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

787PIC

11th Jul 2017, 01:16

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!

nolimitholdem

11th Jul 2017, 01:40

CHfour

11th Jul 2017, 01:44

FAA investigating after incident at SFO where Air Canada flight nearly landed on taxiway | abc7news.com (http://abc7news.com/travel/air-canada-flight-nearly-lands-on-sfo-taxiway/2203462/)

Airbubba

11th Jul 2017, 02:28

*sigh*

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

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

Well, the Air Canada 759 folks asked why they saw lights on the runway. :eek:

The discussion starts at about 25:40 into this clip:

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

An edited transcript from the news article linked in the previous post:

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

SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."

"Where's this guy going? He's on the taxiway," the other pilot said.

SFO TOWER: "Air Canada, go around."

AC759: "Going around. Air Canada 759."

SFO TOWER: Air Canada looks like you were lined up for Charlie there. Fly heading 280. Climb maintain 3,000."

AC759: "Heading 2-8-0, 3,000 Air Canada 759."

UA001 PILOT: "United One, Air Canada just flew directly over us."

SFO TOWER: "Yeah, I saw that."

Nothing close to a disaster? Breathless nonsense? Well, a little close for me... :eek:

AC 759 was an A320 from YYZ. The other aircraft lined up on C behind UA 1 were PR 115, UA 863 and UA 1118. A lot of beacons.

There was a discussion on the thread about the Air Canada YHZ crash that implied that the AC A320's didn't have updated avionics. Was that a player here? Did they have a map shift that lined up perfectly with the taxiway? Obviously they knew there weren't supposed to be planes on the runway but they sure didn't seem to catch the error in time if they overflew United on the tower called go around.

Usual caveats, we mustn't speculate, a report will be out in a year or two, Harrison Ford will be called as an expert witness etc...

pattern_is_full

11th Jul 2017, 02:33

What breathless nonsense. Breathless - agreed. AC pilots did question their clearance and what they were aiming for.

But...

In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. It has happened before: https://en.wikipedia.org/wiki/USAir_Flight_1493

But at SFO, the runway has a honking big array of approach lights, and the taxiway does not. I'd find it hard to confuse one for the other, even more so at night.

Perhaps a database error? EDIT: I see that idea occured to airbubba, too.

hitchens97

11th Jul 2017, 03:45

Was the ILS out?

jack11111

11th Jul 2017, 03:57

Brings added meaning to the phrase, "see something, say something".

Airbubba

11th Jul 2017, 04:42

From the SFO noise monitoring web page a comparison of the tracks of AC 759 on the go around and a few aircraft that landed in the preceding minutes:

Looks like they indeed nailed the taxiway for the line up. :eek:

Airbubba

11th Jul 2017, 05:28

Hard to figure how this could happen on a visual approach at night...

Exclusive: SFO near miss might have triggered ‘greatest aviation disaster in history’

By Matthias Gafni | [email protected] | Bay Area News Group

PUBLISHED: July 10, 2017 at 3:18 pm | UPDATED: July 10, 2017 at 9:06 pm

SAN FRANCISCO — In what one aviation expert called a near-miss of what could have been the largest aviation disaster ever, an Air Canada pilot on Friday narrowly avoided a tragic mistake: landing on the San Francisco International Airport taxiway instead of the appropriate runway.

Sitting on Taxiway C shortly before midnight were four fully-loaded airplanes full of passengers and gas awaiting permission to take-off, according to the Federal Aviation Administration, which is investigating the “rare” incident. An air traffic controller sent the Air Canada Airbus 320 on a “go-around” — an unusual event where pilots must pull-up and circle around to try again — before landing safely, according to the federal agency.

FAA investigators are still trying to determine how close the Air Canada aircraft came to landing and potentially crashing into the four aircraft below, but the apparent pilot error already has the aviation industry buzzing.

“If it is true, what happened probably came close to the greatest aviation disaster in history,” said retired United Airlines Capt. Ross Aimer, CEO of Aero Consulting Experts. He said he’s been contacted by pilots from across the country about the incident.

“If you could imagine an Airbus colliding with four passenger aircraft wide bodies, full of fuel and passengers, then you can imagine how horrific this could have been,” he said.

Exclusive: Air Canada near-miss at SFO sparks FAA probe (http://www.mercurynews.com/2017/07/10/exclusive-sfo-near-miss-might-have-triggered-greatest-aviation-disaster-in-history/)

DaveReidUK

11th Jul 2017, 07:00

Screenshot from SFO WebTrak. The parallel track is the same aircraft landing after the GA:

http://www.avgen.com/ACA759.jpg

Heights shown on WebTrak systems are usually AAL, corrected for QNH and to the nearest 100', though that may not be the case for SFO.

ironbutt57

11th Jul 2017, 07:14

interesting to know if the approach lights and localizer were functioning

eckhard

11th Jul 2017, 07:45

ORAC

11th Jul 2017, 09:16

ACMS

11th Jul 2017, 10:11

Still, in 2017 this should not happen.

ironbutt57

11th Jul 2017, 10:39

Unless you think they would have thought, "what the hell, lets just land on top of them anyway.

no, but they might have come a lot closer before they realized it...good thing the guys on the taxiway were watching and saw it...yah wonder how much further they would have gone without the comment from the crew on the taxiway

DaveReidUK

11th Jul 2017, 10:41

From the transcript it is obvious the Air Canada crew could see the aircraft where they planned to land - that's why they asked ATC the question about them. From that point there was no danger of collision; even if ATC didn't order the go-round at some point the crew would have. Unless you think they would have thought, "what the hell, lets just land on top of them anyway".

Doubtless true.

But nevertheless satisfies a criterion for a "serious incident" per Annex 13:

"5. Landings or attempted landings on a closed or engaged runway, on a taxiway or unassigned runway"

FIRESYSOK

11th Jul 2017, 10:47

'Twas night? Someone posted an altitude plot that read 200'. How tall are those 787 tails? How low do the undercarriage hang?

atakacs

11th Jul 2017, 11:13

As others I'm pretty sure they would have not landed on top of the waiting aircrafts on the taxiway.

A more sinister scenario would have been for the taxiway to be empty up until the very last moment.

altiplano

11th Jul 2017, 11:41

wiedehopf

11th Jul 2017, 12:10

i'd assume as someone already said lighting for 28L was off and they thought 28R was 28L and TWY C was 28R.

check this youtube video for reference: https://youtu.be/O3LTYeZrzH8?t=218

and here is a youtube video with approach lights for both runways on:
https://www.youtube.com/watch?v=MnzNvhQxu90

to be honest the taxiway lights are quite bright but still ...
can't imagine them landing on the strobes of the other airplanes.
on the other hand if you are sure that this is the runway and the tower says it's clear it's not far from disaster.

Ian W

11th Jul 2017, 12:18

Maybe the ILS and approach lights for 28L were OTS. The AC crew saw the lights for 28R, mistook them for 28L and then approached the illuminated strip (TWY C) to the right of 28R, thinking that was 28R?

Similar thing happened at Gatwick in the late 80s(?). A BIA BAC1-11 actually landed on TWY J instead of RW08L. RW08R was closed but the crew saw the bright approach lights for 08L, assumed they were still on for the closed runway and mistook the dim taxiway lighting for RW08L. There was another aircraft taxiing out for departure at the far end but he/she made a rapid exit when they saw the 1-11 flaring for landing right ahead of them!

The tyre marks were visible on the taxiway for months afterwards.

Almost certainly this was the scenario. A visual approach cleared to land on 28R and ahead are two lit strips the left one must be 28L so the right hand one is 28R got manky lighting on it though... and are those lights work in progress on the runway? Ask tower to confirm cleared for 28R

See this incident at Gatwick :
"(i) Runway 26R was clearly visible throughout the approach but the pilots looked for and selected a pattern of lights to the right of it because they assumed erroneously that 26R was in fact 26L and they knew that the designated runway had to be to the right of this. "

https://aviation-safety.net/wikibase/wiki.php?id=147090

It seems that there is a recurrent human factors problem when a clearance is to parallel runways the crew will attempt to identify both (all) runways and therefore which one to land on. If the airport for whatever reason has lights off or dimmed on the other runway but visible brighter lighting on the parallel taxiway then crews who do not fly regularly to that airport may become confused.
Unfortunately, this has become more apparent with LED lighting where blue and green lights can appear white at a distance at high brilliance. (As in the case of a Delta 767 at ATL).

It is easy to dismiss these errors as inattention or stupidity but faced with what is effectively an optical illusion many crews have made mistakes. It is still happening so perhaps more needs to be done. From a report 10 years ago:

"As of August 23, 2007, 267 such events have occurred at 110 airports in the United States."
From: http://www.airtech.tc.faa.gov/safety/downloads/TN07-54.pdf
DOT/FAA/AR-TN07/54
IDENTIFICATION TECHNIQUES TO REDUCE CONFUSION BETWEEN TAXIWAYS AND ADJACENT RUNWAYS

MATELO

11th Jul 2017, 12:45

I can't imagine they were going to land on an aircraft. Again it's obvious where the runway is there. They were probably just not all the way over to the left yet and the go around was initiated with an abundance of caution.

Nope, they confirmed it..

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

dave.rooney

11th Jul 2017, 13:02

Nothing close to a disaster? Breathless nonsense? Well, a little close for me...

On my first solo there was a runway incursion while I was on short final. I saw it, queried my landing clearance with the tower (I was indeed cleared), and decided to go around. I'm betting that, even if the tower didn't issue a go-around order, the pilots who have a little more than my 12-14 dual hours at the time would have decided to do the same.

Granted an A320 moves a little faster than the Katana I was in. :)

JumpJumpJump

11th Jul 2017, 14:33

Do we know what height the GA was initiated at?

DaveReidUK

11th Jul 2017, 14:37

Wider view showing where the ACA intercepted the taxiway extended centreline:

http://www.avgen.com/ACA759(2).jpg

San Mateo bridge in bottom RH corner.

fleigle

11th Jul 2017, 14:48

Seems obvious that they were flying the visual and got confused, but queried and all ended well.
Last flight of the day, how many legs had they done that day?
Phew !

Airbubba

11th Jul 2017, 15:12

Here is an edited clip of the tower audio:

https://soundcloud.com/user-66001055/audio-of-sfo-near-miss-courtesy-liveatcnet

They were cleared for the dreaded FMS Bridge Visual approach to 28R.

Wind was given as 270/8 when AC 759 was cleared to land, nothing unusual.

momo95

11th Jul 2017, 15:30

*sigh*

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

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

Ignoring the AC crew noticing their error, say the taxiway was empty ... at what stage would they have noticed their error?

I'm more interested in your statement i put in bold. In light of the articles posted above, where this has happened at night before, at a large international airport no different to SFO ... what evidence are you using to back your claim that this can never happen? I'm genuinely interested

RAT 5

11th Jul 2017, 15:53

A visual approach cleared to land on 28R and ahead are two lit strips the left one must be 28L so the right hand one is 28R

Just thinking about approach/landing briefs & TEM. Is 28C a landing runway? If that's the case, and it's included in the brief, then identifying 28L means the next one over is 28R doesn't fit the briefing. Surely 28C would have been mentioned.
Also, from a crew behaviour point of view I'm assuming they would not have briefed a visual approach from TOD and not set up an FMC approach. I'm assuming SFO has a preferential takeoff & landing combination; therefore if 28L is preferential takeoff rwy, it follows on that 28R is preferred landing rwy, and the FMC would have been programmed and briefed before TOD. Being short cut to a visual still leaves the MAP programmed for 28R.
I'm not familiar with SFO or A320, so please correct my assumptions as necessary. Someone also asked about the status of ILS on 28R. If it was on, and I assumed tuned, it would have showed some deflection. Were both heads outside all the time? PM duties etc?
Regarding the lights of a/c at night: in EU strobes are normally only used on the runway not holding. Thus perhaps only taxi lights & ACB's were showing. Amidst all the runway & taxiway lights a/c become hidden, especially from above. Remember the accident at LAX when a B737 landed on top of a Metroliner. When NTSB flew the approach they could not see the Metroliner hidden within the runway lighting. It's not that easy, seeing a/c, and you can believe your eyes are playing tricks. The brain has been programmed by ATC that is clear and you believe you're where you are supposed to be. I'm sure a GA would have been made by the crew eventually, but probably at a low height when it all suddenly became abundantly clear with a huge "WTF Go Around" call.

