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

[aterpster]

FAA = Federal Airline Assistant

[glofish]

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

Thanks Aerocat. Now my point:
Taking into consideration that the final part of this approach is requred visual and therefore under full and sole responsibility of the crew, what are we wasting energy on the initial RNAV part of the approach?
If the latter is insufficient, inappropriate or else, then go around, file a report and either have it fixed or desist using it with your equipment.
But trying to explain a mess up of the continuing in required visual condituons by pointing at the previous line up does not make sense.

[RAT 5]

Finally, at last, someone else can see the wood for the trees, ask the most pertinent question and state the blindingly obvious.

Someone started discussing GPS FMC approaches bringing you to the correct line up. Qeh? The line up is visual! There are 2 pilots, 2 brains, 2 sets of eyes = fail passive, but still workable. A GPS line up would not have made it fail operational.

[AerocatS2A]

It may still be a factor if the box lined them up on the taxiway and they put too much trust in the box. A form of automation dependancy.

[RAT 5]

A bit like the early TomToms that told you "after 200m turn next left" and you ended up in a farm yard instead of a dual carriage way while still 5miles from destination. What would you have done???

[AerocatS2A]

I know. It would still a factor leading to the balls up though. Even though it shouldn't be.

Isn't all this FMC stuff just conjecture though? Has there been any confirmation that this aircraft had not been fitted with GPS yet and that it suffered from a bit of map shift?

[OldLurker]

A bit like the early TomToms that told you "after 200m turn next left" and you ended up in a farm yard instead of a dual carriage way while still 5miles from destination. What would you have done???Followed the general rule when using automation: if what you see on the screen disagrees with what you see out of the window, there's a high probability that reality is correct.

[Heathrow Harry]

http://www.pprune.org/members/326184-heathrow-harry-albums-what-airfield-picture734-goat-clouds4.jpg

Gary Larsen of course..................

[mayam13]

ILS was not working in SFO in the year 2013 ( Captn. Sully's remark) when Ashiana B777 crashed near threshold, though engine power was the cause of that accident. Runways are distinguishable from taxiways more by the overshoot paths. In SFO the paths are not clearly defined. Is there a ruling that captains should have landed as co-pilot in SFO before landing as captain? If so why?

[aterpster]

I know. It would still a factor leading to the balls up though. Even though it shouldn't be.

Isn't all this FMC stuff just conjecture though? Has there been any confirmation that this aircraft had not been fitted with GPS yet and that it suffered from a bit of map shift?
Indeed it is, like much of the human-factors speculation in this lengthy thread.

What is not speculation, because it was stated early in the thread, that pilots often couple up at ARCHIE (8,000, msl) to this FMS database visual when in the clouds and remain coupled well after clear of clouds and cleared for the visual. This could be as close in as JANYY or perhaps even closer to the TRACON's MVA over the bay, which is 1,600, msl.

The weather minimums are quite complex for a visual:

[aterpster]

Gary Larsen of course..................

When that cartoon came out, my company made a large poster of it, and mounted it on an easel stand in the lobby of the training center.

[OldLurker]

Aha! Yes, of course, it was a Far Side cartoon. Thanks for finding it, HH.

[underfire]

Taking into consideration that the final part of this approach is requred visual and therefore under full and sole responsibility of the crew, what are we wasting energy on the initial RNAV part of the approach?

The ac did not complete the FMS portion of the procedure. They continued from SAMUL, missing the vector to F101D, which begins the visual portion of the procedure.

Yes, you are correct, albeit, once cleared for the procedure, arent they are responsible for the entire approach from ARCHI?

I think the flavor of the SAFO regarding the incident sums up very well where the responsibility will fall.

http://i.imgur.com/tcLZ32a.jpg

[aterpster]

It was so much simpler in my days flying into SFO. We did the plain vanilla CVFP and had the ILS tuned and ready to intercept in compliance with the CVFP.

The language in the SAFO would make me want to say," Unable visual approach. Request instrument approach."

Of course, they would send me to that holding pattern in Hades.

[mayam13]

A 'Strap on GPS' equipage can instantly enhance flight safety without waiting for integration to FMS/MCDU. Blame game can wait.

[underfire]

We did the plain vanilla CVFP and had the ILS tuned and ready to intercept in compliance with the CVFP.

exactly.

Interesting, I noticed on a different board that a United pilot said they tune the ILS when on FMS Bridge visual. Not sure if that is SOP for them or not...

A 'Strap on GPS' equipage can instantly enhance flight safety without waiting for integration to FMS/MCDU.

Brilliant!

[JPJP]

It's a common practice. I've been doing the same thing for the last ten years - Select Heading and arm Approach after the bridge. Then intercept the ILS for backup guidance for the last couple of miles to the runway.

Yes, it's a visual procedure. But the runways are so close, and you often have another aircraft flying a bastardized formation approach to 28L. Accident waiting to happen, and has been for a long time. In my humble opinion, of course.

[underfire]

Exactly....

We used the #2 system as backup to confirm flightpath, but my experience was in the procedure validation and checks.
You confirm, as I suspected, that it was used in practice.

I concur, with all of the issues with the procedure variables allowed, that this is an accident waiting to happen, but not for lining up on the 28R taxiway at night with 28L closed......that is even out there for all of the potential conflict issues.

[aterpster]

Yes, it's a visual procedure. But the runways are so close, and you often have another aircraft flying a bastardized formation approach to 28L. Accident waiting to happen, and has been for a long time. In my humble opinion, of course.
Same at LAX, when two airplanes are landing either 25L/R or 24L/R. I've had an airplane overtake me inside the FAF. One on the ILS, the other on a visual.

The airports that were designed to be jet airline airports don't have these closely space runway issues that forever compromise safety at LAX and SFO.

[underfire]

The way the general public goes insane when you ty to add runaways or even procedures, has created the problem. When the closely spaced runways are in dual mode, it works as intended, and was never meant for simultaneous operations.
Increased air travel with capacity issues has created these crazy operations.

How many airports do you expect a wake encounter on final?

[b1lanc]

Though I agree that the public goes/is insane, I think the real issue is twofold. First, most commercial US airports servicing larger cities were built on open sites in the bi-plane era. Take a look at some 1930s pictures. Open land all around where the predecessor field locations (mostly AAF sites) were chosen. Hundreds of fast jet flights with hundreds of people on board each was never a thought back then. Second, the character of the traveling public has changed from business/well-to-do (say up through the 60s) to everyone now. People now want cheap seats, and really don't care about a two hour+ drive to get to an airport that will save them $100 in airfare.

Good luck trying to add a runway in the northeast - at some locations that would require a really really really big aircraft carrier. Denver and Dallas/Ft. Worth recognized the dilemma and placed their next sites well outside of city limits where coincidentally there was a lot of open space. Bet you in another 50 years, not much open space around either. Even so, it took decades (and finally a threat from the gov't that it would pick the site) for Dallas and Ft. Worth to agree to a location. And do you remember the reaction to closing Stapleton? People were praying for that baggage system to continue to eat bags. Flew in to Stapleton on a Monday and was supposed to fly out of DIA on Thursday. Stapleton was a ghost town - not even a news cart or a shoe-shine location let alone food. All back on Thursday when I again left out of Stapleton - news cart guy told me that was their third move to DIA and back again.

Used to take me 15 minutes to hop in the car and start pre-flight. Then the N-S runway was closed, land sold, office park added. Then they built a middle school less than half a mile from the remaining threshold. One overshoot with fatalities (hit by on-coming car as ac exited runway onto a street) and bam - airport closed for good due to threat to school.

[aterpster]

Though I agree that the public goes/is insane, I think the real issue is twofold. First, most commercial US airports servicing larger cities were built on open sites in the bi-plane era. Take a look at some 1930s pictures. Open land all around where the predecessor field locations (mostly AAF sites) were chosen.

Mines Field in Los Angeles comes to mind. surrounded by bean fields.

Recall, first Grand Central Air Terminal (Glendale) was the very early airline airport. Then, it became insufficient, so airline operations were moved to Burbank.

And, look at San Diego today. Absurd!

California has a horrible track record except for Sacramento. They did pull that one out of the bag. Not an international airport, though, nor was that intended.

[underfire]

Paine Field in Everett, existing one that Boeing uses for new aircraft. Public uproar when Horizon tried to add 2 flights per day.
San Diego is a good example, that parking structure was permitted (and approved by the FAA) for another level. The only reason there isnt, is that the workers refused after getting scared to death building what they did.

Heathrow and Gatwick, extra runways hasnt quite set in yet with the public

These crazy scenarios with simulataneous parallel ops, reduced sep appraoch, time based sep, and other capacity strategies are here to stay, and are only going to get tighter until the 99.9% is crossed.

[WillowRun 6-3]

KORD. So named, for Orchard Field, which in turn was named for Orchard Place, a small farming village northwest of Chicago. In the 1930s traffic was outgrowing Municipal Airport (the airport now known as Midway, MDW) and the city sought a site for a second airport but without any decision. In 1942 Douglas Aircraft needed a site for a manufacturing plant (and accompanying runways) for C-54 aircraft and an open area near Orchard Place had suitable transportation access especially rail links. The then-CAA insisted that the main runway be configured with parallel directional orientation to Municipal's runway, and hence the construction of the first 32-14 runway. (Willow Run airport near Detroit, Michigan, needless to say never reached O'Hare's league - but its legacy likewise is military aircraft manufacturing, and indeed nothing in Chicago O'Hare Int'l Airport can even remotely compete or match with the Second World War bomber plant heritage at Willow Run.)

The lesson, for those wishing not to be consigned to failure by the mistakes or oversights of the past, is that merely moving out of the city, out into open space, is not a long-lasting solution to the airport needs of an evolving aeronautics and air transport sector. This is beyond the mere sad political theater of a mayoral administration in Chicago designating the small, barely capable airport in Gary, Indiana as Chicago's "third airport." Rather, like generals who cliché always assigns to fighting the last war, responsible urban and regional planning officials historically have not had the luxury of looking beyond the necessarily foreseeable future, and thus have not asked (perhaps with rare exceptions), "what if?" But if any of the nascent aeronautics revolutions occurs - SSTs, space tourism, SSTOs, semi-autonomous aircraft - today's airport planning will seem as incredibly weak and ill-informed as, as, . .......as the ridiculous assertion that a major air carrier flight operation could come within the yardage of a couple three first downs of a catastrophic landing atop a row of planes on a taxiway at a major airport. Ah, well, uhhh, wait.

[West Coast]

The only reason there isnt, is that the workers refused after getting scared to death building what they did.


Apocryphal.

[underfire]

West Coast, I was involved in the design of the structure.
It was permitted to go another story higher. When you look at the structure now, you can see that the ramps are not complete and just end, with an odd configuration to turn around and back out.

You are so smart using such a big word!

[West Coast]

Involved with the design is nice, but doesn't validate your statement that the workers were "scared to death".

[westhawk]

I wonder what year they displaced the 27 threshold at SAN to where it is now. When on the visual glide path, the parking structure does not really seem much of a factor as it is now. It must have been quite sporty at an earlier time!

[Oro-o]

Paine Field in Everett, existing one that Boeing uses for new aircraft. Public uproar when Horizon tried to add 2 flights per day....

Not to dismiss the general theme of your point, but there has, as far as I can tell, been nothing but general excitement at the fact AS is starting daily passenger service out of Paine next year. I don't know when Horizon (or do you mean Alaska?) tried what you are referring to, but the mood seems very different there now.

[aterpster]

I wonder what year they displaced the 27 threshold at SAN to where it is now. When on the visual glide path, the parking structure does not really seem much of a factor as it is now. It must have been quite sporty at an earlier time!
Can't answer that one. I do recall that ALPA was quite upset because the FAA Part 77 specialist did the incorrect calculation, thus issuing a no hazard determination. A subsequent correct calculation showed it should have been a hazard determination. But, by the time the structure had been completed so the FAA just shrugged their collective shoulders. Such a sterling safety agency...not.

[galaxy flyer]

As sporty as KSAN is, try the procedure to 27, circle to land on 18 at NAS North Island at mins in a heavy C-5! In the turn, I could only wonder what it sounded like in terminal building.

[BluSdUp]

So, wonder if they tuned the ILS 28R for the second approach? Eh!

[aterpster]

It's even worse when they have to use the ILS Rwy 9.

[ironbutt57]

So, wonder if they tuned the ILS 28R for the second approach? Eh!


guess if they were cleared for the ILS yes, I'm sure they did, but the FMS Visual approach they initially performed precludes this..

[BluSdUp]

Having the ILS on stby and switching it to active at 4 miles is not an option on the A320?
I am starting to appreciate my old 738 more,
Time to dig out the old A320 manual and review what I am missing out on.
By the way , no GPS , how is that even allowed in an airliner. Seriously.
Oh and visual at night, how safe is that, rely. Not this night anyway.

[Zeffy]

NTSBgov
Published on May 2, 2018

May 2, 2018: San Francisco International Airport Terminal 2 security camera video of the July 7, 2017, Air Canada taxiway overflight.

Air Canada taxiway overflight video

[Zeffy]

Docket (https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=61112&CFID=1915820&CFTOKEN=d17e10dd9a27b0d4-7B4F45C6-9563-5548-0B0060C1BF4EB80D) now open.

[Zeffy]

Aircraft Performance Report (https://dms.ntsb.gov/public/61000-61499/61112/614681.pdf)
The lowest adjusted radio altitude (nominally indicating the bottom of the landing gear, the
fuselage would be an additional 5 ft higher), which occurred as the airplane passed over
PAL115, was 60 ft. Measurements were made using an image of the security camera footage to
confirm this altitude reading. The image when ACA759 and PAL115 are closest is quite small
in the camera frame, so measurements made from the pixilated image are approximate. The
vertical stabilizer of the A340 was well illuminated and is 8.2 m (26.9 ft) tall (Figure 6).
Assuming ACA759 passed directly over PAL1151, the distance between the two airplanes in the
image was measured to be 13.5 ft. Allowing for uncertainty, this measurement was bracketed to
be between 10 and 20 ft of air gap. An A340 is 55 ft tall, so the altitude of the fuselage of
ACA759 as it passed over PAL115 was between 65 and 75 ft. This is consistent with the
adjusted radio altitude.


https://ssl.gstatic.com/ui/v1/icons/mail/images/cleardot.gif

[TheFlyingCyclist]

Perhaps it’s the camera angle but judging from the change in landing light illumination angle, it seems the pull-up is rather abrupt when he flies over the tail of the waiting aircraft. Last moment reaction? Would be interesting to know the precise moment they advanced the power.

[admiral ackbar]

Perhaps it’s the camera angle but judging from the change in landing light illumination angle, it seems the pull-up is rather abrupt when he flies over the tail of the waiting aircraft. Last moment reaction? Would be interesting to know the precise moment they advanced the power.

Saw this chart on another forum, believe it is from the report released with the new video

https://cimg4.ibsrv.net/gimg/www.flyertalk.com-vbulletin/620x653-1/aircanada1_59fd92d359fd01e5090c9b56ccaae0040dfcd99b.png

[J.O.]

Am I the only one who's shocked by the NTSB's release of personal information on the crew? I think it's disgusting.

[Jet Jockey A4]

Am I the only one who's shocked by the NTSB's release of personal information on the crew? I think it's disgusting.


Did not have a chance to read the complete report but what personal info are you talking about?

[iome]

Link (https://go.usa.gov/xQ8Mp) https://go.usa.gov/xQ8Mp

[DaveReidUK]

Link (https://go.usa.gov/xQ8Mp) https://go.usa.gov/xQ8Mp

I think that points to the same page as Zeffy's link yesterday (#1038).

[Airbubba]

Am I the only one who's shocked by the NTSB's release of personal information on the crew? I think it's disgusting.

Are you shocked by release of the training information?

The first officer reported that he had attempted previously to upgrade to captain. After two unsatisfactory attempts, however, he elected to return to the first officer seat. Air Canada records showed that on February 6 and 7, 2017, the first officer had passed his command LOE training. On March 1, 2017, he had an unsatisfactory on his QOE27 and a second unsatisfactory QOE on March 16, 2017.

According to the simulator instructors and checkairmen that conducted the incident first officer’s upgrade attempt, the reason for the unsatisfactory upgrade was the first officer’s lack of situational awareness, failure to correctly identify a mandatory altitude on an arrival, non-precision approaches, and a lack of performance to the Transport Canada required performance standards. Some of the instructors and checkairmen categorized the incident first officer as “nervous” and “a weak candidate.”

Or release of the lifestyle information?

The First Officer’s Personal Background The incident first officer was 42 years old and lived in Toronto, Canada with his wife and children. He felt he needed 8 hours of sleep per night to feel rested and considered himself to be a heavy sleeper. He considered himself a “normal day person” as his children did not allow him to be a night person. He stated he is normally more alert in the evenings however, about 2300, he typically felt sleepy. He would have liked to sleep until 0800 to 0900 if he could. If he was flying a night flight, he normally took a nap in the afternoon for about 90 minutes. He slept well during naps and felt rested following them. He had no history of sleep disorders or changes to his health in the past year.

He reported no changes to his health, financial situation, nor personal life within the preceding year that affected his performance. He reported no issues with health or color vision, and although he passed his medical without wearing glasses but did use them when he flew. He had no issues with his hearing and was not taking any prescription medication. He drank alcohol 3-5 times per week usually consuming a glass of wine or beer with dinner. Prior to the incident he stated his last drink was likely with dinner on Monday or Tuesday, but he could not recall. He did not smoke tobacco nor use illicit drugs. He did not take any medication that would have affected his performance in the 72 hours preceding the incident flight.

https://dms.ntsb.gov/public/61000-61499/61112/614631.pdf

Don't know how they do it in other countries but this seems to be pretty standard fare in the human performance section of an NTSB docket.

[Lascaille]

Don't know how they do it in other countries but this seems to be pretty standard fare in the human performance section of an NTSB docket.

It's all fairly harmless until it isn't... Suppose he didn't live with his wife and children but had a slightly less 'traditional' living arrangement that could affect future job prospects, especially overseas in some less enlightened parts of the world. If exonerated completely by the report how is that cat going to be returned to the bag? Dodgy.

[nnc0]

Am I the only one who's shocked by the NTSB's release of personal information on the crew? I think it's disgusting.

Nope - it is a bit too personal and intrusive isn't it?

[cargosales]

I agree about the personal details being released - a big 'no-no' in my book..

On the other hand, someone either IS or IS NOT up to the job of commanding a flight. End of. There are people's lives at risk and the Captain of an aircraft has a huge responsibility. If he isn't up to the task then someone has to take responsibility and 'call him out' / fail him during sim or safety checks.

