Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO! [Archive] - Page 4

peekay4

11th Aug 2017, 14:32

I think that is a little unfair on the controller at Lexington. The two thresholds were effectively in the same place viewed from the tower. The flight crew chose an unlit GA runway rather than the lit main runway. Visibility over airports at night is confusing at the best of times. By the time the controller could have recognized that the aircraft was attempting takeoff on the short runway he could have said nothing to prevent the accident.
FWIW, I re-read the NTSB final report once again and I think it's fair to say the board believes that having only one controller that morning -- against FAA guidance -- was an additional factor in the accident:

The controller further stated that it might have been possible for him to detect that the accident airplane was on the wrong runway if he had been looking out the tower cab window. ...

The concurrent radar and tower tasks that required the controller to divide his attention occurred during the window of opportunity when the controller could have, but did not, notice that the airplane was stopped short of runway 26.

After the controller transferred control of American Eagle flight 882 to the Indianapolis ARTCC, he did not have any further active radar duties. However, after the transfer, the controller performed an administrative task—the traffic count—instead of monitoring the departure of Comair flight 5191. The controller had turned around in the tower cab to perform this task before the start of the critical window. At that time, the airplane had not yet deviated from the issued clearances. However, at the end of the critical window, the airplane had accelerated beyond the maximum airspeed that would have allowed the airplane to remain on the available runway if the flight crew rejected the takeoff and used maximum braking.

Thus, at that point, the controller missed his final opportunity to notice the flight crew’s error in enough time to take action to prevent the accident.
https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0705.pdf

After the accident, FAA increased staffing at LEX, hiring four additional controllers. It will be interesting to know the staffing levels at SFO at the time of this incident.

JW411

11th Aug 2017, 16:45

We have now had 39 pages of wheat and chaff.

I am still incredulous that two grown men cannot safely fly a visual approach at night to a well-lit runway in good weather conditions without creating 39 pages of wheat and chaff on pprune.

llondel

11th Aug 2017, 18:03

Someone made the decision that computers for safety critical systems had to be 'formally proved' by mathematics. This was difficult but just about achievable with 'simple' 286 chips with a single core and nothing really clever in its operation. However, with multicore CPUs which are effectively a set of computers working together all dropping and picking up threads of programs, pre-fetching expected code branches based on algorithms, being pre-empted and picking up a new thread etc etc., formal proof becomes impossible or at least an nP problem. Certification testing is going to have to change as it makes no sense to restrict the capability of the CPU in the FMC in this way.

The trend now is towards voting systems, so if one gets it wrong due to a glitch, it gets outvoted. I think the space shuttle had multiple systems with the proviso that one was built by someone else to the same spec but was otherwise completely different just in case the other four processors had a common bug.

It is way harder to have a formally-proven system because quite a bit of what is taken for granted in most computer gear is not allowed because it can't be reliably modelled.

ATC Watcher

11th Aug 2017, 18:22

On the controllers shortages at SFO , I do not have the exact figures but Nationwide it is between 15 and 20% , mostly compensated by overtime . NATCA has an interesting piece on the US controller shortage on their web site : http://www.natca.org/
The total number of fully certified professional controllers (CPCs) has dropped 10 percent since 2011 and continues to decline. The most recent FAA count indicates there are 10,532 CPCs. This number represents both a 28-year low and the disturbing continuation of a sharp five-year decline. The lack of a stable, predictable funding stream has made these problems worse. Despite some incremental progress since late 2015, the current total of CPCs is more than 2,300 short of the FAA’s overall operational target of 12,896.

But as to the question : Would an extra controller had spotted the deviation earlier ?
I frankly do not think it would have made any difference in this case , but that is only my opinion.

RAT 5

11th Aug 2017, 18:58

wingview

11th Aug 2017, 18:59

I still don't understand is why the United crew didn't say "AC, go around you're on the taxi way"?! It was clear that ATC didn't noticed it. With that, I'm surprised that ATC didn't see what was going on. Same thing with the Asiana who was below the glide at final. Do they have such old equipment that they can't see it?

peekay4

11th Aug 2017, 21:02

It does seem an odd situation whereby people are asking if a second ATC controller, positioned at the side of an approach, at night, could have a better visual appreciation that a 2 man crew could be lined up, visually, on to the wrong runway.
It's about providing additional layers of safety.

When pilots make errors, we want to give controllers the best chance to detect them so corrections can be made. Likewise when controllers make errors, pilots should also have the awareness and tools to detect and correct them.

I find it odd that the layered approach to safety is so difficult for many to understand. The 'Swiss cheese' model has been around for awhile now.

Carbon Bootprint

11th Aug 2017, 21:57

^^ Nothing wrong with that, but I think wingview's point may have been that since the two-person "layer" didn't work for the AC crew, there's no certainty that two ATCs further removed from the scene would have worked any better. That's the way I read it, anyway.

pilot9249

12th Aug 2017, 00:04

The controller certainly seems to share neither blame nor responsibility.

That said, with hindsight, they did give an unhelpful and mechanical response to an obviously confused arriving aircraft.

From the evidence presented here, I choose to believe that a less busy controller could have added more value, suggesting to me at least that controller staffing levels or workload may be a contributory factor.

aterpster

12th Aug 2017, 00:39

FWIW, I re-read the NTSB final report once again and I think it's fair to say the board believes that having only one controller that morning -- against FAA guidance -- was an additional factor in the accident:

How many checks and balances? Or, hindsight is always 20/20.

The only realistic contributing factor at LEX was the messed up taxiway configuration. (Long since resolved.)

The crew caused this crashed by:

1. Not checking their EHSI magnetic heading against the runway heading for reasonableness.

2. Taking off on an unlighted runway without so much as a question.

3. Far too much extraneous conversation during taxi out.

Also, pre flight of the wrong airplane.

peekay4

12th Aug 2017, 01:19

How many checks and balances?
Why should there be a limit?

The controller was already there, and in his own judgement, if he wasn't doing other tasks he might have been able to detect that the aircraft was lined up on the wrong runway.

Why not support him by:

Not putting him on a schedule resulting in 2 hours of sleep in 24 hours on the backside of his circadian rhythm
Making available a second controller to share his workload, per FAA guidelines
Giving him time & space to observe critical phases of flight, instead of doing admin tasks
Providing additional tools / technology to detect wrong runway incursions

49 people perished on that crash. If another set of eyeballs had a chance to prevent the accident, why not take advantage of that?

underfire

12th Aug 2017, 01:27

But as to the question : Would an extra controller had spotted the deviation earlier ?
I frankly do not think it would have made any difference in this case , but that is only my opinion.

I really doubt, given how close the runway is to the taxiway, and the angle to the Tower, that they would have been able to percieve they were not on the runway.

Ditchdigger

12th Aug 2017, 03:27

I asked my wife, a recently retired controller of the Tower/Tracon variety, if she had any comments after reading the preliminary stuff from the NTSB that was posted many pages ago.

Her third comment was that aircraft lining up with taxiways happens a whole lot more often than you hear about.

Her second comment, which directly addresses the post above, was that it is really difficult from the controller's position in the tower to identify exactly which stretch of pavement an aircraft is lined up with.

Her first comment, addresses workload--at the time this was all unfolding, just before the hour, the lone controller might very well have been cutting a fresh ATIS, in addition to everything else.

FWIW.

Carbon Bootprint

12th Aug 2017, 04:34

Thanks for that, Ditchdigger. It helps to give an ATC perspective.

RAT 5

12th Aug 2017, 07:51

One can surmise that reducing to a single multi-tasking ATC controller at supposedly quiet times is purely a cost saving issue. As has been mentioned on many issues over the past decades there will a point where cost saving starts to impact on safety. The skill in risk assessment application is balancing the cost savings with still providing an acceptable of level of safety. We've all noticed over the past couple of decades how many items have been dumbed down: e.g. reduced reporting times with self briefing; the self-help printing of nav' plans, NOTAMS, weather etc., the removal of crew apron transport = longer times from crew room to a/c all causing less time for in-depth flight preparation, reduced turn-round times = expedited flight preparation for following sectors, reduction in number of licensed engineers, ATC controllers on multi-frequencies, reduced pilot training and SOP's that dilute pilot handling skills, reduced experience for command upgrade, etc. etc.
I wonder if the industry is close to tipping points in some areas. I wonder if TEM & risk assessment techniques are being applied to supporting links in the chain in the same way we are taught to apply them in the cockpit. I wonder if the bean counters just go-ahead with their scalpel un-supervised until it becomes obvious that there is too much bleeding as the fat has been cut to the quick?

underfire

12th Aug 2017, 11:57

Searidge has a tracking capability in their software (not sure about MPH!?!) This does warn if the ac is not on the runway.
https://pp-cdn-madavor.netdna-ssl.com/2017/07/remote-atc-ai.jpg

ZOOKER

12th Aug 2017, 21:56

ATCOs recording ATIS broadcasts?

Bedder believeit

12th Aug 2017, 23:53

In Hong Kong where I last worked in the tower (2 years ago) the tower assistant prepared the basic ATIS info which is mainly electronically generated, but the tower controller had to authenticate the information contained therein before broadcasting the ATIS. This was critical when undergoing runway changes and/or trying to keep ahead of rapidly changing weather conditions. As yet I doubt that there's an ATIS mechanism that is able to anticipate all of the parameters that a live breathing controller is able to forecast.
As for the controller's ability to accurately assess runway alignment for approaching aircraft, in Australia, Dubai and Hong Kong where I worked, the tower controller had a readout of the terminal radar display that indicated where the landing aircraft were tracking. I don't know what happens in the States, but I would have to guess they have something similar.
Just remember, that for every radio transmission that the system records as ATC radio "chatter" is probably about 20% of the controller's workload, particularly when it's busy.
At 2 in the morning it can get pretty demanding.

Obese

13th Aug 2017, 01:35

It is difficult to believe that Canadian duty time rules are really intended to promote aviation safety, but, nevertheless, as a paying airline passenger, I would minimally expect aircrew to listen to destination ATIS prior to descent, especially on an international night flight. Kudos to the Filipino captain for apparently being the first on the ground to activate landing lights. It may have been the brick on the side of the head that Abbott and Costello needed to prompt them to initiate the go around.

Ian W

13th Aug 2017, 07:13

Why should there be a limit?

The controller was already there, and in his own judgement, if he wasn't doing other tasks he might have been able to detect that the aircraft was lined up on the wrong runway.

Why not support him by:

Not putting him on a schedule resulting in 2 hours of sleep in 24 hours on the backside of his circadian rhythm
Making available a second controller to share his workload, per FAA guidelines
Giving him time & space to observe critical phases of flight, instead of doing admin tasks
Providing additional tools / technology to detect wrong runway incursions

49 people perished on that crash. If another set of eyeballs had a chance to prevent the accident, why not take advantage of that?

I don't know how much time you have spent in the visual control tower at night, but it is not easy sometimes to even see an aircraft let alone be certain where it actually is on closely located runways.

But let's assume that the controller was actually supported and only doing visual control. The aircraft taxies to the far end of the airport and calls for takeoff in a position that could be either runway an unlit extra narrow GA runway with a divergent heading or a fully lit standard runway.
The aircraft is cleared takeoff.

I am watching carefully and it seems to be slower than normal on the take off as its angle is not changing so fast after about 15 seconds I think that the aircraft can't be on the active runway.... it could be on the GA runway.

Now - the controller has a VERY difficult choice - one that I am sure you have never had to make.
IFF the controller tells the crew you are on the wrong runway abort takeoff - the aircraft is likely to overrun the end of the runway with a similar result to the crash as the cancel clearance call could be after the aircraft was committed- and the peanut gallery will be saying that they could have become airborne - the controller caused the crash
IFF the controller says nothing as the perception may be wrong - then the controller is in a worse position than now - as the crash MIGHT have been prevented if the cancel clearance call was made before the aircraft was committed (when is that on a 4000ft runway that is already too short?) and the peanut gallery would be saying the controller caused the crash

So the NTSB asked an almost impossible to answer question - could you have prevented the crash if you had been watching - and the controller correctly said - he MIGHT have been able to.

I doubt if anyone in the NTSB actually put a CRJ out on the GA runway at night to see when it would be apparent to a controller that the aircraft was actually on the GA runway not the main runway. Then with that point decide if the aircraft could have been saved after the slight delay for controller 'surprise' that the aircraft was not on 'the' runway.

This is like the Sully assessments that he should have turned back to LGA as he _might_ have made it. All very good in hindsight if every decision had been just right.

PukinDog

13th Aug 2017, 10:41

Too bad the CVR was conveniently overwritten. If it weren't, investigators would know if what should have occurred before this approach began actually occurred, including the crew using the primary, fundamental tools one does in order to plan/know what to expect; bookwork like we're paid to do, planning, and a proper briefing as dictated by Company SOPs. As it is, nobody knows if they followed any or conducted an approach briefing, or even if they used checklists appropriately or observed a sterile cockpit. We do know this, however;

The NOTAMS re the closure of 28L and 28Ls Approach Light System were both published. AC OPs Specs would dictate they were disseminated to the crew.

The ATIS received by the crew before the approach also notified them that 28L was closed and the Approach Light System for 28L was out of service. Company SOPs would dictate this be reviewed by the crew prior to the approach and ATC would expect acknowledgment it had been received.

The publications/Airport Diagram the crew had on hand showed the parallel runways with Approach Light Systems installed on each, and details or each installation plus runway lighting and PAPI. They also show Taxiway C running parallel to 28R.

The crew told the investigators that they thought 28L was 28R. That is admitting they didn't either read the NOTAMs or listen to the ATIS, or means they did but never talked about it/ignored what would could be an operational concern (runway closure).

It also means they were unaware of what they should be seeing for miles before they attempted to land on Taxiway C; an Approach Light System and a PAPI.

A proper approach briefing of any type identifies the primary guidance to be used, and most Company SOPs dictate their review and inclusion. This was a visual approach, at night, over water where any licensed pilot should be well-aware of possible black hole effect which makes the vertical guidance all the more critical to identify. Runway 28R has a diagramed and functioning Approach Light System (ALSF-II) stretching out into the water for lateral guidance. 28R has a PAPI located on the LH side of the runway for vertical guidance. These are ground-based, visual approach light systems that lead directly to the runway and Touchdown Zone of the correct runway. Those are the primary aids for the approach, not the FMS.

How hard is it to brief (and it makes no difference which FMS procedure got them to the point or what green taxiway lights look like from a distance) "the visual segment for 28R will be over water, we'll align with the ALSF-II and follow the PAPI located on the LH side"?

That's what a briefing is all about. To create a picture of what is known and printed right there in our faces about where we're going, and what to look for out the windscreen when the time for looking is at hand.

Briefings, SOPs, and checklists are there to backstop performance, especially when tired, etc. because they focus attention on where it needs to be focused. Even the well-rested pilot that does no bookwork, planning, or briefing will stuff things up a thousand times more often than a tired pilot that does all the above.

One can go around and around about FMS procedures, lack of EVS, "Tunneling" and circadian rhythms, but those aren't going to prevent stuff-ups of this nature if the crew didn't bother with fundamentals and basic adherence to procedures already in place.

Does anyone actually think a detailed, proper briefing that reviewed the primary guidance aids (ALSF-II and PAPI) to be followed for this visual approach was conducted in this case?

The statements by the crew and convenient overwriting of the CVR lead me to suppose this approach wasn't stuffed-up on short final, or 4 miles out due to an illusion, but long before when no attention to detail to what was published and/or briefed regarding the upcoming visual approach to the runway they were (supposed to be) landing on. If they had briefed the critical details of primary guidance aids just like everyone does for an ILS etc, this wouldn't have happened. The aids were right there, yet they never looked for them or (obviously) used them until the 2nd time around. Bear in mind that 2 crew with separate sets of eyeballs missed the same things.

I don't believe there's any big mystery or highly-unusual Human Factors, super-illusion boogeyman at work here. We deal with many all the time, usually by preventative measures. Until it can be shown that this crew followed those time-proven, fundamentals that prevent this sort of thing from happening I'm not going to assume it.

peekay4

13th Aug 2017, 15:05

I don't know how much time you have spent in the visual control tower at night, but it is not easy sometimes to even see an aircraft let alone be certain where it actually is on closely located runways.

True, but there have been two other instances at LEX where a jet incorrectly lined up on 26 instead of 22, and in both cases ATC detected and alerted the flight crews.

In fact one of the incidents happened shortly after the Comair crash in similar conditions. A small Lear 45 was taking off at night and turned to the wrong runway. An alert controller saw it and immediately cancelled the Lear's takeoff clearance.

As reported by the controller:

ASRS ACN: 722668

Date : 200701
Local Time Of Day : 1801-2400
Locale Reference.Airport : LEX.Airport
Flight Conditions : VMC
Light : Night

Narrative (LEX.Tower):

LJ45 TURNED ONTO RWY 26 AFTER GIVEN A TKOF CLRNC ON RWY 22. AN IMMEDIATE CORRECTION WAS MADE BY ALERTING OF THE WRONG RWY -- BEFORE TKOF ROLL BEGAN. TO PREVENT A RECURRENCE SUCH AS THIS ONE, INCLUDE IN THE TKOF CLRNC FOR RWY 22 TO CROSS RWY 26.

Synopsis

LEX CTLR DESCRIBED AN ATTEMPT BY AN LJ45 FLT CREW TO TAKE OFF ON THE WRONG RWY AS THEY TURNED ONTO RWY 26 WHEN RWY 22 WAS ISSUED.

slack

13th Aug 2017, 15:49

With regards to post 789 by Ian I couldn't agree more. Forget the fancy FMS stuff. Using info from notams/atis and their God given eyes (2 sets ) in severe clear wx was all that was required for a routine successful landing.
P.S. I am a retired ( thank God ) a320 pilot

llondel

13th Aug 2017, 21:18

The NOTAMS re the closure of 28L and 28Ls Approach Light System were both published. AC OPs Specs would dictate they were disseminated to the crew.

The ATIS received by the crew before the approach also notified them that 28L was closed and the Approach Light System for 28L was out of service. Company SOPs would dictate this be reviewed by the crew prior to the approach and ATC would expect acknowledgment it had been received.

The publications/Airport Diagram the crew had on hand showed the parallel runways with Approach Light Systems installed on each, and details or each installation plus runway lighting and PAPI. They also show Taxiway C running parallel to 28R.

The crew told the investigators that they thought 28L was 28R. That is admitting they didn't either read the NOTAMs or listen to the ATIS, or means they did but never talked about it/ignored what would could be an operational concern (runway closure).

This one got me thinking. Unlikely, but assume they'd made a mistake and misheard the ATIS that 28L was closed and 28R approach lighting was out. (I assume 'approach lighting' means the stuff sticking out into the bay). Under this scenario you'd expect them to do exactly what they did because they'd be lining up on the tarmac lights to the right of the working approach set. Of course, this immediately begs the question of why the approach lighting would be set up in this configuration.

Akali Dal

13th Aug 2017, 22:22

Briefings, SOPs, and checklists are there to backstop performance, especially when tired, etc. because they focus attention on where it needs to be focused. Even the well-rested pilot that does no bookwork, planning, or briefing will stuff things up a thousand times more often than a tired pilot that does all the above.

