches like this it wouldn't be a bad thing to have the localizer programmed in as a reference for the final lineup with the runway.

So if it isn't a bad thing, why isn't it happening, ie pilots personal preference, varies airline to airline, etc?

[Rob Bamber]

Or how about if ATC informs: "cleared to land on 28R. Please note 28L lights are switched off."?

[+TSRA]

Otherwise known as a NOTAM? At some point, you have to have a little trust that people will read the paperwork given to them, read or listen the ATIS for updated information, and put all that into a plan.

And that is all easy to say sitting in my hotel room and not sitting in the cockpit of an airliner with little energy because my body thinks it should be asleep.

[wiedehopf]

@zionstrat2

i thought stating the reason and asking you to read the answers on the topic of ils tuning in this thread was enough but i guess i'll try again, i wrote
but that is not done because deviations from the glideslope trigger an automated warning requiring to go around.
also the fms is just not set up to do it. why not? i don't know because aircraft computers need to be programmed and apparently it has not been done.

so basically when doing a visual approach without lnav/vnav guidance (FMS visual) it's not a problem to tune the ils because there is no other approach mode active.

but the fms seems to be not flexible enough to accommodate it properly according to this post
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-4.html#post9829103

also read these posts
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-8.html#post9831663
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-9.html#post9832515
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-10.html#post9832855

and this post
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-11.html#post9833997

and finally i can recommend this very nice post:
http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-12.html#post9836345

so it would be nice to have it .... even nicer would be to notice the missing ALSF-II or the missing PAPI.


oh another thing: once you misidentify the runway you might not even look at the ILS indication.

regarding that: observed 2 747s on the VOR22L at JFK with 3 weeks or so in between line up with 22R and go around after the controller caught their error. (observed as in online flight tracking and liveatc)
the procedure lines you up quite well with 22L so the minimums are around 500 ft
but with good visual conditions pilots tend to line up with the runway a lot earlier.
both those approaches where in the daytime.

what would in my opinion be much better (if the radars are sufficiently precise) to give the controller automated warnings about straight lines towards non-runways (22R here would apply as it was an inactive runway).
an international standard about sequenced flashers active for every active runway wouldn't be bad. so no flashers == you don't land.
flashers have the advantage of standing out from other lights at night and being energy efficient enough to make them bright enough for day use and being recognized from far away.

a lot of things would be an improvement, the question is which are going to be an actual improvement to safety. also you could argue no need to spend even more money on this while cars are still statistically much more dangerous. you could also call for lower controller workload which certainly would not be a bad thing :).

i wonder what the system announcing "approach runway xxx" would've given an alert instead or if it wouldve just said approaching 28R because it was relatively close :)

[413X3]

Or how about if ATC informs: "cleared to land on 28R. Please note 28L lights are switched off."?
At that time of night, the single controller is clearance, ground, and tower. He/she has enough to do than remind a pilot to do their job and read the notam and listen to the atis.

[framer]

As a pilot I am often struck by the workload of controllers when they are doing exactly this. I sit there waiting for taxi with a pretty small mental picture of what needs to occur to keep my aircraft safe and marvel at the size of the mental picture the controller is developing and maintaining. The tug driver making a hash of his request for tow at one end of the field, the A320 confirming landing clearance at 300ft ( probably tired due time of day), the Dash requesting taxi half way through the transmission from the China 340 that's just joined a long final and the 737 wanting to read back his digital departure routing clearance.
The controllers do a good job but we ask a lot of them at these times of the day when they would normally be asleep. Have we ( AviatIon Industry) started asking too much of our people in the name of 'lean operations' ?

[AerocatS2A]

That's what I meant by my hypothetical clearance:

"Descend via the track and altitudes of the FMS visual. Expect clearance for the visual passing JANYY."

Later, I am going to plot the FMS28R on the NCT MVAs.

I would assume you are always above the MVA. It is common enough in Australia to have visual STARs that provide tracking to ultimately align with the runway and end with a visual approach. You get progressively stepped down by the controller as you track via the STAR (an Aus thing, they could just as easily clear you to "descend via the STAR" but that is not yet done here). Once you call "visual" you get cleared for the visual approach. An example is the LIZZI 4V into Melbourne. So it can all be in IMC right up to the very end but you're never using it to descend below the MVA.