Sorry if that sounds harsh but I can't see any other way.

CS

[J.O.]

Are you shocked by release of the training information?



Or release of the lifestyle information?



https://dms.ntsb.gov/public/61000-61499/61112/614631.pdf

Don't know how they do it in other countries but this seems to be pretty standard fare in the human performance section of an NTSB docket.
It's the release of the crew's names and personal details for an event that, while serious, caused not a scratch to people or property.

[aterpster]

It's the release of the crew's names and personal details for an event that, while serious, caused not a scratch to people or property.

My view is that the NTSB was really pissed off that the CVR was not preserved. And, the alertness (lack thereof) of the flight crew is very pertinent. This came within feet of making Tenerife look like a Sunday School picnic. OTOH, the pilot on the taxiway who flashed his landing lights may very well had saved the day.

And, go read NTSB accident reports before circa 1980. The name and age of the crew were always in the final report.

[Jet Jockey A4]

. OTOH, the pilot on the taxiway who flashed his landing lights may very well had saved the day.

I'll guaranty you for sure that the only thing that saved the day was the fact that the PAL Airbus 340 pilots did flash their landing lights. Those two morons were going to land on top of those 3 aircrafts waiting inline on the taxiway.

[AerocatS2A]

It is interesting that the previous landing also questioned to themselves if they were lined up on the correct runway stating that the construction lights were very bright and made it impossible to see the closed runway, also that the lack of lights on the jets on the taxiway contributed to their confusion. Of course they sorted things out fine, but it certainly suggests that the visual environment was not good.

[Airbubba]

It's the release of the crew's names and personal details for an event that, while serious, caused not a scratch to people or property.

The crew names are customarily in the docket but not in the final report from what I see in recent mishaps. Things like addresses (physical and email), phone numbers, SSN's and employee numbers seem to be mostly redacted in the online docket.

You would think the NTSB would be extra cautious after the infamous 2013 OZ214 crew name debacle. An NTSB summer intern was fired and four non-Asian producers at KTVU involved were let go as well. Managing Editor Michelle Toy who OK'd the crew list kept her job.

My view is that the NTSB was really pissed off that the CVR was not preserved.

Is there any mention of the missing CVR in the docket documents? I haven't had a chance to flip though them very thoroughly yet.

[Jet Jockey A4]

It is interesting that the previous landing also questioned to themselves if they were lined up on the correct runway stating that the construction lights were very bright and made it impossible to see the closed runway, also that the lack of lights on the jets on the taxiway contributed to their confusion. Of course they sorted things out fine, but it certainly suggests that the visual environment was not good.


Perhaps at some point on the approach that could be true, but at 100 AGL approaching the end of a taxiway full of aircrafts waiting for takeoff? Sorry, but I'm not buying it.

[Jet Jockey A4]

Is there any mention of the missing CVR in the docket documents? I haven't had a chance to flip though them very thoroughly yet.

Good question and I'l like to know too.

[Smott999]

As SLF I'm not able to understand everything I read in the docket....but was curious about the failure to tune the ILS. The FO expressed being upset to note that he'd forgotten to do that on the initial approach (they tuned it for the second approach).
Many of the AC interviewees mentioned that they routinely tune the ILS.
How big (or small) an error is something like that given the difficulties of SFO....?

[cjad100]

It's the release of the crew's names and personal details for an event that, while serious, caused not a scratch to people or property.

This was a serious incident that could have resulted in loss of life approaching 1,000 souls. And there was considerable ethical malpractice in the CVD being deleted at the end of a flight involving such a serious incident. These factors alone necessitate a full enquiry. Not a scratch? Yes - based on the actions mainly of alert pilots on the taxiway. This was a horrendous incident with 60 feet separation or less between fully loaded aircraft.

Regardless of the above - civil aviation pilots generally carry hundreds of pax in airplanes worth over $100m. That carries a responsibility. If you don't like the idea that in the case of a serious incident, relevant personal factors are included in the formal accident report, then don't fly. It's been part of the job for decades and any responsible flyer should completely agree with it.

If the details are irrelevant, then fine, but home life and rested status are directly relevant to human factor safety.

[PaxBritannica]

There's a FDR analysis, but I can find no mention of the CVR.

Several of the crew witness statements from the a/c on the taxiway comment that there was only one air traffic controller, working air traffic, ground and even vehicles. They observe that the single controller had a heavy workload, and was slow to respond to UAL's call of "He's on the taxiway".

For a major airport like SFO, isn't this a bit lightly staffed?

[Ranger One]

They observe that the single controller had a heavy workload, and was slow to respond to UAL's call of "He's on the taxiway".

Not well phrased RT in my book. "He's ON the taxiway" sounds more like giving a GROUND position... on the taxiway, as opposed to 'holding at...' or 'on the ramp' etc. That wouldn't perk my ears up to anything like the same extent as "He's LANDING on the taxiway!"

As for the video, words fail me. Well they don't fail me, but if I used the words that come to mind I would get severely moderated.

[KingAir1978]

This was a serious incident that could have resulted in loss of life approaching 1,000 souls. And there was considerable ethical malpractice in the CVD being deleted at the end of a flight involving such a serious incident. These factors alone necessitate a full enquiry. Not a scratch? Yes - based on the actions mainly of alert pilots on the taxiway. This was a horrendous incident with 60 feet separation or less between fully loaded aircraft.

Regardless of the above - civil aviation pilots generally carry hundreds of pax in airplanes worth over $100m. That carries a responsibility. If you don't like the idea that in the case of a serious incident, relevant personal factors are included in the formal accident report, then don't fly. It's been part of the job for decades and any responsible flyer should completely agree with it.

If the details are irrelevant, then fine, but home life and rested status are directly relevant to human factor safety.

cjad, I do not know if you're a professional pilot or working in aviation in any capacity, but your idea here is undermining the very essence of a 'just' safety culture. Your post implies that the pilots are already guilty of something. The only way that they should be considered guilty of something is if they intentionally did or omit to do something that would break the law. The fact that they went around 'proves' they had no intention to slam their aeroplane into the others lined up on the taxyway.

If your start the investigation with the intention to 'hang them high', you'll never learn anything because the crew will simply refuse to cooperate. Publishing their names has already been tremendously damaging to the people involved.

This is why ICAO is trying to investigate incidents and accidents with the explicit intention NOT to apportion blame.

From what I can see so far, the only thing the crew have been guilty of, is being human. It will be very interesting to see what the outcome of this investigation is. I'm sure it must have involved some kind of lapse of situational awareness due to some kind of visual illusion of some kind. The interesting question would be how to avoid this from happening again in the future.

Only if the investigation reveals some kind of carelessness or recklessness, should this go to a court of law. Only AFTER the crew have been convicted of some wrongdoing (and that is questionable at best), should their names have been made public knowledge.

[aterpster]

From what I can see so far, the only thing the crew have been guilty of, is being human. It will be very interesting to see what the outcome of this investigation is. I'm sure it must have involved some kind of lapse of situational awareness due to some kind of visual illusion of some kind. The interesting question would be how to avoid this from happening again in the future.
The failure to preserve the CVR is quite significant to this aviation professional and has compromised, as you state, ..how to avoid this from happening again.

[pattern_is_full]

@smott999 - It was a visual approach. Therefore theoretically flyable using only the Mk. 1 eyeball, without any ILS tuned (and the visual approach is at a slight converging angle to the ILS track, so one would not be using the ILS to the fullest extent). However, tuning the ILS can be a useful backup, but then one gets into specific airline policies (use it, don't use it) or aircraft operational differences.

@PaxBritannica - CVR was wiped before the NTSB could get to it. See numerous previous posts (including the one immediately above yours!). It is interesting that ,while SFO was supposedly quiet enough at midnight for one controller to handle things, there were four planes lined up for departure at this critical moment (gotta love those west-coast red-eyes!)

Trained, experienced commercial pilots line up with, and sometimes land on, taxiways on the order of once or twice a year. It happens. Usually, there is no traffic on the taxiway - or we'd have heard about it big-time before now. This time was different.

I can feel for the crew. They tried to do everything right (saw the NOTAM, noted the risks of an oh-dark-thirty arrival on their own human performance) - but in the end, they still "lost the picture" in a critical phase of the flight, were slow to respond to their own growing doubts, and nearly produced a major catastrophe. Things slipped through the cracks or "lined up in the cheese," and Murphy was riding in the jump-seat. An object lesson for everyone.

[PaxBritannica]

@smott999 - It was a visual approach. Therefore theoretically flyable using only the Mk. 1 eyeball, without any ILS tuned (and the visual approach is at a slight converging angle to the ILS track, so one would not be using the ILS to the fullest extent). However, tuning the ILS can be a useful backup, but then one gets into specific airline policies (use it, don't use it) or aircraft operational differences.

@PaxBritannica - CVR was wiped before the NTSB could get to it. See numerous previous posts (including the one immediately above yours!). It is interesting that ,while SFO was supposedly quiet enough at midnight for one controller to handle things, there were four planes lined up for departure at this critical moment (gotta love those west-coast red-eyes!)

Trained, experienced commercial pilots line up with, and sometimes land on, taxiways on the order of once or twice a year. It happens. Usually, there is no traffic on the taxiway - or we'd have heard about it big-time before now. This time was different.

I can feel for the crew. They tried to do everything right (saw the NOTAM, noted the risks of an oh-dark-thirty arrival on their own human performance) - but in the end, they still "lost the picture" in a critical phase of the flight, were slow to respond to their own growing doubts, and nearly produced a major catastrophe. Things slipped through the cracks or "lined up in the cheese," and Murphy was riding in the jump-seat. An object lesson for everyone.

Not only were there four planes lined up, there were a lot of flights landing. The report states that the UAL flight of 'He's on the taxiway' fame, had been waiting 30 mins at the time of the near-incident, and had made at least one query of ATC about whether a hole might be found in the the long queue of landing flights.

It would have made no difference to this particular flight, but I imagine passengers arriving at SFO might be surprised that ALL ops at the airport were being handled by just one person.

[West Coast]

Save me sifting through the thread, where is it said the local controller was also working ground, CD, etc?

[Roger_Murdock]

Save me sifting through the thread, where is it said the local controller was also working ground, CD, etc?

It's in crew statements in the recently opened NTSB docket. Several pilots of other aircraft said it was a cause for concern.

[PaxBritannica]

Save me sifting through the thread, where is it said the local controller was also working ground, CD, etc?
From the 'Airplanes on taxiway C' attachment:

While the Air Canada 759 crew made a serious mistake that went unchecked for way too long. I believe that it is important to note that the tower controller was performing way too many functions, IE Ramp, Ground, Tower and at times ops vehicles. I believe that the audio from the 45-55 minutes prior to this event will support this belief. Sincerely, Robert S. Wallace United Airlines 737 Captain

It was clear from tower's comment to someone else on frequency seconds after this incident that there was only one controller working the tower and ground control functions. Greg L Sembower UAL 863 First Officer

Second, I feel the tower controller should not have been the only controller working the entire airport. He was working multiple frequencies, controlling tower duties for Take offs on 1L and 28R, and Landings 28R. He was also performing all ground control duties. I feel when Air Canada called with questions about the runway, this should have been the cue he needed to closely pay attention to that flight. That apparently did not happen. You can tell from the reaction time between when United 1 called "Where is this guy going? He is lined up on the taxiway" to when he told Air Canada to go around. It took a few seconds for him to evaluate the situation. Those few seconds were several more feet that Air Canada continued his approach down to around 100' Sincerely, First Officer Steve Shoquist United Airlines

[India Four Two]

West Coast,

The interview with the controller is here:

https://dms.ntsb.gov/public/61000-61499/61112/614678.pdf

[jurassicjockey]

That's a pretty ugly schedule the controller is working. I've done one similar to that before and didn't care for it. Maximises your days off though.

[Airbubba]

Some NTSB docket analysis in this Mercury News article:
5 feet?! Shocking SFO video, data reveal Air Canada plane came perilously close to aircraft on taxiwayBy MATTHIAS GAFNI (https://www.mercurynews.com/author/matthias-gafni/) [email protected] Bay Area News GroupPUBLISHED: May 2, 2018 at 10:50 am UPDATED: May 4, 2018 at 10:49 am

SAN FRANCISCO — Federal aviation investigators released stunning video footage and data Wednesday showing the near-disastrous landing of an Air Canada flight at San Francisco International Airport came as close as 5 feet from striking a Philippine Airlines jet lined up on a taxiway last July — much closer than previously reported.

In its lengthy report Wednesday on one of the most troubling close calls in SFO’s history — an Air Canada jet almost landing on top of four passenger jets awaiting takeoff — the National Transportation Safety Board found the crew felt fatigued during the flight, that the first officer was twice rejected in his application for promotion, and that another pilot landing at SFO that night complained about too-bright construction lights that made it difficult to find the proper runway.

Aviation experts have said the close call could have led to one of the worst aviation disasters in history with the fully loaded planes carrying upward of 1,000 passengers and crew.

The documents were released a day after the Federal Aviation Administration released its own investigatory findings into other take-off and landing mishaps at SFO, highlighted in a series of reports first detailed by the Bay Area News Group.

The new NTSB report includes never-before-seen SFO surveillance video that shows Air Canada Flight 759, an Airbus A-320, mistakenly aligned with Taxiway C the night of July 7. The black-and-white video shows the Air Canada jet descending perilously close to — and flying directly over — the planes awaiting takeoff before pulling up at the last second. It had been cleared to land on runway 28R, but pilots told the NTSB they got confused because a parallel runway was closed for construction that night.

https://i0.wp.com/www.mercurynews.com/wp-content/uploads/2018/05/aircanada1.png?w=620&crop=0%2C0px%2C100%2C9999px&ssl=1The new data from NTSB shows the plane dropped to only 60 feet above the ground at its lowest point — much lower than previously thought — as it passed over a Philippine Airlines Airbus A340 waiting to take off on the taxiway. The tail of the Airbus model — the tallest point — is 55 feet, six inches.

When asked to confirm that Air Canada passed within 5 feet of the other jet based on the NTSB chart, a spokesman said they would have to consult the investigators. While the federal agency could not confirm the distance, in its performance study report the NTSB estimated the distance between the two planes at 13.5 feet.

Former United pilot Ross Aimer reviewed the NTSB data and said it appeared the planes got incredibly close.“If the tail of (Air Canada) was directly above the A340’s rudder (which may not be the case) the direct vertical distance would be 5 (feet)!” Aimer wrote in an email.

The NTSB report also presents a much clearer idea of what happened in the cockpit during those final crucial moments on approach and named the pilots involved for the first time.

Air Canada Capt. James Kisses switched off the autopilot once the plane reached the final approach and took over flying. As they neared the airport, he saw lights on the runway and asked his co-pilot Matthew Dampier to verify the runway was clear.

At about 11:55 p.m., radio traffic indicates that Dampier asked the SFO air traffic controllers: “Just want to confirm this is Air Canada 759 we see some lights on the runway there across the runway. Can you confirm we’re cleared to land?”

The tower, believing the plane was lined up for the correct Runway 28R, said the runway was clear, not realizing the plane was actually lined up on the crowded parallel taxiway.

https://i1.wp.com/www.mercurynews.com/wp-content/uploads/2018/05/ebt-l-ntsb-0503-90-01.jpg?w=620&crop=0%2C0px%2C100%2C9999px&ssl=1 (https://www.mercurynews.com/wp-content/uploads/2018/05/ebt-l-ntsb-0503-90-01.jpg)

The first officer described how in the moments before radioing the tower for clarification he had been “looking more inside the cockpit than out because” he was focused on preparing the plane for landing, according to the NTSB report.

When Dampier looked up from his chart as the captain asked him to query the tower, he looked outside and said it “didn’t look right” and he had a “bad feeling in his stomach,” according to the report.

“Although he was not certain what was incorrect, he was unable to process what he was seeing. He subsequently commanded the go around to the captain by saying ‘go around go around,’ ” according to the report. Kisses told investigators “things were not adding up” and that it “did not look good,” and as he got even closer it “still felt odd” and he aborted the landing.

The pilot and co-pilot had never flown together before that night. Dampier, 42, said they both began to feel tired while still an hour away from SFO. While neither man had a previous incident or accident, Dampier had two “unsatisfactory” attempts to become a captain.

“According to the simulator instructors and checkairmen that conducted the incident first officer’s upgrade attempt, the reason for the unsatisfactory upgrade was the first officer’s lack of situational awareness, failure to correctly identify a mandatory altitude on an arrival, non-precision approaches, and a lack of performance to the Transport Canada required performance standards,” according to the report.

Some instructors described Dampier as “nervous” and a “weak candidate.”

Air Canada has not said if either man was disciplined. The 56-year-old captain has 20,000 flying hours, and the first officer has 10,000 flying hours. Both men live in Toronto, meaning their body clock was at 3 a.m. during the landing.

Dampier told investigators it was not until they left the plane that night — after a second, successful landing — that they remembered about the runway closure at SFO.

Dampier told investigators as they taxied to the gate at SFO that night he realized the result “could have been bad.”

The NTSB also interviewed the flight crews who got buzzed by the Air Canada plane as they sat on the taxiway. Many pointed to the quick thinking of United Airlines Flight 1 Capt. Keith Freeberg, who had been first in line at the end of Taxiway C waiting to take off. He saw the Air Canada plane headed toward them and radioed: “Where’s that guy going, he’s on the taxiway!”

Steve Shoquist, a relief first officer on United 863, which was third in line on the taxiway, said the plane turned on all its lights in a last ditch effort to warn the Air Canada plane it was about to land on them.

“Air Canada went around, and a huge disaster that would have many fatalities, including myself was avoided,” Shoquist told investigators.

Another pilot told investigators that the air traffic controller that night was overburdened with work directing air, ground and other radio traffic. The FAA has since ordered two controllers to be in the tower at SFO at all times during the night rush hour. At the time of the landing, one controller was in the tower, and the second was on break.

The air traffic controller that night, Brian Delucchi, also was interviewed by the NTSB and recalled talking to the “shaken” Air Canada pilot shortly after the incident.

“He (said the pilot) had not realized how close the aircraft had gotten to each other … and (he) did not want to ‘freak the guy out since he seemed shaken,’ ” according to the report.

The Air Canada pilots were not the only ones confused by runway configuration that night, when Runway 28L was closed for construction. Another airline’s flight crew that landed on Runway 28R four minutes before the Air Canada flight reported to investigators the “construction lights were so bright we could not determine the location of the inboard runway, 28L,” according to the report.