One can go around and around about FMS procedures, lack of EVS, "Tunneling" and circadian rhythms, but those aren't going to prevent stuff-ups of this nature if the crew didn't bother with fundamentals and basic adherence to procedures already in place.

Does anyone actually think a detailed, proper briefing that reviewed the primary guidance aids (ALSF-II and PAPI) to be followed for this visual approach was conducted in this case?
.

But that cannot be. The pilots of this flight are from a first world nation with a super proud tradition of meticulous training and water tight integrity. I am sure the CVR wasn't deliberately meant to be overwritten! They have sound fundamentals and very strict checks and balances. The runway layout, the unnecessary runway closures and unhighlighted notams, the ATC, the tiring schedule, the circadian rhythms, and a whole lot of other contributing factors are largely to blame.

underfire

14th Aug 2017, 02:04

But that cannot be. The pilots of this flight are from a first world nation with a super proud tradition of meticulous training and water tight integrity.

No, they are from Canada.

They have sound fundamentals and very strict checks and balances. The runway layout, the unnecessary runway closures and unhighlighted notams, the ATC, the tiring schedule, the circadian rhythms, and a whole lot of other contributing factors are largely to blame.

Yes, this will likely be the findings....

As noted in other posts by ATC folks...it happens all the time. What is done about it....nothing. Nothing to see here , move along.

Blame, blame, blame...take responsibilty, NO WAY.

The statements by the crew and convenient overwriting of the CVR lead me to suppose this approach wasn't stuffed-up on short final, or 4 miles out due to an illusion, but long before when no attention to detail to what was published and/or briefed regarding the upcoming visual approach to the runway they were (supposed to be) landing on. If they had briefed the critical details of primary guidance aids just like everyone does for an ILS etc, this wouldn't have happened.

Typically, when the FMS Bridge visual or any of the visuals are run on 28R, 28L cannot be used due to the close prox. In that note, it really does not matter that 28L was closed and there was a big white X at threshold. When 28R visual is in use, the lights for 28L would not be there anyways.....forget about all this talk about the 28L lights were not on, so mistook 28R lights for 28L and offset, into the bay......they would never had been on.

peekay4

14th Aug 2017, 02:25

Typically, when the FMS Bridge visual or any of the visuals ar run on 28R, 28L cannot be used due to the close prox.
That's not correct. At SFO both runways often operate in parallel during visual approaches, e.g., while 28R is on the FMS / Quite Bridge visual, aircraft on 27L might be on the Tipp Toe visual (along the ILS 27L localizer).

underfire

14th Aug 2017, 02:32

no, they do not and cannot.

SOIA is not authorized visual. (the hint here is the title...Simultaneous Offset Instrument Approach)

27L might be on the Tipp Toe visual (along the ILS 27L localizer).

oh, you must be Canadien...landing on 27L...blame it on map shift, or circadien cycles. Good Luck! Try not to hit anything.

peekay4

14th Aug 2017, 02:42

no, they do not and cannot.

SOIA is not authorized visual.

I've been saying many times now, a VISUAL APPROACH IS NOT AN INSTRUMENT APPROACH PROCEDURE.

Parallel visual approaches have nothing to do with SOIA.

Note on the FMS Bridge Visual 28R:

Closely-spaced parallel visual approaches may be in progress to Rwy 28L utilizing ISFO ILS 28L localizer.

Notes from TIPP TOE VISUAL if you're shooting the visual on 28L:

CAUTION: AIRCRAFT OPERATING WITHIN 500' TO PARALLEL RWY- POSSIBLE WAKE TURBULENCE

NOTE: Closely spaced parallel visual approaches may be in progress to Runway 28R utilizing the SFO R-095. In the event of a go-around on Runway 28L, turn left heading 265°, or on Runway 28R, turn right heading 310°, climb and maintain 3000, or as directed by Air Traffic Control.

If criticizing pilots, at least try to get basic facts right. :rolleyes:

Airbubba

14th Aug 2017, 02:51

In that note, it really does not matter that 28L was closed and there was a big white X at threshold. When 28R visual is in use, the lights for 28L would not be there anyways.....forget about all this talk about the 28L lights were not on, so mistook 28R lights for 28L and offset, into the bay......they would never had been on.

So, now you claim that the lights to 28L are turned off whenever there are visual approaches to 28R? :D

Lad, something tells me you don't know much about flying a plane. :=

underfire

14th Aug 2017, 03:01

No , that is not what I stated.

Have you flown into SFO at night on the 28R visual approach?

This is exactly what it looks like.

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

With all of your experience, would you consider the approach lighting for 28L on? Would you line up with taxiway C instead of the approach cross?

peekay4

14th Aug 2017, 03:21

Have you flown into SFO at night on the 28R visual approach?

This is exactly what it looks like.

No, that's only what it looked like during that particular approach. You're being misled by what you see (only) online, and making wrong conclusions based on that.

Here's a frame from a night visual approach to 28R while 28L was also operating. You can see the 28L lights (MALSR) are on:

http://i.imgur.com/0GeMXqL.jpg

Ian W

14th Aug 2017, 10:51

True, but there have been two other instances at LEX where a jet incorrectly lined up on 26 instead of 22, and in both cases ATC detected and alerted the flight crews.

In fact one of the incidents happened shortly after the Comair crash in similar conditions. A small Lear 45 was taking off at night and turned to the wrong runway. An alert controller saw it and immediately cancelled the Lear's takeoff clearance.

As reported by the controller:

Well the one shortly after the crash does not surprise me one bit all the controllers will be on edge about crews not able to check runway heading and be using binoculars to check every aircraft departure. Although I am surprised the crew was not more aware.

I cannot comment on the similarity or not of the previous incident. The fact still remains that visually assessing from a distant control tower where an aircraft is lined up at night when the angle subtended between the correct and incorrect positions is very small is not guaranteed.

peekay4

14th Aug 2017, 20:18

Yeah. "Shortly after" is relative here. The incident that preceded the crash happened in 1993 (13 years prior). The Lear incident happened just 4 months after the crash. I don't know if controllers would (still?) be using binoculars to check every single take off, months after the crash?

The fact still remains that visually assessing from a distant control tower where an aircraft is lined up at night when the angle subtended between the correct and incorrect positions is very small is not guaranteed.

Agreed.

pilot9249

14th Aug 2017, 22:39

But as to the question : Would an extra controller had spotted the deviation earlier ?

It does seem an odd situation whereby people are asking if a second ATC controller, positioned at the side of an approach, at night, could have a better visual appreciation that a 2 man crew could be lined up, visually, on to the wrong runway.

But that's not the question being asked.

The question being asked is could a controller with great training and deep experience have given a different initial response to a confused arriving aircraft, if time pressures on that controller were relaxed?

"Go around" is supposed to be safe. Safe enough at least that this controller subsequently issued it.

"There aren't any aircraft on the ground where you think you see them" isn't supposed to be safe.

So without suggesting blame, why was that response issued instead?

underfire

14th Aug 2017, 23:41

Here's a frame from a night visual approach to 28R while 28L was also operating. You can see the 28L lights (MALSR) are on:

You are taking a screen shot BEFORE 28L was closed. You are aware that 28L was closed, correct?
Aside from that, are you expecting to believe that 28L was active for approach in the image that you provided? That aircraft would be on approach, near parallel, and yet no guidance on 28L?
http://i.imgur.com/SFnkGeh.jpg

Entertain me, show me a screen shot you found on the internet for a 28L approach lighting at night. (with 28R active as well) of course, using the visual approach.

http://i.imgur.com/0GeMXqL.jpg

You appear to conflict with your own statement...do YOU see the approach lighting for 28R?

http://i.imgur.com/ZkDQqD0.jpg

Very simple question....Is there any reason, even for you, or anyone....to line up on the taxiway?

Where would you land?

Old Boeing Driver

15th Aug 2017, 00:52

peekay4

15th Aug 2017, 01:28

That picture was only to debunk your repeated assertion that:

when the FMS Bridge visual or any of the visuals ar run on 28R, 28L cannot be used due to the close prox
Where would you land?

You're fixated in asking the wrong question. The fact is, two experienced and presumably well trained pilots from a major North American airline tried to land on the taxiway. The question is: why?

That the active runway looks so obvious at night in comparison to the taxiway -- by design -- only deepens the puzzle of why this incident happened. We want to get to the root cause so we can attempt to prevent other incidents in the future.

Your mantra to simply "blame blame blame" the pilots contribute nothing to safety.

Airbubba

15th Aug 2017, 02:55

I have looked at many of the posts here, and looked at the approach plates for the Quiet Bridge Visual and the ILS to 28R.

For whatever reasons, they lined up on the taxiway instead of 28R.

Being from the "old school", but having used some of the most modern EFIS, I wonder why no one had at least raw data displayed with the ILS tuned and inbound heading set.

The thread is indeed long but take another look. The Air Canada crew was cleared for the FMS Bridge Visual to 28R, not the Quiet Bridge Visual. See earlier posts on why you might not find the FMS Bridge Visual in your Jepps.

And, as explained in previous posts, the ILS is not normally tuned on this approach in an A320 since there is FMS guidance to the runway and it is difficult to display raw ILS data in the 'bus without switching approach modes.

Old Boeing Driver

15th Aug 2017, 11:39

Thanks. I went back and reviewed. Have a great day.

RAT 5

15th Aug 2017, 13:07

And, as explained in previous posts, the ILS is not normally tuned on this approach in an A320 since there is FMS guidance to the runway and it is difficult to display raw ILS data in the 'bus without switching approach modes.

Are you now saying the FMC guided them to the wrong runway/taxiway? I don't think you mean that, but as I've said, the FMS, no matter what kind of 'Bridge' approach they flew, brought them to a point where they then would took over visually to align themselves with the landing terrain. People have said they were not GPS equipped, so there could have been map-shift perhaps, but either way the last 4nm was visual alignment. If they did not have an ILS tuned, then they had PAPI's and full runway + approach lights for visual guidance.

There is still a mystery, and we are churning this around and around. Surely by now there are enough known facts from the crew, AC & FAA to publish a definitive report. There were no deaths and everyone is available to state their case. Have I missed it, or has an interim/final report been published. Sorry if that is the case.

ATC Watcher

15th Aug 2017, 14:06

Peekay4 : The fact is, two experienced and presumably well trained pilots from a major North American airline tried to land on the taxiway. The question is: why?

your question reminds me of something I read long ago : It was something like this : : **** happens for no reason sometimes. One day you do something irrational and no-one can understand why you did it, including yourself "
Fixation , fatigue, light hypoxia, mental distractions, micro-lapses, are for instance things you cannot measure with certainty , especially a posteriori.
Maybe it is one of these, maybe not.

As someone said, the crew is available and surely will be debriefed , but I bet you lots of beers that the PF will say : "I really thought we were aligned with the runway" . An where do you go from there ?

RAT 5

15th Aug 2017, 14:54

PF will say : "I really thought we were aligned with the runway" . An where do you go from there ?

You ask the PM what they thought & were doing.

underfire

15th Aug 2017, 15:20

Airbubba...FMS bridge visual final waypoint is on the extended runway centerline. (unlike quiet bridge visual which is not) They COULD have had the ILS tuned to check.
Map shift or not, the procedure is visual from 4.4 DME

I am not certain if it is common practice, but when flight validating RNP procedures, as a check, the #2 seat is tuned to the ILS to backcheck the alignment, so it is possible.

That the active runway looks so obvious at night in comparison to the taxiway -- by design -- only deepens the puzzle of why this incident happened. We want to get to the root cause so we can attempt to prevent other incidents in the future.

I agree...but. The pilots have, according to the prelim NTSB report, denied they saw aircraft on the taxiway, in fact, they denied being on the taxiway. They did not secure the CVR. They came within inches of aircraft sitting on the taxiway. As there was 'no incident', there was no mandatory substance test.

Would one expect the 2 drivers to be at least stood down pending the findings?

Obese

15th Aug 2017, 16:14

There is still a mystery, and we are churning this around and around. Surely by now there are enough known facts from the crew, AC & FAA to publish a definitive report. There were no deaths and everyone is available to state their case. Have I missed it, or has an interim/final report been published. [/QUOTE]

Good on yer, RAT5, I hope I got your handle right, and that I don't get kicked out on probation for incompetent quoting technique.

Even if there are no PhD rocket scientists currently available to work on this file, there is NO WAY it needs to take the customary 1 to 2 years for a credible investigation report. A really thorough, competent report on this near tragedy would be of tremendous benefit to countless people involved in aviation, both airborne and groundbound, but especially for younger pilots coming up. Even now, with few "details", it it appears to be a compelling example of a "there, but for the grace of God, go I" type of story.

It seems to me that this is an (unenviable) opportunity for the pilots involved to transition from (apparent) zero to hero if they summon all of the courage and integrity they have, and bare their souls to the investigators. Under the circumstances, few of us, myself included, would likely have the guts to do that, but I for one would deeply admire them if they got everything out into the open to help educate all of us about what not to do, and about what to watch for, both externally, and within ourselves.

I'm neither a pilot nor a controller, but I'm 60 and I put in 37 years at QFE at a northern Canadian airport doing work that many controllers seemed to regard as being inferior, (but not the ones who had paid their dues themselves in the North).

za9ra22

15th Aug 2017, 17:55

It seems to me that this is an (unenviable) opportunity for the pilots involved to transition from (apparent) zero to hero if they summon all of the courage and integrity they have, and bare their souls to the investigators.

That is assuming the pilots involved understand what went wrong. Perhaps they do not. If in their minds they did everything right, followed the correct approach, and only suddenly at the last moment saw they were on the taxiway, they may have no explanation for what happened. If they then go through the procedures they followed on the night of the incident, they will end lined up on the runway, because that's where they expected to be, and thought they were.

Airbubba

15th Aug 2017, 18:41

Airbubba...FMS bridge visual final waypoint is on the extended runway centerline.

There is another waypoint, RW28R, on the chart, take a look. The FMS will provide path guidance between F101D and RW28R which may be faulty in what we think is a pre-GPS A320.

Map shift or not, the procedure is visual from 4.4 DME

I heartily agree :ok:, this is a visual segment and any flight director or autoflight guidance should be strictly advisory.

I am not certain if it is common practice, but when flight validating RNP procedures, as a check, the #2 seat is tuned to the ILS to backcheck the alignment, so it is possible.

Being from the "old school", but having used some of the most modern EFIS, I wonder why no one had at least raw data displayed with the ILS tuned and inbound heading set.

Here are some earlier explanations on why A320 pilots normally don't have ILS raw data displayed on this approach:

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

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

I remember the admonition from a sim instructor in an A306 type rating course years ago: 'Use Rose Mode if you really want to get f***ed up on the approach!' ;)

I have done many FMS Bridge visuals in the A320 family. You do not have the ILS raw data because it is an FMS approach. You have VASI and the electronic glidepath. You can hard tune the lLS through the RMP but no one ever does.

We have a crazy policy recomendation to de-tune the ILS for an RNP approach when the runway is equiped with an ILS, why? Because of occasional GPWS glideslope alerts if the ILS is tuned! The GPWS is valid, but because some approaches are 2.8 degree (due hot weather), if it is cold and with enough barometric error you are actually low on path compared to the ILS. Better to turn the noise off than acknowledge the issues. Reminds me of "Shut up Gringo".

Obese

15th Aug 2017, 19:04

za9ra22, your comment is a thoughtful one, but if the AC crew listened to the ATIS, they would have known that a "visual anomaly" was in place, and they logically would have been concerned about it, and would have briefed about it. For all of you pilots out there, if it's any consolation to you, it's even more mind numbingly mundane to record an ATIS than it is to have to listen to them. Plus on every one you record (mine - and I did thousands - were all non-digital), you had to go back and listen to yourself drone through the whole thing each and every time for quality control. Much like a pilot boo boo, it's easy to make a mistake on an ATIS if you're tired or distracted . . .

RAT 5

15th Aug 2017, 20:08

I have the answer. They were looking for the gorilla and forgot to keep their eye on the ball.

(for those not in the know it means a long search back)

underfire

15th Aug 2017, 21:07

Originally Posted by underfire View Post
Airbubba...FMS bridge visual final waypoint is on the extended runway centerline.
There is another waypoint, RW28R, on the chart, take a look. The FMS will provide path guidance between F101D and RW28R which may be faulty in what we think is a pre-GPS A320.

I assumed one knew the differenece between the waypoint on the beginning of the final segment, and the runway endpoint (which defines a segment.) oi vey.

Here are some earlier explanations on why A320 pilots normally don't have ILS raw data displayed on this approach:

All of that explanation is why you only have this selected on the #2 system (ie copilot) as a backup.

We have a crazy policy recomendation to de-tune the ILS for an RNP approach when the runway is equiped with an ILS, why?

This is not an RNP approach...it is RNAV visual.

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

Also, you will note on most RNP charts, glidepath is not coincident, so of course, you may get a noise.

Airbubba

15th Aug 2017, 21:21

All of that explanation is why you only have this selected on the #2 system (ie copilot) as a backup.

I can see where you don't know enough about flying a plane to understand the explanations above from the A320 drivers. It's kinda technical.

underfire

15th Aug 2017, 22:13

I can see where you don't know enough about flying a plane to understand the explanations above from the A320 drivers. It's kinda technical.

I can see why you cannot understand that I was saying the exact same thing....you can do it, and it is not that technical, I do it all the time. As I stated, that is for flight validations, not in the commercial environment.

Pretty damning article...

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.

As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.

It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded.

Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://www.mercurynews.com/2017/08/15/editorial-air-canada-faa-hindered-investigation-of-sfo-near-miss/)

edmundronald

15th Aug 2017, 23:46

I'm not a pilot, just an idiot academic PhD.

The interesting question seems, what would you see on approach *if you are lined up wrong*, not if you are lined up right. And whether by the time the pilot flying took his eyes off his instrument scan and looked out the window, tired after a long flight, his angle of visual awareness may have been reduced due to fatigue or blood sugar issues.

Also, I have a feeling there might be more to this story; some distracting factor, some approach lighting issue ... the usual holes in the cheese lining up. As someone here commented two pilots with decent vision did line up on a taxiway, and it shouldn't be possible.

Edmund

I can see why you cannot understand that I was saying the exact same thing....you can do it, and it is not that technical, I do it all the time. As I stated, that is for flight validations, not in the commercial environment.

Pretty damning article...

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.

As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.

It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded.

Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://www.mercurynews.com/2017/08/15/editorial-air-canada-faa-hindered-investigation-of-sfo-near-miss/)

galaxy flyer

16th Aug 2017, 01:03

I find it hard to believe either the FAA or AC hindered the investigation at the outset. It was in middle of the night, if the crew didn't report it and the lone ATCO, busy with duties, didn't report it until shift change, the plane was probably being readied for departure before there was any hint of an incident. In the morning, the AC flight leaves for YYZ or YUL, bingo, no CVR recording. If anything is suspect, it is the crew's failure to report and trip the CVR circuit breaker. I'll admit it is possible they missed it all on the first approach, but I doubt a sentient crew didn't pick up their mistake on the second approach. Light bulbs had to be going off.

Then, the question is about AC's safety culture. Does it inhibit honest reporting of mistakes. Did the crew feel likely to be disciplined? Were they cognizant of the error and, if so, thought it could be hidden. Their simple answers implies a " cover up" on their part that can't be uncovered now.