DaveReidUK

11th Jul 2017, 16:05

In light of the articles posted above, where this has happened at night before, at a large international airport no different to SFO

Apropos the above: from the report on the 1988 incident referred to in post #13, showing the final positions of the two aircraft involved:

http://www.avgen.com/aar%202-1989.jpg

The One-Eleven (on the left) having come to a stop at the end of its ~950m landing roll on the taxiway and the 737, which had been taxying for takeoff, with both mains bogged down in the grass in an attempt to get out of the path of the oncoming aircraft.

Airbubba

11th Jul 2017, 16:48

PeetD

11th Jul 2017, 16:49

Dumb SLF here so apologies. If my car can know if it is wandering out of the lane I'm driving on, there must be a technical solution to an aircraft being say, 50m left or right of the track it should be on for the runway rather than the taxiway? Why does aviation seem so slow in adopting better technical solutions to the problems in front of it? Coloured lights (imperfect, as pointed out further up this chain) do seem a bit yesterday?

Feathered

11th Jul 2017, 16:50

*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not.

A similar attitude led to 35 people dead, 29 seriously injured on February 1, 1991 at LAX. In this case, the "occupied strip of pavement" was runway 24L. The "occupant" was a Skywest Fairchild Metroliner, and the aircraft landing on the "occupied strip of pavement" was a US Air Boeing 737.

The key difference in that case was ATC cleared the 737 to land on 24L while the Fairchild was also cleared to position and hold on 24L. But yes, a professionally piloted aircraft landed on an "occupied strip of pavement" with tragic results. Thank goodness for the go around instruction by ATC this week at SFO.

fleigle

11th Jul 2017, 17:04

There is no runway 28C at SFO, there isn't enough room for 28L and R on IFR approaches, which is why SFO gets to be really slow in the summer when the fog is in.

costalpilot

11th Jul 2017, 17:22

'Twas night? Someone posted an altitude plot that read 200'. How tall are those 787 tails? How low do the undercarriage hang?

scary rather than a ho hum go around, i would say.

a story went around back in the day that a certain Captain in our regional airline landed on one end of a taxiway in Atl one night, picked up the mike and asked the tower why another aircraft was on the other end of the active runway. then the other pilot said: "I wasnt going to say anything Southern, but you just landed on the taxiway." the story sounded like something the Sou pilot would have said,(in character). if it happened. dont think it made hard copy. not sure.

otoh, I will never forget seeing two stretch 8's in exactly the same attitude on the same runway in the midst of a moderate rain shower, one landing, one taking off, both otg with the same pitch up.

it was eerie. no one said a word.

also I was on a runway holding for TO at a SFla. airport one VFR day and a C-150 flew fight over me and landed down the runway.

gasbag1

11th Jul 2017, 17:40

I might suggest inexperience with SFO is a major factor. There are many AC pilots who read a route Brief on the airport but it doesn't give you all the answers or information. Also the Airbus managed descent for the arrival usually leaves the aircraft high and many pilots are distracted in getting down and slowing down usually getting stabilized between 1000 and 500 ft.

After the Asiana incident I thought the ops in SFO would have the landing runway ILS operating. Hard to ignore the localizer, or may be not.

clareprop

11th Jul 2017, 18:06

Whatever is written or said, what really matters is was whether this was a normal end to a flight. Yes...Fugetaboutit.
No...press and media are going to town.

EGLD

11th Jul 2017, 18:10

FMS bridge visual 28R is an offset approach which requires you to maneuver to the centerline.

It's very obvious which is the runway there, particularly on a clear night.

I can't imagine they were going to land on an aircraft. Again it's obvious where the runway is there. They were probably just not all the way over to the left yet and the go around was initiated with an abundance of caution.

I dunno what scares me more these days, the utter incompetence of pilots entrusted with the lives of their passengers, or their colleagues tendency to attempt to gloss over incidents like this as minor trivialities

They weren't merely not quite lined up, they'd been lined up for a while

And they didn't initiate a go around with an abundance of caution, they were instructed to go around to save from landing on several large fully fuelled aircraft

WHBM

11th Jul 2017, 18:28

The Gatwick landing on the taxyway (actually the relief taxyway alongside the regular one) actually happened twice, the BIA One-Eleven described above, and then later I believe it was an Air Malta 737.

In all these cases there are multiple closely parallel runway/taxyway combinations (three at Gatwick, four it seems at SFO), it happens at night, and heading for the runway on one side, they head for a taxyway further over on that side. Had the SFO runway lights over on 28L been switched off for any reason ? This was what had happened at Gatwick. If you know there are two parallel runways, you are landing on the right hand one, you see from several miles out just two parallel lines of lights, actually the right hand runway and its associated taxiway, you can start to see it.

If I recall SFO correctly, the two closely parallel runways are commonly both used together for simultaneous landings, and also takeoffs, in the "use everything together" style common in the USA but not so much elsewhere. So you might expect two lit runways.

I'm sure that an airport like SFO has superb lighting. In fact the general taxyway illumination is quite likely more brilliant than the runway lighting at some other points the crew encounter on the network, approach lights apart, where the runway is just passable and the taxyway pretty thin viewed from the air.

ZOOKER

11th Jul 2017, 18:52

Looking at the various videos, (both day and night), of the 28R approach available on line, if the full approach lighting system was serviceable and switched on, it's astonishing that this could have happened.
This incident will obviously act as a 'heads-up' for this potential confusion. If both of the 28 approach light systems are routinely displayed simultaneously, a line of eastward-facing HI reds, across the seawall, adjacent to where the building is, while not a high-tech solution, might prevent a similar occurrence.

triploss

11th Jul 2017, 18:54

They were doing some construction on 28L a while back, but I thought that was supposed to have been completed at least a month ago. Construction was on weekends, which matches the Friday evening timing.

When no construction was happening, I've only ever seen aircraft line up directly alongside 28L, which I believe is 28-F (for takeoff on both 28L and 28R), so multiple aircraft on 28-C would also match up with the construction theory. Then again I've never been at the airport around midnight.

Airbubba

11th Jul 2017, 18:58

When no construction was happening, I've only ever seen aircraft line up directly alongside 28L (for takeoff on both 28L and 28R), so multiple aircraft on 28C would also match up with the construction theory. Then again I've never been at the airport around midnight.

Yep, that runway 28C is downright dangerous. :eek:

momo95

11th Jul 2017, 18:59

I dunno what scares me more these days, the utter incompetence of pilots entrusted with the lives of their passengers, or their colleagues tendency to attempt to gloss over incidents like this as minor trivialities

They weren't merely not quite lined up, they'd been lined up for a while

And they didn't initiate a go around with an abundance of caution, they were instructed to go around to save from landing on several large fully fuelled aircraft

Humans are humans ... so long as they are involved incidences like these will occur. It is in our nature, pilots aren't a special breed who were born without flaw.

And they were the first to be aware of their error from what the tape suggests. They were alert when it counted and therefore were able to avert a disaster ... what is the issue?

EEngr

11th Jul 2017, 19:48

Question from the peanut gallery: What sort of visibility or situational awareness does the tower have of proper runway alignment? Other than reports from the crew landing and those waiting (and ducking) on the taxiway? Any thoughts about camera systems lined up with the runway? A plane on proper alignment could be seen as straight on, while one heading for the taxiway would appear to be drifting left.

There is some discussion of using remote ATC for smaller (GA only?) airports. One of the advantages mentioned is that camera feeds sent to the remote facility could provide points of view not available to a traditional tower.

Or would cameras just be another maintenance headache that would end up restricting operations if inop?

ZOOKER

11th Jul 2017, 20:07

EEngr,
You could send the camera feeds directly to the existing ATC Visual Control Room, no need for the facility to be remote from the airfield.
My local airport has 2 closely-spaced parallel runways and has an 'approach monitoring aid'. A piece of kit that alerts ATC of any significant deviation from the R/W centre-line inside 4 miles from touchdown. They have had this kit for at least 5 years.

Musket90

11th Jul 2017, 20:08

Soon after the Gatwick incidents the parallel taxiway lighting was adjusted so it doesn't show towards the direction of approach when the northern runway is in use. So when runway 08R/26L is closed for maintenance and runway lights are switched off. runway 08L/26R runway lights only can be seen. The parallel taxiway lights are visible only after
vacating 08L/26R, Also there is a radar based approach monitoring aid which provides ATC with an audible warning from a few miles out should an arriving aircraft be lined up on
the wrong runway.

EEngr

11th Jul 2017, 20:36

You could send the camera feeds directly to the existing ATC Visual Control Room, no need for the facility to be remote from the airfield.
Yes. I used the remote tower example only because it was noted that, once you have to put in cameras, you can get some interesting viewpoints. That's the context where I had originally heard of this idea.

Shore Guy

11th Jul 2017, 21:33

Safety at airlines is driven primarily by money and mandates. There is a system that would have given ample warning of the impending taxiway landing.

https://aerospace.honeywell.com/en/products/safety-and-connectivity/runway-awareness-and-advisory-system

And it's big brother system.....

https://aerospace.honeywell.com/en/products/safety-and-connectivity/smartrunway-and-smartlanding

ADS-B has the capability of providing onboard incursion/collision alerts.

But, unfortunately, it will take another Tenerife to drive the mandates to equip.

As the worlds airline pilot population becomes less and less (average) experienced, particularly in second and third world countries, the risks will increase. Here is an area where technology can shine.

Let it.......

fox niner

11th Jul 2017, 21:41

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

fleigle

11th Jul 2017, 22:10

fox niner,
So, a positive rate of climb then....:ok:

Here is the map of SFO so that you all can see what is what.

http://flightaware.com/resources/airport/SFO/APD/AIRPORT+DIAGRAM/pdf

In no way, shape or form would they use F for anything but taxying.

OldLurker

11th Jul 2017, 22:26

Many accidents and incidents could be prevented by crews (1) looking out of the window, (2) being able to comprehend that something unexpected is happening – "WTF, this doesn't look right" – (3) being able and willing to respond to unusual circumstances, and unconstrained from doing so. In this case the AC crew had clearly reached the "WTF" stage and it'll be interesting to know whether they'd have made it to stage 3 (go-around) by themselves if ATC hadn't told them to. In other cases, such as Asiana 214 if I understand it correctly, the crew never get as far as stage 2.

A few years ago a 747 was cleared to land at LHR although an A320 was lined up for takeoff on the same runway. Daytime, visual; the A320's topside color happened to be gray, blending with the runway; its company's SOP was to have strobes off at that stage; so the 747 crew didn't see the A320 until the last minute ... but they did make it to stage 3 and went around from about 200ft agl.

RobertS975

11th Jul 2017, 23:20

Back in 2009, a Delta 767-300 arriving from GIG into ATL landed in the pre-dawn hours on a taxiway. Luckily at that early hour of 0600, no flights were taxiing out for departure. Thankfully just an incident, not an accident.

Loose rivets

12th Jul 2017, 00:08

My thought is that the aircraft on the taxiway became the focal issue for the Air Canada guys. Perplexed by what they were seeing* they probably plodded on not really wondering why the VARSIs were WAY over there and other lighting seemed so vague.

That is the very nature of becoming fixated.

However, the very fact they were seeing the taxiing aircraft hopefully means they'd never have simply descended into them.

*When Tower said they had 28R to themselves, you could hear the continuing hint of bewilderment in the reply.

SeenItAll

12th Jul 2017, 00:19

From the AV Herald Incident: Canada A320 at San Francisco on Jul 7th 2017, lined up with taxiway for landing (http://avherald.com/h?article=4ab79f58&opt=0)
AC-759 had already overflown taxiway C by about 0.25nm when ATC instructed the aircraft to go around. 4 aircraft were on taxiway C at the time of the occurrence. It is estimated that AC-759 overflew the first two aircraft by 100 feet, the third by about 200 feet and the last by 300 feet. The closest lateral proximity between AC-759 and one of the aircraft on taxiway C was 29 feet.