That crew said they too questioned whether they were properly lined up for Runway 28R but checked with their instruments to confirm the right path.



https://www.mercurynews.com/2018/05/02/video-new-shocking-sfo-footage-shows-just-how-close-air-canada-plane-came-to-landing-on-four-aircraft/

[Derfred]

As a radio altimeter will return the closest obstacle in the signal path, one could suggest the 60 foot lowest recorded reading is actually from the top of the A340, not the ground.

[wiggy]

Unfortunately unless there’s been a major foul up in the document with regard to definitions I don’t think you can suggest that..

The performance study table in the docket/Airbubba’s post specifically labels the fourth column “altitude” and the amplifying text refers to “altitude” , not “ height” or “radio height” or “radio altitude”.

[ThreeThreeMike]

I begin this post by apologizing for not completely reviewing the thread again before commenting. I did read it while the incident unfolded in the months afterward, but the thread is now so long it precludes the ability to find specific information for memory refreshment.

There has been discussion about the controller's workload; at the time this individual was coordinating aircraft flight and ground operations as well as the movement of ground vehicles.

My thoughts on the issue:

The aircraft was cleared to land and on a visual approach. It therefore seems to me the controller's workload had little bearing on the crew's lineup on the taxiway rather than the runway. Similarly, the controller's go around call was based on his interpretation of a radio transmission from the crew of UAL 1, not information that was available from his equipment.

It seems quite reasonable to state the controller's increased workload had little effect on the situation.

As for the crew's perception of the last seconds of the approach, the situation was undoubtedly confusing.

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

Runway 28L had been closed for five months at the time of the incident. It seems reasonable to assume the crew might have flown into SFO during those months, and therefore on the date of the incident might have been aware 28L had been closed for some time. The NOTAM regarding the runway closure was part of the data the crew reviewed that day, and the ATIS broadcast also contained the information.

In spite of this, it seems the crew did not fully integrate this knowledge into their approach briefing and actions during the approach. The NTSB statement above says the crew mistook the lights of Runway 28R for the closed Runway 28L. But as they should have expected, the closed runway did not have approach lights, PAPI, edge lights, and centerline lights in operation. It did have an elevated brightly lit "X" placed on the centerline of the runway. Why would they make this elementary mistake?

The crew was aware the 28L was closed, and the difference in the sight picture between a fully lit active runway and a taxiway, illustrated by an earlier post of a sim program screencap, is so obvious it seems inexplicable the crew made the misidentification described in the NTSB document.

The inquiry the crew made to the controller about their confused sight picture seconds before the planned touchdown indicates they were aware something was amiss. But because of their alignment on the taxiway, the ASDE-X/ASSC data link did not show the position of AC-759 for several seconds, leaving the controller unaware of the impending collision.

The assertion by both pilots they were "convinced" the aircraft was aligned with Runway 28R seems to be a bit too emphatic to me. If so, why were they confused enough to contact the controller about the situation? "Convinced" conveys the image that they had a clear understanding of what was in front of them, and that characterization seems to be, perhaps, rehearsed.

While giving sufficient weight to human factors, particularly fatigue, the actions of the crew seem to indicate inattention or complacency were also present. This should not be a surprise, human endeavours are often affected by such traits. I have not made the above observations to heap unwarranted criticism on the crew, I am suggesting behavior, though unintentional, that may have played a part in the incident.

[groundbum]

I'm shocked that two controllers were paid to be on duty, but after 30 minutes one of them went off on an extended 3 hour break, a break from what? As the United Pilots said, they were waiting 30 minutes on the ground for departure. How much did this cost the airlines, whilst one controller napped on the sofa or played Minecraft?

G

[Ambient Sheep]

It would have made no difference to this particular flight, but I imagine passengers arriving at SFO might be surprised that ALL ops at the airport were being handled by just one person.


Speaking as SLF, when I first read that back in July I was utterly shocked that a major international airport could have just one ATC on duty no matter what the time of day -- what about sudden incapacitation?

[AerocatS2A]

Speaking as SLF, when I first read that back in July I was utterly shocked that a major international airport could have just one ATC on duty no matter what the time of day -- what about sudden incapacitation?
It wouldn't be a big deal. Those jets on the ground would stay there, and those in the air would land in an orderly fashion. There are places where passenger jets operate in and out of airports that don't have any controllers at all. Despite what they might like you to think, we don't really need them ;).

[AerocatS2A]

I'm shocked that two controllers were paid to be on duty, but after 30 minutes one of them went off on an extended 3 hour break, a break from what? As the United Pilots said, they were waiting 30 minutes on the ground for departure. How much did this cost the airlines, whilst one controller napped on the sofa or played Minecraft?

G
Having another controller isn't going to magically increase the flow rate.

[Ambient Sheep]

I begin this post by apologizing for not completely reviewing the thread again before commenting...

...The crew was aware the 28L was closed, and the difference in the sight picture between a fully lit active runway and a taxiway, illustrated by an earlier post of a sim program screencap, is so obvious it seems inexplicable the crew made the misidentification described in the NTSB document.



You may therefore have missed the following:

It is interesting that the previous landing also questioned to themselves if they were lined up on the correct runway stating that the construction lights were very bright and made it impossible to see the closed runway, also that the lack of lights on the jets on the taxiway contributed to their confusion. Of course they sorted things out fine, but it certainly suggests that the visual environment was not good.


May I thus venture to suggest that the actual situation as seen through the cockpit window on that particular night may not have tallied with the "sim program screencap" -- 28L not dark, and red-X drowned out by construction floodlights perhaps?

[Ambient Sheep]

It wouldn't be a big deal. Those jets on the ground would stay there, and those in the air would land in an orderly fashion. There are places where passenger jets operate in and out of airports that don't have any controllers at all. Despite what they might like you to think, we don't really need them ;).


Ok, thank you for the info. :) And yes I am aware that some small airfields don't have them at all, was just shocked regarding a place as large as SFO, that's all. Again, thank you for replying.

[underfire]

As a radio altimeter will return the closest obstacle in the signal path, one could suggest the 60 foot lowest recorded reading is actually from the top of the A340, not the ground.

Did you see the pictures? it was reading the ground...

[wingview]

SFO should have better equipment and more staff on duty. This was almost a disaster but everybody seems to forget Asiana which would have been prevented with the right radar. To have a blanc spot on very very short final is not acceptable for an airport like SFO with runways used for parallel landings and take off.

[PaxBritannica]

It wouldn't be a big deal. Those jets on the ground would stay there, and those in the air would land in an orderly fashion. There are places where passenger jets operate in and out of airports that don't have any controllers at all. Despite what they might like you to think, we don't really need them ;).

In non-ATC airports, pilots are aware and operate accordingly. This is quite different from a major international airport where flight crew know that there are many a/c in the same airspace and expect a highly-managed environment.

On the night in question, there was a long queue of flights lined up for landing. If everything went smoothly, flights may indeed have landed in 'an orderly fashion'. But things don't always go smoothly. Assume that the single controller had, say, become unconscious. It one flight had failed to clear the runway in time (perhaps not knowing which exit to take, lacking tower instructions), or a vehicle encroached on the runway, there would be no way for the following flight to know that and execute a go-around. How long would it take for the 'spare' controller to become aware of his/her colleague's absence? How long to run upstairs and assimilate the situation?

The single-controller situation seems to me to be a risk. That might be acceptable in a small, remote airport with few flights. But in SFO? With ground and airport full of a/c and vehicles? A major international airport should not be allowed to take that kind of risk.

[DingerX]

Ok, so they can't produce a picture of what it looked like out the window, so we can't know how red the X was or how runway like the taxiway seemed (wasn't it a smaller runway for a few years?)
But single controller was a factor, just not for the obvious reasons.
There's no way you can expect him to spot the misalignment in time, given the angle he has on the 28s.
But, for a relatively calm part of the day, what were all those a/c doing on the taxiway? The lead A/C had been waiting at the bar for thirty minutes.
When the ATCOs made the determination to go to a single controller, they did so based on the number of strips they had.I wonder if they took into account the evening closure of 28R? So, with one controller on ground and tower, Line Up And Wait goes into the break room. With all arrivals on 28R, the heavies have very few gaps to get out in, and no-LUAW means those gaps need to be bigger. So the heavies pile up on the taxiway, because the controllers didn't fully account for the impact of construction, as the AC bus lines up on them, for similar reasons.

ATC has changed their procedures since.

[AerocatS2A]

In non-ATC airports, pilots are aware and operate accordingly. This is quite different from a major international airport where flight crew know that there are many a/c in the same airspace and expect a highly-managed environment.

On the night in question, there was a long queue of flights lined up for landing. If everything went smoothly, flights may indeed have landed in 'an orderly fashion'. But things don't always go smoothly. Assume that the single controller had, say, become unconscious. It one flight had failed to clear the runway in time (perhaps not knowing which exit to take, lacking tower instructions), or a vehicle encroached on the runway, there would be no way for the following flight to know that and execute a go-around. How long would it take for the 'spare' controller to become aware of his/her colleague's absence? How long to run upstairs and assimilate the situation?

The single-controller situation seems to me to be a risk. That might be acceptable in a small, remote airport with few flights. But in SFO? With ground and airport full of a/c and vehicles? A major international airport should not be allowed to take that kind of risk.

Well, it happens all the time. The tower controller doesn’t have a lot to do when it comes to landing aircraft, just clear them to land, they’ve already been sequenced by approach. Remember the controller is busy because he’s dealing with ground vehicles, aircraft wanting an airways clearance, aircraft wanting to taxi and the aircraft on final, if he dies the only aircraft that can’t just wait around are the couple on final. As for vacating the runway, you think we land without briefing an expected exit? We just get off by the most efficient exit, we don’t need someone to hold our hand every step of the way. Is operating somewhere like SFO with no controller a good idea? Of course not, but if there is one controller and he has a heart attack, the aircraft on finals will land with no problem, and once they realize no ones talking to them they’ll be letting approach know pretty quick. If the preceding aircraft is still on the runway then the following just goes around, same with vehicles on the runway. This incident notwithstanding, it is normally easy enough to see if the runway is a, a runway, and b, clear.

[PaxBritannica]

Well, it happens all the time. The tower controller doesn’t have a lot to do when it comes to landing aircraft, just clear them to land, they’ve already been sequenced by approach. Remember the controller is busy because he’s dealing with ground vehicles, aircraft wanting an airways clearance, aircraft wanting to taxi and the aircraft on final, if he dies the only aircraft that can’t just wait around are the couple on final. As for vacating the runway, you think we land without briefing an expected exit? We just get off by the most efficient exit, we don’t need someone to hold our hand every step of the way. Is operating somewhere like SFO with no controller a good idea? Of course not, but if there is one controller and he has a heart attack, the aircraft on finals will land with no problem, and once they realize no ones talking to them they’ll be letting approach know pretty quick. If the preceding aircraft is still on the runway then the following just goes around, same with vehicles on the runway. This incident notwithstanding, it is normally easy enough to see if the runway is a, a runway, and b, clear.


a) Well, apparently not.

b) And you can see everything with absolute clarity at night?

The whole point of aviation safety measures is to minimise the possibility of system failure. Belt and braces and belt and braces. There's a line where there's no real safety gain for extra safety measures. It probably wouldn't increase safety much to have ten controllers in the tower at 23.30. It's probably pointless to have five. But one controller? To go with a single point of failure on the basis that the chances of failure are low and only a few a/c would be affected?

This is not how aviation safety is supposed to work.

Is it just SFO? What other safety measures are shaved to the bone for reasons of cost-cutting, hubris or machismo, that this trusting, fare-paying passenger doesn't know about?

[ThreeThreeMike]

You may therefore have missed the following:




May I thus venture to suggest that the actual situation as seen through the cockpit window on that particular night may not have tallied with the "sim program screencap" -- 28L not dark, and red-X drowned out by construction floodlights perhaps?

I made the assumption that during the previous five months the runway was closed, the situation must not have created undue problems for the thousands of flights that had landed without mistaking the taxiway for the runway.

The closed runway was the subject of a NOTAM and was mentioned in the ATIS broadcast. In spite of this, the crew made no mention of that fact during the approach briefing. While some look for reasons to exonerate the crew from blame, it seems to me they ignored several opportunities to recognize the approach required a bit more attention than they gave it.

[fleigle]

wingview
"SFO should have better equipment and more staff on duty. This was almost a disaster but everybody seems to forget Asiana which would have been prevented with the right radar. To have a blanc spot on very very short final is not acceptable for an airport like SFO with runways used for parallel landings and take off."

The AC crew were the only ones to get "confused" that night, it was severe clear weather.
The Asiana crew totally screwed up, blaming SFO for not having the "right radar" is totally pointing at the wrong problem.
And it is "blank", blanc is French for white.... maybe you are trying to "white-wash" the poor performance of those 2 crews...
f

[AerocatS2A]

a) Well, apparently not.

Yeah, that's what "notwithstanding" means. In spite of the current incident, it is normally pretty easy to tell if a runway is a runway and if it is clear at night.

b) And you can see everything with absolute clarity at night?
No, but it's normally pretty good. Look, I'm a night freight pilot, I do a lot of it, often into largish airports that have only one controller. If the controller falls over dead, it would be of little consequence. We'd all go-around, change to approach, talk to him for a bit while they sorted things out then go and land.

The whole point of aviation safety measures is to minimise the possibility of system failure. Belt and braces and belt and braces. There's a line where there's no real safety gain for extra safety measures. It probably wouldn't increase safety much to have ten controllers in the tower at 23.30. It's probably pointless to have five. But one controller? To go with a single point of failure on the basis that the chances of failure are low and only a few a/c would be affected?

This is not how aviation safety is supposed to work.

Is it just SFO? What other safety measures are shaved to the bone for reasons of cost-cutting, hubris or machismo, that this trusting, fare-paying passenger doesn't know about?

You just don't seem to understand that not only are the chances of the single controller falling over very slim, but the consequences of a single controller falling over are minimal. It just wouldn't matter, therefore there is no need to go totally belt and braces over it.

[Ambient Sheep]

I made the assumption that during the previous five months the runway was closed, the situation must not have created undue problems for the thousands of flights that had landed without mistaking the taxiway for the runway.


Oh indeed, but it seems to me that over those five months the nature of the construction and the number of lights used and/or their position and/or direction may well have changed, possibly rendering that assumption invalid.

And we do have the evidence of the previous flight who said that on that particular night they had found the construction lights far too bright and as a result had found locating the runway difficult.


The closed runway was the subject of a NOTAM and was mentioned in the ATIS broadcast. In spite of this, the crew made no mention of that fact during the approach briefing.


I'll freely confess that -- just as you haven't had time to read the newest part of this thread -- I haven't had time to go through the whole docket yet, but according to this recent post, they DID read the NOTAM:

I can feel for the crew. They tried to do everything right (saw the NOTAM, noted the risks of an oh-dark-thirty arrival on their own human performance) - but in the end, they still "lost the picture" in a critical phase of the flight, were slow to respond to their own growing doubts, and nearly produced a major catastrophe.


(EDIT: I've just realised that there's a difference between seeing the NOTAM at the start of the flight, and (not) mentioning it during the approach briefing. Apologies if this applies.)


While some look for reasons to exonerate the crew from blame, it seems to me they ignored several opportunities to recognize the approach required a bit more attention than they gave it.


Oh I have no wish to exonerate the crew. From my humble position it seems clear to me that they screwed up pretty badly as mentioned above, not least leaving it far too late to go-around. However it does now seem that they were not entirely to blame due to various issues at SFO, and it seems to me best that those are understood by all concerned.

[PaxBritannica]

Oh indeed, but it seems to me that over those five months the nature of the construction and the number of lights used and/or their position and/or direction may well have changed, possibly rendering that assumption invalid.

And we do have the evidence of the previous flight who said that on that particular night they had found the construction lights far too bright and as a result had found locating the runway difficult.

I'll freely confess that -- just as you haven't had time to read the newest part of this thread -- I haven't had time to go through the whole docket yet, but according to this recent post, they DID read the NOTAM:

Oh I have no wish to exonerate the crew. From my humble position it seems clear to me that they screwed up pretty badly as mentioned above, not least leaving it far too late to go-around. However it does now seem that they were not entirely to blame due to various issues at SFO, and it's best that those are understood by all concerned.

I'd be interested to know whether any rules were in place about the management of construction lights on 28L. The lighting log attached to the report suggests that normal runway lighting was switched off, so I assume that the construction work was making use of standalone lights. I'm thinking these would be pretty powerful and also fairly directional? When driving a car, it's certainly possible to be blinded by an oncoming vehicle that's briefly in a bad position, so I imagine the same problem could occur with construction lights and moving aircraft? Is it naive of me to assume that construction teams would have been instructed on this and would have rules to follow?

[aterpster]

Oh I have no wish to exonerate the crew. From my humble position it seems clear to me that they screwed up pretty badly as mentioned above, not least leaving it far too late to go-around. However it does now seem that they were not entirely to blame due to various issues at SFO, and it seems to me best that those are understood by all concerned.

That's why the NTSB is treating it as a major accident investigation.

[DaveReidUK]

Given the sometimes very nasty denunciation of pax (perhaps selfish, perhaps panicked) who endanger the lives of others by dallying to get luggage during an emergency evacuation -- a subject dear to the hearts of some pilots on pprune who sometimes suggest prison or lifetime flying bans for those miscreants -- why is the no similar outcry (in the interests of safety) for the pilots who fail to secure the CVR after a screw-up.

There was no statutory requirement for the Air Canada crew to preserve the CVR tape.

[voyageur9]

There was no statutory requirement for the Air Canada crew to preserve the CVR tape.

So excoriating pax for taking luggage and thus endangering lives is because they broke a regulation not because of the safety implications and therefore pilots who aren't bound by a regulation shouldn't worry about preserving CVR for reasons of furthering aviation safety?

[aterpster]

There was no statutory requirement for the Air Canada crew to preserve the CVR tape.

I understand that. But, I am appalled that neither Canada nor Air Canada doesn't have such a requirement.

[Jet Jockey A4]

I understand that. But, I am appalled that neither Canada nor Air Canada doesn't have such a requirement.

Not to defend the pilots involved in this incident but I have to agree with DaveReidUK on this issue...

There are no Canadian rules that stipulate that a CVR or DFDR must be saved after an event like this.

There are no company (Air Canada) rules that stipulate that a CVR or DFDR must be saved after an event like this.

Let us not forget that this was simply a missed approach followed by a normal landing by those two pilots (in their minds) regardless of what we now know to be the truth in how close to a disaster this could have been.

[aterpster]

Let us not forget that this was simply a missed approach followed by a normal landing by those two pilots (in their minds) regardless of what we now know to be the truth in how close to a disaster this could have been.