GFK

peekay4

16th Aug 2017, 01:22

The pilots have, according to the prelim NTSB report, denied they saw aircraft on the taxiway, in fact, they denied being on the taxiway.
That's not exactly what the investigative report says:

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.

What's missing is the context behind these statements. When during the first approach? On short final? Just prior to the go around? Even after the go around?

E.g.,

NTSB: "So now you're 4nm out, visual, making the first approach. Did you see the other aircraft lining up for take off?"
Pilot A: "No, we didn't see them, although something didn't look right on what we thought was the runway"
Pilot B: "Yeah, that's when we saw some lights, so we called tower, but he told us there's no one on 28R but us"

NTSB Update: "In postincident interviews, both incident pilots stated that, during their first approach... they did not recall seeing aircraft on taxiway C but that something did not look right to them."

peekay4

16th Aug 2017, 01:34

Then, the question is about AC's safety culture. Does it inhibit honest reporting of mistakes. Did the crew feel likely to be disciplined? Were they cognizant of the error and, if so, thought it could be hidden.

Apparently, right after the landing the Captain on his own initiative asked for the ATC's telephone number and called them to discuss the incident. That's not typical behavior of a crew attempting to hide anything.

And, for all we know, the crew might have reported the incident through normal Air Canada channels.

I reviewed NTSB 830 again and surprisingly there is no requirement to immediately report this type of incident to the NTSB.

Airbubba

16th Aug 2017, 01:56

Reportedly, right after the landing the Captain on his own initiative asked for the ATC's telephone number and called them to discuss the incident. That's not typical behavior of a crew attempting to hide anything.

Or, perhaps the tower called the company and told them to tell the pilots to give them a call. They may well have been in the blocks when they asked for the tower phone number on the ground control frequency. The tower controller had switched everyone else to the tower freq a few minutes earlier.

And, the CVR tape was regrettably overwritten, just as it has been in many similar cases over the years. An honest mistake, right? ;)

peekay4

16th Aug 2017, 02:12

Or, perhaps the tower called the company and told them to tell the pilots to give them a call. They may well have been in the blocks when they asked for the tower phone number on the ground control frequency.
Seems a bit unlikely... if the tower called the company presumably the caller would've left his/her name and phone number for the callback.

I can imagine the conversation... "AC please ask the Captain to call me over the radio to ask me for my phone number". When the controller could've just radioed the pilots directly.

galaxy flyer

16th Aug 2017, 02:43

Apparently, right after the landing the Captain on his own initiative asked for the ATC's telephone number and called them to discuss the incident. That's not typical behavior of a crew attempting to hide anything.

And, for all we know, the crew might have reported the incident through normal Air Canada channels.

I reviewed NTSB 830 again and surprisingly there is no requirement to immediately report this type of incident to the NTSB.

In this case, why didn't the captain act to prevent the CVR from being overwritten? If he called the tower, in request or own volition, clearly it was a significant incident. Earlier, it was stated the CAR 700 series requires action to preserve the CVR post serious incident.

GF

peekay4

16th Aug 2017, 04:46

Either way, if tower first notified Air Canada of a serious incident, then they too had a duty to preserve the CVR. It's not only the pilots.

I'm speculating that -- at the time -- neither the pilots, Air Canada, nor the controller had an appreciation of just how close they were to disaster, until the tapes were reviewed.

The pilots probably thought they'd just need to file a safety report in the morning and that would be the end of it.

ATC Watcher

16th Aug 2017, 07:00

Peekay4 : I'm speculating that -- at the time -- neither the pilots, Air Canada, nor the controller had an appreciation of just how close they were to disaster, until the tapes were reviewed.
The pilots probably thought they'd just need to file a safety report in the morning and that would be the end of it.
And I think you are probably right. Lining up with taxi way or wrong runway is not that unusual. It is the media coverage of one case that makes it sensational.
In Frankfurt ( Germany) for instance such incidents are a few per year, we even had an actual landing in the centre taxiway ( an Antonov 124 !) some 20 years ago, and a take off from the same centre one , a couple of years ago. In both cases as no-other aircraft was taxing at the time on it, no news coverage .

reubee

16th Aug 2017, 07:12

...

Entertain me, show me a screen shot you found on the internet for a 28L approach lighting at night. (with 28R active as well) of course, using the visual approach.

http://i.imgur.com/0GeMXqL.jpg

You appear to conflict with your own statement...do YOU see the approach lighting for 28R?

http://i.imgur.com/ZkDQqD0.jpg

Very simple question....Is there any reason, even for you, or anyone....to line up on the taxiway?

Where would you land?

what you should be showing is a photo from the perspective of being lined up on the taxiway, and ask the question what visual clues are there that make you think you aren't where you are supposed to be ...

Bedder believeit

16th Aug 2017, 07:34

Apologies for driftng off topic. When I was in Hong Kong tower we had at least 3 separate instances whereby aircraft that had been cleared for take-off on RWY 07L (it was early morning 1am to 3ish), lined up on TWY ALPHA parallel to RWY 07L. A Finnair A340, A Philippines A330 and a Hong Kong Airlines B738 and all three lined up on the taxyway "ALPHA" and commenced their take-off rolls. I know because I was the one that desperately instructed the PAL aircraft to "Stop immediately" as there was a 10 tonne sweeper operating on TWY ALPHA about 1500 meters down the TWY. Because these were departures there was no facility for immediately reporting and taking action regarding these transgressions. I could merely log the circumstances for management to action the next day. I guess the moral of the story is that there are a number of participants that keep the holes in the Swiss cheese from lining up so .... be careful, be alert, be suspicious (smell the rat) and respect SOP's.

CurtainTwitcher

16th Aug 2017, 09:02

Pretty damning article…

Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://archive.is/Q59Dc)

Editorial: Air Canada, FAA hindered investigation of SFO near-miss

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.

As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.

The fiasco highlights the need for new federal laws or regulations mandating immediate reporting of near-misses and the grounding of aircraft and pilots until after National Transportation Safety Board investigators are called in.

This could have been nearly the worst aviation disaster in history, second only to the two hijacked planes that plowed into the World Trade Center on September 11, 2001.

On July 7, pilots of an Air Canada plane landing minutes before midnight at SFO mistook a taxiway for the runway where they were supposed to land. The latest investigative findingsshow the plane dipped as low as 59 feet off the ground as the pilots aborted their landing, barely missing four fully-fueled aircraft with an estimated 1,000 passengers that were awaiting takeoff.

The FAA, which was responsible for having only one air controller working traffic in the tower at the time, took more than 24 hours to notify the NTSB. The delay allowed Air Canada to use the plane for three flights in which the cockpit recorder was taped over multiple times.

That recorder held potentially critical information about what the pilots were saying as they headed straight for the taxiway. The cockpit conversation between the pilots might have helped explain their confusion.

As for the pilots, a source familiar with the current NTSB investigation told reporter Matthias Gafni that they spent the night in the Bay Area and flew out the next morning on their normally scheduled flight.

It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded. United Airlines’ outrageous response after a passenger was dragged off a plane pales in comparison to this stonewalling.

Similarly, the FAA refuses to explain why it took more than a day to notify the NTSB. The NTSB, in turn, excuses all this by noting that federal rules did not require that it be notified because there was no collision.

That technical rationalization belies common sense. Air Canada Flight 759 came within a few dozen feet and a few seconds of creating an airport inferno the likes of which this nation has never seen.

Jim Hall, former NTSB chairman, told Gafni that those reporting guidelines should be addressed in the investigation. “This was probably the most significant near-miss we’ve had in this decade,” Hall said. “I think splitting hairs on this issue on an incident of this significance is a disservice to safety.”

He’s right. The investigation into this terrifying episode should have started immediately.

This article raises several questions:

Is The Mercury News an authoritative source on air accident and investigation & safety?
Do they have additional information that is generally not known the public?

The article makes no specific claim about additional sources that I could see, so I am going to assume that they have about as much information as PPRuNe has found.

Claim 1 AC and the FAA dragged their feet? Evidence, source? No it was based on the fact that the CVR was erased. Inferred in this statement is that this was a deliberate act. No mention that this is the default mode of operation for this device. Active steps must be taken to avoid erasure.

Claim 2 New laws to protect the CVR are required in the case of a series near miss. The assumption is that either the crew or the tower were aware that the incident was as series as it actually turned out to be. It may not have been clear to the crew just how close it actually was. Unless the tower controller was watching the radar altitude and been aware of the offset, he also may have been unaware the seriousness.

Claim 3 Potentially the second worst disaster ever. True

Claim 4 AC pilots attempted to land on a taxiway. True

Claim 5 Single tower controller. Appears to be true

Claim 6 FAA took 24 hours to notify NTSB. True

Claim 7 CVR overwritten caused by notification delay. True

Claim 8 CVR held vital information about the event. True

Claim 9 Pilots operated out as per schedule. Appears to be true.

Claim 10 AC non assistance with investigation. Appears to be true

Claim 11 FAA has not explained reporting delay. True

Claim 12 No immediate reporting requirement as no collision had occurred. True

Claim 13 Most serious near miss in a decade. True

Most of the specific detail of the article are technically correct. However, the entire assumption of this article and its criticism & tone of malicious intent by the crew & FAA rests on the assumption that there was the recognition of the seriousness of the event by either the crew or the tower controller. We have no way of knowing the state of mind of these three people, and what they believed about their perception of the seriousness of the event. There are only 3 people in the world who know.

Ten years ago, it is almost certain that this event would not have surfaced publicly, as the availability of the information from web based Flight Trackers and ATC recordings were just in their infancy without the widespread coverage and use by the public.

Would an NTSB investigation looked closely enough to also realise the seriousness of the event based on a crew or tower report? That is an unknowable answer.

The entire basis of the “damning” article appears to be about the judgement of how the crew & tower controller perceived the event. The inference from the article is the crew & tower would have been aware. On what basis could this view be formed? Pure assumption or actual knowledge?

To the general public reading this editorial, the crew & tower controller have been judged & convicted, case closed, throw away the key. To anybody with genuine insight, there are many more questions to be asked and information to gather. The truth is, we may never find the truth of this event. Likely this was true of many other near misses in the past that everyone in the system were unaware of. Absence of evidence is not evidence of absence (https://en.wikipedia.org/wiki/Evidence_of_absence).

The system is being judged through a different lens than existed in the past with the explosion of information available for open source analysis.

RAT 5

16th Aug 2017, 10:01

Simple questions, and I apologise if they have already been answered. Had either pilot ever been to SFO before; had they ever landed on 28R; had they ever been there at night; had they ever flown any kind of 'bridge' approach?

If the answer if no to all then there is another slice of holy cheese to add to the puzzle. However, in which case you would expect extreme vigilance not a relaxed approach.

DaveReidUK

16th Aug 2017, 10:25

Claim 2 New laws to protect the CVR are required in the case of a series near miss. The assumption is that either the crew or the tower were aware that the incident was as series as it actually turned out to be. It may not have been clear to the crew just how close it actually was. Unless the tower controller was watching the radar altitude and been aware of the offset, he also may have been unaware the seriousness.

Maybe not as it was happening, but it's hard to avoid the conclusion that very soon afterwards all the parties involved would have been perfectly aware how potentially serious the incident had been.

There are only 3 people in the world who know.

The United crew might beg to differ.

Derfred

16th Aug 2017, 10:53

I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event. After all, that's what investigations are for aren't they? You mob sound like a bunch of vultures out for blood.

RAT 5

16th Aug 2017, 10:59

The United crew might beg to differ.

Indeed, there has been little said about the state of mind of those 'holding a/c crews'. Their cockpit temps might have risen a few degrees and bodies been shaking. Imagine a near-miss, as in 100', at FL250 with a hard left avoidance and perhaps a push. The cockpit climate would have been disturbed for quite a while. These guys were about to get airborne. I would not be surprised if it took quite a while for them to calm down and feel ready to fly. Did they wait for the 2nd approach, or glean it safer to foxtrot-oscar while the runway was clear? Why sit in the sights for a 2nd time?

I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event.

It's not what was said, but rather what was not said: i.e. a brief about the state of the runway environment, how they were going to conduct the approach, what they expected to see in the dark, what threats were created by a closed runway and a visual approach etc. that is why the CVR would be helpful. The prevention process would be that a more thorough planning, briefing & understanding of the unusual circumstances could have been successful.
Remember a crash investigation of a landing over-run in rain storms, perhaps Little Rock? The CVR revealed that the auto speed brake had never been armed and they aqua-planed off the end. The NTSB never heard the 'click' of the lever being armed. CVR's can be more useful than FDR at times.

underfire

16th Aug 2017, 11:11

The United crew might beg to differ.

Would have been interesting to hear the CVR from United and PAL! They were straight for PAL and only missed them by 3 feet of less....that must have been quite the conversation on the flightdeck.

UAL did report them on the TWY to the tower.

what you should be showing is a photo from the perspective of being lined up on the taxiway, and ask the question what visual clues are there that make you think you aren't where you are supposed to be ...

sure, there are all sorts of visual clues to land on the twy....

Derfred

16th Aug 2017, 11:16

Would have been interesting to hear the CVR from United and PAL!

Interesting? Sure.

Useful to the investigation? Nope.

They were straight for PAL and only missed them by 3 feet of less

I seriously doubt that. The NTSB never said that. That's been inferred by posters on here. Without having seen the raw data, radio altimeters report the closest obstacle in the signal path, including an aircraft fuselage. But they were low, granted.

SLFstu

16th Aug 2017, 12:41

Quote:
Originally Posted by Underfire
Pretty damning article…

Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://archive.is/Q59Dc)

This article raises several questions:

Is The Mercury News an authoritative source on air accident and investigation & safety?
Do they have additional information that is generally not known the public?

The article makes no specific claim about additional sources that I could see, so I am going to assume that they have about as much information as PPRuNe has found.

Claim 1 AC and the FAA dragged their feet? Evidence, source? No it was based on the fact that the CVR was erased. Inferred in this statement is that this was a deliberate act. No mention that this is the default mode of operation for this device. Active steps must be taken to avoid erasure.

etc

Disclosure: not a pilot, nor a reporter or a media sympathizer, just a dude from downunder.

Can't see that The Mercury News ever claimed to be an authority on air accidents or near misses. However, the news outlet in question has had an investigative reporter on the case since the story broke. This is at least the second editorial they’ve written as followup to his several stories about the incident. And in a previous editorial, on 17 July, commenting on the reporter's story that day after the NTSB published it’s initial findings, yes, they were calling then for someone’s head. But can we blame them for wanting answers, after all it’s become a big story in their backyard?

Regarding the unavailability of CVR evidence, you are wrong (in your Claim 1 paragraph) to accuse the editors of implying deliberate destruction of evidence, because the original online story of the text you quoted had a clickable link to the reporter’s article describing how CVR’s work.

Incidentally, what that same reporter did unearth was an account by a passenger on AC 759, the first that I have seen since this whole sorry saga broke. Unfortunately for AC and the regulators - 3 of whom he wrote - he happens to be California’s top insurance public official. See a facsimile of his letter to Air Canada at the bottom of the story on this page:
SFO near-miss: Air Canada flew over plane before aborting (http://www.mercurynews.com/2017/07/17/ntsb-air-canada-pilot-actually-flew-over-plane-before-aborting-landing/)
And my favorite quote from his description? “…the pilot made a nonchalant announcement that he had to go around due to traffic at the airport.”

WillowRun 6-3

16th Aug 2017, 13:00

About several hundred posts ago peekay4 (IIRC) showed an analysis of the CVR 30-minutes duration after the go around (using evidently reliable time-stamp information). Wasn't it shown that of the 30 minutes of recorded data potentially available, 19 of those minutes had been consumed by necessity in the go around, second approach, landing and taxiing to the gate? This is not meant to excuse or otherwise deflect attention away from the fact that the CVR such as it was, was not preserved. But it is important as a matter of factual background and context to include this detail, that only roughly the final one-third of the 30 minutes would have been available in any event, just because of the aborted landing. Is this not so?

aterpster

16th Aug 2017, 13:25

underfire

16th Aug 2017, 14:49

I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event.

Really, you mean like trying to figure out why the 2 drivers were lined up on a taxiway, when there is absolutely no reason for that to occur at night with all of that lighting? According to the NTSB, they claim they were on the runway, and didnt see any aircraft. Perhaps the CVR would have shed some light on that.

The NTSB never said that. That's been inferred by posters on here. Without having seen the raw data, radio altimeters report the closest obstacle in the signal path, including an aircraft fuselage.

The NTSB report showed the FDR data, when the began to climb, at the lowest point was 59 feet. That was after PAL aircraft whose tail is at 56 feet.

Yes, you are correct, they did not say 3 feet. (but 59-56 is well...)

I think that given where the ac measures altitude from, even the radalt, the landing gear is below that...actually, it is a bit of a miracle they missed them.

It is interesting that the report shows screen shots from a video, but does not show a shot when the AC was directly over the PAL ac....they do have it though.

cappt

16th Aug 2017, 15:36

There is way too much focus on the CVR here. There would be no "smoking gun" to point at. Of course they didn't catch the NOTAM, we know that.
The CVR would contain the usual descent check and brief, some chit-chat, I've got the airport in sight, call it? Yeah sure. Whats with the runway lights? yeah it looks like somethings on it? should I ask? yeah? WTH? lets go-around.

BRDuBois

16th Aug 2017, 15:49

sure, there are all sorts of visual clues to land on the twy....

That wasn't the point being made.

underfire

16th Aug 2017, 17:10

There is way too much focus on the CVR here. There would be no "smoking gun" to point at.

Just another missing piece of the puzzle.

This will be a very interesting report when it does come out.

this video may explain some of the issues....AC A320-200 flightdeck tour...those screens would be difficult to use! I see why they lined up on the TWY now, after watching that for 6 hours!

https://www.youtube.com/watch?v=mj3Y0hyQrOA

Maybe the FO was flying and is left handed...

llondel

16th Aug 2017, 17:28

As I said earlier, they've reconstructed what happened, it's the 'why' that is important now, because understanding how they got so close is key to preventing it happening again. The CVR might have shed some light on that, I assume there was a cockpit discussion about the lights before the ATC call and a reason for the mistake might be found.

It was probably human error, but if so, the system needs to be changed to throw in an extra check somewhere to try to prevent it from happening again. The CVR might give a good hint as to the nature of that check and where to put it.

Until you understand why they did it, you can't honestly say for certain that you wouldn't have done the same thing.

A320ECAM

16th Aug 2017, 17:35

Have the AC pilots been dismissed yet?

underfire

16th Aug 2017, 17:38

http://i.imgur.com/vYt6Wnj.jpg

..............................^ 28L...............................^28R..............^2 red/2 yellow perfect!

seems reasonable...easy mistake to make.

Until you understand why they did it, you can't honestly say for certain that you wouldn't have done the same thing.

Considering many, many aircraft used this approach and after, that same night, and did not try to land on the TWY......according to the drivers, they did not do anything wrong, just did a GA because "something didnt seem right"

Obese

16th Aug 2017, 20:52

On pages 78-79 of the Transportation Safety Board of Canada final report on Air Canada 624 (A320, Halifax, March 2015 - just Google Air Canada 624 report) it is indicated that ACA's remaining non-GPS A320's were to receive retrofitting. What bitter irony if C-FKCK (ACA759) was on the list, but hadn't made it into the hangar yet.