I am sorry if there are people on this forum who are saying that the AC crew had everything under control and that there was no significant danger. Three seconds more reaction time and the first plane's tail gets clipped, and the rest happens like dominos. If the unidentified guy on the tapes hadn't alerted the tower that AC was over the taxiway, there would have been a disaster. This is way too close a call to dismiss.

misd-agin

12th Jul 2017, 00:20

747 tail height 65'6"

cordwainer

12th Jul 2017, 01:21

Yep, I'm sure a lot happened in the pre-cellphone video era that was never reported. Or, so they tell me. ;)

Unfortunately, or fortunately perhaps, these Continental guys made the tabloids with a taxiway landing at EWR:

AIRLINE PILOT IN BLUNDER LAND TOUCHES DOWN ON NEWARK TAXIWAY | New York Post (http://nypost.com/2006/10/31/airline-pilot-in-blunder-land-touches-down-on-newark-taxiway/)
Regarding runway lights: the full NTSB narrative for the Continential 1883 incident is available at https://ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20061101X01592&ntsbno=NYC07IA015&akey=1

It references some differences in lighting brightness despite what should have been discernably different step levels.

Since the report also notes the investigation assessed REIL, PAPI and color (green/white) visibility, it made me curious as to which specific, comparable elements are equally pertinent to the SFO incident, and are likely to be addressed in the investigation.

Also: the source quoted on the 2006 Continental 1883 incident seemed to feel landing on the taxiway there was a truly inexcusable f-up. Whereas with regard to this SFO incident, professionals here seem to be of mixed opinion, but overall seem to consider it less egregious.

Are the two really even comparable? Just curious.

_Phoenix

12th Jul 2017, 02:55

Post #4 includes a good audio of ATC, at about 25:45:
“There's no one on 2-8 Right but you!”
“OK, Air Canada 75/Where's this guy going? He's on the taxiway!”
Fortunately, there was a guy more alert than AC flight deck and ATC, all together. He cut off the AC re-confirmation. Hundreds of souls are still with us today because of this guy. Congratulations, well done, unknown hero! :D

ACMS

12th Jul 2017, 03:05

Questions:-

1/ was the ILS operating on their intended RWY?

2/ were the HIAL on?

3/ were the RTZL on?

If they were then how could a trained crew in an A320 stuff it up?
If they weren't on then why not?

Swiss cheese holes very nearly lined up that evening.

Sounds like all flights at night should be ILS approaches at so equipped runways, or all crews should be trained to tune and ident the ILS then monitor it on final for correct runway alignment. Irrespective of the wx at Airports with close parallel runways and taxiways. AND all the fancy HIALS RTZL should be operating.

TowerDog

12th Jul 2017, 03:17

. 747 tail height 65'6"

If the A-320 passed over at 100', 34' clearance, minus the landing gear, probably 6', 28' clearance, 8,5 meters. Damn..:eek:

pfvspnf

12th Jul 2017, 05:29

The big red does it again , amazing how if it's them , these things are only a minor mishap, no problem at all .

If it happens in Africa or Asia , we have no clue what we are doing

Roger Greendeck

12th Jul 2017, 05:53

The American practice of clearing aircraft to land when there is still traffic ahead to land or taking off doesn't help in this situation. If you only get your clearance when there is one finishin vacating or sure to have cleared the upwind threshold or turned then you've plugged another hole in the cheese.

Bergerie1

12th Jul 2017, 05:59

I am convinced that one day (in the not too distant future I hope) ADS-B In and Out will become a major part of the ATM environment. If information on other traffic is displayed on the moving map nav display, together with suitable warnings) the mis-perceptions that seemed to have played a part in this incident may be avoided.

https://www.skybrary.aero/index.php/Airborne_Separation_Assurance_Systems_(ASAS)

ZFT

12th Jul 2017, 06:12

The big red does it again , amazing how if it's them , these things are only a minor mishap, no problem at all .

If it happens in Africa or Asia , we have no clue what we are doing

Unfortunately true. Was thinking just the same earlier

fox niner

12th Jul 2017, 06:19

About one week ago, the NTSB released a video from the Asiana crash, viewpoint from the control tower. It was a security camera, I am sure that most of us have seen it. I'm sure that that particular camera is still in place. It must have caught this incident as well.
At Jacdec I saw a pic which indicated which other airplanes were involved:
UAL 1, UAL 1118, UAL 873 and Philippine airlines 115.

DaveReidUK

12th Jul 2017, 06:36

That's supported by the FR24 playback. At the time of the incident the queuing aircraft on twy C were (in order, from the front):

1. UAL1 B789 SFO-SIN
2. PAL115 A343 SFO-MNL
3. UAL863 B789 SFO-SYD
4. UAL1118 B739 SFO-MCO

Fortuitously, no 747s or (worse) A380s.

EGLD

12th Jul 2017, 06:41

Humans are humans

Which is surely why there is at least two humans involved, backed up by some of the most sophisticated avionics available!

DIBO

12th Jul 2017, 07:12

Make that 3 humans, SFO TWR with all its equipment could also have picked up the misalignment much earlier. Not required to, but could/maybe should have...

reubee

12th Jul 2017, 12:25

Midnight in San Francisco = 3am in Toronto, it will be interesting to see the AC crew recent duties ...

funfly

12th Jul 2017, 12:33

Originally Posted by EGLD
I dunno what scares me more these days, the utter incompetence of pilots entrusted with the lives of their passengers, or their colleagues tendency to attempt to gloss over incidents like this as minor trivialities

As an ex pilot now a potential passenger, I totally agree with the above statement. What happened to Papy's, runway lighting etc. No excuse to close ranks.

F-MANU

12th Jul 2017, 12:50

T-00s AC759: "Tower, just want to confirm. This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?"

T-08s SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."

T-16s "Where's this guy going? He's on the taxiway," the other pilot said.

T-20s SFO TOWER: "Air Canada, go around."

T-22s AC759: "Going around. Air Canada 759."

T-23s SFO TOWER: Air Canada looks like you were lined up for Charlie there. Fly heading 280. Climb maintain 3,000."

T- 29s AC759: "Heading 2-8-0, 3,000 Air Canada 759."

T- 33s UA001 PILOT: "United One, Air Canada just flew directly over us."

T -42s SFO TOWER: "Yeah, I saw that."

From G/A instruction to 'they flew over us' => 13 seconds

Now remove from the equation: AC759 reaction time to initiate G/A + engine spool-up (inertia) + UA001 pilot reaction time to report the low pass...

khorton

12th Jul 2017, 13:16

CTV News has an interesting video with some background info and a bit of speculation:

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

Basil

12th Jul 2017, 13:38

That helps to explain a reason. Must say, it's a long time since I operated into SFO and don't recollect the offset.

SYD has close parallel runways but, IIRC, has lined up ILS but with a 'Breakout procedure' if an aircraft on approach deviates towards the other runway.

FlyingCanuk

12th Jul 2017, 14:04

I don't buy that explanation
The 28R approach is offset to the right, and at 4 miles, the aircraft on approach is to line up with the runway centerline.

This aircraft was lined up with taxiway Charlie until the go around at approx. 100'

WillowRun 6-3

12th Jul 2017, 14:15

Is it not still the case, where fundamentals as well as operational practices and methods are concerned, that the basic model for safety is stated as "not having the holes in the Swiss cheese line up" - at least for the traveling public, and the legions of governmental, manufacturer, and other interested parties who never have held an airliner in their hands in the left seat, the right seat, or anywhere else conceivable? I think it's still a darn good way of explaining a rather (!) complex set of variables with so many possibilities that the word "infinite" might even be warranted. Lighting, visual fixating, crew rest, reaction time, height of lined-up aircraft tail, plus CRM, plus familiarity with SFO, and let's not forget (amorphous though it certainly tends to be) automation on the airliner flight deck.

This was way too close for categorization as "the system worked, no sweat, pipe down SLF." True, a catastrophe was avoided - but the margin of error was approaching (pun intended or not, I don't care) holey Swiss.

eckhard

12th Jul 2017, 14:18

That helps to explain a reason. Must say, it's a long time since I operated into SFO and don't recollect the offset.

There is an offset LDA and LDA (PRM) approach to RW28R. FAC 281. (RWY QFU 284.)
There is also a regular straight-in ILS approach to RW28R with FAC 284.

My understanding is that the Air Canada was cleared for the "Quiet Bridge" visual approach to RW28R. This involves an initial course of 275 towards the SFO VOR (centre-field) and then an alignment at 6D (5nm from THR) to the RWY QFU of 284. The 28R ILS GS is available for vertical guidance.

glofish

12th Jul 2017, 14:41

There are many possible factors that explain how it can come to such a situation. Fact is, that such offset visual procedures, be they LDA or RNAV feeded, are known to be tricky. There are numerous briefings available and many required to perform such approaches, outlining the dangers, the visual illusions, the possible holes in the Swiss cheese.
What bothers me in this particular incident, is the non-reaction of the crew after recognising that something is not quite right. Many of us might have experienced a bad line-up, an initial heading for the wrong piece of concrete, a wrong approach setting, etc., at least I have. The important part is to A) recognise an error and B) mitigate it, take action.
The query by this crew about funny lights on the runway shows that they suspected something’s not right. By just continuing once the tower told them the runway was clear and only initiating a go-around on input by a taxiing aircraft and subsequently the tower, and especially how low they passed over the taxiing aircraft once started the G/A, shows how long (too long) the passivity of the crew was ongoing.
In any uncomfortable situation that is highly unprofessional and even frightening.

slack

12th Jul 2017, 14:54

Don't know where Mackey comes up with 30 kts from the north. Tower reported winds 270\08. Some expert.

Airbubba

12th Jul 2017, 15:15

In no way, shape or form would they use F for anything but taxying.

Taxiway F was not involved in this incident, the aircraft were lined up on C waiting to take off on 28R.

My understanding is that the Air Canada was cleared for the "Quiet Bridge" visual approach to RW28R.

Not the Quiet Bridge Visual, they were cleared for the FMS Bridge Visual approach to 28R.

JumpJumpJump

12th Jul 2017, 15:16

OldLurker

12th Jul 2017, 15:18

What bothers me in this particular incident, is the non-reaction of the crew after recognising that something is not quite right. Many of us might have experienced a bad line-up, an initial heading for the wrong piece of concrete, a wrong approach setting, etc., at least I have. The important part is to A) recognise an error and B) mitigate it, take action.
The query by this crew about funny lights on the runway shows that they suspected something’s not right. By just continuing once the tower told them the runway was clear and only initiating a go-around on input by a taxiing aircraft and subsequently the tower, and especially how low they passed over the taxiing aircraft once started the G/A, shows how long (too long) the passivity of the crew was ongoing.
In any uncomfortable situation that is highly unprofessional and even frightening.The crew's response surely indicates that somehow they were certain that they were lined up on the runway and had become fixated on that certainty, despite the various visual indications to the contrary. They queried the lights on the runway, but the tower said the runway was clear, so since they were sure they were heading for the runway, it must be clear despite the funny lights ... Nothing in that radio conversation triggered a realisation that they were looking at the taxiway, not the runway.

eckhard

12th Jul 2017, 15:22

Not the Quiet Bridge Visual, they were cleared for the FMS Bridge Visual approach to 28R.

Ok, I don't see a chart for that one. Do you have a reference please?

fleigle

12th Jul 2017, 15:25

Airbubba
I was referring to Triploss when I mentioned Taxi-F, who wrote:-
"When no construction was happening, I've only ever seen aircraft line up directly alongside 28L, which I believe is 28-F (for takeoff on both 28L and 28R), so multiple aircraft on 28-C would also match up with the construction theory. Then again I've never been at the airport around midnight."

Anyhow, a huge accident avoided.

Airbubba

12th Jul 2017, 16:10

Ok, I don't see a chart for that one. Do you have a reference please?

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

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

This RNAV approach requires specific approval for each airline and is what I would call a 'company page' in the Jepps.

I was referring to Triploss when I mentioned Taxi-F, who wrote:-
"When no construction was happening, I've only ever seen aircraft line up directly alongside 28L, which I believe is 28-F (for takeoff on both 28L and 28R), so multiple aircraft on 28-C would also match up with the construction theory. Then again I've never been at the airport around midnight."

Thanks :ok:, I probably got lost with the mention of 28-C which must mean taxiway C, not a mythical center runway.

c52

12th Jul 2017, 16:11

Would an airline's insurance policy cover destroying five planes and that many lives?

flown-it

12th Jul 2017, 16:14

Ok, I don't see a chart for that one. Do you have a reference please?