You need to read the NTSB interview with the tower controller. Here's an excerpt:When ACA759 was about one-tenth of a mile on final, the airplane looked “extremely strange,” regarding its proximity to the aircraft on taxiway C, and the taxiway itself. It was then Mr. Delucchi made the decision to send ACA759 around. There was no indication that ACA759 was in the wrong place until the aircraft was on short final. About that time, he heard a second transmission on the frequency, which he assumed was from one of the three United Airlines pilots holding short of runway 28R on taxiway C, state “he’s lined up on the taxiway.” Mr. Delucchi assumed it was a United Airlines pilot because three of the four aircraft holding short of runway 28R were United Airlines, and one was Philippine Airlines. The pilot making the transmission did not have a foreign accent. After the second transmission, “he’s lined up on the taxiway,” he directed ACA759 to go around, assigned a runway heading, and instructed the pilot to contact NCT. He noted the callsign, type aircraft, and time for documentation purposes and directed ACA759 to contact NCT. He took a minute to relax and then started departing aircraft from runway 28R. ACA759 landed shortly thereafter without incident.

After ACA759 landed, the pilot asked for and was provided the telephone number for the tower’s unrecorded line. Mr. Delucchi was going to give him the number for the tower anyway. The pilot called a bit later and was concerned about the possible seriousness of the go around, and he sounded “shaken up. During the telephone conversation he was primarily attempting to calm the pilot down. They discussed the process of what happened. It was not a lengthy conversation, because he was still working ground traffic. Mr. Delucchi had calmed down between the time of the incident and the phone call with the pilot; he had not realized how close the aircraft had gotten to each other. Mr. Delucchi was slightly more concerned with how the pilot was taking it and did not want to “freak the guy out” since he seemed shaken.
(emphasis added)

[RAT 5]

Let us not forget that this was simply a missed approach followed by a normal landing

Would that also be the case if the GA was due to a microburst GA; or a misjudged/cowboy approach that need up at 500' & 30kts too fast and only half flap; or an attempt to land at the wrong airfield...or...?

Are you saying that all GA's are just normal manoeuvres and the reason has no significance?

About this specific approach I have always been curious what they were using for vertical guidance. PF had gone manual flight some miles out. One would normally do this, especially at night, when one was good confident visual with the landing runway. From photos the only PAPI's were those associated with 28R. One is used to the PAPI's being closely adjacent to the runway and touchdown lights. The PAPI's for the correct 28R were displaced a significant distance from the centreline. If they were following those PAPI's the picture should have looked very iffy from a long way out. Only the crew will know.

[Jet Jockey A4]

You need to read the NTSB interview with the tower controller. Here's an excerpt:
(emphasis added)

First of all ...

The controller told AC to go around after the crew had already initiated the procedure so it is irrelevant. It doesn’t matter how bad the approach was flown or how close they came to other aircrafts on the taxiway in so far as the CVR and DFDR are concerned.

My two points here are not about the Go Around itself but a reply about why some of you think the CVR and DFDR should have been preserved.

#1 - Again, there is no Canadian rule of law or Air Canada directive that state that the CVR and DFDR must be preserved after an incident like this. If there were such directives, to preserve both contents everytime there was a GA, wouldn’t you be grounding the aircraft and perhaps crews at every incident until the CVR and DFDR are read and a report concluded?

#2 - Whether justified or not, I am convinced those two pilots never thought about the CVR and DFDR because in “their minds” they had just accomplished a GA followed by a normal landing even though they might have known it was a close call.

[Smott999]

SLF here - since GA can occur for all sorts of reasons , is it not normal or even required to describe the cause of the GA? As mentioned it could be something outside the crew's control such as weather....in this case it was a mis-alignment resulting in near-miss.
So GA could be fairly benign vs not so.
Is there no reqmt to describe the cause? The docket seems to say AC took this very seriously indeed once they got the details.

[Airbubba]

SLF here - since GA can occur for all sorts of reasons , is it not normal or even required to describe the cause of the GA? As mentioned it could be something outside the crew's control such as weather....in this case it was a mis-alignment resulting in near-miss.

Good question. In years past many carriers would require a report to be submitted to the airline if a go-around was done. As a result, some folks would go to extremes trying to salvage a bad approach in part to avoid some paperwork. Old-timers here on PPRuNe would sometimes brag that they never had to do a go-around not ordered by the tower.

It was realized that the failure to go-around in an attempt to 'get it on the ground' no matter what had caused avoidable accidents. The no-fault go-around became policy whereby no paperwork or explanation was required for the missed approach.

Even if no report is required (I don't know if that is the case at Air Canada), the tower will usually ask the reason for the go-around. 'We didn't meet our stable approach criteria' is normally a good answer. If you say you encountered windshear on final, you'd better make sure you filed the required w/s report. I know all this sounds like CYA but it is the reality of the modern closely monitored cockpit work environment.

Now, about that missing CVR... ;)

As I speculated earlier on this thread:

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

Canada is a little behind the times on CVR legislation by their own admission. The CVR has been added to the shutdown checklist at many places in the U.S. after a rash of 'accidental' failures to pull the CB after an incident.

The tower controller says that the Air Canada captain was shaken up when he called the tower from the gate. The claim that he didn't know that the incident was serious seems unlikely to me.

Anybody from the Great White North know if Air Canada has any guidance in their books about preserving the CVR after a significant event?

[RAT 5]

Again, there is no Canadian rule of law or Air Canada directive that state that the CVR and DFDR must be preserved after an incident like this. If there were such directives, to preserve both contents everytime there was a GA, wouldn’t you be grounding the aircraft and perhaps crews at every incident until the CVR and DFDR are read and a report concluded?

I think you are taking things to extremes, where that was never intended. This incident was akin to a very very near armies. This was not a normal GA. It's a damn good thing they made one, but because it was made so late and during hat we believe to be a period of severe doubt, means it was not a normal GA in the accepted sense of the manoeuvre. They were within a whisker of causing 00's of deaths. The root cause of this could very likely go back to the approach briefing, or lack of, and then into possible disquieting utterances during the approach. All useful information into preventing it happening again. This was close to the most major crash and loss of life in an aviation accident in USA ever. It was not 'just an incident'.

[AerocatS2A]

You are missing the point. Whether or not the crew think to pull the CVR or not depends not one little bit on what the incident was, it only depends on what they perceived the incident to be at the time. If they didn’t perceive it to have been a near disaster they may not have considered pulling the CVR.

Given they had had so little situational awareness during the incident it doesn’t seem like a stretch to me to think that their lack of situational awareness may have continued until well after landing.

[mixer_1979]

It was not a lengthy conversation, because he was still working ground traffic.

Not to fault the controller, but had a second controller been working would the handling controller not feel as rushed leading to a more lengthy conversion and a preserved CVR? Yes, that's a mouthful. Further, and I don't recall reading anything of the like, but did any of the then-waiting aircraft indicate a severity of the incident to the controller prior to AC's post-flight phone call, something that would independently prompt someone that night to think the CVR needed to be preserved?

Despite my feelings, this feels like pie in the sky swiss cheese. We are hoping the holes line up to succeed.

[groundbum]

in this day of super connectivity and tiny high capacity gadgets it seems a bit antiquated to "pull CBs" to preserve something that documents the near loss of 100s of passengers, and could well prevent a similar accident in the future. Suggestion, why not use a secure wifi connection to automatically dump an encrypted 3 hour CVR to a secure airline server when the plane pulls into the gate. Every trip. Can only be examined by accident investigators etc.

G

[RAT 5]

There was a discussion some months ago about FDR/CVR data being transmitted live via satellite and stored on servers back at the home base of operator. This would answer many questions about MH370 and various other accidents. Some said the technology was no problem; it just needed the will to do so.

[aterpster]

in this day of super connectivity and tiny high capacity gadgets it seems a bit antiquated to "pull CBs" to preserve something that documents the near loss of 100s of passengers, and could well prevent a similar accident in the future. Suggestion, why not use a secure wifi connection to automatically dump an encrypted 3 hour CVR to a secure airline server when the plane pulls into the gate. Every trip. Can only be examined by accident investigators etc.

G

You have my vote!

[RAT 5]

Suggestion, why not use a secure wifi connection to automatically dump an encrypted 3 hour CVR to a secure airline server when the plane pulls into the gate. Every trip. Can only be examined by accident investigators etc.

Because accident investigators are usually investigating accidents that never reached the gate.

[Ian W]

There was a discussion some months ago about FDR/CVR data being transmitted live via satellite and stored on servers back at the home base of operator. This would answer many questions about MH370 and various other accidents. Some said the technology was no problem; it just needed the will to do so.
There is now sufficient bandwidth for aircraft to continually stream DFDR and CVR data on connection oriented encrypted links to the destination of the operators choice. These days storage is also no problem either. So we are back to 'is there the will to do so'. There are qualms in some quarters that management will be 'listening in' (as they can currently do with controllers who have permanently open microphones) and that is a reason to prevent not only streaming CVR but also to object to Video recorders in the cockpit. It does seem somewhat antediluvian to have a cadre of experts gathered around a CVR playback trying to make out 'what that sound is' - when streaming video would have shown what happened. If there is concern over misuse then the information could always be held 'in escrow' by a trusted 3rd party and only released on formal written request from AAIB/NTSB/BEA or equivalents. It would certainly have assisted in the search for MH370, indeed it may have prevented it if there was an intent to 'get lost' that would have been thwarted by the aircraft avionics.

[DaveReidUK]

Some said the technology was no problem; it just needed the will to do so.

And others said that the cost of equipping the world's fleets to mitigate against something that happens once in a blue moon would be prohibitive.

[RAT 5]

If there is concern over misuse then the information could always be held 'in escrow' by a trusted 3rd party and only released on formal written request from AAIB/NTSB/BEA or equivalents.

Is that not now the case with OFDM data? FDR/CVR would just be an extension of that. Introducing & applying legal constraints that are contractual should not be beyond the whit of man; unions or not. Video would surely require hugely more bandwidth. That's beyond my knowledge. Should any manager be identified as abusing the system they would not only be fired, but end up in court under heavy financial & penal threat. Are FAA/ EASA/Boeing/Airbus even discussing this? Surely an airline could invest in this on its own and take the initiative. It does not need legislation. ACARS was a customer option and look how many have that. When the airlines e.g. Qantas who could see just what their A380 was doing when its engine blew up, decided to invest in that technology you wonder why they don't go further and include FDR/CVR. Mind you that would need cooperation of the manufacturer. But surely the technology to achieve this would be simplistic compared to FBW and all the transmitted systems data, and the manufacturers invested zquillions in that.

[pattern_is_full]

That's been the argument throughout aviation history - right up until there is a big body count, and then "tombstone engineering" figures out that, oh - yes - well, maybe it wasn't as prohibitive as we thought. ;)

"Radar coverage over the entire US??!! That's prohibitive!" "CVRs/FDRs on all commercial airliners??!! That's prohibitive!" etc.

[BluSdUp]

Interesting .
Some of you want us to be continuously filmed and taped just because a AirCanada crew did not go to SpecSaver.
You have to be joking.
Donate a GPS to AirCanada, that is money better spent!

The day there is a camera in my flight-deck is the the day I resign!

[evansb]

I am post #111_ on this incident. We all pretty well know what happened. The pilots were qualified on type, high-time hours wise, had flown to KSFO before, and had a varied experience operating in and out of airports globally.

Clearly a new debate on a different topic has evolved, Nothing new is being added on the topic of this thread. Enough already. Perhaps a new thread about mandatory installation of cameras in the cockpit and on the nose cone of airliners? No more visual approaches to complex high traffic airliner-only airports? A mere suggestion.

BluSdUp : Many jobs now have cameras monitoring full-time what the employee does. Recently in Canada, a heavy-haul (semi) truck (articulated lorry) allegedly blew through a STOP sign, colliding with a chartered motor coach (bus), killing 16 people, mostly youths. Proof is lacking. No video evidence. Should interior security video cameras and forward facing security video cameras be mandatory on all heavy (10-tonne) trucks and commercial buses (motor coaches)? Remember that even routine telephone calls of an air traffic control staffer are recorded and retained for at least one month unless otherwise specified. It has been such for decades.

The driver's compartment (cab) of many school buses are required to be video recorded. Not audio. No forward facing (dash cam) is presently required in most states/provinces.

Do you want the cameras on school bus drivers removed?

Bank tellers have continuous camera on them.

Is the job of an airline pilot less critical to public safety than a school bus driver?

Do you want the cameras on bank tellers removed?

What about cameras on police officers and their patrol cars?

Perhaps these are topics of a new thread.

[BluSdUp]

Evansb
Read George Orwells 1984.
We are heading for a police state. Indeed another thread.

Back to the Incident:
How this is possible is incredible. And NO, it cant happen to anyone,
Tune and fly the ILS inside 4 miles,at night.
And AirCanada sounds like they need a reality check and need to review their whole operation!

[DingerX]

Look, I think it's fair to say that there are very few people who would be opposed to cockpit video being provided to accident investigations that do not apportion blame and cannot be cited in a court civil or criminal.

But what if those videos of the last terrifying minutes got made public?
What if they were used by court systems in populous countries as evidence in criminal proceedings to railroad foreign pilots?
What if they were cited in tort cases for massive civil awards?
What if the airline used them to bolster a league table of pro-airline actors on the flight deck, giving bonuses to the most management friendly?

These things (at least the first three) have already happened with CVRs. So, would it help here to be useful enough?

FWIW, one of the AC mgmt types said that, in a go around from a taxi, they would expect an immediate report and to pull the FDR/CVR.

[evansb]

I'll say it again,.. Do you want the school bus driver video monitor removed?

Would a simple video camera aid in the investigation of the recent tragic Canadian truck/bus collision? Certainly. As the crash site is in a somewhat remote location, a vehicle mounted camera is better than a government funded and maintained land-based camera. Make the commercial vehicle camera requirement a tax deduction.

I don't want government surveillance of my backyard BBQ. Who does?

Note that traumatic crash evidence doesn't have to made public, if only to a jury/public court. Jurisprudence applies. Some court evidence is never made open to the media. State sponsored executions don't have to made public.

I will vehemently ( ve·he·ment·ly
ˈvēəməntlē/
adverb
in a forceful, passionate, or intense manner; with great feeling.)
state that I don't want government surveillance of my backyard patio nor my front drive way. I will provide my own security devices, thank you. If I picnic in a public park? Go ahead, video away. Just notify me in advance that my actions are being monitored. Otherwise, I just don't care. I do care that Google (or other agencies, such as Big Government) already tracks (and monitors conversations and text messages on a coded basis) my mobile phone locale even when the phone is turned off! My private phone is NOT the same as vehicle license plates for private automobiles operated on public spaces.. I do NOT want locale history, nor do I knowingly pay for this type of surveillance. Who does? But when a cop pulls me over? Sure, I would like video and audio history.

Is it just me?

Will most airlines video and audio monitor the cabin in the future? You are probably right..

Curiously in post-totalitarianism Russia, nearly every car has a dash cam, although it is not required by the State.. Nearly all dash cams being purchased privately.

[West Coast]

Not to fault the controller, but had a second controller been working would the handling controller not feel as rushed leading to a more lengthy conversion and a preserved CVR?

Are inferring that the controller would have discussed preserving the CVR data?

If so, you’re confused as to the role/scope of a controller’s job.

[xetroV]

The AC crew were the only ones to get "confused" that night, it was severe clear weather.

No, they were not, as evidenced by the statement by the captain of the preceding Delta flight:

There was a lot of traffic that night and we were vectored off the DYAMD3 arrival and flew past the SFO
airport, then given a 180 degree turn to the East, then a turn near TRDOW to intercept the FMS Bridge Visual
28R. The weather was VFR and RWY 28L was under construction and NOTAM’d closed. Aircraft were lined up on
taxiway C for takeoff and this caused me to question if I was lining up on the correct runway.

The last time I had flown the bridge visual was several months prior and it was in the daytime. I
could see what I thought were two sets of parallel runway lights. Aircraft on taxiway C were stopped and had
their taxi lights off which helped to create this miss conception that taxiway C was RWY 28R. Had the runway
sequenced flashing lights been on it would have defined the landing runway or had we flown the ILS we would
have had precision course guidance which would have eliminated the illusion that we were not lined up on 28R.

Because we were flying a visual approach and not a precision approach, this also caused me to question
if I was lined up on 28R. We confirmed that we were lined up with 28R,cross checking it with the LNAV on final.
I was preparing to go-around if I could not confirm which runway I was landing on. It was confirmed
prior to crossing the threshold when I saw 28R painted on the runway.

And the First Officer of the Delta flight:
Once we turned on final, there was some confusion. We were lined up on a runway, to the left was an obvious
construction site and to the right was what appeared to be a taxiway. However, the lighting was different and I
did not know until after landing that was because there were aircraft lined up on it waiting to takeoff.


As noted earlier in this thread:
It is interesting that the previous landing also questioned to themselves if they were lined up on the correct runway stating that the construction lights were very bright and made it impossible to see the closed runway, also that the lack of lights on the jets on the taxiway contributed to their confusion. Of course they sorted things out fine, but it certainly suggests that the visual environment was not good.
I think this will be a very important observation for the final NTSB report.

[RAT 5]

Because we were flying a visual approach and not a precision approach, this also caused me to question
if I was lined up on 28R. We confirmed that we were lined up with 28R,cross checking it with the LNAV on final.

I'm surprised by this. From what has been reported it would seem AC & Delta were flying a visual, slightly offset, at night to a runway which had an ILS transmitting, yet neither had the ILS tuned. Why would anyone not avail themselves of all the help they could, especially under these conditions? It's a combination of airmanship & SOP's. In my EU airlines it was SOP to tune all aids even if a visual was expected. Why would you not do so? You may not be flying down the ILS for the whole of finals, but you will for sure end up 'in the slot' below 1000'. Every little helps.

[Derfred]

Do any airlines have SOP's to turn off taxi lights if pointing towards landing aircraft?

My airline doesn't, but most pilots turn them off anyway.

Interesting that this common practice may have been one of the holes in the swiss cheese.

[Capn Bloggs]

Aterpster, I think I read somewhere that they didn't have GPS. Is the Airbus non-GPS RNAV system so accurate that it would be "perfectly aligned"? Further, I doubt their SOP would have allowed autoflight, in LNAV, down to 100ft, especially at night.

[RAT 5]

Aterpster, I think I read somewhere that they didn't have GPS. Is the Airbus non-GPS RNAV system so accurate that it would be "perfectly aligned"? Further, I doubt their SOP would have allowed autoflight, in LNAV, down to 100ft, especially at night.