[AerocatS2A]

The controllers do a good job but we ask a lot of them at these times of the day when they would normally be asleep. Have we ( AviatIon Industry) started asking too much of our people in the name of 'lean operations' ?

I think so. And I think the people have a "can do" attitude and persevere. This results in the bean counters getting the impression that everything is just fine while the workers are gradually being ground down. Consider a pilot base that has 30% less than optimum pilot numbers. Through hard work, overtime, callouts, etc, all of the flying gets done. The accountants think they have just the right number of pilots while the pilots consider there to be a dire staff shortage.

[llondel]

Otherwise known as a NOTAM? At some point, you have to have a little trust that people will read the paperwork given to them, read or listen the ATIS for updated information, and put all that into a plan.

With all the confirmation readbacks with ATC and mention of ATIS via radio, what safeguards are there to ensure you have possession of all the relevant NOTAMs? While it is ultimately the flight crew's responsibility to be fully informed, I assume that in practice they're provided with copies of relevant NOTAMs by their company system, so how do they know they've been given all of them?

[Ian W]

A very pertinent question. However, normally the problem is that to ensure that none are missed the crew are given a slab of paper with all the NOTAMs for the region(s) being flown in. The crew are expected to wade through these and ensure that they have read and understood the effect on their operation of the important ones.

This is slowly changing with the use of electronic flight bags where the tablet computer has all the NOTAMs but can filter out those needed for the particular flight and even display them graphically if necessary. I have often wondered if the beancounters ever cost out all the paper and special impact printers and crew and departure gate time vs the cost of a tablet computer. Not to mention the increase in safety from better presentation of information weather, PIREPs, SIGMETs, NOTAMs and other aeronautical information

[czarnajama]

The CBC's main newscast "The National" for the evening of Aug. 9 had an 11.5 minute segment on AC 759:

https://www.youtube.com/watch?v=LmqSdRfEaeU&spfreload=10

It was hosted by anchor Wendy Mesley, and after a sketchy account of the incident, presented a much better in-depth discussion of pilot fatigue and Canada's very poor regulations in this regard. Barry Wiszniewski ( ‎President at Aviation Safety Management Experts - ‎Canadian Society of Air Safety Investigators) and Dana Adamus (International (Canada) President, ALPA) were interviewed, with sound bites from government officials to illustrate the influence of the airline lobby preventing improvement of Canadian rules (in contrast with a successful post-Colgan US citizens' campaign). An improvement is now vaguely "promised".

[aterpster]

For you techies.

Attached is the procedure in question plotted with the NCT MVAs and the SFO TAC. I have confirmed the procedure goes from terminal to approach sensitivity (RNP 1.0 to RNP 0.30) at F101D.

[peekay4]

Nice aterpster!

It would be interesting to plot some of the ADS-B data points against the procedure. To my eye it does not look like the aircraft made the turn across the bridge towards F101D, perhaps suggesting the PF was already hand flying prior to the bridge.

Incidentally it's JANYY instead of JANNY (a different waypoint near Los Angeles).

[portmanteau]

Framer, thanks for the recognition but Atcos like millions of other people, including pilots,
work during the day and during the night. I never heard of problems due to circadian cycles
in my time in the air and in Atc. In Atc one of the skills is in knowing what the aircraft are going to say before they say it. It works, most of the time. Also it is unlikely that even a single controller on duty in the Tower will be alone. Alongside him/her will be a clued-up assistant.

[aterpster]

Nice aterpster!

It would be interesting to plot some of the ADS-B data points against the procedure. To my eye it does not look like the aircraft made the turn across the bridge towards F101D, perhaps suggesting the PF was already hand flying prior to the bridge.

Incidentally it's JANYY instead of JANNY (a different waypoint near Los Angeles).
Thanks for the catch. I'll correct it and repost with TRDOW included.

I am familiar with JANNY, a STAR into KBUR.

[Rob Bamber]

At that time of night, the single controller is clearance, ground, and tower. He/she has enough to do than remind a pilot to do their job and read the notam and listen to the atis.
I agree entirely. That was not what I meant.