Neither do I!
19-1 Tipp Toe visual
19-2 Quiet Bridge visual.
Did the latter many times. The key is to have an FMS extended line from the runway to monitor when going visual from the bridge. 3 key strokes in the Honeywell FMS and there's both a lateral and vertical back-up.

underfire

12th Jul 2017, 16:16

folks, look at Quiet Bridge procedure, the offset is to threshold. Note the runway is at 284, while the approach is 275 until threshold.(not to 4nm as I have seen posted) As a reminder, it is a visual approach.
http://i63.tinypic.com/2who57s.jpg

Thus, you will be off on the PAPI until threshold if you follow the procedure. That being said, the ac in question offset to a point far out from that, and was aligned with the taxiway for an extended timeframe, even questioning lights on the runway. The ac never deviated from the alignment on the taxiway. (even when GA, and it is not clear if the ac initiated GA before it was instructed to)
What is apparent, at least to me, is that if the taxi had been clear of other ac lights, it is very, very likely the ac would have landed on it. TCH is 55 on 28R, so a GA at 100 (as reported) means that, well, as much as many want to say this was not an issue and the crew recognized and did a GA, well, damn, they were going to land, face it. (when you GA at 28R, you turn to 265 on GA...no deviation in that FP by the crew.

In regards to the visual comment at the beginning, SFO has and does use ADSB. Comments regarding ADSB use, and how it may have saved this are not accurate. Note that ADSB, (out and in) with latency, is about useless on final in this case. Also note, that many ATM systems, in order to remove clutter from the ATC screens, remove the ADSB data (due to clutter and accuracy issues at that point)

Airbubba

12th Jul 2017, 16:24

At least the approach had 'Bridge' and 'Visual' in the name. Don't think it was the Quiet Bridge Visual though... :=

deSitter

12th Jul 2017, 16:27

The crew's response surely indicates that somehow they were certain that they were lined up on the runway and had become fixated on that certainty, despite the various visual indications to the contrary. They queried the lights on the runway, but the tower said the runway was clear, so since they were sure they were heading for the runway, it must be clear despite the funny lights ... Nothing in that radio conversation triggered a realisation that they were looking at the taxiway, not the runway.

Absolutely, this is the key point. I was reminded of Western DC-10 in Mexico City.

It is very fortunate that a happy end was had, and people need to look at this very, very hard.

Another example would be Comair in Lexington. Despite no runway lights, they initiated TO and were completely unaware until they ran out of runway. This is clearly a "thing", fixation on unreal situations despite the obvious evidence.

llondel

12th Jul 2017, 16:27

At least the approach had 'Bridge' and 'Visual' in the name. Don't think it was the Quiet Bridge Visual though...

Could have been quite loud if things had run to an unpleasant conclusion.

underfire

12th Jul 2017, 16:32

http://i68.tinypic.com/2ppwojb.jpg

underfire

12th Jul 2017, 16:41

At least the approach had 'Bridge' and 'Visual' in the name. Don't think it was the Quiet Bridge Visual though

umm..what procedure do you think they were cleared for? I did not notice the "FMS28R able" call for the ac? Where do you see cleared for Bridge visual, especially Air Canada in the US? Aside from that, it is the same procedure, just with waypoints.

Isnt 'visual' the operative word here?

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

WillowRun 6-3

12th Jul 2017, 16:43

Posted by deSitter: "Another example would be Comair in Lexington."

The Comair crash was the focus of a presentation recently, in Montreal (McGill), by an official (of the U.S. Justice Dep't) who had been involved in the litigation which resulted. Facts - meaning the official iteration of the relevant investigation-produced facts as recorded (or mostly recorded) in official reports - are not available, obviously (no kidding) yet, about the SFO "what did not happen" event. But even trying to think about the litigation that could have been a byproduct of a horrid conflagration - mind-boggling. I'll leave it to someone who pilots airliners (or who has) to note, or dismiss, irony in the Asiana incident at the same airport, the fire truck, the "ground getting bigger" amid silence . . . up front.

DaveReidUK

12th Jul 2017, 16:55

http://i68.tinypic.com/2ppwojb.jpg

At the risk of beng picky, if you are going to overlay two images, you want to scale them the same first.

The (colour) image showing the actual flightpath from WebTrak has the San Mateo Bridge just visible in the bottom RH corner.

The (black and white) approach chart has the (same) bridge right in the centre.

eckhard

12th Jul 2017, 17:02

folks, look at Quiet Bridge procedure, the offset is to threshold. Note the runway is at 284, while the approach is 275 until threshold.(not to 4nm as I have seen posted) As a reminder, it is a visual approach.

Thanks underfire; however, further down the chart (not visible on your excerpt) it says:

Aircraft should remain on the SFO R-095 until passing the San Mateo Bridge

So, presumably after this position they are free to align with the runway.

This is at SFO 6D, or 5nm from the threshold. My Lido chart shows an alignment manoeuvre with the runway at this point.

eckhard

12th Jul 2017, 17:06

The image showing the actual flightpath has the San Mateo Bridge just visible in the bottom RH corner.

Good spot DaveReidUK. I think the two bridges at bottom RH corner are the Dumbarton Bridges.
The narrow white bridge is probably the San Mateo Bridge. If so, the northerly first track shows the aircraft lining up with the 'runway' at the correct point.

I agree that the superimposition seems to be not to scale.

Airbubba

12th Jul 2017, 17:08

umm..what procedure do you think they were cleared for?

As I've said repeatedly on this thread :ugh::

Not the Quiet Bridge Visual, they were cleared for the FMS Bridge Visual approach to 28R.

Where do you see cleared for Bridge visual, especially Air Canada in the US?

It is in the approach control audio clip I cited above, take a listen:

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

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

This is an 'unpublished' approach that requires specific operator approval. I agree that it mimics the Quiet Bridge but the fact that it is an FMS approach may be very pertinent to the nav setup on an early glass cockpit plane in my opinion.

I sheepishly admit to some Airbus time but I've never flown the A320. On some planes of that pre-GPS era you have to be creative to display raw data and the FMS picture at the same time. Sometimes you get a dotted line that you think may be raw data but in actuality the line is subject to a map shift.

Maybe some AC folks can verify that the FMS Bridge Visual to 28R is in their charts. Back during the glory days Air Canada did their own charts in-house, I don't know whom they use for a vendor these days.

eckhard

12th Jul 2017, 17:17

This is an 'unpublished' approach that requires specific operator approval. I agree that it mimics the Quiet Bridge but the fact that it is an FMS approach may be very pertinent to the nav setup on an early glass cockpit plane in my opinion.

Agreed and thanks for the clarification.

underfire

12th Jul 2017, 17:20

Sorry, I thought I had posted the correct image...thanks for spotting that.

http://i67.tinypic.com/2dvsvwk.jpg

The FMS Bridge Visual Approach 28R is an AR procedure, so without ref to that coding, not sure what procedure looks like. I would be curious as to why the FMS bridge visual, ie RNAV visual procedure does not overlay the Quiet bridge procedure.

Aside, from that, the crew lined it up visually, and with the taxiway. A bit surprised they had it, but good luck keeping the AR

BluSdUp

12th Jul 2017, 17:34

Visual at night is not a good idea without a ILS or VNAV- PATH as primary and visual as backup.
This near disaster proves it.

SeenItAll

12th Jul 2017, 17:38

Would an airline's insurance policy cover destroying five planes and that many lives?

At typical U.S. payouts for such an occurrence, my answer would be "only if the policy's liability limit approached $10 billion."

NGDRIVER

12th Jul 2017, 17:51

Anybody thought that fatigue may have played a part in this incident, who knows what these guys where rostered in the preceding duties?

F-MANU

12th Jul 2017, 18:17

Where are you going with this? Are you saying that after 13 Seconds AC should have been/was higher than what is being clainmed here, or are you sugesting that AC took a long time to react? Or something else?

13 seconds seems reasonable between "go around" being said and UA001 commenting; given the exchange after the go around was initiated between AC and ATC, and then a pause to check that there was nothing else to be said between AC and ATC by ua001 to not step on AC/ATC.

Reasonable ? Just think about it:

T0 GA instruction given
T0+??s AC crew pushes throttles to TOGA
T0+?s A320 gets a positive climb rate
T0+ 10s (presumably): AC759 roars up 100ft above UA001
T0+ 13s: astonished UA001 reports the close call

According to the AVH quoting the Canadian TSB: AC-759 had already overflown taxiway C by about 0.25nm when ATC instructed the aircraft to go around !

Based on a quick calculation: when ATC instructs to abort landing, AC759 and UA001 are horizontally 8-10 seconds from each other (600-800m ie. less than 0.5 NM) with seriously converging altitudes. Tiny margin left at that point :sad:

And a 789 taxiing towards you followed by more airliners at night is a arguably a pretty visible sight. How could AC759 be so severely confused to the point to having to wait the ATC in extremis instruction ?

Looking forward to the full report.

West Coast

12th Jul 2017, 18:59

Visual at night is not a good idea without a ILS or VNAV- PATH as primary and visual as backup.
This near disaster proves it.

Ground track suggests that's exactly what they were doing, the FMS Bridge visual approach which provides lateral and vertical guidance to touchdown.

.Scott

12th Jul 2017, 19:21

Visual at night is not a good idea without a ILS or VNAV- PATH as primary and visual as backup.
This near disaster proves it.I can't agree with this.

Ages ago, I was on a visual night approach to IAD from the southeast, runway 1C I think. When I didn't report the runway in sight, the control tower asked for that information. It wasn't that I didn't know where the runway was, but I did not have a direct view of the runway lights - so I responded "No". Shortly after that, they asked the question again. I was less than 3 miles from the runway threshold, but still didn't have the view I needed - so I said "No".

They're response surprised me. They turned on the approach lights. It looked like a huge bright ball heading straight for the runway - repeating its path every second or two. I can't image what the electric bill for that was. It certainly left no doubt about where the runway was. Anyway, I reported "Yes", thanked them, and landed as instructed.

There are certainly many more challenges in landing a large jet compared to my little Cessna 172. Then again, won't they always give an ATC flight a straight in approach?

At SFO, 28R has: ALSF2: standard 2,400 foot high intensity approach lighting system with centerline sequenced flashers (category II or III)

Chris2303

12th Jul 2017, 21:03

Looking forward to the full report.

Who is going to do it? NTSB as the incident happened in the US or TSB Canada as the state of registry?

DingerX

12th Jul 2017, 21:04

Of course, I'm dismayed by the reaction of many around the internet that this incident is either "nothing" or "something".
Technically, it's "not nothing". I say that as a qualified ontologist.

Here's the points to take home:
The crew's bodies were in that magic 2-4 AM zone, fatigued or fresh, they were at their circadian low.
Their call was classic cognitive dissonance: what they were seeing was not what they expected to see, and so they sought confirmation of what they expected to see.
They then went around successfully.

Here's what cannot be said at the moment:
*Whether the crew initiated a go-around of its own accord
The unidentified voice from UA1 cuts in immediately after AC's readback. There are three possibilities:
1. During the readback, the PF decided to go around. The information they were given did not match what they were seeing out the window.
2. When UA1 calls "They're on the taxiway", they hit that TOGA button right quick.
3. They waited for the GA instruction from the tower.

I can see any of the three scenarios happening.

*How high they were when they flew over UA1
They had to go around fairly close in, since UA1 would need to be able to recognize that they were lined up on the taxiway. UA1 would spot it before the tower did. I think I posted a few years ago when another flight finished its bad day by lining up on 28R instead of 28L, causing the aircraft about to line up on 28L to bail out onto C. In that case too, the aircraft at the end of the 28s saw it before the tower, and that makes intuitive sense.
In any case, it's not clear how high they were or where they were when this happened. Simon over at AvHerald says "100 ft and past the 'taxiway threshold'." Of course, it's his "journalistic" policy not to name sources, and he's been wrong with this fine-grained data before, so, in this case, I'll wait for the NTSB animation (since nobody's gonna be filming that).

*Whether any other action was taken to avoid collision.
I wouldn't condemn those stuck behind UA1; they had limited visibility, and there's only one Tower frequency at KSFO. The press likes to cite Tenerife, but instrumental in Tenerife was a blocked transmission. I'll also note that thankfully, everyone on frequency was more or less speaking the same language. But there's no saying from the evidence so far whether anyone did anything. Would you risk blinding the crew with your landing lights, for example?

Two other notes:

I believe that for a very brief period about a decade ago, 28R was 28C, and the taxiway was 28R for lighter aircraft.

KSFO has inaugurated a new tower since the Asiana incident, so they probably won't be operating the same old camera.

smith

12th Jul 2017, 21:09

Did they not put a kink in the taxiway after the LGW incident, so as you could see it was not a straight runway?

Airbubba

12th Jul 2017, 21:12

Who is going to do it? NTSB as the incident happened in the US or TSB Canada as the state of registry?