Again, only the crew will know: PF went manual flight some nm's out from touchdown. There has been discussion that they programmed the FMC for a 'Bridge visual approach' (I think). Going manual would they leave the FD's ON. If so they would be linked to the FMC. So when they lined up with the taxiway the lateral mode FD might/should have been showing a strong 'fly left'. Equally the magenta line would have been off to the left. And my earlier comments about the PAPI's for 28R being well off to the left is still valid. It would seem there were lots of clues. Curious. I can't believe 2 pilots would fly an approach from 3-4nm without some scan inside. Perhaps AB operators of this older model can help here.

[BluSdUp]

We used to do IRS alignment on all turnarrounds in my company, now we do not.
I always check for drift as I regularly fly 3 to 6 hrs legs: the drift is always great and in the range of 1\4 to 1 mile, so , dependent on DME DME triagulation update that Airbus did NOT have an accurate LNAV position after 4 to 5 hrs flt from Toronto!
The ILS drift ,on the other hand, is generally less then 1/10 degree per YEAR if I remember correctly from my Calibration Flights.

Oh, and they killed the FD when the Cpt disconnected , ca 4 miles.
Again I fly the odd visual, but generally with full automation to assure no OFDM trigger.
Come to think of it the last one was to CPH and the A/C two places ahead of me made a G/A from a botched visual?
If one wants to practice manual visual, providing the Company SOP let You, a busy International airport at night , at 03:00 BodyClock is not smart. As proven here.
Regardless WTF the clearance was!!!
Is this so hard to understand!

[sprite1]

RAT 5

We go F/D’s Off when going manual (All Airbus operator, Airbus SOP’s) and select the Bird on. They would have had no instrument back-up at that stage. As in, they’re visual and positioning the aircraft in accordance with what they see outside, not by what some lateral bar or needle is saying on the PFD.

The F/D’s would’ve come back on automatically when TOGA selected.

I’d be more interested to hear of their previous months roster, time asleep the previous 24hrs, etc. I think that is more applicable here in this incident.

That video is just, wow. So close to the second tail.

[aterpster]

Aterpster, I think I read somewhere that they didn't have GPS. Is the Airbus non-GPS RNAV system so accurate that it would be "perfectly aligned"? Further, I doubt their SOP would have allowed autoflight, in LNAV, down to 100ft, especially at night.They didn't have GPS. When the lead carrier flight inspected the procedure before it was approved, they did it with and without GPS. The DME/DME environment on the entire approach was very good.

So, yes, a D/D/I airplane should be in as good as shape as a GPS/I airplane. 100 feet was to make a point. The rollout on final is at F101D at 1,200 msl. 3.5 miles from the AER. And, keep in mind this procedure is approved for IMC to as low as 1,000 and 3 with or without GPS provided: SFO Ceiling 1000' - VIS 3 With VIS 5 in Eastern Quadrant (030^ Clockwise 120^) and San Mateo AWOS Ceiling 2400' - VIS 5 [San Mateo AWOS info available from SFO Tower. If San Mateo AWOS inop, use San Carlos (KSQL) ceiling of 2400'-VIS 5; San Carlos ATIS on 125.9]

[CaptOveur]

If you'd indulge an SLF, I'm wondering about this: The ALSF-2 was on at the time of the event according to the air traffic controller on duty except for the strobe in the white centerline bar lightsHad the runway sequenced flashing lights been on it would have defined the landing runway
From a cursory look on YouTube, it seems that some places have them on in CAVOK, and others (including KSFO's 28R) don't. Are there standard criteria dictating their use?

[aterpster]

NTSB to hold board meeting to determine probable cause of the Air Canada 759 near disaster:

https://www.ntsb.gov/news/press-releases/Pages/NR20180831.aspx

[underfire]

A charter jet missed four taxiing airplanes by as little as 200 feet after it mistakenly lined up with a taxiway instead of the nearby runway, the National Transportation Safety Board (https://www.bloomberg.com/quote/0229241Z:US) said Thursday.

The Aug. 10 incident at Philadelphia International Airport (https://www.bloomberg.com/quote/1066718D:US) is one of at least four similar cases since July 7, 2017, when an Air Canada (https://www.bloomberg.com/quote/AC:CN) plane missed four others on the ground in San Francisco by only a few feet. Collisions between airliners on the ground have been among the most deadly kinds of aviation accidents.

A Gulfstream IV charter jet operated by Pegasus Elite Aviation was cleared to land on runway 35, but instead pilots aimed for a parallel stretch of pavement just to the left, the NTSB said in a preliminary report (https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20180813X11107&AKey=1&RType=Prelim&IType=IA). The pilot aborted the landing and started climbing about 1/10 of a mile before the runway. It flew just 200 feet (61 meters) above an Embraer SA (https://www.bloomberg.com/quote/ERJ:US) regional jet and then passed above the three other planes, NTSB said.

In a 2017 incident (https://www.bloomberg.com/news/articles/2017-08-02/air-canada-plane-averted-san-francisco-collision-by-just-feet), an Air Canada (https://www.bloomberg.com/quote/AC:CN) plane tried to land on a taxiway at San Francisco International Airport. The plane came within 59 feet (18 meters) of the ground and the first plane it passed over has a tail that is 56 feet high, according to NTSB and aircraft manufacturer data.

NTSB is holding a meeting on Sept. 25 to conclude the cause of the San Francisco incident.

The agency is also investigating an incident on Dec. 29 in which a Horizon Air flight landed on a taxiway in Pullman, Washington. No one was injured. Horizon is owned by Alaska Air Group Inc. (https://www.bloomberg.com/quote/ALK:US)

A Delta Air Lines Inc. (https://www.bloomberg.com/quote/DAL:US) plane also lined up with a taxiway instead of the runway in Atlanta on Nov. 29, according to the NTSB. It came within 60 feet (18 meters) of the ground before climbing.




https://www.bloomberg.com/news/articles/2018-09-06/charter-nearly-hit-four-taxiing-jets-at-philadelphia-airport?utm_source=yahoo&utm_medium=bd&utm_campaign=headline&cmpId=yhoo.headline&yptr=yahoo

[Airbubba]

Some excerpts from a synopsis of the NTSB's final report published at a hearing today, subject to editing.

Probable Cause

The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information.


Executive Summary

On July 7, 2017, about 2356 Pacific daylight time (PDT), Air Canada flight 759, an Airbus A320-211, Canadian registration C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), San Francisco, California, but instead lined up with parallel taxiway C.1 Four air carrier airplanes (a Boeing 787, an Airbus A340, another Boeing 787, and a Boeing 737) were on taxiway C awaiting clearance to take off from runway 28R. The incident airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before starting to climb. None of the 5 flight crewmembers and 135 passengers aboard the incident airplane were injured, and the incident airplane was not damaged. The incident flight was operated by Air Canada under Title 14 Code of Federal Regulations (CFR) Part 129 as an international scheduled passenger flight from Toronto/Lester B. Pearson International Airport, Toronto, Canada. An instrument flight rules flight plan had been filed. Night visual meteorological conditions prevailed at the time of the incident.

The flight crewmembers had recent experience flying into SFO at night and were likely expecting SFO to be in its usual configuration; however, on the night of the incident, SFO parallel runway 28L was scheduled to be closed at 2300. The flight crew had opportunities before beginning the approach to learn about the runway 28L closure. The first opportunity occurred before the flight when the crewmembers received the flight release, which included a notice to airmen (NOTAM) about the runway 28L closure. However, the first officer stated that he could not recall reviewing the specific NOTAM that addressed the runway closure. The captain stated that he saw the runway closure information, but his actions (as the pilot flying) in aligning the airplane with taxiway C instead of runway 28R demonstrated that he did not recall that information when it was needed. The second opportunity occurred in flight when the crewmembers reviewed automatic terminal information system (ATIS) information Quebec (via the airplane’s aircraft communication addressing and reporting system [ACARS]), which also included NOTAM information about the runway 28L closure. Both crewmembers recalled reviewing ATIS information Quebec but could not recall reviewing the specific NOTAM that described the runway closure.

The procedures for the approach to runway 28R required the first officer (as the pilot monitoring) to manually tune the instrument landing system (ILS) frequency for runway 28R, which would provide backup lateral guidance (via the localizer) during the approach to supplement the visual approach procedures. However, when the first officer set up the approach, he missed the step to manually tune the ILS frequency. The captain was required to review and verify all programming by the first officer but did not notice that the ILS frequency had not been entered.

The captain stated that, as the airplane approached the airport, he thought that he saw runway lights for runway 28L and thus believed that runway 28R was runway 28L and that taxiway C was runway 28R. At that time, the first officer was focusing inside the cockpit because he was programming the missed approach altitude and heading (in case a missed approach was necessary) and was setting (per the captain’s instruction) the runway heading, which reduced his opportunity to effectively monitor the approach. The captain asked the first officer to contact the controller to confirm that the runway was clear, at which time the first officer looked up. By that point, the airplane was lined up with taxiway C, but the first officer presumed that the airplane was aligned with runway 28R due, in part, to his expectation that the captain would align the airplane with the intended landing runway.

The controller confirmed that runway 28R was clear, but the flight crewmembers were unable to reconcile their confusion about the perceived lights on the runway (which were lights from airplanes on taxiway C) with the controller’s assurance that the runway was clear. Neither flight crewmember recognized that the airplane was not aligned with the intended landing runway until the airplane was over the airport surface, at which time the flight crew initiated a low-altitude go-around. According to the captain, the first officer called for a go-around at the same time as the captain initiated the maneuver, thereby preventing a collision between the incident airplane and one or more airplanes on the taxiway. However, at that point, safety margins were severely reduced given the incident airplane’s proximity to the ground before the airplane began climbing and the minimal distance between the incident airplane and the airplanes on taxiway C.

The flight crewmembers stated, during postincident interviews, that the taxiway C surface resembled a runway. Although multiple cues were available to the flight crew to distinguish runway 28R from taxiway C (such as the green centerline lights and flashing yellow guard lights on the taxiway), sufficient cues also existed to confirm the crew’s expectation that the airplane was aligned with the intended landing runway (such as the general outline of airplane lights—in a straight line—on taxiway C and the presence of runway and approach lights on runway 28R, which would also have been present on runway 28L when open). As a result, once the airplane was aligned with what the flight crewmembers thought was the correct landing surface, they were likely not strongly considering contradictory information. The cues available to the flight crew to indicate that the airplane was aligned with a taxiway did not overcome the crew’s belief, as a result of expectation bias, that the taxiway was the intended landing runway.

The flight crewmembers reported that they started to feel tired just after they navigated through an area of thunderstorms, which radar data indicated was about 2145 (0045 eastern daylight time [EDT]). The incident occurred about 2356, which was 0256 EDT according to the flight crew’s normal body clock time; thus, part of the incident flight occurred during a time when the flight crew would normally have been asleep (according to postincident interviews) and at a time that approximates the start of the human circadian low period described in Air Canada’s fatigue information (in this case, 0300 to 0500 EDT). In addition, at the time of the incident, the captain had been awake for more than 19 hours, and the first officer had been awake for more than 12 hours. Thus, the captain and the first officer were fatigued during the incident flight.

Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident. Although the National Transportation Safety Board (NTSB) identified significant safety issues during our investigation into this incident, CVR information, if it had been available, could have provided direct evidence about the events leading to the overflight and the go-around. For example, several crew actions/inactions during the incident flight demonstrated breakdowns in crew resource management (CRM), including both pilots’ failure to assimilate the runway 28L closure information included in the ATIS information, the first officer’s failure to manually tune the ILS frequency, and the captain’s failure to verify the tuning of the ILS frequency. However, without CVR information, the NTSB could not determine whether distraction, workload, and/or other factors contributed to these failures.

https://www.ntsb.gov/news/events/Documents/DCA17IA148-Abstract.pdf

Pictures from the hearing: https://www.flickr.com/photos/ntsb/sets/72157671654176207/

[rmac2]

https://youtu.be/u59bJZEitRI

Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?

[sleeper]

https://youtu.be/u59bJZEitRI

Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?

Not, according to Murphy.😉

[73qanda]

A lot of pilots are flying around with degraded performance capabilities due to rostering practices now days.
A lot of pilots are reporting same.
Nothing will change until reasonable hard legal limits are put in place to prevent fatigue.
Will Canada take real steps to reduce fatigue?

[infrequentflyer789]

Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?

When you say "every runway", do you mean "every runway" or "every open runway", or perhaps different variations of the two options at different airports, just to keep the pilots awake and alert? :E

[aterpster]

Some excerpts from a synopsis of the NTSB's final report published at a hearing today, subject to editing.

A damning report, on a number of levels.

[Airbubba]

Video of yesterday's NTSB hearing posted here:

National Transportation Safety Board (http://ntsb.capitolconnection.org/#)

[WHBM]

https://youtu.be/u59bJZEitRI

Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?
Doesn't do anything for a crew who think the one on the left, with lots of lighting, is the one closed, and the strip visible on the right is the one to go for. As here.

Similar situation happened at London Gatwick TWICE, one with a based operator, with jets actually landing on the (fortunately vacant) taxyway, before some changes were made to procedures when a runway is advised as closed. I trust the enquiry here has looked closely at those cases. They also put a joggle in the relief taxyway so it looks crooked from the air.

[wonderbusdriver]

A visual approach at night is no laughing matter.
Flying one into SFO due to all the local aural and visual chatter does not make it easier.
And then they were tired and/or became a bit complacent and were then way behind in setting up the airplane (i.e. putting the correct ILS app into the FMS, as soon as the ATIS said so, etc.) and being on the same page as a crew.

It has happened to all of us in one way or the other - the sudden question: "WTF? How did I get here?!"

BUT - they figured out they were wrong and went around - Problem solved.

That - does not happen to all of us.

[Zeffy]

A significant number of new reports were posted yesterday on the NTSB Docket (https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=61112&CurrentPage=1&EndRow=15&StartRow=1&order=1&sort=0&TXTSEARCHT=).

[DaveReidUK]

A significant number of new reports were posted yesterday on the NTSB Docket (https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=61112&CurrentPage=1&EndRow=15&StartRow=1&order=1&sort=0&TXTSEARCHT=).

Includes a 37-page submission from Air Canada: Air Canada Submission to the NTSB in the Investigation of the Overflight of a Taxiway at San Francisco International Airport on July 7, 2017 (https://dms.ntsb.gov/public/61000-61499/61112/618785.pdf)

ACA-determined Probable Cause:

"The Probable Cause of the ACA759 overflight incident was the flight crew’s misperception of SFO Taxiway C as Runway 28R during the approach. Contributing to the incident were: (1) San Francisco International Airport’s inadequate lighting of the runway environment, including lighting of the ongoing construction, to distinguish the normally-configured parallel runways from runway 28R and Taxiway C given the closure of runway 28L; (2) failure of the sole, combined local controller/controller-in-charge (LC/CIC controller) in the KSFO tower to provide any direction or information to the flight crew, following the flight crew’s request, until after the flight crew had already initiated the go-around; and (3) insufficient training and knowledge by the combined LC/CIC controller on use of available lighting resources and ADSE-X/ASSC capabilities."

NTSB-determined Probable Cause:

"The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information."

[Mr Angry from Purley]

A lot of pilots are flying around with degraded performance capabilities due to rostering practices now days.
A lot of pilots are reporting same.
Nothing will change until reasonable hard legal limits are put in place to prevent fatigue.
Will Canada take real steps to reduce fatigue?

Difficult to get a bigger picture unless you see the full roster - for all we know the Crew could have had 4 days off prior.
When you say hard limits please give some idea's i.e. no flying between 02-06LT or what?
IMHV reducing fatigue is a three way process - CAA AOC and crewmembers - what will you do e.g. was the Captain commuting pre flight or are we not allowed to go there?

[DaveReidUK]

Difficult to get a bigger picture unless you see the full roster - for all we know the Crew could have had 4 days off prior.

We do know - and no, they hadn't.

[CYTN]

Wonderbusdriver - Quote

"BUT - they figured out they were wrong and went around - Problem solved." , 🤤🙄🤤

They missed their maker by a baw hair - so hardly problem solved .

They got got more luck than you need to get 6 numbers up on the lottery .

[73qanda]

When you say hard limits please give some idea's i.e. no flying between 02-06LT or what?
Ok, for narrow bodies with no bunk;
Hard legal limits in the regulations, just like truck drivers and taxi drivers have.
Want to operate more than 8 hours stick time? Put a third crew member on.
Want crew to fly between 0200 and 0600? No problem, x hours free of duty prior and x hours free of duty after.
Max 28 hours duty in any 72 hour period.
Max 3 significant circadian shifts per 30 day roster. ( not earlies/ one day off/ lates/ one day off/ earlies etc etc)
Max of one single day off per roster, the rest as doubles etc etc etc
IMHV reducing fatigue is a three way process - CAA AOC and crewmembers
I agree 100% .
was the Captain commuting pre flight or are we not allowed to go there?
We can go there. If you commute and know it means you will have been awake for 19 hours on arrival then you are irresponsible imho. I have no idea if anyone commuted in this case.

[underfire]

ACA-determined Probable Cause:

"The Probable Cause of the ACA759 overflight incident was the flight crew’s misperception of SFO Taxiway C as Runway 28R during the approach. Contributing to the incident were: (1) San Francisco International Airport’s inadequate lighting of the runway environment, including lighting of the ongoing construction, to distinguish the normally-configured parallel runways from runway 28R and Taxiway C given the closure of runway 28L; (2) failure of the sole, combined local controller/controller-in-charge (LC/CIC controller) in the KSFO tower to provide any direction or information to the flight crew, following the flight crew’s request, until after the flight crew had already initiated the go-around; and (3) insufficient training and knowledge by the combined LC/CIC controller on use of available lighting resources and ADSE-X/ASSC capabilities."

WOW....really?

[SeenItAll]

Includes a 37-page submission from Air Canada: Air Canada Submission to the NTSB in the Investigation of the Overflight of a Taxiway at San Francisco International Airport on July 7, 2017 (https://dms.ntsb.gov/public/61000-61499/61112/618785.pdf)

ACA-determined Probable Cause:

"The Probable Cause of the ACA759 overflight incident was the flight crew’s misperception of SFO Taxiway C as Runway 28R during the approach. Contributing to the incident were: (1) San Francisco International Airport’s inadequate lighting of the runway environment, including lighting of the ongoing construction, to distinguish the normally-configured parallel runways from runway 28R and Taxiway C given the closure of runway 28L; (2) failure of the sole, combined local controller/controller-in-charge (LC/CIC controller) in the KSFO tower to provide any direction or information to the flight crew, following the flight crew’s request, until after the flight crew had already initiated the go-around; and (3) insufficient training and knowledge by the combined LC/CIC controller on use of available lighting resources and ADSE-X/ASSC capabilities."