There have been intelligent, insightful comments re the inflexibility of the EFIS on the older A320's, especially if non-GPS, but here's a can of worms I haven't seen opened yet . . .

You are in an IFR aircraft, on an active IFR flight plan, inbound to SFO 28R, in VMC, cleared for the FMS Bridge, essentially an enhanced visual approach. If I remember correctly from my "Talk and Gawk" days, you had to have reasonable expectation of remaining visual to get approved for a visual approach, but you still had the option of "re-transitioning" back into IFR at any time, provided you didn't CANCEL IFR. Also, if I remember correctly, the controller still had to provide IFR separation for you, and also still had to protect the IFR missed approach area.

Now, I admit that, in the real world, if you were maintaining VFR in VMC, and a go-around became necessary for whatever reason, normally, you would be cleared for, and would execute, a VFR go-around, as ACA759 did. HOWEVER, in the given scenario, I submit that that would not have been your only option, again provided you had not cancelled IFR.

In the unlikely event that some unusual factor arose, such as fast-moving scud rolling in, migratory birds at circuit altitude, wind shear conditions, wake turbulence hazard, traffic, whatever, you would still be entitled to request clearance for an IFR missed approach, into the still-protected IFR missed approach airspace, despite your previous clearance for the FMS Bridge.

Sooo . . . (and I hope you're still awake, reading this) even if you are in a non-GPS beater A320, wouldn't you want your seat mate to be primed for, and/or tuned in for, immediate transition to IFR in case the IFR missed approach became necessary? If you were already prudently set up for that, would it involve all that much button pushing to quickly peek at ILS or VOR/DME data as a cross check while still on the FMS Bridge? Methinks not.

jurassicjockey

16th Aug 2017, 20:56

Considering many, many aircraft used this approach and after, that same night, and did not try to land on the TWY......

Do you know that for a fact. There was a Delta go-around previous to this on the same night. Are you privy to the reasons for that

peekay4

16th Aug 2017, 21:20

Considering many, many aircraft used this approach and after, that same night, and did not try to land on the TWY......according to the drivers, they did not do anything wrong, just did a GA because "something didnt seem right"

The Asiana 214 crash at SFO happened in part due to a misunderstanding of a peculiar way the 777 Auto-Throttle worked in a set of circumstances the NTSB described as "very rare" -- after all, many many aircraft use auto-throttles on approaches all the time, without issue.

However, only after the accident did we start to look for other times crews made the same mistake. By analyzing historical FOQA data, one US airline reported that in their fleet pilots made the same mistake several times a day! Another US airline found seven instances that the same misunderstanding almost led to accidents, including one where the approach speed had deteriorated to almost 20 kts below Vref.

So while the vast majority of A/T approaches were incident free, mistakes were happening. An accident like Asiana 214 was just a matter of time, and likely could have happened to almost any 777 operator. The Asiana crew were simply the unlucky ones.

Similarly, in my view, through this AC759 incident we will find out many similar cases at SFO and/or other airports which had not been reported before. That many aircraft used the same night visual approach successfully that has no bearing to the fact that there might be an underlying cause such that a serious incident like this one might have been inevitable over time. Hence it's important for us to understand it, so we may try to prevent future occurrences.

underfire

16th Aug 2017, 21:46

Hence it's important for us to understand it, so we may try to prevent future occurrences.

What does circumstantial evidence say? (as the drivers have denied an incident)

All FDR evidence shows they tried to land on the TWY.
Video evidence shows they tried to land on the TWY
Crew denies they were on the TWY.
Crew denies they saw ac on the TW.
CVR not available.
As no incident, no substance testing?

Historically, how many other aircraft have tried to land on TWY C? EVER?

Do you believe the 2 drivers story?

What exactly do you feel will be learned from this?

Not allow visual approach for the other 99.99% that can figure out where the runway is?
Not to trust the drivers, and have 4 hour CVR's?
Have video recorders on the flightdeck?
Not allow visual for AC aircraft?

Exactly WHAT WILL BE LEARNED?

Every criminal in prison professes their innocence.

There was a Delta go-around previous to this on the same night. Are you privy to the reasons for that

Why was that, pray tell?

Perhaps they were behind the AC ac that tried to land on a few other aircraft?
Since you know, why be so coy?

peekay4

16th Aug 2017, 22:29

Do you believe the 2 drivers story?
As they perceived it, YES 100% WITHOUT RESERVATION.

aterpster

17th Aug 2017, 00:35

So while the vast majority of A/T approaches were incident free, mistakes were happening. An accident like Asiana 214 was just a matter of time, and likely could have happened to almost any 777 operator. The Asiana crew were simply the unlucky ones.

Disagree. Not for a pilot/crew that were trained in the fundamentals of flying. Unabated IAS below Vref would simply not happen to those who really understand how to fly.

peekay4

17th Aug 2017, 00:54

Plenty of airline pilots who were "trained in the fundamentals of flying" have stalled and crashed on approach. The NTSB has five decades worth of reports testifying as such.

The Asiana 214 commander was an elite pilot with the Korean Air Force. The PF had a 20-year career with Asiana flying the A320, 737, 747-400 before transitioning to 777s. The observer pilot sitting jumpseat flew F-16s. To suggest that they weren't "trained in the fundamentals of flying" is a bit of a stretch.

The fact that FOQA data shows that numerous similar deviations below Vref due to the same issue were happening at more than one US majors clearly suggest that this was an accident waiting to happen. If you read the NTSB final report (https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1401.pdf), the statement by NTSB chairman Robert Sumwalt (starting at page 136) is quite illuminating.

I think many pilots will look at Asiana 214 or AC759 and simply think, "this can't happen to me, I'm a better pilot!". Don't be so sure.

DaveReidUK

17th Aug 2017, 06:19

Crew denies they were on the TWY.

I must have missed that part. Where and when did they say that?

RAT 5

17th Aug 2017, 10:49

As per the Westjet near crash into the sea at St. Maarten, and again here the crew made a GA then flew the same approach again and succeeded. I've wondered & asked in both cases what they did differently the 2nd time. By knowing that we might learn, from them, how they screwed up the 1st time.
I read somewhere, I think, that AC's 2nd approach was via a straight in ILS; is that correct? If so we may not learn their fundamental mistake, but what the crew can say, without any doubt, is that the picture they saw on the 2nd approach was vastly different from that on the 1st. In which case how can they say they were not lined up on the taxiway for the 1st attempt. If "something didn't look right" on their 1st visual then it sure a heck looked normal on the 2nd, or they wouldn't have landed.

AerocatS2A

17th Aug 2017, 10:58

They didn't say they were not lined up with the taxiway, they said they "believed they were lined up with 28R". Well duh! Obviously they thought they were lined up with the runway, they're not going to line up with a taxiway on purpose just for ****s and giggles. This is not the same as denying they were lined up on the taxiway as Underfire keeps banging on about. They also don't recall seeing aircraft. Again that doesn't mean they didn't see the aircraft, it just means they didn't recognise what they were looking at as aircraft, instead it "just didn't look right".

Nowhere does it say that the crew deny the fact they were lined up with the taxiway or that they overflew aircraft, they are talking about what they perceived at the time.

AerocatS2A

17th Aug 2017, 11:00

I must have missed that part. Where and when did they say that?

They didn't.

The quote from NTSB is this:

...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.

Maybe they misunderstood the ATIS and NOTAM and thought the approach lighting was out for 28R. I've been into Sydney many times after curfew when the closed runway 34R is lit up like a bonfire while the in use runway 34L has a displaced threshold, no approach lights, temporary PAPIs hiding behind taxiway signs and a couple of vehicles on the runway doing an inspection. If you did an approach on what looked like a runway you'd balls it up (and it has been done), instead you are expected to make an approach on to a mess of lights that don't look much like a runway. Granted, Sydney is not SFO, but perhaps these guys had talked themselves into expecting to see 28R with no approach lights next to a 28L with approach lights. Who knows? I don't know. What I do know is that they didn't set out to purposefully land on a taxiway, something screwed up their expectations.

aterpster

17th Aug 2017, 13:43

The fact that FOQA data shows that numerous similar deviations below Vref due to the same issue were happening at more than one US majors clearly suggest that this was an accident waiting to happen. If you read the NTSB final report (https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1401.pdf), the statement by NTSB chairman Robert Sumwalt (starting at page 136) is quite illuminating.

I think many pilots will look at Asiana 214 or AC759 and simply think, "this can't happen to me, I'm a better pilot!". Don't be so sure.

I am familiar with Sumwalt's statement. He was upset that the Board wouldn't recommend that Boeing modify the 777 A/T system. I share that concern. Automation has created a generation of "children of the magenta line." Sumwalt also went on to say:

The above remarks are an attempt to explain how the pilot flying may have relied on the aircraft to maintain a safe airspeed. Despite his reliance on the automated system, there is no doubt that he should have monitored airspeed. The investigation found that the pilot flying didn’t monitor for 24 seconds, and the instructor pilot didn’t monitor for 17 seconds. These were critical errors that were causal to the crash.

As far as the PIC's experience is concerned, that and $10 will get you coffee at Starbucks. The KAL PIC at Guam (KAL800) also had lots of merit badges.

underfire

17th Aug 2017, 18:13

When they passed 3 feet over PAL (with their lights on), do you think they realized they were on the taxiway?

Did they hear UAL radio they were on the taxiway 5 seconds before GA? Did they see UAL pass under them?

To continue to say they thought they were on the runway is disengenuous to say the least.

They never said we did the GA because we saw we were landing on the taxiway.

Again, denial of the simple facts.

DaveReidUK

17th Aug 2017, 20:21

DIBO

17th Aug 2017, 20:32

First lessons learned, changes being implemented:
https://www.flightglobal.com/news/articles/faa-changes-san-francisco-landing-procedures-after-a-440380/

Carbon Bootprint

17th Aug 2017, 21:40

Two controllers during the nighttime rush, no visual approaches at night when a runway is closed. That's something, I guess, at least for a quick and easy fix. Hopefully it'll cover some of the holes in the cheese.

underfire

18th Aug 2017, 00:02

Originally Posted by underfire View Post
When they passed 3 feet over PAL (with their lights on), do you think they realized they were on the taxiway?

Did they hear UAL radio they were on the taxiway 5 seconds before GA? Did they see UAL pass under them?

To continue to say they thought they were on the runway is disengenuous to say the least.

They never said we did the GA because we saw we were landing on the taxiway.

Again, denial of the simple facts.
You seem to be going round in circles.

Are you still asserting that the crew denied they were on the taxiway ?

Given the FACTS......

Yes

Insert
I swear I was on the RWY, I did call in and ask why there were aircraft on the runway,
I did not hear UAL on radio say that I was on the taxiway,
I passed over one aircraft on the runway, then
I did not see that I passed 3 feet over aircraft with that just turned its landing lights on...
but I decided to do a go around because I was not on the taxiway, but something just did not seem right.

Glad I had 2 days to practice my story and , ooopsies, no CVR.

It is interesting that pilots want to claim they are responsible for the aircraft....until something happens, then the blame game surfaces.

Bleve

18th Aug 2017, 02:43

Given the FACTS......

Yes

Insert
I swear I was on the RWY, I did call in and ask why there were aircraft on the runway,
I did not hear UAL on radio say that I was on the taxiway,
I passed over one aircraft on the runway, then
I did not see that I passed 3 feet over aircraft with that just turned its landing lights on...
but I decided to do a go around because I was not on the taxiway, but something just did not seem right.

Glad I had 2 days to practice my story and , ooopsies, no CVR.

It is interesting that pilots want to claim they are responsible for the aircraft....until something happens, then the blame game surfaces.

Versus:

"Lets make an approach to the taxiway full of aircraft ...
To cover our butts, let's make a call that 'something doesn't seem right' ...
To make it really exciting we'll do a go-around at the last possible moment..."

:ugh:

AerocatS2A

18th Aug 2017, 03:21

Given the FACTS......

Yes

Insert
I swear I was on the RWY, I did call in and ask why there were aircraft on the runway,
I did not hear UAL on radio say that I was on the taxiway,
I passed over one aircraft on the runway, then
I did not see that I passed 3 feet over aircraft with that just turned its landing lights on...
but I decided to do a go around because I was not on the taxiway, but something just did not seem right.

Glad I had 2 days to practice my story and , ooopsies, no CVR.

It is interesting that pilots want to claim they are responsible for the aircraft....until something happens, then the blame game surfaces.

Cool story bro.

You get all of that from "we believed we were on 28R". Amazing.

glofish

18th Aug 2017, 04:46

IF there were two controllers, one to check if no one lines up wioth taxiway, waterway etc. ....
IF there was only a RNP 0.11 RNAV approach that could be completely coupled with the AP ....
IF there was a great big orange lit cross marking 28L closed, a great big orange lit cross marking the beginning of taxiway C and bright, standard lighting for 28R ....
IF there were sharp pilots on each and every aircraft on taxiway C warning any fellow pilot wrongly lining up to it ....
IF there was any a "optic-radar-laser-differential GPS positioning-high precision" measuring and warning unity installed on every possible approach vector for every possible and published approach for every runway ....
... and maybe a German shepherd dog on every extended runway bearing who could bite a highly trained flagman equipped with a VHF transceiver if it spots a deviation of an approaching airliner ....

Then we could proceed another step closer to pilotless aircraft.

See what i'm drifting at?
Even if there were contributing factors, this still remains a huge f%ck up of two highly trained professionals who would defend their above average salary with the above average responsibility they assume.

Stand for it! It is the pilots who are finally responsible for a safe flight.

WillowRun 6-3

18th Aug 2017, 05:25

Without getting into any of the contentions about the mechanics of flying specific approach profiles or the contours and structure of any of those profiles, there is one aspect of the, shall we call it, back-and-forth with underfire, about the blameworthiness of the pilots, which should be called out. Anyone who has taken a witness's statement in a preliminary setting or situation, when the factual picture is far from complete, will admit it is a rare indeed situation where a more complete factual recitation - through Q&A - is not elicited once the facts reach their ultimate level of development or discovery.
The point this sets up is simple: the snippets of verbal responses the pilots are quoted in the preliminary Board report as having said were the product of a rather preliminary type of questioning by Board staff, were they not? If a detailed, meticulous and methodical Q&A were to be conducted upon a full factual record, common sense and experience strongly indicate that a clearer picture would emerge about there having been a moment of shocking revelation when what they thought was 28R was shown to be the taxiway instead. When exactly this moment occurred, I would argue, is not determined by the snippets of verbal responses quoted in the preliminary report. Of course the apparent failure to preserve the CVR makes the pilots look worse than they already did (and the carrier, and possibly FAA), and causes some presumably significant (useful and relevant) information to be unavailable. But that fact does not convert an ambiguous set of short-hand answers into a detailed, moment-by-moment timeline. Particularly with respect to the moment when the nature of the concrete they had had in sight on the first approach was revealed with accuracy.
If this is giving too much credit to the ambiguities apparent in the reported statements by the crew, I am sure various posters will drive right at it and cause it to dive into oblivion.

DaveReidUK

18th Aug 2017, 06:23

You seem to be going round in circles.

Are you still asserting that the crew denied they were on the taxiway ?Given the FACTS......

Yes

OK, thanks for clarifying that. Then permit me to ask again the second part of my original question, that you haven't answered:

Where and when did the crew issue that denial?

You do know what "deny" means, don't you?

ATC Watcher

18th Aug 2017, 07:18

from the Flight global article linked earlier :he A320 pilots overflew the taxiway by about 0.25nm before controllers ordered it to go around. They descended to minimum altitude above the taxiway of 59ft and passed within 29ft laterally of one aircraft and 100ft above two others, according to US and Canadian investigators.

At the time of the incident, San Francisco's runway 28L was closed and unlit.

Pilots of the Air Canada A320 told US investigators they thought the lighted runway was 28L and that taxiway C was runway 28R, the NTSB said.
If this is indeed correct , then 90% of the posts on this thread are obsolete.

Point 1 : The controller became aware as he/she ordered a go around.But late .
Point 2 : 100ft above an 30 ft lateral , looks like it would not have resulted in the " worst collision ever" even if they would have actually landed on the taxi way .
Point 3 : they were misled by the lighting configuration and thought they were lining up with a runway. Confirmation of what we thought from the beginning.
Why is obvious , and the FAA change in procedures will definitively help in ensuring the repetition of this case is unlikely.

What do you want more? Hang the 2 pilots in the Control tower balcony?

Ian W

18th Aug 2017, 07:37

OK, thanks for clarifying that. Then permit me to ask again the second part of my original question, that you haven't answered:

Where and when did the crew issue that denial?

You do know what "deny" means, don't you?

As I have posted earlier:

* the crew queried 'something on the runway' :
* tower says no its clear all yours,
* the crew initiated a go around because they see things on the 'runway' that do not look quite right;
* Tower commands a go around;
* Crew responds we are in the go around - and are probably thinking - "we were right tower screwed up and there was traffic on the runway"

I doubt that the misconception was noted indeed it may have continued until the crew shut down. So there was no reason to 'deny' anything - it was a tower screw up and that was why they were being asked to call tower. Why should they protect the CVR if they thought it was a tower screw up?

It will be instructive to find out when the crew became aware that they had actually made an approach to the taxiway. I suspect their first response was "no - we made both approaches to 28R!"

DaveReidUK

18th Aug 2017, 07:39

If this is indeed correct, then 90% of the posts on this thread are obsolete.

The Flight article contains no new facts about the incident, only details that have been known for several weeks.

Nevertheless I'm sure that 90% of those who have posted during that period are feeling suitably chastened.

We look forward to more of your insights.

ATC Watcher

18th Aug 2017, 08:08

Dave : The Flight article contains no new facts about the incident, only details that have been known for several weeks.

Some details were new to me at least , not everyone is the secret of the investigation, but you did not comment on my last remark, which was my point : : what are you all after now that the facts are known and remedy to prevent recurrence has been implemented ?
Why the hunt for a culprit at all costs ? We are supposed to be applying just culture in our daily jobs , but seem to be the first to deny this on this forum.

End of my "insights"

RAT 5

18th Aug 2017, 08:47

what are you all after now that the facts are known and remedy to prevent recurrence has been implemented ?

ILS used for all approaches. Is there a problem with the spacing between 28L & 28R for a/c to use them both at the same time and hence the offset bridge approach? If so, and if a/c were spaced longitudinally at 2nm, could they use both ILS's at the same time. With equal speeds there would not be a lateral space problem. However, would there be a TCAS issue?

framer

18th Aug 2017, 09:03

What I do know is that they didn't set out to purposefully land on a taxiway, something screwed up their expectations.
I agree. Their expectations of a certain picture must have been strong.
If we can learn why they expected a picture that was obviously wrong we would be better off as in industry. If we get all pissy about who we should blame for this event will will be no better off as an industry.

ATC Watcher

18th Aug 2017, 09:52

Framer : I could not agree more .