Don't know about the TSB but the NTSB is certainly going to take a look:

@NTSB_Newsroom

NTSB investigating last Friday’s incident involving an Air Canada Airbus A320 at San Francisco Airport.
5:58 AM - 12 Jul 2017

https://twitter.com/NTSB_Newsroom/status/885121284513959936

BluSdUp

12th Jul 2017, 21:17

This would not happen if the crew use ILS or VNAV-PATH for cross reference to back up a visual at night.
My question is what strength was the Approach and RWY lights on. If low, and focused on the taxiway, I can see this developing. But to take it as far as they did is pure madness.
My guess is that AC needs to fire the chief pilot and the head of training and get some competent people that knows how modern aircraft works.
Or are they going to blame this one on Airbus as well?

I wonder were MOT is in all this and if they have AC under control.
Me thinks not.

Anyway , it ended well and we shall all take notes, Eh!

fox niner

12th Jul 2017, 21:22

I would put my money on their circadian low being a factor in this incident.
Perhaps we should start adding "circadian" to our callsign if we are in it. Just like "heavy" or "super".

Something like this: "Air Canada 123 circadian, established on final runway 28R."

DaveReidUK

12th Jul 2017, 22:33

Did they not put a kink in the taxiway after the LGW incident, so as you could see it was not a straight runway?

Google "Juliet Kink" (though it has since been straightened out).

voyageur9

12th Jul 2017, 22:46

My guess is that AC needs to fire the chief pilot and the head of training and get some competent people that knows how modern aircraft works.
Or are they going to blame this one on Airbus as well?
!

Air Canada: isn't that the outfit that gave us the Gimli (I can't do simple arithmetic) Glider and the Let's Fly below the threshold in Halifax who-cares boyz and now Hope SFO ATC know where I am because I've not a clue. Long past time that TSB stopped covering up for their buddies.

Airbubba

12th Jul 2017, 23:07

Here's a couple of possibly pertinent SFO Notams in the traditional cryptic format:

SFO 07/026 SFO RWY 10R/28L CLSD 1707080600-1707081500
SFO 06/017 SFO RWY 28L ALS OUT OF SERVICE 1706021357-1707211500

From the Mercury News article "’11 seconds to impact’: Expert calculates how close SFO near-miss was to disaster" :eek::

Pilots receive NOTAMS — notices to pilots — regularly alerting them to closed runways or other changes in normal flight procedures, and Air Canada would have dispatchers alerting their pilots of a closed runway, Trescott said.

SFO spokesman Doug Yakel said that Runway 28L closed down at 10 p.m. Friday [isn't 0600Z 11 p.m. in SFO? -Airbubba], about two hours before Air Canada was scheduled to land. A NOTAM was sent alerting pilots of the closure until 7 a.m. Saturday [8 a.m. local?], and the airport had a large, flashing “X” at the landing area to reinforce the closure, he said.

The FAA and NTSB, which have launched investigations into the event, declined to provide further details of the incident Wednesday.

“We may have investigators in the Bay Area within the next few days,” said NTSB spokesman Keith Holloway. “It is possible that part of the NTSB investigation going forward will be to review (air traffic control) procedures and practices for that airport.”

SFO near-miss: Air Canada pulled up with 11 seconds to spare (http://www.mercurynews.com/2017/07/12/11-seconds-to-impact-expert-calculates-just-how-close-air-canada-plane-at-sfo-was-to-disaster/)

TowerDog

13th Jul 2017, 01:59

ACMS

13th Jul 2017, 03:06

Long Haul

13th Jul 2017, 04:02

1/. If the ILS was serviceable, yes, it was on. They don't just turn it off for no good reason.
2/. Approach lighting is set to an appropriate level for the prevailing conditions. If they are set to high and the vis is good, it can be distracting.
3/. In modern aircraft we don't "tune the ILS." That happens automatically. If they were going to land on 28R and the localizer was operating, I have no doubt that it was displayed in the cockpit. Being able to include that information in your scan when you are landing at 140 kias visually at night at 3 am against a confusing background is another thing altogether.

Good job to all those involved for averting what could have been a disaster.

ironbutt57

13th Jul 2017, 04:31

if they were doing the Quiet Bridge Visual, just crossing the San Mateo bridge, the chart depicts joining the localizer...possibly there had visual contact and decided to continue visually..is this procedure in their FMGS database is an interesting question

update....if the Quiet Bridge is selected from the FMGS database and activated, the localizer is not tuned, and no ILS data will be displayed...

WHBM

13th Jul 2017, 05:54

SFO 06/017 SFO RWY 28L ALS OUT OF SERVICE 1706021357-1707211500 If you had seen the NOTAM several hours beforehand that the Approach Lighting System was out of service, even though it was for a runway one character different, would that be in your mind as you line up visually for what looks like the right hand of two parallel lit strips, knowing SFO has two parallel runways (it seems all the lighting for 28L had been turned off for works, not just the approach lights).

I also wonder why they were given this curved visual nighttime approach at a time of low traffic to a runway fully equipped with all the aids. I'll bet when they came back round again that was not done.

And you have to wonder how the Flight Radar 24 traces shown above, which is something put together by a bunch of enthusiast amateurs, can show quite clearly, based on real time information, that they were lined up on the taxiway, and not like the later parallel trace shows for the runway, yet with all the millions of dollars of kit the ATC staff in the tower didn't get to be aware of this.

Aztec Kid

13th Jul 2017, 06:48

This attached chart is dated, and not for use for navigation.

jack11111

13th Jul 2017, 07:06

"I also wonder why they were given this curved visual nighttime approach at a time of low traffic to a runway fully equipped with all the aids. I'll bet when they came back round again that was not done."

This approach is used at this time of night because of the extreme noise sensitivity of the area. The folks on both sides of the bay have telephones and they use them.

rmac2

13th Jul 2017, 07:50

Having read all of the posts so far ... sounds like the holes on a very large Swiss cheese almost all lined up together.
1. Parallel runway lights switched off, giving impression that taxiway is the parallel runway.
2. Visual approach for noise abatement with no auto tuning of the ILS
3. Pilots at low point of circadian rhythm and fatigued

Far from being a long way away from disaster, this look to be very close ....

Flocks

13th Jul 2017, 08:42

3/. In modern aircraft we don't "tune the ILS." That happens automatically.

I disagree with that, the last modern plane I used to fly (ejet) was tuning automatically frequency and inbound course with what inserted in FMS. It was happening around 30nm from destination.
But everybody in my compagny were tuning manualy inbound and ils/vor/loc, ... frequency in the standby frequency box during the briefing.

I don't know the airbus or boeing, but I like to set my approach aids myself and not just relied on FMS.
Just my 2 cents.

Finally when I do visual approach, I have always backup (ils, vor, fms ...) To check what I m doing.
I read too many article of plane landing wrong airport (Ryanair in Milan) or wrong runway ... I don't do "just" visual.

Basil

13th Jul 2017, 08:48

extreme noise sensitivity of the area. The folks on both sides of the bay have telephones and they use them.
Of course they wouldn't know there was an airport there until after they moved in :rolleyes:

ACMS

13th Jul 2017, 09:44

Long Haul:---thanks for the lesson mate.:) My A330 and 777 before that do indeed automatically tune the ILS but if they don't I do know how to myself and indeed do on occasion. We certainly check the whole NAV RAD during the approach briefing and setup before TOD and adjust as required.

As to HIAL being too bright and therefore distracting on a clear night......ok well ask ATC to turn them down a stage..........certainly it should have been on and it is a fantastic aid to find the runway in all weather down to CAT 2 ....Much better than a black hole to land on like I had in Jakarta 07L last month.....:ooh:

RTZL on or off? Way better if they are on ( at an appropriate level )

It's not hard for the PM ( and the PF higher up ) to scan the PFD on approach at 1,000' and 500' etc to monitor the LLZ/GS as well as the IAS/VS and then make appropriate trend callouts. ( as they already are required to do on all approaches anyway in my Airline )

Indeed it should be taught that if the info is displayed for your runway then check it.......for this very reason
Especially in places like SFO with close parallel runways and taxiways.

Flocks:---good practice that will serve you well.:ok:

BluSdUp

13th Jul 2017, 10:47

I assume the CVR has been removed, if not we lack a critical tool to learn from this mess.
I challenge you FR24 experts to check if the aircraft departed as planed with in the morning.
If it did there is two cases:
1 The CVR pulled and new inserted and the inbound CVR on its way to NTSB.
2 The aircraft departed and the CVR was over written and we will never know what happened in the flight deck.

If the aircraft is grounded due to lack of CVR we are good.
Anyone?

Sea Eggs

13th Jul 2017, 11:14

DIBO

13th Jul 2017, 11:23

Basic FR24 skills suffice:
C-FKCK
DATE_______FROM__________TO____________FLT___FL.TM___STD___A TD____STA
08 Jul San Francisco (SFO) Montreal (YUL) AC780 4:58 7:30 AM 7:48 AM 3:50 PM Landed 3:46 PM
07 Jul Toronto (YYZ) San Francisco (SFO) AC759 5:12 8:55 PM 9:58 PM 11:23 PM Landed 12:11 AM

BluSdUp

13th Jul 2017, 11:38

Norwegian Chief Pilot just commented on this incident and stated that a visual night approach is prohibited in his company.
This is the case in most EU companys.
I am a big fan of visual approaches , but seldom do it as we have to do a separate brief.
What I do is call visual and intercept ILS or LNAV-VNAV path no later than platform alt with HDG/ VS +, VORLOC/GS armed .
All low risk and wasting 31 seconds...
Done plenty of yank and bank in the old days, seen to much and read to much to be the slightest interested to satisfy the local ATC agenda.
Love FAA and the safe execution milions of flights, but they are overdue for a big one.
Conveniently this one is on the Canadiens , but take notes.
Visual night approach to a big international airport, give me a f.... break.
Seriously.

DaveReidUK

13th Jul 2017, 11:39

feueraxt

13th Jul 2017, 11:45

Is this picture and video similar to what CA would have seen?

28L unlit (except for red "X"?), 28R illuminated, Taxiway C green centerlights.

https://storage04.dropshots.com/photos6000/photos/1398257/20170713/073903.jpg

rNMtMYUGjnQ

White Knight

13th Jul 2017, 11:59

Visual at night is not a good idea without a ILS or VNAV- PATH as primary and visual as backup.
This near disaster proves it.

I'm with you on that - especially when fatigue is a factor! Another airport where the 'greenies' rule:yuk:

RAT 5

13th Jul 2017, 13:24

These photos are an interesting addition to the conversation; and we are still waiting confirmation about the radiating status of the 28R LS. I see PAPI's on LHS of rwy threshold; I see standard green threshold lights; I see standard approach light & touchdown zone lights. That looks like a runway. I can't believe taxiway C had anything like this, so how can you line up on a strip of concrete, at night, that you can't see too well anyway, that doesn't have appropriate lighting. That's all you can see at 4nm, not the concrete/tarmac. I'm also surprised they could see a/c lights hidden in all the airport lighting. They would have been 2 candle power compared to what was surrounding them. But they said they could see something odd.
What approach did they brief at TOD? It can't have been only some kind of visual; they must have briefed an IFR approach of some kind and set the nav boxes for it. If 28R ILS was in the air it should have been tuned and identified, surely? How far out were they when cleared for this odd, last minute offset visual? To an unfamiliar crew that would be a huge cheese hole, right there, if it's last minute and unbriefed. (A bit like ATC asking you to take the next exit just as you touch down. It's a bit late now, mate)
If 28ILS was in the air, and if it was tuned and displayed, what was PM looking at on finals? It would have shown almost full scale deviation at 4nm. What calls does AC have on their approaches? It does seem like 2 heads outside ands no-one managing in the office inside. Were they in autopilot CMD or manual? If A/P, was CMD what was it following; FMS, VOR or ILS? If manual were the FD's on and what were they following? It would seem that they should follow 275 until passing the bridge and intercepting 284, by what ever method laterally.
If they were lined up with the taxiway, which seems invisible in the photos, what were they using for glide path guidance?
One reason that dismissing this as a minor event is not a good idea, is that no-one will investigate and find out how the holes lined up. Damn sure it will happen again. Time to plug the holes.

ACMS

13th Jul 2017, 13:51

The mind boggles........