If ACA really believes this, one wonders why they are still choosing to fly into SFO, especially at night. Indeed, of ACA's 26 points of proposed findings of the causes of this incident, 24 of them are attributed to SFO, the FAA and the ATCO, while only 2 of them are levied against ACA.

5.1.14. The ACA759 flight crew were likely affected by some degree of WOCL/Fatigue.
5.1.22. The lack of onboard GPS, HUD or software tools to assist with alignment placed the crew in a position where they would be susceptible to illusions and biases.

Including erasing the CVR, it would appear that safety culture deficiencies are present up to the very top at ACA.

[fdr]

ACA, that is an unfortunate submittal to the NTSB investigation. The runway still had a full set of runway lights and approach lights, and a LLZ, GS etc. The crew presumably had a RWY 28R position on the ND, but of course that may be subject to position errors depending on the status of the MMR/GPS equipment, although the aircraft is presumably fully compliant with ADSB out/in GPS position accuracy. 10 out of 10 for supporting your flight crew, but it is a poor response. Suspect the NTSB will be more supportive of the flight crew and the constraints on human perception that exist.

It is understandable that the crew may have an expectation of the visual cues that differs from reality when the configuration of the runways is changed. The NOTAM itself may assist in ensuring that does not occur, but it is not a direct defence against misperception by the flight crew. The crew would eventually detect the differences in observed features as they approached the assumed runway end, but there are common cues that occur on every approach, and these were perceived late in the sequence, and apparently simultaneously by the Captain and the FO. The error appears to have been perceived earlier by the crew in the aircraft on the taxiway, which is also understandable, they are stationary and at a reasonably low level of cognitive load at that time, just observing a mess developing. Intervention by the flight crew on the ground is fraught with delay and confusion, and at 200FPS, that translates to quite a potential for the aircraft to get close to the taxiway before taking any action.

The controller had a pretty high workload, and appears to have never comprehended what the issue raised by the AC A320 crew really meant; the process of assimilating the A320 info, ascertaining the implications and responding takes time, probably much more than selecting TOGA on the ATS would have done. Even with multiple ATC officers, it is going to be an open question whether the interrogative from the A320 is going to trigger suspicions with the ATC officer that the flight crew have a S.A. error and are heading towards the weeds (and aluminium tubes).

Upgrading EGPWS systems is a possibility, with the improved accuracy of the nav systems that is associated with ADSB, that could give improved cueing to the flight crew of alignment. You get better information from FOREFLIGHT than the ND on the Boeings or Airbus aircraft at this time. The technology certification cycle and cost is close to being a negative to flight safety as much as it ensures safety through compliance.

Notice on the ATIS on the NOTAMS is of limited value, it may provide a cue to the visual aspect expected to be seen, but it is also subject to being lost in the noise of the rest of the operational information.

The AC submission makes the case for continued ground based nav aids to be maintained, which would be nice to have, but is opposite to the trend of progressing towards SBAS approaches. A RNP-AR type approach would have given adequate guidance to the actual runway, at least to the same level of reliability as a LLZ which is subject to its own errors and interferences. ASDE would assist, but it needs to be alerting the ATCCO in such instances, or it is a passive tool only.

Collectively, we as a group have been dealing with KSFO and it's oddities for a long time. While we appreciate the geographic issues that exist for this airport, it is remarkable how many bandaids exist in giving approaches to the airport. As much fun as Quiet Bridge and similar approaches are to fly, I'm not sure that they are collectively in the best interest of the public, they provide expediency but with a substantial increase in complexity of the task the crews face. At what point do the airlines and flight crew call it quits with dealing with simops, dependent parallel non aligned approaches, etc? Operating a cross runway for departure and two non compliant spaced parallel approaches and departures at the same time suggests it's time to get a new airport. This is not the first incident that came close to crews sharing cockpits, and it is unlikely to the the last at this airport. As much as I like Lefty O'Douls, the fare payers probably deserve a better infrastructure, or one that manages the operating tempo with more margin for error.

[Mr Angry from Purley]

Ok, for narrow bodies with no bunk;
Hard legal limits in the regulations, just like truck drivers and taxi drivers have.
Want to operate more than 8 hours stick time? Put a third crew member on.
Want crew to fly between 0200 and 0600? No problem, x hours free of duty prior and x hours free of duty after.
Max 28 hours duty in any 72 hour period.
Max 3 significant circadian shifts per 30 day roster. ( not earlies/ one day off/ lates/ one day off/ earlies etc etc)
Max of one single day off per roster, the rest as doubles etc etc etc

I agree 100% .

We can go there. If you commute and know it means you will have been awake for 19 hours on arrival then you are irresponsible imho. I have no idea if anyone commuted in this case.
https://www.youtube.com/watch?v=F8hCIolZRTU
From around 2 mins on

[73qanda]

Thanks for posting that, I watched five or six minutes.
All three (Regulator, Airline, Individual) appear to be dropping the ball in his story.....Captain as well. If that is anywhere near normal over there then no wonder people are making errors that well rested folk can’t comprhend.
Regulator needs to set hard limits Airline needs to create/enforce commuting rules, Individuals need to live where they are based and if that is too expensive.....quit like that guy did. The wages would rise pretty quick.

[aterpster]

Thanks for posting that, I watched five or six minutes.
All three (Regulator, Airline, Individual) appear to be dropping the ball in his story.....Captain as well. If that is anywhere near normal over there then no wonder people are making errors that well rested folk can’t comprhend.
Regulator needs to set hard limits Airline needs to create/enforce commuting rules, Individuals need to live where they are based and if that is too expensive.....quit like that guy did. The wages would rise pretty quick.
Commuting will not go away. Airlines open and close crew domiciles. Also, family and other personal commitments usually prevent moving.

[evansb]

Canada is presently reviewing the daily maximum hours duty time/flying time rules. Truckers in Canada have better rules than Canadian aircraft pilots. The U.S. flight time rule is more favorable to the pilots.

[73qanda]

Commuting will not go away. Airlines open and close crew domiciles. Also, family and other personal commitments usually prevent moving.
Does it only exist because you can ride the jump seat though?
People don’t normally commute to Airline jobs in the countries I’ve lived and flown in. Maybe 1% tops.

[aterpster]

Does it only exist because you can ride the jump seat though?
People don’t normally commute to Airline jobs in the countries I’ve lived and flown in. Maybe 1% tops.
Jump seating makes it much easier. That came about in the mid-1980s when I was still working. Prior to that, on my airline at least, a commuter had to use his pass. Full airplane meant no ride on that flight.

[wiggy]

Does it only exist because you can ride the jump seat though?

Depends where you are but that’s not really the driver now where I am....at a guess we have rather more than 1% that commute by air, and it certainly isn’t jumpseat access that has caused it (and FWIW due to our regs we pay even for a jumpseat ride, unless it’s a domestic flight), it’s more that fares structures have made it more viable economically.

A basic standby on our own airline possibly costs more than a full fare with the Loco which often serves the same city pair, and a discounted full fare with our own airline can sometimes be only marginally more expensive than the staff standby,possibly jumpseat ticket, on the same flight....so I’d suggest lifestyle choices/base closures/employer changes plus the need for family stability have probably caused many to commute.

[underfire]

People don’t normally commute to Airline jobs in the countries I’ve lived and flown in. Maybe 1% tops.

In the US, it is prevalent, especially on the East Coast. Many commuter flights have a dozen or so crew mixed in with the pax.

[Airbubba]

Jump seating makes it much easier. That came about in the mid-1980s when I was still working. Prior to that, on my airline at least, a commuter had to use his pass. Full airplane meant no ride on that flight.

Back in the 1980's there were jumpseat airlines like Pan Am, TWA and Northwest that would take other carriers' pilots and in some cases dispatchers and mechanics. Other airlines, like United, would only take their own pilots and I believe Delta would not even take their own pilots at one time.

At Pan Am I remember having a Delta pilot on the jumpseat over the pond. The Clipper Skipper asked the Deltoid why they didn't take other airlines' pilots on the jumpseat. 'We don't consider it professional' was the reply.

Over time reciprocal jumpseat agreements spread but as always there is no good deal that a pilot gets that somebody doesn't abuse. Some folks would get must ride positioning tickets issued on another carrier, ride the jumpseat and refund or rewrite the ticket for personal use. And some non-sked cargo outfits would use the jumpseat to position crews for free. Or, so I'm told.

Some carriers were better to me riding free internationally as a jumpseat rider than they were riding on a pass or a full fare positioning ticket it seemed.

9-11 messed up jumpseats, especially internationally, but with many U.S. airline domiciles over half of the pilots still commute more than 100 miles to the base.

The commuting issue was kinda swept under the rug in the last revision of FAR rest rules but it should be part of the discussion in my opinion since some folks really push the envelope. Again, might not be a player in this SFO incident but I submit that it is an element of fatigue in many cases.

[aterpster]

Back in the 1980's there were jumpseat airlines like Pan Am, TWA and Northwest that would take other carriers' pilots and in some cases dispatchers and mechanics. Other airlines, like United, would only take their own pilots and I believe Delta would not even take their own pilots at one time.

I was TWA 1964-90.

We couldn't ride our own jump seat without management authorization until late 1970s. Then, TWA-ALPA got the jump seat for TWA commuters only. Not for me since I lived within the defined local distance of LAX.

Then, in early 1980s, with the retirement of pioneer "black knight" senior VP of Flight Ops, it became wide open. Some of it made me a bit uncomfortable. I never refused but insisted they take a cabin seat unless we were full.

Interestingly, the "black knight" placed controllers ahead of TWA commuters in the late 1970s. Then, the PATCO strike and the controllers went behind TWA commuters and subsequently behind all commuters.

[aterpster]

The commuting issue was kinda swept under the rug in the last revision of FAR rest rules but it should be part of the discussion in my opinion since some folks really push the envelope. Again, might not be a player in this SFO incident but I submit that it is an element of fatigue in many cases.
Indeed, there should be FAR duty and rest rules for commuting.

In 1983 I got bounced to STL for several months. I always went from LAX to STL the day before and rented a hotel room. I was part of a small minority.

[Cropduster]

Neither the Capt. nor the F/O had commuted. The Capt. was on reserve and got called in that day.

[73qanda]

From the Australian Civil Aviation Safety Authority website;
The FAA (2012, p. 359), reference to a 13 hour FDP could result in periods of wakefulness in excess of 16 hours before their FDP resulting in a human performance similar to that of an individual over the legal limit for alcohol consumption.
• In their study quantifying the performance impairment associated with fatigue Lamond and Dawson (1999) identified that being awake for approximately 17 hours has a similar impairment on many aspects of performance as having a Blood Alcohol Concentration (BAC) of 0.05%. Being awake for approximately 21 hours has a performance impairment equivalent to 0.10% BAC.
We need to be aware of how long we will have been awake for when our duty ends.

[PJ2]

Canada is presently reviewing the daily maximum hours duty time/flying time rules. Truckers in Canada have better rules than Canadian aircraft pilots. The U.S. flight time rule is more favorable to the pilots.

Well, Canada has been "presently reviewing the daily maximum hours duty time/flying time rules" for at least 45 years that I know of, and they are nowhere near any conclusions.

Why this is so should be a matter of an independant, objective examination say, of a Royal Commission like the Moshansky Commission way back in '89. so Canadians can know why their Ministry of Transport has succeeded in avoiding addressing this scientifically-established issue for so long.

Virgil P Moshansky; Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario (Canada) (https://www.worldcat.org/title/final-report/oclc/25552864)

and another: Moshansky comments to the Transport, Infrastructure and Communities Committee, February 2007 (https://openparliament.ca/committees/transport/39-1/39/virgil-p-moshansky-1/only/)

It appears that no matter what happens, Canada is not serious about fatigue issues.

PJ2

[AerocatS2A]

It is easy to tackle safety issues like CFIT, mid air collisions, loss of control, and so on. They typically have a fairly obvious cause and affect. Fatigue is a bit more nebulous. It is often a contributing factor but rarely, if ever, a sole cause of an accident. It can therefore be shuffled down the priority list when it invariably turns out that fixing fatigue issues is commercially inconvenient. There is also the fact that a pilot must not present to work in an unfit state. Whenever fatigue rears it’s head the authorities can always just say that the pilot was at fault for not getting adequate rest or standing themselves down.

[grizzled]

As PJ2 rightly suggests, Transport Canada has not addressed the issue of fatigue in any serious way. I would add that this is just one manifestation of a much larger -- and very serious -- issue of civil aviation oversight in Canada. Put succinctly, Transport Canada is no longer funded, or even structured, in a way that ensures adequate safety levels and regulatory oversight in Canada. I`ll go even further and assert that Transport Canada is no longer meeting its mandate and obligations, under Canadian statutes and under its ICAO obligations.

There are many reasons but the two primary underlying causes are:

1. Resources. TC has been in a `death spiral` for many years. Example: Serious underfunding has led to too few inspectors to meet TC`s own schedule of surveillance. The added workload on those on that front line has led in turn to morale being lower than the Mariana Trench, which has led to further resignations and early retirements, which has led to even higher workload, which has led to TC reducing and even eliminating its mandated surveillance activities. And on and on and on.

So, given that TC does not have the resources to meet its primary role and first responsibility, what do you think it`s doing about addressing issues like fatigue – and the multitude of other serious safety issues and concerns raised by CTSB, users, service providers, unions, ICAO, the public, etc.? Nada…

2. Structure. Transport Canada is NOT an independent, autonomous Civil Aviation Authority, as recommended (strongly) by ICAO, and as most countries have. TC is simply another department of the (Canadian) federal government. A few of TC’s areas of responsibility include: civil aviation, motor vehicles, railways, shipping and marine transportation, etc. As ICAO rightly asserts – and the experience of many countries attests – without an independent autonomous CAA, aviation safety issues are just another budget item for another branch of another department of a huge federal bureaucracy.

Canada’s international reputation as a model of civil aviation safety is based on a philosophy, a structure, a commitment and an entity that existed in Canada in the late 20th century. That is all gone. Transport Canada’s logo should be the setting sun (an Avro Arrow disappearing into the sunset would be a nice touch…)

[fdr]

A thorough briefing where both pilots pay attention to detail in order to emphasize correct and critical focal points is the primary tool/measure used by a crew to prevent blowing-it, minimize unworthy distractions, or being suckered in by illusion. Doing so purposely creates for the crew their own set of preconceived notion as to what the correct picture the approach and landing should look like. A proper briefing uses current, published information and NOTAMs, discusses what's to follow, and sets expectations/limits. It discusses what aids will be used to shoot the approach, what to expect and look for, what is to be confirmed, and limits set to wave themselves off the approach if they aren't met. SOPs are written so crews cover many of these things by following them....



Obviously, they didn't align themselves correctly when they transitioned. But how were they supposed to pick the correct string of lights way out there in the distance?

Well, 28R has charted, visual lighting aids specifically designed and calibrated for that purpose; ALSF-II and PAPI. They're both designed to be seen from miles away for use by a crew to 1) visually align themselves with the centerline of the runway (ALSF-II) and 2) visually join the correct vertical path that within a given distance ensures obstacle clearance down to near the Touchdown Zone (PAPI).

Given the existence of an ALSF-II and PAPI for 28R, let's start by throwing out the notion held by many that a visual approach at night to 28R is unreasonable or unsafe if it's based on the idea there's no ground-based guidance to use or back oneself up with if bog-s***t FMS equipment doesn't allow that back up to be an electronic ILS. ALSF-II and PAPI are ground-based guidance aids for 28R. Their existence should be noted, looked-for out the windscreen, and used for their intended purpose.

Even in a briefing for an Instrument approach, the type of ALS is noted and visual sighting while on the approach itself prompts a callout. Just because this was an FMS approach to a long visual segment doesn't negate the need for reviewing and emphasizing the ALS for 28R. The fact it's a visual approach segment doesn't negate the need for the crew to verbally confirm when these visual guidance aids are acquired visually. On the contrary, the fact that the FMS portion of the approach doesn't align the aircraft with the centerline should only raise awareness and emphasize the visual aids' existence and the need to notice/confirm them. Again, it's what they are for; visually acquiring and guiding oneself to the runway.

However, everything so far about the flight in question (ground track, altitudes, ,transmission) suggests the crew was oblivious to the existence of an ALSF-II and PAPI on 28R because, as it happened, they visually acquired, lined-up on, and overflew Taxiway C which has neither. As someone asked before, with the nearest PAPI being on the opposite side of RWY 28R from their position, what was this crew using for vertical path guidance for miles during the visual segment until reaching Taxiway C?

Also, in addition to RWY 28L's closure being NOTAMed, 28L's approach light system, a MALSR (not an ALSF-II, which is the only ALS they would have seen that night), was also NOTAMed OTS. If the crew mistook Taxiway C for RWY 28R and RWY 28R (with it's operating ALSF-II blazing away to their left) for 28L, this suggests no review of current NOTAMS that could (and did) directly affect their operation and lack of knowledge (or review) regarding Approach Light System configurations.

.


Good points PD.

Briefings are routinely interfered with by the real world, and are not infallible. Having a standardised process is of some value, however, that also fails when there is interruption.
On lighting, I agree on the merit of briefing all of that, to the extent of what type of lighting, PAPI or VASI, is it asymmetric (L or R) etc. The downside is that every brief takes one crew member out of the loop, and the second crew member is in effect being distracted form monitoring by the brief itself. Correlation of brief with programming is a great method, but that works when tactical changes don't occur in close. The 'Bus display logic is annoying in the constraints on LS, compared to a Boeing, where you can track one thing and display another, and have different setups on either side.That has it's own set of issues but it is not a bad way of doing business. HUDs remove the problem in general, however I was involved in investigating a HUD equipped aircraft that landed on a taxiway, so there are always ways of getting hurt. HUD's become problematic in strong crosswind conditions where the lateral viewing angle may not show the track and target information well.

As long as taxiways are parallel to runways, planes will get into strife. The current best tool in my kit is the foreflight moving map, that consistently will give a reliable guide of position vs the runway. The Boeing EFBs were good, but only when you were taxying.

In this day and age, the FMS programming of approaches still leaves lots to be desired; It would be reasonable to have a legs programmed that actually is what you intend to fly, not abbreviated just when things get interesting by the G/A procedure taking it's place. The systems today comprehend a G/A occurs on large jets, by the selection of TOGA, at which point the G/A procedure should be active, but until that point, there is no need for it to be taking precedence over the actual approach to the actual runway that is intended. For aircraft without ATR or GA modes, then a sensed GA could be determined where descent alters to climb for a period of time or a minimum period of time/alt gain.