RAT5 : I thought we have visual APP because it increases both efficiency and capacity . As a controller, if you all want ILS only and 2NM spacing ? no problem for me , on the contrary , but this means you all get down to the same speed to the Kt from the OM onward...abut even then , wake turbulence separation is likely to upset that.

would there be a TCAS issue? on parallel APPs? , normally no. TCAS will only give you an RA is your tracks are converging and further no RAs below 1000 ft anyway.

Old Carthusian

18th Aug 2017, 10:58

Hi All
I've been following this incident with interest and observing the reactions of various people closely. OK my flying experience is limited to grass airfields so I don't know commercial airports but I would assume that the taxiways are lit differently to the runways. At least I hope so and I would expect pilots to know this. As to reactions to this kind of situation if I was an airline manager it would be summary dismissal. There is no excuse for endangering passengers in this way.

the_stranger

18th Aug 2017, 11:33

Framer : I could not agree more .

RAT5 : I thought we have visual APP because it increases both efficiency and capacity . As a controller, if you all want ILS only and 2NM spacing ? no problem for me , on the contrary , but this means you all get down to the same speed to the Kt from the OM onward...abut even then , wake turbulence separation is likely to upset that.

Numerous airports in Europe, all busier then SFO (by flights), use almost only ILS. Rarely visuals, no RNAV, just 99% ILS. Even with 4NM spacing, slow and fast traffic.
So it can be done efficiently, but probably depends on layout and (noise) procedures.

wiggy

18th Aug 2017, 11:57

I would assume that the taxiways are lit differently to the runways. At least I hope so and I would expect pilots to know this

......And I suspect if you asked the AC pilots involved before this incident about airfield lighting they will have have been happily be able to describe to you the difference between taxiway and runway lighting....indeed I'd bet a significant number of pilots who have landed on parallel taxiways instead of runways in broad daylight could describe Threshold Markings, Touch Down Zone Markings, etc.

. As to reactions to this kind of situation if I was an airline manager it would be summary dismissal.

That's the way to improve things..string them up, no need for further questions....but that improves safety for the rest of us who operate into "big" airports with multiple runways how, exactly? We know they stuffed up, they I'm sure know they stuffed up. I'm probably a bit of a soft old liberal but personally at the very least before firing them (if you must) I'd like to know why they didn't see the Gorilla, so I don't miss it the darned thing the next time I go into the likes of SFO...........

DaveReidUK

18th Aug 2017, 12:00

I doubt that the misconception was noted indeed it may have continued until the crew shut down.

That would imply that the crew didn't take seriously the United pilot's "They're on the taxiway!" transmission (but went around anyway).

It will be instructive to find out when the crew became aware that they had actually made an approach to the taxiway. I suspect their first response was "no - we made both approaches to 28R!"It will indeed, though I suspect that their first response was rather more immediate and rather more Anglo-Saxon.

Unless they were Québécois. :O

CargoFlyer11

18th Aug 2017, 12:14

DaveReidUK

18th Aug 2017, 12:23

Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://www.eastbaytimes.com/2017/08/15/editorial-air-canada-faa-hindered-investigation-of-sfo-near-miss/)

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.......:ugh:

See post #821:

Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://www.mercurynews.com/2017/08/15/editorial-air-canada-faa-hindered-investigation-of-sfo-near-miss/)

RAT 5

18th Aug 2017, 12:57

To clarify my comments about spacing on finals: I was meaning staggered spacing. If the runways are too close for parallel approaches with the a/c 'side by side', then they can be staggered, at the same speed, with 2nm longitudinal spacing, but on the // runway. They would still have the required spacing of traffic ahead on their own runway, but staggered from the neighbouring one and thus achieve not lateral conflict. It would be necessary for the respective GA routings to ensure sufficient separation.
I also questioned whether this would trigger a TA on finals. the preceding traffic could be less than 3nm, but there would be no closure. The boffins will tell me.
This staggered spacing is used at some airports in a different way. There are crossing runway tracks and initial GA tracks my intersect too closely if the a/c touchdown simultaneously. ATC utilises a ghost radar picture. This shows the a/c landing on 1 runway and the a/c landing on the crossing runway to be superimposed as if they are landing on the same runway. It shows the effective spacing, nominally 2nm, between their landings.

betterfromabove

18th Aug 2017, 13:27

ATC Watcher

18th Aug 2017, 14:10

RAT5 : Misunderstood, Clear now , I thought you meant everybody 2NM behind one another . in FRA 2,5 NM spacing is done on some clear days , but that is about as low as you can go to stay legal and to avoid excessive GAs.
TCAS is no issue since (normally) as you said there is no closure and as I mentioned earlier inhibited below 1000 ft anyway.

DaveReidUK

18th Aug 2017, 14:24

peekay4

18th Aug 2017, 14:24

To clarify my comments about spacing on finals: I was meaning staggered spacing. If the runways are too close for parallel approaches with the a/c 'side by side', then they can be staggered, at the same speed, with 2nm longitudinal spacing, but on the // runway. They would still have the required spacing of traffic ahead on their own runway, but staggered from the neighbouring one and thus achieve not lateral conflict. It would be necessary for the respective GA routings to ensure sufficient separation.

At SFO, there are two kinds of simultaneous parallel instrument approaches that can be used:

1. Independent offset approaches (SOIA), with 28L using ILS PRM while 28R on the LDA PRM (or their RNAV equivalents). But SOIA is not an option in "hard IFR" because the LDA PRM minimum is fairly high (> 1,000ft).

2. Dependent approaches. SFO has authorization to conduct staggered approaches with 1.5nm spacing between aircraft on the parallel runways. In this case both 28L and 28R can use the normal (non-PRM) ILS approaches down to 200' DH. The 1.5nm spacing is possible because the ILS 28L glideslope was tweaked down a bit to 2.85 degrees a few years ago, providing additional vertical separation from staggered aircraft on the right.

rog747

18th Aug 2017, 14:51

the AC759 skipper (or the PF) called ''IN THE GO AROUND'' - that was heard on about page one of these 45 pages BTW
- this call was in response to ATC telling him to go-around after a quarter of a mile of the taxiway had been overflown by now scaring the crap out of United and Philippines.

His tone and his snappy (quick retort) response left no doubt in my mind that he was already in the overshoot when ATC told him to AND shows having clearly realised oops there are some planes in front of me where I was going to land

I think it is only DaveReid and myself on here that gets it (and got it from Page 1)

Now, why there were in that place in the first place is the case for the investigation - we can all pontificate another 45 pages but I dont have the wibble and froth time

Ian W

18th Aug 2017, 14:51

That would imply that the crew didn't take seriously the United pilot's "They're on the taxiway!" transmission (but went around anyway).

It will indeed, though I suspect that their first response was rather more immediate and rather more Anglo-Saxon.

Unless they were Québécois. :O

I doubt if the crew even heard the UAL transmission (or more correctly comprehended it) why would they think it is about them?

A more constructive transmission would have been Air Canada you are lined up on the taxiway; or aircraft on approach to 28R you are landing on the taxiway.

When someone has cognitive tunneling, the first sense to go is understanding what is being said. Once they had started the go around they were out of the tunnel.

There was a lot to be said for the RAF 'runway controller' firing a red flare :D

galaxy flyer

18th Aug 2017, 15:26

My guess, the various clues all came in focus for the crew and they decided to go--the radio comment by UA, the tower saying the runway was clear when they thought it was not and PAL flashing his lights. They just starting doubting themselves very late. They can't have mistaken the UA comment--they were the only ones it could possibly have applied to.

Without the CVR, we'll never know the truth sadly.

As to the UA and PAL crews, what would expect them to do? Taxi back and leave 600 pax stranded. Close call, move on

GF

MarcK

18th Aug 2017, 15:53

AVweb and Flight Global are now reporting:
The FAA has made operational changes at San Francisco International Airport in response to last month’s aborted landing by an Air Canada A320, the Bay Area News Group reported on Tuesday. The FAA no longer allows visual approaches for aircraft approaching SFO at night with an adjacent parallel runway closed, FAA spokesman Ian Gregor told the News Group. “When these conditions prevail, our controllers issue pilots Instrument Landing System approaches or satellite-based approaches, which help pilots line up for the correct runway,” Gregor said. “Additionally, SFO tower management is requiring two controllers to remain on position working traffic until the late-night arrival rush is over.”

DaveReidUK

18th Aug 2017, 15:55

I doubt if the crew even heard the UAL transmission (or more correctly comprehended it) why would they think it is about them?

That will no doubt be one of the questions the crew have been asked by the investigators.

Grammatical niceties aside, they may well have been graduates of the "when there is doubt, there is no doubt" school of GA decision-making.

RAT 5

18th Aug 2017, 16:01

DIBO

18th Aug 2017, 16:38

There is one aspect of this incident that intrigues me and I don't think anyone has talked about yet on this thread, namely what the "sitting duck" aircraft on the taxiway did next...

If the event was THAT close to the United and PAL aircraft, it seems their crew was still happy enough shortly afterwards to proceed to line up and depart. Does this surprise anyone?

I'm coming at this from an HF point of view.

Must have been some very interesting conversations over coffee on those legs.....:hmm:

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

but not much reaction then...

As to the UA and PAL crews, what would expect them to do? Taxi back and leave 600 pax stranded. Close call, move on
For UA it was a close-ish call, with the pointy end well out of the way and aiming South, they missed most of "the show"...
For the PAL guys.... well they are probably made out of "The Right Stuff"... I'm certainly not.
But know that minutes later the PAL crew lined up and asked "confirm we're cleared for take-off?", while nothing of the kind was stated by TWR, their RT based SA (ref. EK Seychelles topic, with the crew being condemned by the pprune jury for missing completely RT based SA) seemd to be missing the constant 'inter-meshed' T/O's on the crossing rwy, including the one that was rotating the very moment they asked. But the PAL crew did the right thing: when in doubt, get clarification (unlike the E195 @BRU topic).
Was that merely an honest doubt/mistake?? Or still a bit shaken from things 15min. before?
The TWR controller surely wasn't a bit shaky, and given his firm reply, wasn't going to let things get screwed up twice in 15min. times....

slack

18th Aug 2017, 17:07

[QUOTE=CargoFlyer11;9865669]Editorial: Air Canada, FAA hindered probe of SFO near-miss (http://www.eastbaytimes.com/2017/08/15/editorial-air-canada-faa-hindered-investigation-of-sfo-near-miss/)

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.......:ugh:[/QUOTE

If ac did not report for 1 or 2 days I would suggest flying another airline. The duty pilot must have known or should have known within minutes of the incident.
As for the faa it was a weekend and good golfing weather. Did not expect much more from this lot. Your tax dollar at work NOT. AC management pilots should have several of their own heads on the chopping block. :ugh::ugh:.

I spent 35 years (8 years on the computer driven 320 ) in the industry and can't remember such a :mad: up. AC and FAA we are all awaiting your report. Over a month ago and they can't find the wording to smooth this one out. :=

peekay4

18th Aug 2017, 22:22

If ac did not report for 1 or 2 days I would suggest flying another airline.

The required deadline for reporting this type of incident: 10 days.

I suspect the relevant rules may be revisited.

BluSdUp

19th Aug 2017, 08:13

FAA says no more visual approaches to 28R when 28L is closed. And two Controllers in twr until evening rush over.

Wow, I wish I would have thought of that.

A thing I forgot to ask you chaps that regularly frequent SFO with airliners: Is the whole operation of 28L and 28R done with noise in mind. Ie, when traffic is less in the evening and at night they regularly shut down 28L and give visual 28R ( Wx permitting) to keep traffic away from the shoreline to the left.

I assume this is the case . And I could read the airport details, but I am interested in what they do , not what they write.

In my humble opinion , local rules and regs for noise make for way to much unnecessary yank and bank .

This accident avoided was created partly by the noise people.

With CDA ( Continues Decent Approaches ) there is no noise until 500 feet spool up. It is time to revise all departures and arrivals for modern jet.

A bit of drift there: Lets get back to the LOC and get on the GS.

KISS from Cpt B and FAA

Old Carthusian

19th Aug 2017, 10:53

That's the way to improve things..string them up, no need for further questions....but that improves safety for the rest of us who operate into "big" airports with multiple runways how, exactly? We know they stuffed up, they I'm sure know they stuffed up. I'm probably a bit of a soft old liberal but personally at the very least before firing them (if you must) I'd like to know why they didn't see the Gorilla, so I don't miss it the darned thing the next time I go into the likes of SFO...........[/QUOTE]

How to express this clearly. The pilot is responsible for the safety of the lives of the passengers on the flight. If as a pilot you accept this responsibility you are duty bound to ensure (as much as you can) that the other people do not die or are not harmed. This is an absolute. If the pilot stuffs up others die. Passengers trust the pilot not to stuff up and have to be able to rely on the pilots ability. Liberal values have nothing to do with it - peoples lives matter more. SFO is a known quantity and how the AC crew lined up on a taxiway without noticing escapes me. It does not represent the basic professionalism that a passenger has the right to expect. The incident also could have led to the death of people in other aircraft. Summary dismissal is the only response in this situation.

framer

19th Aug 2017, 11:06

The pilot is responsible for the safety of the lives of the passengers on the flight. If as a pilot you accept this responsibility you are duty bound to ensure (as much as you can) that the other people do not die or are not harmed. This is an absolute
Is it an absolute? If so, why do planes crash? Is it because all crashes involve pilots who don't take their responsibilities seriously? Or because pilots make mistakes.....just like Ghandi, Schumacher, Tiger Woods, Michael Jordan, Chuck Yeager , Mother Theresa and Nelson Mandela?
Summary dismissal is the only response in this situation.
What about adding one more response? Like investigating how two humans log 30,000 boring flight hours and then do this?

Old Carthusian

19th Aug 2017, 11:37

Yes it is an absolute - a pilot flying other people is responsible for them. And I don't recall Ghandi, Schumacher, Tiger Woods, Michael Jordan, Mother Theresa or Nelson Mandela being pilots. Lets not have any spurious equivalency here.

Lets put it this way - 100-500 people could have died because the crew lined up on the taxiway not the runway. It is not really relevant that two humans log 30,000 boring flight hours. Others could have died. They are supposedly professionals and are paid to be professional. The responsibility they bear is very hefty but they accept that when they become commercial pilots. If you fly airliners you are responsible for the people who fly on your aircraft. You make sure that you do your best because other people trust you with their lives. Seriously there is no excuse for trying to land on a taxiway instead of a runway.

BBK

19th Aug 2017, 11:47

Old Carthusian

It's not WHAT they did but WHY that most professional aviators are interested in. You do know that's it's 2017 and in advanced countries it's the how the "holes in the cheese lined up" that is more important than blaming professionals.

Maybe they were negligent, maybe they were two god guys having a bad day (night!). I don't know so I won't speculate.

I am curious as to why they weren't flying an ILS at night. That's not a criticism as it may not have been an option. When I started flying to the USA I was told if offered a visual just say "no!".

BBK

Old Carthusian

19th Aug 2017, 12:14

Holes lining up is actually not as relevant as some think. If one shifts one's perspective and looks at it from the point of passengers dying can you give the people who died their lives back? So though why is important the response to what is also important and in this case just as important.
Even in European countries there comes a point when a person is responsible for their actions. It becomes especially onerous if one also assumes the responsibility for other people as well. However, if one does assume this responsibility then one also should accept that there may be sanctions if one fails in that duty.

BluSdUp

19th Aug 2017, 12:35

You are not an Airline pilot are You!
And you do not understand how things work in the industry,do you?
It must be confusing for you.

wiggy

19th Aug 2017, 12:35

OC

You conveniently forgot to mention Yeager in your attempted riposte...was that an inconvenient truth?

Anyhow in an earlier post you stated:

1. OK my flying experience is limited to grass airfields so I don't know commercial airports

Then in a subsequent post state:

2. Seriously there is no excuse for trying to land on a taxiway instead of a runway.

I'll leave that observation hanging, others may care to comment.....

As for You make sure that you do your best because other people trust you with their lives. .... It's probably unlikely the crew in question pitched up at report for the duty and said to each other "lets not really do our best tonight"...in fact I wouldn't be surprised if the A C pilots actually thought they were doing their best.... as they came down the approach..

Not offering excuses but have you seen any of the Human Factors/ Human Perception videos others and myself have alluded to in this thread? I ask because it can come as a nasty shock, even to seasoned aviators, even in the calm of class room, to realise that in certain circumstances what you think your perceive may not actually what is out there in the real world, staring you in the face.

underfire

19th Aug 2017, 12:41

Without the CVR, we'll never know the truth sadly.

Equally, if the crew initiated the GA before ATC I wonder if it was PF or PM that called the GA. Remember they were studying the lights, and having doubts, for 2 minutes or more.

My thoughts and comments are basic on logic, and simple fact.

Do you really think the crew, after hearing UAL, seeing landing lights, and passing feet over aircraft, did not recognize it as the taxiway?

Did tower even say over the radio, you were lined up on the taxiway, and vector the GA?

Is it normal for aircraft to line up on the active runway for DEP? (facing backwards?)

IF what the NTSB stated is the case, that they stated they were lined up on 28R and did a GA because it didnt look right....

To answer other comments, they do the FMS bridge Visual, because all of the vector points and step downs are coded in, thus relieving ATC from all of that.

The CSPR procedures are a different lot.

A more constructive transmission would have been Air Canada you are lined up on the taxiway; or aircraft on approach to 28R you are landing on the taxiway.

How would UAL know its AC? One would assume that the drivers of all of those ac were busy with preflight, rather than stare out the windscreen plane spotting? In addition, if you are on Quiet Bridge visual, you approach the 28R TCH at an angle to extended centerline.

Bergerie1

19th Aug 2017, 13:26

wiggy,

I agree entirely. I spent most of my professional life as an instructor pilot and it is indeed very salutary to realise how vulnerable, we, as human beings, are to perceptual mistakes. Despite all the precautions we take there are still occasions when we can be caught out.

As many others who have posted here have said, the important things is to find out WHY.

aterpster

19th Aug 2017, 13:51

The CSPR procedures are a different lot.

What's that?

WillowRun 6-3

19th Aug 2017, 13:55

Pretty thoroughly, comprehensively, and rigorously indisputable that an air transport pilot is responsible for the safety of the people on board, certainly as a legal question. Does that mean that neither SARPs nor national laws pertaining - to pick an example at random - to training prior to licensure, including awareness of optical illusions existing (or prevalent) in airfield lighting could not be improved, because the Pilot is Responsible Ultimately? If a poster thinks that answer is "yes", I would strongly disagree.

And about summary dismissal: without asserting that summary dismissal could tend to weaken or mitigate the extent of co-operation and honesty on the part of the dismissed pilots, nevertheless, summary dismissal is presumptuous in this matter. The exploration of all the possibly causative and/or contributing factors is too important in this case to allow a kind of retaliatory lust to take over. If it indeed is warranted (and from information already in the NTSB record it very well could be warranted, but I do not know that) to dismiss the pilots, dismissal, like revenge, will be served better cold.

DIBO

19th Aug 2017, 15:14

Closely Spaced Parallel Runways

peekay4

19th Aug 2017, 15:49

It's really CSPO (Operations) to airports with CSPR, e.g., the procedures already described in post #898 (http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-45.html#post9865767).

aterpster

19th Aug 2017, 16:01

Closely Spaced Parallel Runways

Thanks! Too many acronyms.