.Scott

13th Jul 2017, 13:53

I'm with you on that - especially when fatigue is a factor! Another airport where the 'greenies' rule:yuk:Speaking as a "greenie":

Would you claim that this Air Transport Pilot was so fatigued that he didn't recognize the runway - but alert enough that had he been provided ILS he could have landed safely?

I am willing to believe that some (perhaps most) ATPs would prefer ILS over visual, but I am not ready to believe that so few of them find visual such a handicap that it could be characterized as "not a good idea".

Airbubba

13th Jul 2017, 14:00

Finally a balanced viewpoint instead of sensational nonsense...

CTV News Channel: 'Situation was unusual' | CTV News (http://www.ctvnews.ca/video?clipId=1165295&playlistId=1.3497833&binId=1.810401&playlistPageNum=1#_gus&_gucid=&_gup=Facebook&_gsc=ORXa0tJ)

'An unusual set of circumstances that created something that's probably going to turn out to be a non-event'.

Yep, I'm sure the FAA and the NTSB will agree. ;)

Captain Mackey does do a good job of explaining the runway setup and construction at SFO. As DaveReidUK said, this was an early assessment and more information on the incident has emerged.

I also wonder why they were given this curved visual nighttime approach at a time of low traffic to a runway fully equipped with all the aids. I'll bet when they came back round again that was not done.

And you have to wonder how the Flight Radar 24 traces shown above, which is something put together by a bunch of enthusiast amateurs, can show quite clearly, based on real time information, that they were lined up on the taxiway, and not like the later parallel trace shows for the runway, yet with all the millions of dollars of kit the ATC staff in the tower didn't get to be aware of this.

From the 0700Z approach control reel at liveatc.net, on the second approach AC 759 was vectored for a visual approach behind an AA B-777. Other planes were still using the FMS Bridge Visual though.

I don't believe any of the posted plots of AC 759 overflying the taxiway, including mine, came from FlightRadar24. The data in close to the runway on FR24 didn't look too good to me but you can definitely see who the players are as the incident evolves.

update....if the Quiet Bridge is selected from the FMGS database and activated, the localizer is not tuned, and no ILS data will be displayed...

That's what I've been told by a friend who flew A320's years ago. Can anyone with recent experience on legacy A320's confirm this?

Did the AC A320 have GPS for the Nav Display? On some older planes as we've discussed on other threads, ADS-B, TCAS and EGWPS may have GPS data but the ND might not display it depending on the installation. I've flown older '75's that were like this for a while before a subsequent update.

n5296s

13th Jul 2017, 14:50

Another airport where the 'greenies' rule
Nothing to do with 'greenies', though I'd buy 'nimbies'. I live about 25 miles south of KSFO, under the BDEGA (from the north, with a teardrop turn) and SERFR (from the south) approaches. The amount of fuss in neighbourhood forums, town meetings and such, especially about the latter, is just unbelievable - people claiming they can't leave their house during the day because of the noise and so on. There are quite a lot of people who file a complaint with the airport EVERY time a plane flies overhead.

Now, do you think these people wear vegan sandals and walk everywhere they go? Or do you think they take the cheapest flight they can to travel several times per year? Yeah, right. But it doesn't stop them complaining.

ahilliard

13th Jul 2017, 15:26

If they were lined up with the taxiway, which seems invisible in the photos, what were they using for glide path guidance?
One reason that dismissing this as a minor event is not a good idea, is that no-one will investigate and find out how the holes lined up. Damn sure it will happen again. Time to plug the holes.

Could any white lights on four evenly-spaced airplanes on the taxiway create some kind of a runway-like appearance?

neila83

13th Jul 2017, 16:17

I'm with you on that - especially when fatigue is a factor! Another airport where the 'greenies' rule:yuk:

Need help with that shoehorn, it looks mighty heavy?

Its called compromise, it's how society generally functions. Believe it or not, and contrary to the belief of many here, aviation is not the single most important priority in the world, and does not have to be satisfied first at all times before any other decisions can be made, which must be made in deference to the wishes of a few pilots on the internet.

Noise regulations generally strike a good balance between airports operating efficiently and not causing unnecessary disturbance. What can be wrong with that unless you just get a kick out of annoying people? In which case you probably haven't reached the metal age to be flying a plane.

This forum confidently told me after Asiana that only Asian pilots did things like this, perhaps some reflection is in order?

WHBM

13th Jul 2017, 16:27

how can you line up on a strip of concrete, at night, that you can't see too well anyway, that doesn't have appropriate lighting.

Well it's more likely once you've had that Notam that the approach lighting is U/S.

How far out were they when cleared for this odd, last minute offset visual? To an unfamiliar crew that would be a huge cheese hole, right there, if it's last minute and unbriefed.
Reading the flight times above, they were an hour late, due before midnight, getting there after midnight. Does the noise abatement approach only come into force at a certain time.

cactusbusdrvr

13th Jul 2017, 16:38

I asked before but was ignored.

1/ was the 28R ILS switched on? If not why not?
2/ where the HIAL's and RTZL's switched on? If not why not?
3/ did the crew bother to tune the 28R ILS and check it.?

This should not happen, if a runway is equipped with an ILS and it's not U/S then it should be switched on by ATC and all landing A/C should tune it to use as a backup for just this very reason.
Especially at Airports like SFO with close spaced runways and taxiways.

It's should be common sense and airmanship.

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

As others have said, you have to work to get it down to 1800 feet at SAMUL. You are given the clearance with no time to waste getting it in the descent out of 11000. Speedbrakes are usually required with speed changes given as well. Late night arrivals have less restrictions on speed so the tendency is to keep the speed up.

It's a massive dark hole coming in over the water. With 28L out and the lights off the tendency would be to focus on the lights you see - 28R and the taxiway. Preconceived expectations of what you should see can be hard to overcome. And the difference in lining up on the taxiway and the runway would not be apparatus to the tower until close in. If they were doing the PRM approaches then yeah, radar controller would have caught it a few miles sooner but Late night operations in good weather have minimum staffing. It works fine that way all the time.

West Coast

13th Jul 2017, 16:50

Visual night approach to a big international airport, give me a f.... break.
Seriously.

Given that the procedure in question provides positive course guidance provided to the runway, the same screwup could be just as evident on an ILS.

How far out were they when cleared for this odd, last minute offset visual? To an unfamiliar crew that would be a huge cheese hole, right there, if it's last minute and unbriefed.

The approach is advertised on the ATIS. The ATIS is digital so they could have known for hundreds of miles or even at the departure gate in Canada if so inclined and concerned enough to look. It is tied into the STAR after the approach is line selected (closing the discon, perhaps different on your jet). The instructions from SFO TRACON on initial contact are at ARCHI, join the FMS Bridge routing and only after sighting certain bridges and the airport are they cleared for the approach. From first hand experience, this isn't a particularly challenging procedure to fly having done so numerous times and the routing drops you exactly on CL with VNAV all the way down. AC aren't infrequent visitors to SFO either.

WillowRun 6-3

13th Jul 2017, 16:51

Its called compromise, it's how society generally functions. Believe it or not, and contrary o the belief of many here, aviation is not the single most important priority in the world, and does not have to be satisfied first at all times before any other decisions can be made, which must be made in deference to the wishes a few pilots on the internet.

Noise regulations generally strike a good balance between airports operating efficiently and not causing unnecessary disturbance. What can be wrong with that unless you just get a kick out of annoying people? In which case you probably haven't reached the metal age to be flying a plane.

Well, then, let's all sign off our call signs and just go home. And if we're taking a civil air transport flown by an ATP to get there, let's not worry whether noise abatement restrictions have a statistical, or unquantifiable but nonetheless real, detrimental impact on safety. After all, the whole Swiss cheese model, why, that's just the concoction of a "few pilots on the internet." :ugh:

DaveReidUK

13th Jul 2017, 17:16

neila83

13th Jul 2017, 17:40

WillowRun 6-3

13th Jul 2017, 18:02

About angled approach to KSFO 28R - I'm making no claim about current approach designs at all (and also, not claiming that D-R-UK is wrong). The noise abatement factor had been raised by other poster(s) in context of visual approach at night under certain conditions. If that association does not exist in fact, then nothing about differing points of view regarding different approach designs or their components should have elicited any comments about noise abatement (including mine).
As to whether noise abatement as such is relevant, I disagree, neila83. I can make no claim about this incident's causes, but I'll take your word for it (unless and until some future analysis of the airspace architecture reveals that concern for noise abatement compliance yielded a suboptimal approach design). But the lack of an incident where abatement was a contributing factor is just a nice historical fact. As airspace gets more and more heavily utilized, and as complications of CRM, automation of the flight deck, fatigue, and other factors threaten to drill into the Swiss cheese with greater and greater impact, I don't agree that past compromises necessarily are a template for contemporary and near-future decisions. After all, isn't the reasonableness of the compromises being saluted undermined to some extent (not completely) by the simple fact that very nearly everyone who complains about airport noise knew the airport was there before they moved close to it?

ZOOKER

13th Jul 2017, 18:10

With all the technology we have at our disposal today, ('Go-Pro/High Res' Cameras, cockpit display screens, electronic flight bags, etc), surely it should be possible to provide crews with visual data, annotated as necessary, in addition to the charts which you obviously have to have.
It surely wouldn't be difficult to photograph each R/W approach from, say, 2 or 3 points on the centre-line, downwind, base-leg or whatever, in day/night and VMC/IMC, under the heading of...'This is what it will look like when you're lined up, or bang out of cloud.
O.K., you might not need it for every R/W at every airfield, just the ones where confusion may occur or has done in the past.
It's often said that 'a picture is worth a thousand words', and the acquisition of a library of visual images would be easy and relatively cheap to assemble. Just put a few cameras in cockpits for a month, and it's done.

martinprice

13th Jul 2017, 18:22

This incident has nothing whatsoever to do with noise abatement. As a society we constantly deal in levels of risk and decide what is acceptable. Given there hasn't been an incident as far as I'm aware in the history of aviation where noise abatement was considered a contributing factor, perhaps they've got it right?

There's one that I'm aware of - a Saratoga vs a Skyhawk at Oakland 30 years ago, although the noise abatement procedures at the time were put in place without FAA approval. Not particularly relevant to this case but it was a contributing factor. More background at '87 Oakland Midair (http://www.check-six.com/Crash_Sites/1987-Oakland-Midair.htm)

+TSRA

13th Jul 2017, 18:46

With all the technology we have at our disposal today, ('Go-Pro/High Res' Cameras, cockpit display screens, electronic flight bags, etc), surely it should be possible to provide crews with visual data, annotated as necessary, in addition to the charts which you obviously have to have.

This is already done by Jepp for a number of different airports if one cares to go that deep into the charts. As you mentioned, it is not done for all runways, but certainly is done for those runways I operate to where a little more "heads up" on the local area is advised.

However, I wonder whether such a chart would have done any good, as the pictures I've seen in the Jepps are always taken during daylight and could not cover all the variables of different airport, city, and sky lighting conditions. A picture does cover a thousand words, but only if those are the thousand words you're looking for.

.Scott

13th Jul 2017, 18:56

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

I can only imagine that he didn't know that 28L was out so deduced the two things he was seeing were 28L and 28R when they were actually 28R and Charlie. Is there any other possibility that I am not considering?

If so, this doesn't have anything to do with noise abatement.

jurassicjockey

13th Jul 2017, 19:29

I'm also surprised they could see a/c lights hidden in all the airport lighting. They would have been 2 candle power compared to what was surrounding them.

Helps that a couple of the taxi a/c were 87s. That beacon stands out like nothing else

ZOOKER

13th Jul 2017, 21:17

There seems to be some confusion regarding the serviceability or otherwise, of the approach lighting systems for 28R and 28L at the time this event occurred.
In The U.K., any failure, or irregular functioning of approach-aids, constitutes 'Essential Aerodrome Information', and 'shall' be passed to aircraft, by Aerodrome Control' The use of 'shall', means a mandatory instruction.
Notwithstanding the possible promulgation by NOTAM, the information is usually re-inforced by transmission to each individual a/c, or by inclusion on the arrival ATIS. Was this done, I wonder?

O.K, I know that USA and U.K. ATC systems operate differently, but, someone is bound to say that 'lessons will be learned'.

Earlier on in the discussion, someone mentioned the responsibility of the TWR controller, regarding 'looking out of the window'. When I started my ADC training, it was drummed into us that it was essential. It's where the action is.
Having said that, I've never been to KSFO, but looking at the charts, the angle of view and distance, to the 28 thresholds, might make detection of an errant approach to either R/W, or it's parallel taxiway, difficult to detect without the use of in-VCR technology.