If we continue to remove ground based nav aids, then the irritations that are inherent on the Airbus LS/FMC data for these types of approaches becomes moot. Again, Boeings have tried and succeeded in landing on the taxiways, so a better solution should be considered to the issue.

[RatherBeFlying]

Let's not forget the Phoenix payroll fiasco where many civil servants are being under- or over-paid.

​If over-paid you can be asked to return the entire amount, but Canada Revenue Agency received a big chunk of that overpayment and it will take a bunch of paperwork, time and effort to get that money out of their claws:sad:

Any other employer would long ago have been taken to a labor tribunal and ordered to pay up pronto.

Is it any surprise that a bunch of Transport Canada staff have departed to other employers:}

[aterpster]

Is it any surprise that a bunch of Transport Canada staff have departed to other employers.

That is just plain scary.

[Zeffy]

Taxiway Overflight Air Canada Flight 759 Airbus A320-211, C-FKCK San Francisco, California July 7, 2017 (https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1801.pdf)

[grizzled]

Taxiway Overflight Air Canada Flight 759 Airbus A320-211, C-FKCK San Francisco, California July 7, 2017 (https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1801.pdf)

Now that's an example of a well written report that resulted from a well-resourced, appropriately focussed investigation. Even the additional Board Member comments at the end are on point and deserving of applause -- and wide distribution. Everybody in safety sensitive positions in civil aviation should read this report.

And I have to add that this level of investigation used to occur in Canada as well, but (sadly for aviation safety) the Canadian TSB is not the agency it once was. If this incident had occurred at Toronto, Montreal or Vancouver the resultant report by the Canadian TSB would have been a short ineffective report after a shallow investigation.

Grizz

[underfire]

Canadian TSB is not the agency it once was. If this incident had occurred at Toronto, Montreal or Vancouver the resultant report by the Canadian TSB would have been a short ineffective report after a shallow investigation.

ahhh, so you read the Air Canada Submission to the National Transportation Safety Board in the Investigation of the Overflight of a Taxiway at San Francisco International Airport on July 7, 2017 NTSB Investigation Number: DCA17IA148

[73qanda]

Both crewmembers recalled reviewing ATIS information Quebec but could not recall reviewing the specific NOTAM that described the runway closure.
sometimes when there is a lot of information on an ATIS I have found myself guilty of not reading every sentence on the ATIS. I think I subconsciously assume that it will be ‘business as usual’ and because my brain is inherently lazy, elect not to read anything I don’t have to. I recognised this in myself a few years ago when my F/O mentioned something about LAHSO and I was unaware that LAHSO was in force. I now try very hard to be disciplined about reading every line but can understand how this occurs in a busy flight deck.
Multiple events in the National Aeronautics and Space Administration’s aviation safety reporting system database showed that this issue has affected other pilots, indicating that all pilots could benefit from the improved display of flight operations information.
The way Notams are presented, and the time allocated to reviewing notams increases the likelyhood of important information becoming lost in the volumes of unimportant information. This is a safety issue globally.

[FlightDetent]

Notams and their presentation to airline crew have a lot to be desired. If the incident is used as a wedge to move into 21 century, an applause would be due. But are we surely not wagging the dog here?

My best judgement is that the crew knew rather well they should be landing on the starboard side the deck, and that's exactly what was almost achieved.

The notams change might be a win, but without shining the light on the real cause, the job of preventing the next occurrence has not even started.

[DaveReidUK]

The notams change might be a win, but without shining the light on the real cause, the job of preventing the next occurrence has not even started.

You don't think there's any value in the 7 Safety Recommendations in the report ?

[bud leon]

The report raises the "need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use" and seems to focus on a more conspicuous X marking, and the ludicrously antiquated NOTAM which goes without saying. It seems the DAL521 FO's recommendation to ATC to "turn on the lights for RWY 28L" would have averted this incident. But that seems to have been overlooked in the report as a strategy. The other thing I don't understand in that respect is the DAL521 captain stated that the sequenced flashing lights were not operating on 28R. The report covers the incidence of runway lighting colouring being mistaken in other incidents, and talks about the possibility of aircraft lighting being mistaken for runway lighting. Despite all that, the report rules out airport lighting as a factor in the incident stating it was compliant with regulations. It seems to me airport lighting is a significant factor in this incident. The report quite rightly talks about expectation and confirmation bias but it seems the lighting aspects have not been given adequate emphasis. It's hard to imagine this incident would have occurred if 28L lights were on and 28R sequenced flashing lights were operating.

[aterpster]

The report raises the "need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use" and seems to focus on a more conspicuous X marking, and the ludicrously antiquated NOTAM which goes without saying. It seems the DAL521 FO's recommendation to ATC to "turn on the lights for RWY 28L" would have averted this incident. But that seems to have been overlooked in the report as a strategy. The other thing I don't understand in that respect is the DAL521 captain stated that the sequenced flashing lights were not operating on 28R. The report covers the incidence of runway lighting colouring being mistaken in other incidents, and talks about the possibility of aircraft lighting being mistaken for runway lighting. Despite all that, the report rules out airport lighting as a factor in the incident stating it was compliant with regulations. It seems to me airport lighting is a significant factor in this incident. The report quite rightly talks about expectation and confirmation bias but it seems the lighting aspects have not been given adequate emphasis. It's hard to imagine this incident would have occurred if 28L lights were on and 28R sequenced flashing lights were operating.

Nonetheless failure to use available lateral guidance is a lot higher on the fault tree than any confusing lighting.

[Ian W]

Nonetheless failure to use available lateral guidance is a lot higher on the fault tree than any confusing lighting.

If all landings were to Cat 3b these incidents would not occur either is this a case where automation is safer than human pilots? While visual approaches are allowed setting up "confusing lighting" would appear to be a fundamental flight safety risk. Expectation of two lit runways led to the right hand runway and the taxiway being assumed to be the runways. Once that expectation is fulfilled it is difficult to correct. There are many antiquated ways of signalling on airports that need some human factors testing and psychological reassessment - or as you allude to, automate out the human error.

[JayMatlock]

How can someone confuse a taxiway lighting with a runway lighting ?
Is there a proper reconstitution of what the pilots saw that night ?

My guess, before reading the report, is that both of them had a busy schedule and were fatigued. Fatigued enough that they forgot how a runway looked like.

[DaveReidUK]

My guess, before reading the report, is that both of them had a busy schedule and were fatigued. Fatigued enough that they forgot how a runway looked like.

Let us know what you think once you have read it.

[bud leon]

Nonetheless failure to use available lateral guidance is a lot higher on the fault tree than any confusing lighting.

I think it's an interesting question which one is higher, but my point is the report wrongly dismisses airport lighting as a factor.

[JayMatlock]

Let us know what you think once you have read it.
The report actually do points out crew fatigue, due to late duty.
The report also describes confusion in the cockpit, with the first officer not even looking at the runway during final approach, and the captain going around just to be sure. Because things did not add up. He did not really understood he was on the taxiway until after the event.

My opinion remains that a runway IS clearly distinguishable from a taxiway at night.

[Carbon Bootprint]

My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
I don't think anyone has disputed your opinion, but the NTSB report clearly states the AC crew did not make that distinction until a bit late into the game.

The NTSB, doing what they do, have made some recommendations on how this all might have been avoided. Hopefully some will be adopted, but the record of NTSB recommendations being put into FAA regulations has not always been stellar.

[jurassicjockey]

Doesn't really look like any of the recommendations from 7 years ago have been implemented, so I don't really anticipate any short term changes.

https://flightsafety.org/asw-article/blue-edge-lights/

[bud leon]

My opinion remains that a runway IS clearly distinguishable from a taxiway at night.

The DAL521 pilots who arrived just prior said they found it visually confusing and could have made the same mistake if they were not using lateral guidance. I think you are missing the well made point in the report on the role of expectation bias and confirmation bias. One important point made in the report is the lights from the planes lined up on the taxiway may have given a false impression of runway lighting. Fortunately there was some kind of pattern recognition process going on in their minds and it was that which resulted in narrowly avoiding what may have become the worst ever aircraft collision.

Your opinion is a bit moot actually because these competent pilots did not clearly distinguish the taxiway from the runway. The visual clues were not strong enough and the poor implementation and existing deficiencies of a number of safety barriers led to the incident.

It's a very informative case of human factors and multiple root causes.

[fdr]

The report actually do points out crew fatigue, due to late duty.
The report also describes confusion in the cockpit, with the first officer not even looking at the runway during final approach, and the captain going around just to be sure. Because things did not add up. He did not really understood he was on the taxiway until after the event.

My opinion remains that a runway IS clearly distinguishable from a taxiway at night.


Jay, congratulations, you would not have done what AC did, and you would not have been confused as the preceding aircraft had as well. Equally, you don't have the risk of making the error that occurs on average every few weeks in the rest of the world, english speaking and otherwise. The AC SOP is great for the QB approach, except that it is a major pain on an aircraft like an Airbus. The crew are asked to fly an approach to protect the tender ears of the dear people that have built properties to the south and east of the airfield, sine the jets have been used there. So the crews are set up to not have the best nav displays for a straight in approach, in fact we end up with converging flight paths with aircraft on an adjacent runway which is well below the standard for lateral separation, and so we are playing dodgems with other aircraft as well, and institute special procedures so that the "Risk" can be managed. Frankly, its about time to tell the world to stuff off on placing pax at risk for noise impact which results in increased risk to the crew and passengers. Globally, development has occurred around the approach paths and departure routes of airports, as the land was cheap, and then the restrictions have been applied.

We nearly ended up with 5 dead aircraft at SFO in this event, which would have added a bit of noise to the issue. About time to change the discussion, and start protecting the crew and pax rights.

[DaveReidUK]

Doesn't really look like any of the recommendations from 7 years ago have been implemented, so I don't really anticipate any short term changes.

https://flightsafety.org/asw-article/blue-edge-lights/

Two of the four Safety Recommendations made by the NTSB following the Hartsfield taxiway landing were adopted by the FAA and classed as acceptable action.

[JayMatlock]

Jay, congratulations, you would not have done what AC did, and you would not have been confused as the preceding aircraft had as well. Equally, you don't have the risk of making the error that occurs on average every few weeks in the rest of the world, english speaking and otherwise. The AC SOP is great for the QB approach, except that it is a major pain on an aircraft like an Airbus. The crew are asked to fly an approach to protect the tender ears of the dear people that have built properties to the south and east of the airfield, sine the jets have been used there. So the crews are set up to not have the best nav displays for a straight in approach, in fact we end up with converging flight paths with aircraft on an adjacent runway which is well below the standard for lateral separation, and so we are playing dodgems with other aircraft as well, and institute special procedures so that the "Risk" can be managed. Frankly, its about time to tell the world to stuff off on placing pax at risk for noise impact which results in increased risk to the crew and passengers. Globally, development has occurred around the approach paths and departure routes of airports, as the land was cheap, and then the restrictions have been applied.

We nearly ended up with 5 dead aircraft at SFO in this event, which would have added a bit of noise to the issue. About time to change the discussion, and start protecting the crew and pax rights.
I would probably make many mistakes if I was in a state of fatigue.

You're going on and on about theoretical concepts but please.. Let me show you the illustration in the report
https://i.gyazo.com/ef35b018638a0d55fa654b1970a499ef.png
To me, the real problem is with runway lighting.
First, many airports, in their penny-wiseness, don't turn on all the available runway lighting.
For instance, I've landed at many international airports where you only had runway edge lights, PAPI, runway entry lights (the green line) and nothing else !
Then you can confuse it with a taxiway, because you can see on the picture it just looks like a green runway, which is confusing.
Second, airports could (and some do) use some ground lighting for taxiways. In Europe, many airfields have blue lighting that is completely invisible from the air.

[73qanda]

JayMatlock
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
Sooooo.......why did they try and land on a taxiway then?
Perception is a funny thing. People ( yourself included) regularly perceive things that aren’t there at all, ie they don’t exist.
What you see and what you perceive are two different things.

JayMatlockTo me, the real problem is with runway lighting.
So a runway isn’t clearly distinguishable from a taxiway at night? I’m confused.

[JayMatlock]

You have to put together all the elements I'm quoting :
- Taxiways should be completely invisible from the air. But at SFO they were very visible.
- A runway with complete lighting (approach lights, papi, touchdown zone lights, centerline) is easily distinguishable from a taxiway (even if lit)
- But airports often wanna save pennies and turn off approach lights, centerline lights, and touchdown zone light
- In these conditions, a runway is only left with papi, edge, and entry lights. And now a runway like this is closer to a lit taxiway.
- The safety margins are now reduced because a lit taxiway resembles a poorly lit runway
- But it still takes fatigue or another aggravating circumstance to mix up a white runway and a green taxiway

Plus there were other cues, visual or instrumental.
The crew should have expected a taxiway to the right of the runways.

[73qanda]

Ok, I think I’m nearly with you.
Would you agree that
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
could more accurately be written as
“My opinion remains that a runway SHOULD BE clearly distinguishable from a taxiway at night.”?

[aterpster]

Plus there were other cues, visual or instrumental.
The crew should have expected a taxiway to the right of the runways.
Spot on, on both counts.

[underfire]

This is about exactly what they saw...(save for the ac lined up) where would you land? Ignore that big white line of things pointing to the runway?
(where would one expect the VASI to be in regards to a runway?)

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/649x302/zkdqqd0_970de02795eae1d679701196c23b4e1b3c3c0a39.jpg

[wiedehopf]

This is about exactly what they saw...(save for the ac lined up) where would you land? Ignore that big white line of things pointing to the runway?
(where would one expect the VASI to be in regards to a runway?)


I guess they should buy another red cross and stick it at the end of the taxiway.

Or just switch off taxiway centerline lights if they can't dim them like the runway lights.

Both of those solutions would be an obvious improvement, if it is the correct approach to solving the problem is another question.

[underfire]

Other drivers had no problem landing. Stop making excuses for unqualified crew. Was this the same crew that failed to respond to ATC instruction to GA because the runway was still occupied

[RatherBeFlying]

Vice Chairman Bruce LandsbergConcurring Statement – Air Canada Taxiway Overflight InvestigationConcurring statements for SFO

This incident report should be required reading for all pilots. Only a few feet of separation prevented this from possibly becoming the worst aviation accident in history. I have some reservations about some of our recommendations where we may have gone farther than necessary in some cases and not far enough in others. Time will tell if we got it right.

Recommendation A-18-24 to the FAA on Preflight Information:
From a human factors perspective, the preflight briefing system is archaic and poorly designed. This Air Canada crew missed two warnings about the closed runway in SFO, first in pre-departure and secondly, via ACARS before landing. Concerns about legal liability rather than operational necessity, drive the current system to list every possible Notice to Airmen (Notam) that could, even under the most unlikely circumstance, affect a flight.

The current system prioritizes protecting the regulatory authorities and airports. It lays an impossibly heavy burden on individual pilots, crews and dispatchers to sort through literally dozens of irrelevant items to find the critical or merely important ones. When one is invariably missed, and a violation or incident occurs, the pilot is blamed for not finding the needle in the haystack!

GPS and TFR notices often fall into the same category of overly complex and geographically irrelevant. The legalistic descriptions of TFRs and poorly-descriptive GPS outage areas are worthless to pilots and dispatchers without tremendous and time-consuming effort. A graphic presentation of where a flight might be restricted or impacted should be easily found on FAA’s website and suffice as an official brief. It should also be disseminated to other preflight or electronic Flight bag providers and be both accurate and timely. FAA should not be allowed to hide behind FSS using this disclaimer which currently appears on the official FAA TFR website. “Depicted TFR data may not be a complete listing. Pilots should not use the information on this website for flight planning purposes. For the latest information, call your local Flight Service Station at 1-800-WX-BRIEF.”

VC Landsberg says 95% of what I was thinking.

My one addition would be to include runway lights will be off with all nighttime runway closure notams.

[underfire]

A graphic presentation of where a flight might be restricted or impacted should be easily found on FAA’s website and suffice as an official brief

Instead of text, you want someone to create a cartoon to follow? Pilots need to go to the FAA website as part of a pre-flight or during flight check?

[Capn Bloggs]

Other drivers had no problem landing.

From the report:

Given that the general outline of airplane lights along taxiway C (in a straight line) had likely confirmed the crew’s expectation that the right-side surface was a runway, the omission of conflicting color cues in the crew’s assessment of the runway environment was consistent with the effects of expectation bias.105 The captain of DAL521 (the flight that immediately preceded the ACA759 into SFO) provided a similar assessment during postincident interviews. Specifically, the DAL521 captain stated that the airplane lights on taxiway C gave the impression that that surface could have been a runway.106

[fdr]

Other drivers had no problem landing. Stop making excuses for unqualified crew. Was this the same crew that failed to respond to ATC instruction to GA because the runway was still occupied

UF, the crew WERE qualified, that's the point. They didn't wake up that morning and decide to have a bad day, they were at the sharp point of the intersection of reality and practices. they probably wont do it again, but they are not the first, and will happen again. DId they make assumptions or have expectations that were different to the real world, absolutely, as almost all accidents outside of UA 232 etc have had.

The QB APPR is less than desirable with the Airbus architecture. Why are we doing them at all?

The AC crew didnt design the lights of the taxiways, nor did they design the airport that places runways too close together.

[wiedehopf]

Other drivers had no problem landing. Stop making excuses for unqualified crew. Was this the same crew that failed to respond to ATC instruction to GA because the runway was still occupied

I'm not making excuses for anyone.
The fact is you will always get a percentage of fatigued and/or distracted and/or incompetent pilots.
You can reduce that percentage by providing regulations. Cutting it to zero will be next to impossible.

The by far easiest improvement to night landings on parallel taxiways is to buy a few more LEDs when lighting the taxiway and putting a red cross at the end.
When something is long and straight some people will think it's a runway. You can't change that. There is a reason for the big TAXI markings on the taxiway pavement in BOSTON.

You could argue that's the cost of doing visual approaches at night, you have to install additional lighting.
I'm not arguing something super expensive to cater for rare events. I'm not even arguing to install such red crosses everywhere.
Just saying it's not that costly and after a warning shot like this incident why not defuse that hopefully rare situation.

Do you think it would not help or introduce other dangers?

[spoon84]

I think that this report shows a very interesting fact. The fatigue and the human error a strongly correlated to the fact that fatigue + human perception are very strong and can led to confuse both pilots. I think that with all the info (NOTAM, ATIS) and also the visual clues, it's was really obvious which was the RWY and which one was the TWY but with the fatigue together with some bias about the airport rwy configuration, led to this almost tragic event.

I am also really surprise about the visual approaches during night, i think it could add another level of difficulty.