They've been doing that at SFO so many years I even flew them. It really backed things up when the weather was "200 and 1/2."

peekay4

19th Aug 2017, 16:04

What's "new" at SFO is the 1.5nm spacing between aircraft on parallel runways. Only introduced in the past 5 years or so.

underfire

19th Aug 2017, 19:29

It's really CSPO (Operations) to airports with CSPR, e.g., the procedures already described in post #898.

Unfortunately, not quite correctly discribed.

From 2010 CSPR https://www.faa.gov/documentLibrary/media/Order/JO7110.308CHG3inc.pdf this modified the 2008 order, which modified the etc order.

CSPR is the concept, it has been around for many years in several different formats and names, so yes, if you were in there since about 2000, you did fly one of the variants. This is not only at SFO, but many others...I think some of the first were at ATL (1000' feet between rwys) and STL (1300') in 1998! (with 3 III runways)

Recently, the FAA has added a spacing based on prevailing wind direction and strength, for mitigate wake turbulence issues. This is pioneered at SFO.

(terpster) The theory: Different interpretation of DA from the FAA AIM...(SAMUL would be the DA on FMS Bridge Visual) Can you tell from your database if SAMUL is a flyover as shown in this diagram, or a flyby as I have in mine?
https://www.skybrary.aero/images/SOIA_Geometry.PNG

EDIT: terpster, the FAA calls SAMUL a DA.... what is the Jepp definition of SAMUL?

peekay4

19th Aug 2017, 20:52

CSPR is the concept, it has been around for many years in several different formats and names

What? CSPR is not a "concept". CSPR just means Closely Spaced Parallel Runways, defined as parallel runways closer than 2,500ft.

And .308 did not define a new approach concept, just a change in policy (authorization) on conducting dependent approaches on CSPR pairs, specifically allowing 1.5nm parallel aircraft separation on dependent approaches to CSPRs.

Notice the phrasings in .308 (quoting the latest revision):

Simultaneous Dependent Approaches to Closely Spaced Parallel Runways[/B] ...
7. Procedures.
a. Airport Criteria Allowing Conduct of Simultaneous Dependent Approaches on CSPR ...
b. Procedures for Dependent Approaches to CSPRs. ...
Specific Airports/Runway Geometries Approved for Dependent Approaches to CSPRs

You'll find the same definition used by ICAO, Eurocontrol, etc.

so yes, if you were in there since about 2000, you did fly one of the variants.

Umm, no. Dependent approaches have been around since at least the 1970s, but until 2008 they were not authorized on runways spaced closer than 2,500 ft. The old separation criteria meant approaches to close parallel runways were effectively equivalent to conducting approaches to a single runway only.

And at SFO the 1.5nm separation did not take effect until 28L glideslope changes were made in 2013, as previously discussed.

Different interpretation of DA from the FAA AIM...(SAMUL would be the DA on FMS Bridge Visual)

DA on a visual approach... right...:rolleyes:

underfire

19th Aug 2017, 21:16

DA on a visual approach... right...
Argue with the FAA AIM on the subject. As shown in the diagram, for example, does an RNP AR procedure have a DA?

What? CSPR is not a "concept". CSPR just means Closely Spaced Parallel Runways,
Since you love to argue, that comment was in response to your CSPO comment.

And at SFO the 1.5nm separation did not take effect until 28L glideslope changes were made in 2013, as previously discussed.

Arguing with yourself again...

So, moving forward.

NTSB's formal investigations.

There is an Executive Section and Probable cause section.

https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1402.aspx

Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain.

Contributing to the accident were (1) the flight crew's failure to properly configure and verify the flight management computer for the profile approach; (2) the captain's failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured; (3) the flight crew's expectation that they would break out of the clouds at 1,000 feet above ground level due to incomplete weather information; (4) the first officer's failure to make the required minimums callouts; (5) the captain's performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and (6) the first officer's fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.

I am pointing the phraseology used in this and most of the other reports the NTSB has formally issued

First off, the NTSB report wording put the fault directly with the flight crew?

It then goes on with the Contributing factors. Specifially notice (5) and especially (6) in bold.

In reference to "fatigue, distraction, or confusion,"..."acute sleep loss resulting from her ineffective off-duty time management and circadian factors."

https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1603.aspx
https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1603.aspx

Asian SFO...similar phraseology

The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the PF's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances.

Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing's documentation and Asiana's pilot training, which increased the likelihood of mode error; (2) the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the PF's inadequate training on the planning and execution of visual approaches; (4) the PM/instructor pilot's inadequate supervision of the PF; and (5) flight crew fatigue, which likely degraded their performance.

peekay4

19th Aug 2017, 21:23

First off, the NTSB report put the fault directly with the flight crew.

From the report (and in all NSTB reports), page 3:
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

aterpster

20th Aug 2017, 00:32

From the report (and in all NSTB reports), page 3:
That is carefully crafted language to keep NTSB investigators and Board members immune from being dragged into endless tort litigation.

I am not sure, but I believe the NTSB regulations are backed up by public law (acts of Congress, signed into law by the president). I have no doubt a competent aviation litigator could provide further enlightenment.

aterpster

20th Aug 2017, 00:41

EDIT: terpster, the FAA calls SAMUL a DA.... what is the Jepp definition of SAMUL?
Where do you find the FAA calling SAMUL anything?

The airline TARGETS source shows SAMUL as a FB step-down within the intermediate segment. This is all "story board" stuff, since the source designer is using a program intended for IFP design to design a FMS visual approach track.

I hope the NTSB really opens this can of worms, although I seriously doubt they will.

SalNichols

20th Aug 2017, 00:42

If assigning fault for an error in judgement or procedure is unimportant, I wonder why the Navy has no problem cashiering ship captains that run into other objects, be it an underseamount in an LA class attack sub, or a container ship in the case of the USS Fitzgerald. I can't think of a single instance in which a Navy captains career has survived his or her poor judgement that resulted in damage to their ship and/or loss of life.

I have over 3M miles sitting back there, and frankly...29' is cutting things a little bit close for me. 20-30K hours and all the bloody swiss cheese in the world doesn't make this better, it was a major screw up. Fix it.

galaxy flyer

20th Aug 2017, 01:14

Sal

There are two tracks--safety investigation aimed at "fixing it" and disciplinary track aimed at uncovering criminal responsibility. It is entirely possible there is no criminal negligence here, humans make mistakes that are not criminal negligence after all. Go around firing or jailing people will not fix the problem, as the USN has proved.

SLFstu

20th Aug 2017, 01:24

In response to Old Carthusian's most recent post you wrote:
You are not an Airline pilot are You!
And you do not understand how things work in the industry,do you?
It must be confusing for you.
Disclosure - non-pilot opinion. Oh and I work in a life/death safety critical industry too. I signed up knowing that if I stuff up, people may die. And a known consequence is being tossed out of the gig.

Old Carthusian is calling for the crew’s heads to roll because mistakes were made that should not have been made by competent drivers. Is it relevant whether he knows “how things work in the industry”?

As a pilot you do of course, and we know what you mean because in earlier posts you said you hope that AC and the union take care of the 2 pilots. You know that only with an understanding employer and a protective union will these guys’ jobs be preserved. You yourself have banged on and on that there is no excuse for what these guys did.

Here’s some of your choice language pertaining to the incident, excerpted from your 18 posts, crafting a picture of what you called your “rather harsh description of the crew”:
…“near disaster; pure madness; fire chief pilot and head of training; this mess; FAA overdue for a big one; no excuses whatsoever; incompetent crew; it is simple, positive identification, always; severe incompetence of the crew; crew should get new glasses; aghast; conveniently developed amnesia; too lame; selective memory, at best; so there is no excuse now; my money is on complacency.”

What is there to be confused about?

peekay4

20th Aug 2017, 01:36

Different interpretation of DA from the FAA AIM...(SAMUL would be the DA on FMS Bridge Visual)

https://www.skybrary.aero/images/SOIA_Geometry.PNG

Argue with the FAA AIM on the subject. As shown in the diagram, for example, does an RNP AR procedure have a DA?
I'm sorry underfire, do you even understand what this diagram represents? The diagram shows a typical SOIA geometry, which has nothing to do with visual approaches like FMS Bridge! :ugh:

That DA on the top of the diagram is for the offset LDA PRM or equivalent, not for an RVFP. Just because FMS Bridge coincidentally has a similar left turn doesn't make SAMUL a DA!

And insisting that visual approaches have a DA just shreds your credibility on this topic.

galaxy flyer

20th Aug 2017, 01:59

SLUstu,

Except, in your industry, if you stuff it up, do you die along with the others?

peekay4

20th Aug 2017, 02:00

That is carefully crafted language to keep NTSB investigators and Board members immune from being dragged into endless tort litigation.
No, it is the central tenet of almost all transportation safety boards around the world. It's also a major reason of why the NTSB was separated from the FAA (which does assign fault).

Besides, all US federal employees -- including NTSB investigators and board members -- already have "absolute immunity" against all torts when acting within the scope of their duties, except for violations of the Constitution or federal law (in which case they have qualified immunity, which may still protect them from litigation).

SLFstu

20th Aug 2017, 03:26

SLUstu,

Except, in your industry, if you stuff it up, do you die along with the others?

Nup.
Therefore in aviation incidents that should remove at least one hole from the swiss cheese - self-preservation. No?

galaxy flyer

20th Aug 2017, 03:42

No, but the point is the pilots don't go to work planning on dying. I was in military crash that killed to other pilot, neither went to work planning on a mid-air. The AC didn't either and proving criminal negligence should have a high standard of proof. We're human, just like you, and make mistakes, are subject to illusions, misinterpreted data or simple task and mental saturation. Those are not criminal offenses.

SLFstu

20th Aug 2017, 04:16

GF
Yegods, no one's raised the stakes to this extreme, yet. Though as I pointed out in an earlier post CA's top insurance lawmaker was none too pleased after learning why his AC579 flight did a sudden and weakly explained away GA.
My respect to you for suffering that horrifying event from your earlier flying.

llondel

20th Aug 2017, 05:12

Old Carthusian is calling for the crew’s heads to roll because mistakes were made that should not have been made by competent drivers. Is it relevant whether he knows “how things work in the industry”?

Probably apocryphal, but there's the tale of the manager at IBM who screwed up and cost the company millions of dollars. He got called in to see the CEO and said "I guess you've called me in to fire me". The response was "Are you kidding? I just spent $30million teaching you a lesson."

What's the chance that either of those pilots, regardless of the reason they got it wrong this time, will make that mistake again?

CurtainTwitcher

20th Aug 2017, 05:38

liondel, how about taking it to the next level? Learning from others close calls & mistakes should be in our DNA
What's the chance that of us pilots, regardless of the reason they got it wrong this time, will make that mistake again?
My hope is that there are many of us are now flying around with awareness of another potential "failure mode". I certainly am.

A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience.

framer

20th Aug 2017, 07:41

20-30K hours and all the bloody swiss cheese in the world doesn't make this better, it was a major screw up. Fix it.
Fix it. That's the aim that of most on this thread I imagine.
Firing the crew could be warranted I guess but what does it achieve? Almost nothing from a safety perspective. All the other crews remaining still have the same motivation not to crash as they did last week/ last month/ last decade.
Learning what factors lead to the mis-perception would greatly improve safety globally when the lessons were trained to tens of thousands of pilots through recurrent training programs.
It's easy to see reading this thread those who understand how Aviation achieved it's outstanding safety record and those who find comfort in the romantic notion that everyone up the pointy end is made of ' the right stuff'.

Ian W

20th Aug 2017, 07:57

Probably apocryphal, but there's the tale of the manager at IBM who screwed up and cost the company millions of dollars. He got called in to see the CEO and said "I guess you've called me in to fire me". The response was "Are you kidding? I just spent $30million teaching you a lesson."

What's the chance that either of those pilots, regardless of the reason they got it wrong this time, will make that mistake again?

Far more importantly, and the reason that Old Carthusian is mistaken in his eagerness to can the crew, is that all other pilots can be taught the same lesson of why this incident occurred. A crew who believe that they may be summarily dismissed will do their best to gild the truth in a way that hides any mistakes they may have made and nobody identifies the hole in the cheese. Fine - now that leaves another crew to make the same mistake and this time they do land on a queue of widebodies - that major accident may not have happened if the first crew had not been under threat of dismissal for that same human misperception.

The only times when dismissal is merited is when it can be shown that an accident/incident was due to intentional mishandling or a gross lack of skill that had a level of history in training or in previous incidents.

BluSdUp

20th Aug 2017, 09:18

The AC crew followed more or less standard practice that night.Until they got it wrong.
There is in my opinion something dramatically wrong with doing a visual at night without a ILS backup when available.
I do not expect you to understand this or the Old one, but at least he has a PPL.

The crew almost set a new record, then nicely pulled up for us to learn. And for AirCanada and FAA to get their stuff sorted.

I am disappointed with AC latest incidents and this crew was incompetent on this approach, but to fire them is not what we do.
Management in AC is not good and some should loose their job.

Finally SLF:
What profession do you represent that makes you think you can have a go at me.? On PPRUNE?
Seriously Dude.

darkbarly

20th Aug 2017, 09:37

IanW well said.

It is important for pilots to understand key failures learned in an event like this. In the real world of aviation, the follow up to such near hits is not always well thought out and applied by the powers that be. I too would very much like to know where our (multicrew) next signpost for error may be pointing.

Old Carthusian, your post is well timed but maybe not well informed. Perhaps you dont know what you dont know, yet. In a world where some believe our spheroid is still flat, it is important, however, to be reminded of our responsibilities. They do not diminish in actual fact, but do erode in our daily psyche. There are many posters here au fait with the aftermath of their own and others error's, perhaps they have experience that better qualifies their view where it differs from yours wrt the outcome for the AC crew?

It has been pointed out that you aviate. It would be reassuring to know that you, like other good aviators, are always trying to improve. Perhaps your short term path would benefit immensely from a wee study of aviation human factors, the behaviour of humans in complex systems. You never know, there may just be something gleaned that you can apply whether your shooting your next approach to a green lit taxiway or a grass runway.

Or, just look up 'wrong way Corrigan'. The truth may never come to light.

nolimitholdem

20th Aug 2017, 09:58

Old Carthusian

20th Aug 2017, 10:36

AerocatS2A

20th Aug 2017, 11:09

Certainly learning from the incident - why it happened is important. I would not deny that. However, what Ian W and Darkbarly miss I think is that any organisation needs to set limits. Things which cannot be accepted no matter what the excuse. Now I would submit that trying to land on a taxiway which is clearly marked with different coloured lights is one of those things. It is basic to being a professional isn't it?

Organisations do set limits. The limit, in a modern airline with a Just Culture, is along the lines of wilful violations, gross negligence, and destructive acts. If an incident occurs due to a genuine mistake then dismissal is generally counter productive because all it does is foster a "cover it up" culture among the work force.

Trying to land on a taxiway is what happened. In order to determine whether the crew should be punished in some way, you need to find out why it happened.

If it turns out the crew said to each other, "hey look, there are four jets on C, lets give them a dust up!" Then absolutely, you fire them. If, on the other hand, they thought they were on 28R until it all clicked and they did the go-around, then no, you don't fire them. You try and find out what set of circumstances led them down the garden path, then you pass that information on to all the other pilots and airlines around the world in the hope we can learn something from it. If there is a procedure that can be changed to help prevent it happening again, then you consider changing it (I'm not a fan of changing procedures in response to a single incident unless there is evidence that similar incidents are likely to occur.)

aterpster

20th Aug 2017, 12:41

No, it is the central tenet of almost all transportation safety boards around the world. It's also a major reason of why the NTSB was separated from the FAA (which does assign fault).

I can't speak to the other transportation safety boards, but the NTSB's immunity from having to even testify was enacted by Congress. On your other point, the NTSB was never part of the FAA. The NTSB's function was previously handled by the Civil Aeronautics Board, which was also the parent agency over the FAA's predecessor agency, the Civil Aeronautics Administration (CAA). But, the NTSB wasn't within the CAA.

In 1958 both the FAA and the NTSB were created as independent agencies. A few years later the Federal Aviation Agency was folded into the Department of Transportation and became the Federal Aviation Administration.

Besides, all US federal employees -- including NTSB investigators and board members -- already have "absolute immunity" against all torts when acting within the scope of their duties, except for violations of the Constitution or federal law (in which case they have qualified immunity, which may still protect them from litigation).

Correct, but only NTSB employees are immune from being called to testify in civil litigation, which may result from a transportation accident.

crippen

20th Aug 2017, 12:44

938 posts on this thread.

I wonder how many times the pilots and ATC have replayed the incident in their minds?

peekay4

20th Aug 2017, 14:28

The NTSB's function was previously handled by the Civil Aeronautics Board, which was also the parent agency over the FAA's predecessor agency, the Civil Aeronautics Administration (CAA). But, the NTSB wasn't within the CAA.

In 1958 both the FAA and the NTSB were created as independent agencies. A few years later the Federal Aviation Agency was folded into the Department of Transportation and became the Federal Aviation Administration.
I should have originally written, "... a major reason of why the NTSB was separated from the DOT".

The NTSB wasn't created in 1958, but later in 1967 when the FAA was renamed and folded into the DOT. But back then, the NTSB was also (administratively) part of the DOT, which created some conflicts of interests.

So in 1974, the NTSB was separated from the DOT and became fully independent. The role of investigators to find probable causes of accidents and incidents -- instead of determining faults or to place blame -- is very central to NTSB's mandate as an independent safety board.

(As an aside, it seems that the Civil Aeronautics Board was never the parent agency of the Civil Aeronautics Administration either. Both were spun off from the Civil Aeronautics Authority.)

On possible administrative sanctions, if warranted, even the FAA may have limited recourse in seeking enforcement actions against the AC759 pilots since presumably the pilots only hold Transport Canada licenses and not FAA certificates. The FAA may refer possible violations to Transport Canada via the State Department and the Canadian Embassy; However, it would be up to Transport Canada to take matters further (or not).

RatherBeFlying

20th Aug 2017, 14:36

At a certain Southern Ontario small airport, visiting aircraft often line up on the taxiway the first time in because it has more contrast to the terrain than the actual runway.

Illusions happen. At night much more often.

Smott999

20th Aug 2017, 14:59

If it turns out the AC chaps failed to do a thorough briefing and missed the NOTAM, potentially increasing their chances for 28L/R confusion....is that grounds for dismissal?

_Phoenix

20th Aug 2017, 15:14

If it turns out the crew said to each other, "hey look, there are four jets on C, lets give them a dust up!" Then absolutely, you fire them.
Except they confused C with 28R,
...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.
The cockpit voice recorder had been overwritten.

http://www.mediafire.com/convkey/e191/pqfxd06bk37zzazzg.jpg

aterpster

20th Aug 2017, 17:49

On possible administrative sanctions, if warranted, even the FAA may have limited recourse in seeking enforcement actions against the AC759 pilots since presumably the pilots only hold Transport Canada licenses and not FAA certificates. The FAA may refer possible violations to Transport Canada via the State Department and the Canadian Embassy; However, it would be up to Transport Canada to take matters further (or not).

From what little I know those referrals often go nowhere. When I was still working I was being hooked up to a tow bar to be towed into a gate at LAX Terminal 3. A KAL 747 was lost in the smog on a visual to 24R. He did a 90 degree turn descending out of about 500 feet and rolled wings level just in time to prevent the right wing from hitting the ground. It make the local radio news.