Bleve

13th Jul 2017, 21:27

Correct me if I'm wrong, but the angled approach to KSFO 28R has nothing to do with noise abatement and everything to do with the fact that you can't fly simultaneous IFR parallel approaches to two runways that are only separated by 750'.

Maybe, maybe not. The 'FMS Bridge Visual' approach is the FMS version of the 'QUIET Bridge Visual' approach (they have the same ground track). QUIET in the name strongly suggests noise abatement. Of course the approach may also provide the ability to fly simultaneous approaches as you suggest. But in this case 28L was closed, so the only approaches were to a single runway (28R). And yet they were still cleared via the equivalent of the 'QUIET Bridge Visual' approach and not the ILS. Excuse the pun, but that 'sounds' like noise abatement was a factor.

ZOOKER

13th Jul 2017, 21:48

Bieve,
Or could the 'QUIET' designation mean that the airport is relatively quiet, due to a lack of traffic, and therefore nothing is happening on 28L?

JuniorMan

13th Jul 2017, 22:52

Maybe, maybe not. The 'FMS Bridge Visual' approach is the FMS version of the 'QUIET Bridge Visual' approach (they have the same ground track). QUIET in the name strongly suggests noise abatement. Of course the approach may also provide the ability to fly simultaneous approaches as you suggest. But in this case 28L was closed, so the only approaches were to a single runway (28R). And yet they were still cleared via the equivalent of the 'QUIET Bridge Visual' approach and not the ILS. Excuse the pun, but that 'sounds' like noise abatement was a factor.

Also might have something to do with arrivals and departures into SJC and OAK. I know when we are in the transition from the DYMND 3 arrival to the FMS Bridge Visual, traffic landing in OAK are below us and traffic departing SJC make an immediate right turn and are just west of us. The step down altitudes keep us above OAK arrivals, the offset keeps us clear of aircraft departing SJC.

jack11111

13th Jul 2017, 23:17

How can one mistake 28 left is closed or not...there's a big lighted "X" on the threshold.

ACMS

14th Jul 2017, 03:19

Cactusbusdrvr:--- fair enough I understand the dive bomb high speed approach into a dark hole over water approach to SFO is quite challenging but maybe now you'll take the bold airmanship step of manually tuning the 28R ILS and selecting the LS push button on. It's the simple things that will save the day and add another layer of safety for just these scenarios.

It might save your ass too from an embarrassing stuff up to something a whole lot worse.

Live and learn.

Oh and "it's works fine that way all the time". Ahhhhhhh, it would seem that is not the case.

AC have dodged a bullet and in doing so have highlighted a problem that needs addressing.

Airbubba

14th Jul 2017, 03:32

Rozy1

14th Jul 2017, 03:34

How can one mistake 28 left is closed or not...there's a big lighted "X" on the threshold.

It's odd that it took 4 pages to mention this. Maybe it's done otherwise in the eu, but unless it was just closed seconds prior, the huge, lighted, white X would have been there.
At the threshold.
Facing east.

DaveReidUK

14th Jul 2017, 06:34

Maybe, maybe not. The 'FMS Bridge Visual' approach is the FMS version of the 'QUIET Bridge Visual' approach (they have the same ground track). QUIET in the name strongly suggests noise abatement. Of course the approach may also provide the ability to fly simultaneous approaches as you suggest. But in this case 28L was closed, so the only approaches were to a single runway (28R). And yet they were still cleared via the equivalent of the 'QUIET Bridge Visual' approach and not the ILS. Excuse the pun, but that 'sounds' like noise abatement was a factor.

OK, point taken. In fact, a bit of digging shows that the airport does actually specify:

"To reduce the impacts of aircraft noise in surrounding communities, particularly between the hours of 2300 and 0700, the Airport encourages the use of the following procedures.

(cut)

(4) Use the Quiet Bridge Approach to Runway 28L/R."

Rules and Regulations: San Francisco International Airport (http://media.flysfo.com.s3.amazonaws.com/media/sfo/about-sfo/sfo_rules_regulations_2017.pdf)

787PIC

14th Jul 2017, 07:00

"Finally a balanced viewpoint instead of sensational nonsense.."

Canadian prelim report:
"The closest lateral proximity between ACA759 and one of the four aircraft on taxiway C was 29 feet."

What is 29 feet between friends? :-)

JumpJumpJump

14th Jul 2017, 07:04

Here is the TSB Canada incident report with the estimates quoted in the media that AC 759 overflew taxiway C for a quarter of a mile before the tower called the go around and they missed the first two aircraft by 100 feet :eek:.

Thanks for the document AirBubba.

2 observations from this. I'm not being flippant, I am interested to know the purpose of the "unknown" fields in the document. Can the number of unkown injuries ever exceed zero? What exactly is this field used for?

The part (I paraphrase) "The closest lateral distance bectween AC and any aircraft was 29 feet"... Is that distance between the wingtips or distance from cockpit to cockpit, do we also know whether this distance was between C and 28R or on the other side of C from 28R? looking at the photos and video of a landing on 28R at KSFO, you can see four or five sitinct red lights to the right of the frame, given that the aircraft had already passed "over" taxiway C, was the aircraft to the right and heading to these lights?

DaveReidUK

14th Jul 2017, 07:43

do we also know whether this distance was between C and 28R or on the other side of C from 28R?

WebTrak would suggest the former - slightly offset on the runway side of Twy C.

http://www.avgen.com/ACA759(3).jpg

Note that aircraft symbols on WebTrak are generic ones and not specific to type or to scale.

West Coast

14th Jul 2017, 07:58

https://www.flysfo.com/community/noise-abatement/noise-abatement-procedures

The tab above noise abatement also touches on the Bridge/FMS Bridge visual.

portmanteau

14th Jul 2017, 09:32

TSB report and ATC tape differ. Interim report by NTSB within 30 days will be interesting.

ExXB

14th Jul 2017, 10:51

From NavCan. TSB Report#A17F0159: C-FKCK, an Airbus 320-200 aircraft operated by Air Canada, was conducting flight ACA759 from Toronto, ON (CYYZ) to San Francisco, CA (KSFO). As the aircraft was on a visual approach to Runway 28R at KSFO, ATC cleared ACA759 to land. Approximately 0.6 nautical mile from the runway threshold, the flight crew asked ATC to confirm the landing clearance for Runway 28R because they were seeing lights. ATC responded in the affirmative, and re-cleared ACA759 to land on Runway 28R. The controller was coordinating with another facility when a flight crew member from another airline taxiing on Taxiway C queried ATC as to where ACA759 was going, then stated that ACA759 appeared to be lined up with Taxiway C which parallels Runway 28R. ACA759 had overflown Taxiway C for approximately 0.25 miles when ATC instructed the aircraft to go around. Four aircraft were positioned on Taxiway C at the time of the event. It is estimated that ACA759 overflew the first two aircraft by 100 feet, the third one by 200 feet and the last one by 300 feet. The closest lateral proximity between ACA759 and one of the four aircraft on Taxiway C was 29 feet. The NTSB is investigating.
UPDATE: FAA Report: The following information was reported by FAA Washington Operations Centre: On July 7 at 23:56 PST (July 8 2017 at 02:56 EDT) Air Canada flight 759, an Airbus A320 from Toronto (CYYZ) to San Francisco (KSFO) was cleared to land runway 28R and instead line up for Taxiway C which is parallel to the runway. The aircraft overflew United 1 and Philippine Airlines 115 by 100 feet, United 863 by 200 feet and United 1118 by 300 feet before being issued a go around by Air Traffic Control.

Ian W

14th Jul 2017, 11:52

jack11111
How can one mistake 28 left is closed or not...there's a big lighted "X" on the threshold.

It's odd that it took 4 pages to mention this. Maybe it's done otherwise in the eu, but unless it was just closed seconds prior, the huge, lighted, white X would have been there.
At the threshold.
Facing east.

It would really do everyone a lot of good to read about visual perception and visual cognition. Our brains invent a huge amount of what we think we are 'seeing' much of the time our eyes are scanning around but the brain uses the informaiton from the balance system to edit out the movements of the eyes (see http://thebrain.mcgill.ca/flash/capsules/pdf_articles/type_eye_movement.pdf )

In these studies, observers engage in a continuous task that requires them to focus on one aspect of a dynamic scene while ignoring others. At some point during the task an unexpected event occurs, but the majority of observers do not report seeing it even though it is clearly visible to observers not engaged in the concurrent task

(See http://www.drjoebio.com/uploads/1/8/1/3/1813500/gorrila_in_our_midst.pdf )

The above paper includes the well known cognition experiment where a basket ball game is played back on video and observers asked to count the number of passes as the game goes on a person wearing a gorilla suit walks through the players across the screen - the gorilla is almost never noticed.

I remember from a long time ago an incident where an aircraft taxiing taxied into a large red British post office truck lost on the taxiway - the pilot 'didn't see it'

There are two effects here - something that is unexpected may be edited out by the cognition process in the brain that includes extra things happening or seeing things happen because they are expected to happen. So I expect to see 2 runways so I see 2 runways, I do not expect to see a large red cross - so I see no large red cross.

Add to this the effect of workload on a challenging approach that tends to lead to 'cognitive tunneling' or fixation on particular tasks and it is unsurprising that what should be obvious is not. All of these effects are exacerbated by fatigue and circadian stress making them far more likely.

It is really worth reading the two references and other similar references to understand what can _and_will_ happen to you.

It is important that ANSPs also realize that reliance on 'large red flashing crosses' will not work. Indeed the more attention getting it is the more likely the brain is to edit it out like the gorilla in a basket ball game. Therefore, the ANSPs that insist that the tower verbally reinforce the warning that the runway configuration is different have got it right - all of a sudden the red-cross is expected and it will be seen.

Don't fly into any gorillas :ok:

DaveReidUK

14th Jul 2017, 11:57

The TSB and FAA reports are subtly different.

The TSB reports that the aircraft had overflown Twy C for around a quarter of a mile at the point when ATC instructed a GA.

The FAA state that the A320 had passed over all four queuing aircraft before being told to GA.

That may or may not amount to the same thing, although if FR24 is to be believed there was about 0.4 miles between the first and last queuing aircraft at the point where the ACA flew over (UAL1 was just about to turn the corner towards the threshold and UAL1118 was just past the November link).

That aside, given that both reports confirm the A320 was already climbing by the time it overflew the third aircraft in the queue, it's clear that the GA was instigated by the pilot before the ATC instruction was given. That's consistent with the ATC recording:

SFO Tower: "Air Canada, go around."

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

Bergerie1

14th Jul 2017, 12:24

Ian W,

You speak great sense. Whether or not the illusions you describe are applicable in this incident, it behoves all pilots to study the types of visual illusions that can occur when flying. Take a look at this:-

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

.Scott

14th Jul 2017, 12:39

Considering these three things:
1) From his remarks, the pilot was observing Charlie closely - seeing what he believed was traffic on that "runway".
2) Images were posted earlier in this thread of roughly what might be seen from the cockpit. Those images should have made the runway situation very clear to the pilot.
3) Before the go around was issued, the pilot had already overflown a quarter mile of runway.

I don't see an easy explanation for this. But here is my best guess:
On first siting of the runways, at long distance, the pilot mis-identified Charlie as 28R. He also saw traffic on that runway. From that point on, he was focused on the status of that traffic. In his mindset, it was more important to resolve the traffic issue that to further peruse the overall runway pattern. (Per a previous post, he wasn't looking for the guerrillas.)

At a certain point on his approach, he decided that the traffic might not resolve in time for his landing - so he informed the tower of the traffic - and was recleared for the landing.

He have had a rapidly improving view of the traffic of Charlie - so it is unlikely (or impossible) at that point that he would have resolved to land. Quite the contrary, he must have been very alarmed at the tower response. It probably indicated to him that they were completely unreliable.

By the time the other craft alerted the tower of the Charlie approach, 759 had no intention of landing and the go around was already in progress. But at that point, he still had a problem: he didn't not know what clearance the other traffic on "28R" (ie, Charlie) had received or would soon receive. So his close approach to the runway was likely intentional - for the purpose of keeping his avoidance options open and to see and be seen.

aterpster

14th Jul 2017, 13:06

So his close approach to the runway was likely intentional - for the purpose of keeping his avoidance options open and to see and be seen.

That does not compute.