We need to really be careful about fatigue, especially in the future where I can see pressure coming to reduce level of cost on crew side, with the increase of fuel price!

[arketip]

Other drivers had no problem landing.

Isn't that always the case in an accident? Everybody before and everybody after do not crash.
Or do you expect hundreds to crash at the same time and place?

[DaveReidUK]

it was really obvious which was the RWY and which one was the TWY

Except that it clearly wasn't, to two people at least.

[msjh]

Anyone with more info or possibly the ATC tapes of an incident in SFO, on Friday July 07, just before midnight local time?
Apparently an Air Canada jet cleared to land on 28R had lined up with the parallel taxiway "C".
There were up to 5 "heavies" full of fuel and pax waiting for T/O on that taxiway.
Unconfirmed reports indicate that the Captain of UA 001, (a 787 bound for SIN) may have said something on the Tower frequency to get the pilot's attention and causing them to go around!
Perhaps averting the most horrific aviation disaster in history!

I'm interested in aviation but only a (lapsed) microlight pilot. So a simple question: why is it not mandatory for lit runways to have a pattern of lights that spells out the runway name that can be seen by landing aircraft? e.g. "28R"

[CurtainTwitcher]

I'm interested in aviation but only a (lapsed) microlight pilot. So a simple question: why is it not mandatory for lit runways to have a pattern of lights that spells out the runway name that can be seen by landing aircraft? e.g. "28R"
You don't always get to see the runway until a few seconds to touchdown. We are doing about 65 to 75 metres per second, and operating in visibilities down to 200m visibility. Not a lot of time to see the runway and confirm everything is where is should be. A picture is worth a thousand words:


Q0BNpgphL7s

Most approaches aren't in conditions like this. However, we have something far better than some new runway identifier, the ILS beam with ident specific to the runway that is good for at least 25nm. In this incident, Airbus doesn't display the ILS for some types of approach by default, extra steps need to be taken, and they weren't. Not mandatory to have it displayed for the approach they were flying, but it would have given additional cues earlier that there was a problem.

[Capn Bloggs]

In this incident, Airbus doesn't display the ILS for some types of approach by default, extra steps need to be taken, and they weren't. Not mandatory to have it displayed for the approach they were flying, but it would have given additional cues earlier that there was a problem.
I'm not sure about that. The centreline is only joined at 3.6nm from the threshold; even if they had had the ILS tuned up, it would have been indicating fly left until then, and could therefore have been disregarded, given it would have been displaying garbage for the approach until the F101D waypoint...

[reubee]

This is about exactly what they saw...(save for the ac lined up) where would you land? Ignore that big white line of things pointing to the runway?
(where would one expect the VASI to be in regards to a runway?)

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/649x302/zkdqqd0_970de02795eae1d679701196c23b4e1b3c3c0a39.jpg

No, that is NOT what they saw. That is what they should've seen.

Unfortunately the report did not make any effort to setup the lights as they were and take a number of photos at varying distance from when the autopilot would've been disconnected showing and comparing the views lined up on 28R and lined up on the taxiway.

[CurtainTwitcher]

I'm not sure about that. The centreline is only joined at 3.6nm from the threshold; even if they had had the ILS tuned up, it would have been indicating fly left until then, and could therefore have been disregarded, given it would have been displaying garbage for the approach until the F101D waypoint...
Agreed that the cue would be late in the game, just another subtle clue earlier rather than having the "oh crap, this isn't looking right" in the last 200'. The did ask the question about being cleared to land, they appear to have doubts about the picture not looking right. Having the ILS up would have instantly resolved the doubt and confirmed they were off the centreline. We get pretty good at looking at lots of pieces of information. When something like a localizer is still pegged full scale when on final, it is hard to miss.

[aterpster]

Agreed that the cue would be late in the game, just another subtle clue earlier rather than having the "oh crap, this isn't looking right" in the last 200'. The did ask the question about being cleared to land, they appear to have doubts about the picture not looking right. Having the ILS up would have instantly resolved the doubt and confirmed they were off the centreline. We get pretty good at looking at lots of pieces of information. When something like a localizer is still pegged full scale when on final, it is hard to miss.I don't know squat about the Bus. Can they display the LNAV/VNAV of the FMS 28R Visual and the 28R LOC and GS at the same time?

[J.O.]

UF, the crew WERE qualified, that's the point. They didn't wake up that morning and decide to have a bad day, they were at the sharp point of the intersection of reality and practices. they probably wont do it again, but they are not the first, and will happen again. DId they make assumptions or have expectations that were different to the real world, absolutely, as almost all accidents outside of UA 232 etc have had.

Underfire believes pilots are meant to be automotons - perfect in every way and completely immune to the vagaries of humanity.

[CurtainTwitcher]

I don't know squat about the Bus. Can they display the LNAV/VNAV of the FMS 28R Visual and the 28R LOC and GS at the same time?
Yes it can. From the Report: Taxiway Overflight Air Canada Flight 759 Airbus A320-211, C-FKCK San Francisco, California July 7, 2017 (https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1801.pdf)https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1284x294/screen_shot_2018_10_16_at_7_04_19_am_42f0c6839d40be32931a8b1 2bb46626d9cac2ea4.png
https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/1446x572/screen_shot_2018_10_16_at_7_03_41_am_94b0e6bbc97aa46d62acaf9 a1acd2b0abdbf907a.png

[WHBM]

This is about exactly what they saw

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/649x302/zkdqqd0_970de02795eae1d679701196c23b4e1b3c3c0a39.jpg
That's not really what they saw, they were lined up on the taxyway as we know; this image is lined up on the runway. Different perspective. Would be good to see it.presumably the X loses its prominence the more to one side of it you are, likewise the approach lighting.

At the risk of repeating myself the parallels with the TWO incidents at Gatwick where there were actual landings on the taxyway are too close to ignore.

- Runways unusually far closer together that most places, as close as taxyway spacing elsewhere.
- Lights turned off on a runway that is closed.
- Random bright construction lights on the closed runway make it look like a ramp area, not a runway.
- Crew see two parallel strips and, regardless of the actual lights displayed, have in their mind that the left hand one is closed and they should be headed for the right hand one.
- ILS not used (the Gatwick northern runway I believe did not have it installed) so a manual night approach.

[Intrance]

That's not really what they saw, they were lined up on the taxyway as we know; this image is lined up on the runway. Different perspective. Would be good to see it.presumably the X loses its prominence the more to one side of it you are, likewise the approach lighting.I have yet to see any approach lighting system that becomes unrecognizable as such outside a ~5 degree or so slice from the threshold. Most unidirectional lights would be very much still visible when lined up on the taxi way at 4nm or 10nm or probably even further out. They'd only be hard to see from very close in or at significantly wider angles, think 45 degrees of centerline. My homebase has some of the hardest to see unidirectional ALS I have encountered, and even that becomes very recognizable once you are within those 45 degrees.

I am not saying no one can make a mistake, or discounting human factors and fatigue, I mean I've made my fair share of ****-ups. But I do think that it requires a significant amount of fatigue or disconnect from situational awareness to miss those approach lights, even being lined up on the taxiway, so slightly to the right. Just discounting the image as "well this isn't exactly what they saw" is a bit silly. If you've been flying into larger airports for a while you should have no problem pulling up a mental image of what it would look like if you transposed yourself a bit to the right.

[msjh]

You don't always get to see the runway until a few seconds to touchdown. We are doing about 65 to 75 metres per second, and operating in visibilities down to 200m visibility. Not a lot of time to see the runway and confirm everything is where is should be. A picture is worth a thousand words:


Q0BNpgphL7s

Most approaches aren't in conditions like this. However, we have something far better than some new runway identifier, the ILS beam with ident specific to the runway that is good for at least 25nm. In this incident, Airbus doesn't display the ILS for some types of approach by default, extra steps need to be taken, and they weren't. Not mandatory to have it displayed for the approach they were flying, but it would have given additional cues earlier that there was a problem.

Well that video just makes me amazed at the technology and pilot skill that too often we civilians take for granted.

[Ian W]

I have yet to see any approach lighting system that becomes unrecognizable as such outside a ~5 degree or so slice from the threshold. Most unidirectional lights would be very much still visible when lined up on the taxi way at 4nm or 10nm or probably even further out. They'd only be hard to see from very close in or at significantly wider angles, think 45 degrees of centerline. My homebase has some of the hardest to see unidirectional ALS I have encountered, and even that becomes very recognizable once you are within those 45 degrees.

I am not saying no one can make a mistake, or discounting human factors and fatigue, I mean I've made my fair share of ****-ups. But I do think that it requires a significant amount of fatigue or disconnect from situational awareness to miss those approach lights, even being lined up on the taxiway, so slightly to the right. Just discounting the image as "well this isn't exactly what they saw" is a bit silly. If you've been flying into larger airports for a while you should have no problem pulling up a mental image of what it would look like if you transposed yourself a bit to the right.

The crew did not 'miss those approach lights' - they assumed that they were the approach lights to 26L and that the taxiway to its right was the runway. This may have been assisted by the taxiway not being empty but having a line of widebodies with their lights on (also not shown in the much overused picture of what the crew did not see). Like all visual illusions once your brain has seen the illusion it is difficult to 'unsee' it. Similarly, as I said a lot earlier in the thread your brain will not see things it does not expect to see. (See the gorrilla illusion (http://illusionoftheyear.com/2010/05/the-monkey-business-illusion/) ) However, once it has been pointed out it is obvious, and like all of the commenters here, the 'illusion' has already been pointed out so commenters like you cannot see the illusion and cannot see how anyone can.

I have had multiple experiences as tower controller when aircraft have made approaches to the wrong runway - it is common as is landing on parallel taxiways. There is one way to guarantee it does not happen again and that is to automate all landings. This is completely feasible but it will mean that pilots lose another skill set.

[73qanda]

This is completely feasible but it will mean that pilots lose another skill set.
I agree it can be done but not any time soon in the 737-800 I fly. There is no way the auto- land could cope with gusty conditions with over 25 kts crosswind. ( maybe other types can?)The odd jet lining up on a taxiway would be the least of our worries.There would have to be a technology change before it happens.

[WHBM]

Like all visual illusions once your brain has seen the illusion it is difficult to 'unsee' it..
This is very true. Take the FedEx logo on the side of their aircraft and everywhere. Most see it initially as five letters. Only when somebody points out that the space between the orange E and the X forms a (deliberate) right pointing arrow do you see this, and thereafter whenever you see the logo it is difficult to not do so. To those who have "seen it" then it is "obvious". Not to others. And once you have seen the lights of the right-hand strip, that is what your brain is going for. Goodness, people have quite regularly lined up on and landed at the wrong nearby airport, let alone taxyway.

https://cimg4.ibsrv.net/gimg/pprune.org-vbulletin/129x40/fx_f8438ea278e38efd22e75f439c4380f1c09f7de0.jpg

[aterpster]

Yes it can. From the Report: Taxiway Overflight Air Canada Flight 759 Airbus A320-211, C-FKCK San Francisco, California July 7, 2017 (https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1801.pdf)https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1284x294/screen_shot_2018_10_16_at_7_04_19_am_42f0c6839d40be32931a8b1 2bb46626d9cac2ea4.png

That statement doesn't say that both the FMS database visual LNAV/VNAV and the ILS LOC and GS can be displayed at the same time. It says lateral guidance via the localizer should supplement visual approach procedures. Are you current on the Air Bus? If so, could you expand on whether this capability exists?

[Derfred]

I have had multiple experiences as tower controller when aircraft have made approaches to the wrong runway - it is common as is landing on parallel taxiways. There is one way to guarantee it does not happen again and that is to automate all landings. This is completely feasible but it will mean that pilots lose another skill set.

Well, there is the solution! You heard it first, here on Prune. It is completely feasible. A tower controller said so. Automate all landings.

[Sailvi767]

If all landings were to Cat 3b these incidents would not occur either is this a case where automation is safer than human pilots? While visual approaches are allowed setting up "confusing lighting" would appear to be a fundamental flight safety risk. Expectation of two lit runways led to the right hand runway and the taxiway being assumed to be the runways. Once that expectation is fulfilled it is difficult to correct. There are many antiquated ways of signalling on airports that need some human factors testing and psychological reassessment - or as you allude to, automate out the human error.

If all landings were Cat3B you would need to vastly reduce the numbers of operations at most if not all airports.

[Sailvi767]

If all landings were to Cat 3b these incidents would not occur either is this a case where automation is safer than human pilots? While visual approaches are allowed setting up "confusing lighting" would appear to be a fundamental flight safety risk. Expectation of two lit runways led to the right hand runway and the taxiway being assumed to be the runways. Once that expectation is fulfilled it is difficult to correct. There are many antiquated ways of signalling on airports that need some human factors testing and psychological reassessment - or as you allude to, automate out the human error.

As I pointed out in another post you would dramatically limit airport operations and many airports have no runways certified for auto lands. The two most dangerous landings I have been involved in were autolands. There is a lot that can go wrong.

[deSitter]

This is very true. Take the FedEx logo on the side of their aircraft and everywhere. Most see it initially as five letters. Only when somebody points out that the space between the orange E and the X forms a (deliberate) right pointing arrow do you see this, and thereafter whenever you see the logo it is difficult to not do so. To those who have "seen it" then it is "obvious". Not to others. And once you have seen the lights of the right-hand strip, that is what your brain is going for. Goodness, people have quite regularly lined up on and landed at the wrong nearby airport, let alone taxyway.

https://cimg4.ibsrv.net/gimg/pprune.org-vbulletin/129x40/fx_f8438ea278e38efd22e75f439c4380f1c09f7de0.jpg

Whatever happened is not an illusion. There is nothing illusory in the scene presented to them - there is nothing latent, nothing hiding. They simply do not see it. The closest incident to this one is Comair at Lexington. "Man that is weird with no lights..." Why would any pilot with more than 3 days' experience at commercial airports in the dark not immediately hit the brakes when he perceives himself to be on a runway with no lights?

It is often said that pilots must be far ahead of the airplane. I think this can be taken too far. The steps have become so routine and the automation so unchanging that the crew seemed to be too far ahead of the plane, maybe tasting the beer already and headed for a well-earned rest. In any case something needs to be done about all this, something binding and something with serious intent.

-drl

[underfire]

Automate all landings.
You can have RNAV or RNAV/RNP visual approaches...next best thing, automation and a visual minima.

That's not really what they saw, they were lined up on the taxyway as we know; this image is lined up on the runway. Different perspective. Would be good to see it.presumably the X loses its prominence the more to one side of it you are, likewise the approach lighting.

Umm, the point is the big white line of lights leading you to the end of the runway?!

The further out, even if on the taxiway, the 'X" and the runway lights should be pretty evident.

Is this better (from the magic of the internet)..

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/867x473/pyubyxc_26cee0300e11fa631cb6d85d57fba0d2f7c25b92.jpg


or this.... would seeing the runway approach lights out the left window be a bit of a clue? (at this point they still didnt even consider GA)

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/451x190/vyt6wnj_30281974f8fb0bec552612805d15e24e40bc9e82.jpg

It says lateral guidance via the localizer should supplement visual approach procedures. Are you current on the Air Bus? If so, could you expand on whether this capability exists?

I know it works for RNP approach when we validate, it is compared with the ILS as backup. Then again, I have not been on a validation exercise with an ac without GPS.

The crew did not 'miss those approach lights' - they assumed that they were the approach lights to 26L and that the taxiway to its right was the runway.

If they had flown into SFO when both were active, or even checked the chart, they would see that the approach lights for L are different than R. Even so, no approach lights?
(and VASI?)

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1920x1080/hguxuyztxzdz_fcf42d85352ac392be59c7cf592ac6324a179cf9.jpg

[Ian W]

If all landings were Cat3B you would need to vastly reduce the numbers of operations at most if not all airports.

You are talking in terms of the obsolescent ILS where there are concerns over multipath effects with aircraft ahead and even on the ground close to the runway. GLS, GBAS and the capabilities such as Established on RNP have no such issues. The retention of ILS is a huge hidden cost for airports. Runway acceptance rate is reduced in IFR operations and the cost of calibration of a single runway ILS exceed the cost of ownership of a GBAS that will provide GLS to every runway end at the airport. ANSPs should issue an NPRM to withdraw ILS by say 2025

[Sailvi767]

You are talking in terms of the obsolescent ILS where there are concerns over multipath effects with aircraft ahead and even on the ground close to the runway. GLS, GBAS and the capabilities such as Established on RNP have no such issues. The retention of ILS is a huge hidden cost for airports. Runway acceptance rate is reduced in IFR operations and the cost of calibration of a single runway ILS exceed the cost of ownership of a GBAS that will provide GLS to every runway end at the airport. ANSPs should issue an NPRM to withdraw ILS by say 2025

There is far more to eliminating ILS approaches than you post. I suspect it will continue to be widely used for the next 20 years. I am not aware of any current airliner certified for a auto land off any approach other than a ILS. Even if the new technology can be retrofitted into existing aircraft there are very serious security considerations that need to be overcome. They are a long way from that.

[bud leon]

My opinion remains that a runway IS clearly distinguishable from a taxiway at night.

The DAL521 pilots who arrived just prior said they found it visually confusing and could have made the same mistake if they were not using lateral guidance. I think you are missing the well made point in the report on the role of expectation bias and confirmation bias. One important point made in the report is the lights from the planes lined up on the taxiway may have given a false impression of runway lighting. Fortunately there was some kind of pattern recognition process going on in their minds and it was that which resulted in narrowly avoiding what may have become the worst ever aircraft collision.

Your opinion is a bit moot actually because these competent pilots did not clearly distinguish the taxiway from the runway. The visual clues were not strong enough and the poor implementation and existing deficiencies of a number of safety barriers led to the incident.

It's a very informative case of human factors and multiple root causes.

[WillowRun 6-3]

July 7 2017 - San Francisco . . . Air Canada 759 very narrowly misses a collision with aircraft awaiting clearance for departure on a taxiway, due to improper alignment on approach.
NTSB report on the incident:
https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1801.pdf

FAA changed some approach procedures, and some modification of fatigue-related regulations occurred by Transport Canada. There also was an FAA Flight Standards Service Safety Alert for Operators (SAFO 17010, Aug. 8, 2017) "Incorrect Airport Surface Approaches and Landings" - with this classic restatement: "The old aviator's adage, 'when in doubt, go-around' still applies."
https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2017/SAFO17010.pdf

Was enough done to address the causes or contributing factors?? - the thread on this forum at the time, three years ago, was pretty extensive . . . I mean (as an SLF with an interest in private and public international air law especially insofar as aviation safety is concerned) if I am recalling properly.