An FAA friend told me that the tower was really upset. It was written up and sent via the State Department to the Korean equivalent. Nothing came of it. KAL could do no wrong.

llondel

20th Aug 2017, 18:10

llondel, how about taking it to the next level? Learning from others close calls & mistakes should be in our DNA

My hope is that there are many of us are now flying around with awareness of another potential "failure mode". I certainly am.

A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience.

True, I've always tried to learn from the mistakes of others because it's way less embarrassing that way (and when flying, way safer). However, a lot of people are in the "it can't happen to me, I'd never do that" camp until it does. I'm not saying this is one, but there are some mistakes you have to make personally before fully appreciating and understanding them.

I've always tried to blame "the system" for errors. Sometimes there is indeed gross negligence where the finger can be pointed at an individual or team, but for the most part they're following the routine where there are checks to spot mistakes and just occasionally something happens for which there isn't a check and we get a smoking hole. This one was saved because someone else thought it was wrong and spoke up in time, and that's probably another lesson to take on board, to keep an eye on what's in the air while you're anywhere near the landing point.

galaxy flyer

20th Aug 2017, 19:28

liondel, how about taking it to the next level? Learning from others close calls & mistakes should be in our DNA

My hope is that there are many of us are now flying around with awareness of another potential "failure mode". I certainly am.

A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience.

To those seeking discipline in this event, read the above--it describes how aviation became the safest means of transporting us around.

peekay4

20th Aug 2017, 20:12

An FAA friend told me that the tower was really upset. It was written up and sent via the State Department to the Korean equivalent. Nothing came of it. KAL could do no wrong.
Yeah. It gets complicated because many countries prohibit domestic legal action based solely on foreign evidence / investigation by a foreign country. It gets into due process, sovereignty, etc.

I'm going to correct myself a bit: I've been told that Canada is a "special case" and the FAA has a "direct line" to Transport Canada for referrals (so the State Department doesn't have to get involved). However, it would still be Transport Canada's decision to pursue the matter further or not.

AerocatS2A

20th Aug 2017, 23:33

Except they confused C with 28R,

I know. I was just giving an example of behaviour that would result in dismissal. I didn't mean to suggest that this is what happened.

If it turns out the AC chaps failed to do a thorough briefing and missed the NOTAM, potentially increasing their chances for 28L/R confusion....is that grounds for dismissal?

That would depend on why they didn't do a thorough briefing and missed the NOTAM.

underfire

21st Aug 2017, 04:23

Where do you find the FAA calling SAMUL anything?

The airline TARGETS source shows SAMUL as a FB step-down within the intermediate segment. This is all "story board" stuff, since the source designer is using a program intended for IFP design to design a FMS visual approach track.

I hope the NTSB really opens this can of worms, although I seriously doubt they will.

That is what I was getting at. We had discussed before the FAF definition on Jepp charts. This is very close to the FMS Bridge visual procedure.

This is the mixed bag visual detailled out, and given that, I was surprised to see a DA listed. Was interesting to see the RNP AR to visual.

Obese

21st Aug 2017, 07:25

In the long run, if it turns out that the pilots and airline in question are truthful and cooperative, that means that they place a high value on contributing to aviation safety for the greater good, and that they deserve to be respected and treated fairly. If, on the other hand, it were to turn out that the whole thing morphed into a cynical, sick, worthless charade, well then, I think that passengers, regulators, and insurers could perhaps take note. Over time, the prestige of airline aviation will die a death of a thousand cuts, if it is demonstrated to young and aspiring airline pilots, and to the flying public, that it is bean counters, mouthpieces, and deal makers who are really, in effect, the ones in the cockpit.

underfire

21st Aug 2017, 23:26

n the long run, if it turns out that the pilots and airline in question are truthful and cooperative, that means that they place a high value on contributing to aviation safety for the greater good, and that they deserve to be respected and treated fairly.

Well, the airline HAS made a decision to equip its aircraft with GPS, a known safety equippage. That being said, it does not appear to be implemented yet on this ac that flew this international route.

Does that put the airlines contribution to safety in context? Perhaps the money the airline is willing to spend on the aircraft, and the upkeep of the aircraft?

As a passenger, are you be happy to know that the airline did not even spend enough money to put a GPS system in the AC? You have one in your car, your phone, and your watch, but the airline didnt even get around to putting one in the the aircraft you are riding in.

framer

21st Aug 2017, 23:30

As someone who claims to design approaches for a living you know better than that Underfire, are you just stirring?

underfire

22nd Aug 2017, 00:22

you are correct, questioning an airline that flies international routes to major airports for not equipping an aircraft with GPS is just stirring.

aterpster

22nd Aug 2017, 00:41

As someone who claims to design approaches for a living you know better than that Underfire, are you just stirring?

He is spot on.

galaxy flyer

22nd Aug 2017, 00:50

Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.

RAT 5

22nd Aug 2017, 08:28

Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.

This was a Mk.1 eyeball & Mk.2 brain created problem not a technological one.

aterpster

22nd Aug 2017, 13:47

Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.

True enough if they don't have RNAV. But, the early RNAV FMS birds that do not have GPS are subject to small inaccuracies when the DME geometry is not good. Those small inaccuracies can become a significant factor flying an FMS visual, especially down low and close in.

We do not know if that happened in this case. But, the potential is there using DME updating instead of GPS for position determination, particularly as the airplane gets low and loses good DME geometry.

With the tight spacing of Runways 28L/R and especially 28R and Taxiway Charlie, this 28R FMS Visual should mandate GPS. Look at the RNAV IAPs to 28R. They state "DME/DME RNP-0.30 not authorized." The FMS 28R Visual should have the same restriction, particularly since it uses RNP 0.30 from F101D inbound.

aterpster

22nd Aug 2017, 13:48

Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.

This was a Mk.1 eyeball & Mk.2 brain created problem not a technological one.
Do you have an authoritative cite for that conclusion?

MATELO

22nd Aug 2017, 14:34

Do you have an authoritative cite for that conclusion?

Isn't the whole thread the authoritative?

aterpster

22nd Aug 2017, 15:10

Isn't the whole thread the authoritative?

I'll stick with the NTSB.

galaxy flyer

22nd Aug 2017, 15:13

aterpster

While I completely agree on the technicals of DNE/DME, it's a visual approach and the FMS procedure is there, as I understand, to create a more accurate path for visual pick up of the runway environment, not as a substitute for an IFR in IMC IAP.

As my clay shooting instructor says, "don't use equipment as a solution for a training problem".

aterpster

22nd Aug 2017, 16:43

It certainly is not an instrument approach. Nonetheless, the air carriers have seen fit to create the beast and we know at least a portion of the procedure is often flown in IMC with ATC using radar altitudes to provide obstacle clearance since an FMS visual has no criteria. And, indeed it is "a more accurate path to visually acquire the runway." So, it should work as "advertised," which only can be assured by training and RNAV GPS.

Either that, or Flight Standards should step up to bat, and cancel the concept of FMS Visuals. I doubt their airline masters would be pleased, though.

underfire

22nd Aug 2017, 21:17

The concept of RNAV GPS and RNAV RNP to visual is sound. All of the benefits, especially of RNP AR would be fantastic. The benefit of DA/MDA, containments to .3 to really optimize, and buck up and add the missed...

Allowing it to be bastardized with FMS DME and non-GPS ac is the problem. Lack of standardization and adherence to standards is a problem.

Flight Standards needs to quit with all of the exceptions they grant the procedures they validate and certify themselves.

This whole concept of the lowest common denominator, to allow everyone access, is really constraining everything.
Best equipped, best served, let the rest wait in a hold pattern...

Example, time based trial, Dubai to Heathrow, dep within 2 mins of schedule, arrive at hold waypoint within 2 mins of schedule, and drive on in. Enroute management, no holds on arrival. It was sucessful.
Why dep and drive as fast as possible, to wait 2 hours in hold?
That is the future of aviation, not coddling 3rd rate airlines and drivers that constrain the system.
Airlines equip your aircraft, train your drivers, maintain standards. Get rid of the flack.
It is just that simple.

AerocatS2A

22nd Aug 2017, 22:31

you are correct, questioning an airline that flies international routes to major airports for not equipping an aircraft with GPS is just stirring.

Is it actually known that this particular A320 was not equipped with GPS?

glofish

22nd Aug 2017, 22:34

"A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience."

To those seeking discipline in this event, read the above--it describes how aviation became the safest means of transporting us around.

There is a marked difference between seeking only disciplinary actions, mainly called punitive leadership, and doing all the seeking “why” and learning from an incident, while still holding the crew responsible.

I get the impression that the discussion on here goes too much in the direction of either/or.

Insinuating that those calling to hold the crew responsible for the incident only wanting to hang them, is calling the wrong shot. No one wants to crucify them, but we should acknowledge that they mad a grave mistake. Notwithstanding that there were contributing factors, we are in the cockpits to ensure safe flight and not to screw-up – point à la ligne!

We can then go and do the soul searching about the "whys and how comes".
By doing this, we can then assist and help the concerned crew by pointing relentlessly to all the enemy factors we know so well. Simultaneously we should not let only accident boards, regulators, airlines and manufacturers go ahead with the inquiries and verdicts. We all know that therein lies the main problem: Collusion and corruption. In the name of the holy profit, too many interest groups and their beancounters go ahead with cutting all corners in assessments, training and equipment/tools for all the professionals involved in civil aviation. It makes our job more difficult and leaves access to too many ill-suited participants, which then makes the system more incident prone than necessary. Accident reports are more often than not very partially executed and their outcome is most often a lip service to safety, but a huge service to the aforementioned with new but mainly useless regulations and more gadgets for the industry to sell inflated to the taxpayer and airlines with little or no effect. It however definitely costs more than a better assessing and much better training of the aspiring young future employees.

In dollars and human losses.

underfire

22nd Aug 2017, 22:46

refer to post http://www.pprune.org/9866948-post917.html

look at that NTSB report, and while there look at the others, and the findings.

We can then go and do the soul searching about the "whys and how comes".
By doing this, we can then assist and help the concerned crew by pointing relentlessly to all the enemy factors we know so well. Simultaneously we should not let only accident boards, regulators, airlines and manufacturers go ahead with the inquiries and verdicts.

This is a profession, with professional responsibilities.

In transportation, truck, rail, and ship accidents, the driver, captain, or responsible person is held accountable.
The train driver who missed the signal has his license taken away, the truck driver who ran the red light has his license taken away, the boat captain who misjudged the pier has his license taken away.
So the aircraft drivers who try to land on a taxiway full of aircraft should be just a learning lesson?

How about this as a learning lesson.

FIRE them. Did you see what happened to the drivers from the 777 crash at Dubai..FIRED.

Complain about hours and circadian rythmns, ENFORCE the rules. Make your airline follow the rules.

In reality, blaming it on circadian stuff is equivalent to claiming your parents abused you. It is a trending psychological term, that was never in aviation. Just another term to avoid responsibilty for ones actions.
Just a few years ago, drivers just knew how to fly the aircraft, and did so in adverse conditions with no automation.

Complain about lack of training and understanding of the aircraft systems. Drivers learn them or fire them. Did you see that the NTSB report showed the driver of the Cogan disaster repeatedly failed, yet was still driving. FIRE THEM.

AerocatS2A

22nd Aug 2017, 22:56

refer to post http://www.pprune.org/9866948-post917.html

look at that NTSB report, and while there look at the others, and the findings.

Is that directed to me? If so, what am I supposed to be looking for?

Carbon Bootprint

22nd Aug 2017, 23:23

As my clay shooting instructor says, "don't use equipment as a solution for a training problem"
From one clay shooter to another. :D

you are correct, questioning an airline that flies international routes to major airports for not equipping an aircraft with GPS is just stirring.

Does AC actually consider ops within Canada and US "international"? Technically, they are -- I realize that -- but lots of things happen between the nations that blur that line, US Customs clearance in CA one of them.

That aside, I'm just inquiring about how the airlines view these operations and if that might affect outfitting. Thanks.

320goat

23rd Aug 2017, 05:39

underfire,

There is definitely a position in airline management for you out in this part of the world, any of the ME carriers would welcome you with open arms. As to whether your approach would make the industry safer, well that's another debate.

RealUlli

23rd Aug 2017, 06:26

This is a profession, with professional responsibilities.

In transportation, truck, rail, and ship accidents, the driver, captain, or responsible person is held accountable.
The train driver who missed the signal has his license taken away, the truck driver who ran the red light has his license taken away, the boat captain who misjudged the pier has his license taken away.
So the aircraft drivers who try to land on a taxiway full of aircraft should be just a learning lesson?

Frequently, these events occur because the driver was distracted doing stuff not related to driving/docking/whatever. If that is the case, he should rightfully have his license suspended/revoked and get fired. The same if he did what he did because he couldn't be bothered to obey the law "because he is more important than that".

However, if he is doing his level best to avoid the event, he should be allowed to keep it. E.g. you run a red light to make room for the ambulance behind you. If there is no crash, nobody will blame you.

Even in aviation, if you break the rules because you feel like it or because you can't be bothered to do proper preparation, you should be prosecuted. To my knowledge, you are. This impinges on this case - they should have been aware of the issue with the runway lighting. They did download the NOTAMs, read them, etc. How come they missed this? I don't think they were just going through the motions. There is a gap in there somewhere that should be fixed.

I cannot imagine these pilots were trying to die. They were doing their best to land the aircraft safely. They (hopefully) had a sterile cockpit, they noticed something amiss and even queried ATC about it. IMHO, they should not be fired.

I'm sure they will never make that mistake again, they will go around much earlier if something looks wrong (imagine a 380 had been waiting there...). They triggered a discussion that may save someone else in the future (remember, a landing is an approach that doesn't end in a go-around!).

(Disclaimer: just an SLF)

MATELO

23rd Aug 2017, 09:42

I'll stick with the NTSB.

OK, then check the update on their website and refrain from popping on here. :ok:

aterpster

23rd Aug 2017, 13:44

Quoting me out of context. That doesn't help the discussion.

aterpster

23rd Aug 2017, 14:27

FAA issues safety alert because of this incident.

WillowRun 6-3

23rd Aug 2017, 20:57

I'd like to offer some defense of underfire . . . about sanctions of crew, and whether anyone other than drivers situated in what they refer to as pointy ends can hold responsibility at the system and systemic level.

First, it is akin to civilian control of the military (notwithstanding any deficits in current U.S., uh, personages). The civil aviation system in the U.S. and Canada and really now, in probably a significant majority of ICAO member states, exists organically within a legal structure, a governmental structure. As supreme as the aviators are within their realm and in certain respects outside of it, they are not the ultimate responsible parties, by themselves, at the system and governmental level. I don't think this is a controversial view. Or, it shouldn't be controversial.

Second, there actually is no reason to impute to underfire's views - or to the views of anyone who advocates at the very least, for consideration of the most severe sanction available - any disregard for the safety inquiry and improvement processes. As a prior post quite nicely said, it is not either/or. Is there even a single example which can be provided where, because a crew with stuffed-up results on their record were given a heavy sanction rather than a milder one, safety inquiry and system improvement suffered, even suffered at all?

Not least, there is a case to be made for something that sounds harsh, and is harsh. Sometimes the unjustness which appears to be visited upon one or a small handful of individuals is, when weighed in a significantly larger context, justified. It is being emphasized, over and over here, that the set of causal factors likely to be found and reported by the formal and official investigation will include a number of things; . . . . the lighting obviously on the taxiway and runway, the attentional tunneling problem that has been aped about, maybe the approach set-up in the airspace architecture and as specified in procedures and for equipment lacking certain avionics, and even the bugaboo fatigue and "daily timeclock routine" (aka rhythm of circadian type). So, if one believes these factors were present or might have been present, in some combination or even all of them, then maybe the right approach is to make an example out of this crew. The unfairness to them, such as it might be, could be worth the slap-across-the-chops the example would give to others. This is not what I am saying obviously must be done or needs to be done. Still it is a case to be stated and pondered. This was a very, very close call, was it not? And if it had gone into accident mode, I don't think anyone yet can say "well the physics of the situation show us that the extent of needless death and destruction would have been no more or less than X" - but we can say with reasonable confidence that if it had gone into accident mode there would have been at least many serious injuries if not fatalities. So, from this standpoint, underfire's clamor for the most severe sanction is a reasonable point of view, and the option must be in the mix of possible outcomes. In sum, a near-accident that has the appearance - at the very least - of having been horrible had it turned into an accident, may warrant severe sanction, once all the facts are determined and officially charged rapporteurs have had their day in print.

peekay4

23rd Aug 2017, 22:49

How do you know I do not have the qualifications to drive the aircraft?

Sorry, but it's pretty obvious.

Is there even a single example which can be provided where, because a crew with stuffed-up results on their record were given a heavy sanction rather than a milder one, safety inquiry and system improvement suffered, even suffered at all?
Unfortunately there are many.

E.g., the "most severe" sanctions, to borrow your words, would be criminal ones. As such, in many countries accident investigations fall into purview of the criminal justice system, along with very strict rules of evidence, etc., required by that system. Yet this focus to "criminalize" pilot conduct has had an impact to safety:

1. After the ValuJet crash in the everglades, employees of ValuJet's maintenance company SabreTech were charged in Florida with 110 counts of 3rd degree murder and 110 counts of manslaughter -- one for each crash victim. A few years later, when the NTSB investigated the 1999 pipeline rupture in Bellingham, everyone "lawyered up". And worse, prosecutors prevented the NTSB from doing their job. Statement from NTSB Chairman Jim Hall at the time:

"The NTSB wants the answers to all of these questions, and we need to know them as soon as feasible. But, my investigators have been stymied by the prospect of criminal prosecutions . . . A number of our investigative activities has been suspended because most of the central players will not talk to us. And, prosecutors have asked that we not test the valve of the pipeline until their concerns regarding evidence preservation can be allayed. "

2. In 2009, a Cessna Citation crashed near Rome. The judicial authorities immediately seized the CVR & FDR and refused to release them to the Italian Transportation Safety Board (ANSV), for months!

3. Similarly after the XL Airways / Air New Zealand A320 crash in the Mediterranean sea, French judicial investigators took custody of the FDR and interfered with the safety investigation, preventing the damaged FDR from being sent to the US for read out at the manufacturer (Honeywell) until a compromise was found.

4. Indonesian authorities wanted to "send a message" after the Garuda Flight 200 crash in Yogyakarta by criminally sentencing the Captain and sending him to jail. Afterwards, dozens of the Indonesia's most senior pilots and ATCO left to other countries rather than work in an environment where there's constant fear of criminal prosecution. If anything, the country's safety situation only worsened further.

5. I recall at least one case where the CVR was lost to fire because judicial investigators refused to give timely access to safety investigators who wanted to secure the blackboxes in the aftermath of a crash.

These are inevitable consequences from the urge to "throw the book" and impose "severe sanctions" for unintended operational errors.

Criminal prosecutions are warranted in cases of where there's willful violations of the law. Otherwise, pilots, mechanics, ATCO, everyone else involved in aviation will simply "plead the fifth" on any incident or accident. There will be no self-reporting and coverups will become the norm. Safety will greatly suffer.