My analysis is this. When the pilot is cleared to land on 28R, there is an implicit instruction here to be careful not to land on 28L. These pilots were so fixated on avoiding L that they lined up on a taxiway. There's been a lot of discussion about technological solutions, and hand-wringing that the plane was not equipped with GPS. I'm offering the idea there may be a simpler solution.

Let me reframe my inicial suggestion. How about, when one runway is not visible, atc drops the L and R, and simply says cleared to land on 28. Cognitive dissonance should then snap any pilot, whose not as prepared as they may be, out of a tunnel-vision routine.

[peekay4]

Good to see outside-the-box thinking but it's not workable operationally or legally. Eg., procedures are often runway specific, performance calculations, etc., and may create unintended consequences. All else equal it's better to give pilots the full picture rather than hiding info from them.

[cossack]

Framer, thanks for the recognition but Atcos like millions of other people, including pilots, work during the day and during the night. I never heard of problems due to circadian cycles in my time in the air and in Atc. In Atc one of the skills is in knowing what the aircraft are going to say before they say it. It works, most of the time. Also it is unlikely that even a single controller on duty in the Tower will be alone. Alongside him/her will be a clued-up assistant.
I certainly don't feel on the top of my game during the night and work in a tower where I do work alone, all positions combined, without an assistant, usually using a crossing runway, noise preferential configuration answering phone calls about sundry crap.
Controlling the frequency (all frequencies are cross-coupled) is paramount and prioritizing your tasks to maintain control comes with experience. Just a couple of "say agains" and that control can be lost for a while and the timing of a take off clearance maybe delayed so that you can't shoot that gap any more.
Maintaining an effective traffic scan is paramount but there's no doubting I could do it better during the day when I was more alert and so don't push it. I do sit right next to the coffee machine though.:ok:
framer: If we fattened up the night shift to allow two controllers to work all night, we would lose one from the much busier times of the day which we already can't fully staff most days without copious overtime. If we can't staff the unit fully with what we do now, we're not going to get very close to adding one more on nights.

[OldLurker]

All else equal it's better to give pilots the full picture rather than hiding info from them.Indeed. And one thing that's hidden from the pilots in a night visual approach is the runway ident, such as 28R, painted on the runway – not that clearly, but visible in daylight, not of course at night.
Suppose you replaced the arrays of red and white approach lights before the threshold (see photo on page 7 of this thread) with lights spelling the runway ident, suitably elongated on the ground so as to be readable from the angle of the approach?
And at places with a history or danger of taxiway approaches or actual landings, such as Seattle's taxiway T (or this one at SFO), maybe put lights similarly before the 'threshold' of the taxiway, spelling TAXIWAY or TWY, readable from the angle of the approach?

[DaveReidUK]

It would be interesting to plot some of the ADS-B data points against the procedure.

As previously discussed, the elderly ACA A320 was not equipped with GPS and so its ADS-B transmissions almost certainly didn't correspond with where it actually was.

Look at its track on FR24 and you will see what I mean.

[peekay4]

I'm not talking about their actual flight path, but whether or not there was a turn to F101D (and then to the runway).

If they were on A/P until F101D, then even without GPS the ADS-B plot should still parallel the FMS procedure with the same turns, i.e., the same lateral & vertical profiles but just shifted a bit.

(I don't have an FR24 subscription else I'd plot it myself).

[underfire]

Attached is the procedure in question plotted with the NCT MVAs and the SFO TAC. I have confirmed the procedure goes from terminal to approach sensitivity (RNP 1.0 to RNP 0.30) at F101D.

It appears you dont have SAMUL at 7DME shown.

F101D D4.4 (1200), SAMUL D7.0 (1500), JANYY D10.0 (2500)...etc.

The easiest way to get some valuable help would be to program the landing runway into the FMS as the last waypoint, with an extension on the aligned bearing.

It already is. When you call it up in the box, it is all there, to RW28R.

The design is squeezed a bit, with a 'FAF' at 4.4nm instead of 5nm, and the dogleg from SAMUL to F101D is in reality making F101D a FROP as well.