Pilot DAR

23rd Aug 2017, 23:01

Posters, please play the ball, not the players.

WillowRun 6-3

23rd Aug 2017, 23:02

peekay4, good thing I couldn't assess interest charges on borrowing my words. I was imprecise.
The most severe sanction to which reference was made, or within context of the argument by underfire, was termination of employment. But I left the door open to criminal prosecution being understood as within the question as I wrote it.
I believe there is some body of legal research (academic, mostly) on the impact of criminal prosecutions (and even criminal investigations) on safety investigations and, while it is not something I have read closely or thoroughly, I think the quite dominant view aligns closely with your litany of examples.
But termination of employment, as the most severe sanction in this incident -- seems far-fetched even to think about any possibility of a prosecution or criminal inquest here. So, are there examples in your lexicon of employment termination, as opposed to some milder sanction, impeding either safety investigation or implementation of any recommended system modifications?

underfire

23rd Aug 2017, 23:04

FAA issues safety alert because of this incident.

Thank you terpster...very interesting SAFO.

"due to the severity of the incident a review and incorporation of these recommendations is strongly encouraged"

EDIT: Willow. with all due respect, why should a pilot be afforded such luxury on incompetence? What other profession, given life safety issues, is afforded such luxury?
The question of punative sanction on the individual is veiled on the impact of aviation in general?
While there is certainly a lesson to be learned, how does that somehow releave the responsiblity of the perpetrator?

Bottom line, the individuals have been removed, and the impact has been mitigated, both present and future. Interesting , when people see a crime, and the perpetrator has previous offenses, everyone wonders why they still able to commit more crimes.....why didnt enforcement prevent this from happening.

tale of the tape:
FMS Bridge Visual is flown every few minutes into SFO on a daily basis.
One operator decides to land on the taxiway.
Lesson to be learned or punative action?

peekay4

23rd Aug 2017, 23:13

So, are there examples in your lexicon of employment termination, as opposed to some milder sanction, impeding either safety investigation or implementation of any recommended system modifications?
Not a great example but one that immediately pops into my mind is Capt. Kinzer's firing at Allegiant (http://www.pprune.org/north-america/570566-allegiant-fires-pilot-after-ordering-emergency-evacuation.html) we've previously discussed, WillowRun 6-3.

If you'd recall, the Captain's employment was terminated after he allegedly did not follow company SOP on evacuations. I can't speak for Allegiant pilots but it seems to me that if another were put into a similar situation after the firing, he/she might think twice about ordering a needed evacuation, and who knows what the safety repercussions would've been?

Similar to criminal prosecutions, threat of termination over operational mistakes (vs. willful misconduct, gross negligence, etc.) will simply encourage many to cover up safety issues. Is this what we really want?

Incidentally, the Allegiant case is now scheduled for jury trial in October.

underfire

23rd Aug 2017, 23:52

So, are there examples in your lexicon of employment termination, as opposed to some milder sanction, impeding either safety investigation or implementation of any recommended system modifications?

PK, how does your example, and explanation answer the question?

So, in your opinion, the threat of punative action will typically cause a coverup?

How far does this go?

What about a FOQA bust? A wake encounter?
All of the other mistakes and lack of aircraft system knowledge and capabilites, that we see outlined in posts here on PPrune?
Where is the learning experience if everyone covers their mistakes or covers lack of aircraft system knowledge?

Wait for an accident?

Again, FMS Bridge Visual is flown every few minutes into SFO on a daily basis.
One operator decides to land on the taxiway.
Lesson to be learned or punative action?

Should the restrictive (punative) action be against all operators? If you were United, would you want to be restricted due to Air Canada?

I think everyone can see from the FAA SAFO terpster provided, where this is going.

WillowRun 6-3

23rd Aug 2017, 23:53

peekay4, good point. But. The Allegiant pilot was, if I am recalling correctly, defended in the forum thread pretty stridently or at least consistently, for having done the right thing. And the carrier management scored, again stridently or consistently (in same thread), for having tanked the man, predicated on his not having done anything wrong. Do you recall differently (and yes, it was a, uh, spirited exchange previously). I can't see that the AC759 aviators are being portrayed or defended here as having done nothing wrong.
(Perhaps the Allegiant trial will contribute to a growing, if still nascent, body of advocacy for an overhaul of massive proportions of US federal labor and employment law applicable to air carrier operations.)

WillowRun 6-3

24th Aug 2017, 00:11

......why should a pilot be afforded such luxury on incompetence? What other profession, given life safety issues, is afforded such luxury?
The question of punative sanction on the individual is veiled on the impact of aviation in general?
While there is certainly a lesson to be learned, how does that somehow releave the responsiblity of the perpetrator?

Bottom line, the individuals have been removed, and the impact has been mitigated, both present and future. Interesting , when people see a crime, and the perpetrator has previous offenses, everyone wonders why they still able to commit more crimes.....why didnt enforcement prevent this from happening.......

Really there are two things at work here, aren't there? I think your position tends to emphasize a kind of preventative as well as punitive purpose. These two pilots stuffed up so obviously and so badly that they cannot be trusted to operate an air transport category aircraft again - that's me paraphrasing you, and I hope accurately and fairly. Then there is the system view. And the point I was trying to make is that even if someone in the ultimate authority seat for decisions on such a termination of employment might decide on a lesser sanction based on the degree of stuffed-up-edness, that decision-maker might instead opt for termination, to make an example of them. Rather than affording luxury, I was trying to say, make it more severe, even if not as convincingly warranted in these two individual cases, to signal to everybody else that this is a dangerous set of conditions or circumstances and vigilance needs to be increased. Or to consider this option -- as I originally posted, this should be considered, but until the facts are known, I am not inclined, at all, to hold any certainty.

peekay4

24th Aug 2017, 00:27

I can't see that the AC759 aviators are being portrayed or defended here as having done nothing wrong.
When we talk about punishment, we need to look at the bigger picture, not just this specific instance -- because punishment for operational mistakes sets a precedent regardless if others are supportive of the pilots or not.

Just culture is becoming the predominant safety culture, at least in North America (I can't really speak about elsewhere.) It's not just about pilots, but in all safety critical fields, including all forms of transportation (under the NTSB, Canadian TSB, etc.), nuclear safety (see IAEA's stance on open reporting of errors), medicine, etc.

In fact one of the most notable quotations about just culture was made by a physician:

The single greatest impediment to error prevention in the medical industry is
“that we punish people for making mistakes.”

-- Dr. Lucian Leape
Harvard School of Public Health
Testimony before US Congress.

A culture of safety must be based on trust. Pilots are human beings asked to make real-time, split-second decisions. Mistakes will happen. The solution is not punishment but to improve the system as a whole.

Some posters here (ahem) seem to be of the opinion that because many planes land successfully at SFO, that means nothing can be learned and nothing needs to be improved. This type of thinking is very dangerous.

Aviation is very safe because we are continuously learning and improving. Once we start blaming, trust will be lost, and the consequences will be severe.

aterpster

24th Aug 2017, 00:38

Thank you terpster...very interesting SAFO.

"due to the severity of the incident a review and incorporation of these recommendations is strongly encouraged"

Alas, not any mention of the FMS database visual they were cleared for. (almost hypocritical.)

Properly executed (airplane and/or flight crew) it (the FMS Visual) would have satisfied all the flight guidance requirements of the SAFO.

I believe this SAFO is systemic of our dysfunctional FAA (on a corporate level) trying to get out in front of what I suspect is a very angry NTSB.

peekay4

24th Aug 2017, 00:40

Indeed the SAFO almost hints that the FMS wasn't being used for the latter parts of the approach...

AerocatS2A

24th Aug 2017, 03:33

Again, FMS Bridge Visual is flown every few minutes into SFO on a daily basis.
One operator decides to land on the taxiway.
Lesson to be learned or punative action?

Should the restrictive (punative) action be against all operators? If you were United, would you want to be restricted due to Air Canada?

I think everyone can see from the FAA SAFO terpster provided, where this is going.

Almost every accident and incident that occurs was done flying a procedure that everyone does every day. And every time a change in SOP or regulation comes out in response to an incident, it is a case of a restriction being applied to the majority in response to a mistake by one person. This is nothing new.

Sometimes this approach is justified. When someone makes a mistake and it is subsequently identified that lots of other people almost make the same mistake but catch it in time, then a change in procedure is justified in my opinion. On the other hand if a mistake was made due to crew incompetence then I don't think procedures should change, instead the crew needs to be retrained or, in the most severe cases, removed from the industry.

The Colgan Capt should have been either dismissed or made a career FO a long time before their accident. A history of marginal performances is not a good sign.

I don't have a problem with considering punitive action against the Air Canada crew. My problem is that you are basing your "prosecution" on a very brief NTSB preliminary report that doesn't say what you think it says.

WillowRun 6-3

24th Aug 2017, 11:27

peekay4 (no. 984): "When we talk about punishment, we need to look at the bigger picture, not just this specific instance -- because punishment for operational mistakes sets a precedent regardless if others are supportive of the pilots or not. Just culture is becoming the predominant safety culture, at least in North America (I can't really speak about elsewhere.) It's not just about pilots, but in all safety critical fields, including all forms of transportation (under the NTSB, Canadian TSB, etc.), nuclear safety (see IAEA's stance on open reporting of errors), medicine, etc.
In fact one of the most notable quotations about just culture was made by a physician [quotation omitted].
A culture of safety must be based on trust. Pilots are human beings asked to make real-time, split-second decisions. Mistakes will happen. The solution is not punishment but to improve the system as a whole.
Some posters here (ahem) seem to be of the opinion that because many planes land successfully at SFO, that means nothing can be learned and nothing needs to be improved. This type of thinking is very dangerous.
Aviation is very safe because we are continuously learning and improving. Once we start blaming, trust will be lost, and the consequences will be severe."

A very thought-provocative post, peekay4. Perhaps you would comment on either or both of two further questions:
1) if there is a dividing line between different levels of accountability or responsibility - and also possibly between levels of sanction - is it not the case that such separating lines are adjusted over time? For example, the criminal offense of rape sometimes was a capital offense in the early 20th century. The point is, if a dividing line is accepted, its acceptance is understood to be subject to adjustment in a later time.
2) is there not a difference between mistake, on one hand, and what in laws and legal processes is identified as "gross negligence"?

I would not attempt, even, to argue with the fundamental premise that trust is a sine qua non of the safety system writ large; that blame and punishment are counter-productive. But I do question, is there not a point at which this rationale gets overtaken and thus becomes secondary to the level of "wrong action" by the aviators? -- and is not this line still a lower level than that which is sufficient to warrant (justify) criminal investigation and even more so, prosecution? I think there is such a point, and it exists in other areas of law, gradations between mistake or bare incompetence; and gross negliglence; gross misconduct; willful misconduct; criminal intent. But again, by these gradations being mentioned I do not mean to slight or ignore the concern over degradation of the safety culture.

aterpster

24th Aug 2017, 13:50

Almost every accident and incident that occurs was done flying a procedure that everyone does every day. And every time a change in SOP or regulation comes out in response to an incident, it is a case of a restriction being applied to the majority in response to a mistake by one person. This is nothing new.

The so-called safety bulletin the FAA issued is a knee-jerk reaction of a somewhat dysfunctional aviation regulatory agency. The bulletin doesn't even mention the airline-rolled (as in, roll your own cigarettes) Flight Management System RNAV database visual flight procedure (RVFP), which was Air Canada's approach clearance.

The bulletin is negligent in its omission about the operating requirements and limitations of RVFPs. This is likely because the FAA doesn't have any criteria or operational guidance for the use of RVFPs. They are wholly a procedure developed by the airlines for the airlines. In this respect, the airlines are regulating themselves.

That's not the way the system is supposed to work.

Mac the Knife

24th Aug 2017, 20:56

After a recent (obligatory) symposium on Medical Ethics, in the Q&A afterwards I suggested that we were moving away from Ethics-driven Ethics to Legal-driven Ethics.

IOW, do what you are least likely to be sued for rather than what is old-time ethically correct.

The Chairman was not happy, "I sincerely hope that you are wrong1"

She later cornered me and said that it was a very worrying statement.

So it goes.

Stick to the written SOPs and you're safe (but possibly dead - a much more desirable place to be than a Court of Law).

underfire

24th Aug 2017, 22:07

I don't have a problem with considering punitive action against the Air Canada crew. My problem is that you are basing your "prosecution" on a very brief NTSB preliminary report that doesn't say what you think it says.
I actually did not rely on the NTSB findings, but what I saw and heard. The NTSB data simply confirmed what virtually everyone already saw and knew.

Alas, not any mention of the FMS database visual they were cleared for. (almost hypocritical.)

Properly executed (airplane and/or flight crew) it (the FMS Visual) would have satisfied all the flight guidance requirements of the SAFO.

I believe this SAFO is systemic of our dysfunctional FAA (on a corporate level) trying to get out in front of what I suspect is a very angry NTSB

Exactly on point. This procedure has been flown every few minutes for years.

I also agree that it is a bit of a basket case with allowing sub-standard aircraft to use it. Is there is a problem with allowing non GPS aircraft to use the procedure? the intent of the procedure was to reduce workload, I simply cannot see that with a non-GPS aircraft.
They should all be restricted, or just this crew/airline?
I mean really, how many non-GPS equipped ac are flying international these days?

The bulletin is negligent in its omission about the operating requirements and limitations of RVFPs. This is likely because the FAA doesn't have any criteria or operational guidance for the use of RVFPs. They are wholly a procedure developed by the airlines for the airlines. In this respect, the airlines are regulating themselves.

That's not the way the system is supposed to work.

Opening the procedure designed by UAL to other operators is the issue. Does Air Canada go back to UAL for the issues, or to the FAA which allowed them to do it?

aterpster

24th Aug 2017, 22:25

Opening the procedure designed by UAL to other operators is the issue. Does Air Canada go back to UAL for the issues, or to the FAA which allowed them to do it?
The FAA should be holding the dime, not UAL. UAL's design is fine, at least for GPS aircraft.

peekay4

25th Aug 2017, 05:20

This fixation with GPS (on a visual approach!) and the level of misinformation in this thread about RVFPs are getting ridiculous.

1. The criteria for RVFPs are developed by the FAA Flight Standards Service.

2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.

3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.

4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.

It's not like UAL designed the procedure on the back of a napkin and had Jepp print it up without FAA's involvement, reviews and approval. :hmm:

AerocatS2A

25th Aug 2017, 05:41

I actually did not rely on the NTSB findings, but what I saw and heard. The NTSB data simply confirmed what virtually everyone already saw and knew.

No. You continually state that the crew deny being on the taxiway. The only source for this information is a brief statement in the NTSB report, but it doesn't say what you keep claiming it says.

framer

25th Aug 2017, 05:56

This thread has been made unbareable by someone who isn't even qualified to fly a visual approach let alone anything more complicated. Waste of time even checking it now days.

RAT 5

25th Aug 2017, 07:32

Stick to the written SOPs and you're safe (but possibly dead - a much more desirable place to be than a Court of Law).

Indeed. At various interviews with differing operators a common question was "what do you think about SOP's?" There were some standard answers that 2 pilots who did not know each other would know what the other was going to do and when etc. etc. Then an old TRE, 15 years ago, told me another reason to be studious in following SOP's. It was to cover your backside in the event of................
I thought that to be rather sad, if you could see the SOP was not the best thing to do a that moment. Perhaps it would work, but there was a better way. However, if during your alternative technique Sod's law came into play you were on your own. Under Plan A rules you had a defence.

glofish

25th Aug 2017, 08:21

4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.

Bears the question what 'airport environment' effectively means.
To me this means and includes that the active runway must be clearly identified.

aterpster

25th Aug 2017, 12:35

This fixation with GPS (on a visual approach!) and the level of misinformation in this thread about RVFPs are getting ridiculous.
You are certainly entitled to that opinion. However, since the procedures go to approach mode for the final portion of the database procedure, the standard for accuracy should be the same as that required for an RNAV IAP; i.e., GPS required. This isn't about obstacle clearance containment areas, it is about assured alignment with the runway when that is the design objective. There are no notes about the critical DMEs for D/D/I, unlike on LEETZ SIX RNAV SID at KSLC, as an example.

1. The criteria for RVFPs are developed by the FAA Flight Standards Service.

Are these criteria in a public order? I'm not disagreeing, I just don't know.

2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.
I participated in the monthly RAPT telecons for AWP and ANM for four years until recently. I don't recall any discussion or vote about RVFPs, but I could have missed it.

3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.
Without notes on the chart about critical DMEs they aren't doing a stellar job. And, what are these FAA RNP and RNAV groups? I do know that AIS in OKC (the folks who design SIAPs, etc.) are not in any way involved in the process.

4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.
As I've stated previous I have no issue with the IMC phase because it is really a radar route predicated on MVAs at that point. It's the visual portion without GPS that concerns me.

It's not like UAL designed the procedure on the back of a napkin and had Jepp print it up without FAA's involvement, reviews and approval. :hmm:
I never suggested that the design wasn't carefully done by UAL. I have the TARGETS package. It is all fine for FMS/GPS aircraft. As to the extent of the FAA involvement and approval, you know more about that then I do. What I do know is that there is no small skepticism about the process in certain quarters of the FAA.

AerocatS2A

25th Aug 2017, 13:06

Bears the question what 'airport environment' effectively means.
To me this means and includes that the active runway must be clearly identified.

Of course. And I'm sure that at some point they thought they had clearly identified the runway. Turned out they were wrong.

aterpster

25th Aug 2017, 14:07

It's not like UAL designed the procedure on the back of a napkin and had Jepp print it up without FAA's involvement, reviews and approval. :hmm:

I found the order 8260.55. Really nothing more than an outline. Criteria it is not. Having read it, it would be beyond the RAPT's mandate to get involved in approving these RVFPs.

underfire

25th Aug 2017, 16:17

1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
Incorrect. The procedures are simply designed to emulate existing visual procedures. There is no other guidance or criteria on how this is accomplished. You can use TF/TF or even TF/RF/TF legs. There is no criteria which is why it is considered a tailored approach.

2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.

Incorrect. RAPT is only involved in a cursory manner. Only if there are conflicts with the design is the procedure even routed to RAPT for review. When a procedure is designed, it can be a good idea to route it through RAPT, especially if one wants to delay approval.

3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.
Incorrect. These groups are only involved if the procedure requires. If you have RNP to visual, the RNP group is involved, if you have RNAV GPS required, the RNAV group is involved. If if is DME/DME/IRU, only the AWO is involved. The operator submitting the procedure, uses RNAV-Pro to evaluate the DME coverage. That program decides if it is sufficient, not the AWO. The operator supplies the results to the AWO with the findings. There is no decision, it is simply the results of the program analysis. The procedure approval path is then determined, and routed accordingly to the different groups by the AWO for review/approval.
The AWO is not a decision maker, but simply the focal point in the process as a manager, assisting in routing the documents to the respective groups.

This thread has been made unbareable by someone who isn't even qualified to fly a visual approach let alone anything more complicated. Waste of time even checking it now days.

I certainly hope you are not foolish enough to be talking about me in this case. You would be completely wrong. As a tech pilot, I would be willing to bet I am typed on far more aircraft than you are.