.Scott

14th Jul 2017, 13:21

By my guess: It was intentional in the sense that he had a plan for avoiding traffic - and was following it fairly accurately. And the plan was formulated well before he reached the runway threshold.

roybert

14th Jul 2017, 13:39

Scott As a non pilot but former flight engineer your speaking gobbly gook. From what I've read his intention was to land plain and simple.

lomapaseo

14th Jul 2017, 13:55

roybert

I believe that human minds do not work "plain and simple" in order to fly safely.

I support the issues mentioned by Ian W above.

standbykid

14th Jul 2017, 14:15

The crew were lined up with the wrong 'runway' crossing the threshold. Went around successfully. Corrected pilot error. Mitigating circumstances TBD.

DIBO

14th Jul 2017, 14:19

But at that point, he still had a problem: he didn't not know what clearance the other traffic on "28R" (ie, Charlie) had received or would soon receive.
I'm pretty sure that was not one of his problems while initiating the go-around. They were all on the ground and none of them was pointing West.
However they were all too close for comfort...
So his close approach to the runway was likely intentional - for the purpose of keeping his avoidance options open and to see and be seen.Seriously? Give the man some credit!

Airbubba

14th Jul 2017, 14:36

TSB report and ATC tape differ. Interim report by NTSB within 30 days will be interesting.

How do the TSB report and ATC tape differ?

Does the NTSB issue an interim report within 30 days?

RAT 5

14th Jul 2017, 15:33

Before the go around was issued, the pilot had already overflown a quarter mile of runway.

Whether the GA was pilot induced or ATC induced is a debate. The above statement/report causes me a question. (Thanks to those who posted the diagrams. Early in the post there were people talking about 28L, 28C & 28R, I thought. My mistake, as we now see C is to the outside of 28R and not between.)
The threshold 28R and the beginning of taxi C are side by side; or is there a heavily displaced rwy threshold. I've asked what was the PF using for glide path guidance. If it was the ILS 28R then the LLZ deviation should have alerted PF & PM: if it was the PAPI then they are on the left edge of 28R. If AC overflew the taxiway for 400m BEFORE the GA, and at a low height, and if they were on the correct glide path to land the correct distance in, it suggests they flew level for 3-400m. That in itself is an odd manoeuvre. I've missed something earlier. how far down the taxiway were the holding a/c? Were they taking full length or an intersection? If the AC initiated the GA at 100', but after 400m down the taxiway, where was the touchdown aiming point? And at that point the holding a/c must have been very visible.
What happens in USA after an incident like this? Is there an immediate debrief of the crew on site by an FAA or airport official? I'm assuming they night-stopped; is that correct?

aterpster

14th Jul 2017, 15:54

How do the TSB report and ATC tape differ?

Does the NTSB issue an interim report within 30 days?
News to me. NTSB investigated last December 16th EVA's near-CFIT departing LAX. As of this date nothing has been released. The NTSB is under no obligation to issue incident findings or reports. (The FOIA can force them to release to an individual.)

Do we know whether the NTSB is even looking at this SFO incident?

DaveReidUK

14th Jul 2017, 16:10

Whether the GA was pilot induced or ATC induced is a debate.

No, it isn't. We know (from the TSB report) that the aircraft was already climbing when the controller instructed a GA.

The threshold 28R and the beginning of taxi C are side by side; or is there a heavily displaced rwy threshold.No significantly displaced threshold according to Google Earth or the airport chart.

If AC overflew the taxiway for 400m BEFORE the GA, and at a low height, and if they were on the correct glide path to land the correct distance in, it suggests they flew level for 3-400m.See above. We don't know at what point the pilot initiated the GA, and we're unlikely to until we see the final report. But we DO know from the TSB that the aircraft had established a positive ROC by the time it overflew UAL863 (the third aircraft in the queue) and maybe even before that. It looks like the heights being quoted have a ±50' resolution, so it may even have been climbing by the time it passed over the second or even the first aircraft (which, scarily, would suggest that it may have been even lower than 100' at that point).

Were they taking full length or an intersection?See my previous post. Subject to the usual FR24 caveats, all 4 aircraft in the queue had passed the last link (November) that would have permitted an intersection takeoff.

Propellerhead

14th Jul 2017, 16:26

Clearly a serious incident but clearly not the first crew to have done it. Quite a few US airports have multiple parallel runways and wide taxiways that can be confused (Las Vegas springs to mind). Confirmation bias of seeing only 1 lit runway to the left. Not all runways have approach lights and centreline lights so a taxiway can look a bit like a runway. The ILS probably wouldn't be tuned as think it's an RNAV type approach.

In some ways I find it harder in daylight into a setting sun to distinguish runways and taxiways, especially as the lights are hard to see then. San Diego has a centre stripe down the middle of the runway which is a different texture which makes it look like a taxiway until you see it has another section either side.

The newest Boeings have RAAS which tells you what you're lined up with on final approach and would warn you if lined up with a taxiway, so technology is catching up.

WillowRun 6-3

14th Jul 2017, 17:19

" . . .so technology is catching up."

Well, that's really cool, cool tech kit. Except.....what percentage of Air Transport category aircraft will be equipped with it, at specified time intervals, say, 1 year, 3 years, and so on? I read somewhere (not on the internet) that something called "technological de-alignment" is occurring globally, in other words, the tech-rich are getting richer and the out-of-date getting more decrepit. Technologically speaking, that is.

TRW Plus

14th Jul 2017, 17:26

I wonder if it would be feasible to change the taxiway lighting plan to have the letter T formed by sets of lights along taxiways? That would require adding lights to the existing lights so that the letter T was clearly visible to landing pilots (don't head for tea might be the motto).

Different rates of flashing might also assist with the colour code clearly not doing the job with 100% effectiveness. I intend these suggestions for all airports not just SFO.

Final suggestion, some change to the take-off-ready light signals from waiting aircraft. Pilots would soon get used to the different look of taxiways and this might prevent an accident like this near miss.

What if the lighting appeared like this?

L L ]] T T
L L :: T T
L L :: T T
L L :: T T

or even flat ground-level electronic signs embedded in ground at runway and taxiway end points saying RUNWAY and TAXIWAY in large enough script to be readable from half a mile ... only pilots flying could see these, no visual distraction to aircraft taking off. Should give enough warning to go around even if nobody else is aware. (or make a lane change) :hmm:

JumpJumpJump

14th Jul 2017, 17:47

wiedehopf

14th Jul 2017, 17:53

@trw

if anything i'd rather have flashing leadin lights for every runway.
way easier to implement ...

Eric Janson

14th Jul 2017, 18:05

@trw

There is already a huge difference in runway lighting vs. taxiway lighting.

This is even more obvious at night.

Not sure how you can confuse them but it's obviously possible.

Ian W

14th Jul 2017, 18:09

It's been done literally hundreds of times in the US alone.

Propellerhead

14th Jul 2017, 18:15

Well if the regulators deem it a big enough threat then it could be mandated that all air transport aircraft be fitted with RAAS or equivalent. Of course that costs the airlines money.....

llondel

14th Jul 2017, 18:39

I assume the CVR will be the biggest clue here, even if NTSB are the only people to listen to it. That ought to capture the decision-making process in the cockpit, when the crew had the first WTF? moment and when they decided it was going pear-shaped and hit the TOGA button.

ortotrotel

14th Jul 2017, 18:53

I don't understand how you can line up on a taxiway with blue lights, narrower, and no approach lights, instead of a RUNWAY with white lights, center-line lighting, wider, and approach lighting which the crew would have reviewed before landing...?

And after they were told there's no other aircraft on the runway, is there no lightbulb moment flashing?

There doesn't seem to be anything in the thread about how long they had been flying/on duty, fatigued, or at the end of a stressful day. Anyone have info on that?

JumpJumpJump

14th Jul 2017, 19:07

..... the old saying... there are two types of pilot..... those that have never [insert] those that will [insert] ...........

...... there will be another gear up landing in the next 6 months

wingview

14th Jul 2017, 19:10

What I don't understand is that both of the FC must have had a unhappy feeling to say the least. Why not GA at that time? Same for ATC!

Bergerie1

14th Jul 2017, 19:18

It is surprising how easy it is to misperceive what is right in front of you. Sometimes, even the obvious is not obvious. When under a high workload, or under stress, you perceive what you want to see regardless of the visual evidence.

I think that many aviators have experienced this, usually without a bad result. There are many tricks that can be used to help you but, in the hurly-burly of the real world it is not always easy to apply them.

I think we should wait until the aviation psychologists have had something to say about this one.

Airbubba

14th Jul 2017, 19:27

Do we know whether the NTSB is even looking at this SFO incident?

Yep, they are:

Don't know about the TSB but the NTSB is certainly going to take a look:

@NTSB_Newsroom

NTSB investigating last Friday’s incident involving an Air Canada Airbus A320 at San Francisco Airport.
5:58 AM - 12 Jul 2017

https://twitter.com/NTSB_Newsroom/status/885121284513959936

What happens in USA after an incident like this? Is there an immediate debrief of the crew on site by an FAA or airport official? I'm assuming they night-stopped; is that correct?

Some personal speculation on how things may have played out last weekend:

My guess is that after midnight Friday evening you're not going to have a lot of feds in the SFO office even if a report was immediately filed. The tower probably filled out an incident report but it may not have been seen until Monday morning when the media started calling about reports of the incident based on radio transmissions monitored by 'ham radio operators'.

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

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

I assume the CVR will be the biggest clue here, even if NTSB are the only people to listen to it. That ought to capture the decision-making process in the cockpit, when the crew had the first WTF? moment and when they decided it was going pear-shaped and hit the TOGA button.

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.

deSitter

14th Jul 2017, 19:34

You guys who drive are missing the point that only you can clarify - as OldLurker pointed out, these guys were fixated on an unreal situation and it has happened before. It most likely has to do with fatigue or just being up at the wrong bio-cycle. How is it possible to fixate on a situation and not take in the evidence? How did Comair Lexington happen? How did Air France remained stalled for 38,000 feet? I can't believe that among 3 experienced pilots, no one understood how to recover from a stall. Has anything similar ever happened to one of you?

DIBO

14th Jul 2017, 20:08

What I don't understand is that both of the FC must have had a unhappy feeling to say the least. Why not GA at that time? Same for ATC!They possibly had that moment when they sought confirmation/clarification with SFO TWR. And given that the answer received (ATC did not yet have a clue on what was going on), probably only added to their confusion, the FC surely must now regret their decision to query TWR io. initiating the G/A, as at 0.6 miles out that would have saved their day...

BluSdUp

14th Jul 2017, 20:19

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

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

Kal Niranjan

14th Jul 2017, 20:28

jack11111

It would really do everyone a lot of good to read about visual perception and visual cognition. Our brains invent a huge amount of what we think we are 'seeing' much of the time our eyes are scanning around but the brain uses the informaiton from the balance system to edit out the movements of the eyes (see http://thebrain.mcgill.ca/flash/capsules/pdf_articles/type_eye_movement.pdf )

(See http://www.drjoebio.com/uploads/1/8/1/3/1813500/gorrila_in_our_midst.pdf )

The above paper includes the well known cognition experiment where a basket ball game is played back on video and observers asked to count the number of passes as the game goes on a person wearing a gorilla suit walks through the players across the screen - the gorilla is almost never noticed.

I remember from a long time ago an incident where an aircraft taxiing taxied into a large red British post office truck lost on the taxiway - the pilot 'didn't see it'

There are two effects here - something that is unexpected may be edited out by the cognition process in the brain that includes extra things happening or seeing things happen because they are expected to happen. So I expect to see 2 runways so I see 2 runways, I do not expect to see a large red cross - so I see no large red cross.

Add to this the effect of workload on a challenging approach that tends to lead to 'cognitive tunneling' or fixation on particular tasks and it is unsurprising that what should be obvious is not. All of these effects are exacerbated by fatigue and circadian stress making them far more likely.

It is really worth reading the two references and other similar references to understand what can _and_will_ happen to you.

It is important that ANSPs also realize that reliance on 'large red flashing crosses' will not work. Indeed the more attention getting it is the more likely the brain is to edit it out like the gorilla in a basket ball game. Therefore, the ANSPs that insist that the tower verbally reinforce the warning that the runway configuration is different have got it right - all of a sudden the red-cross is expected and it will be seen.

Don't fly into any gorillas :ok:

Wow you are all so knowledgeable and so very kind.

Had this incident happened to a non western carrier, the amount of scorn and racial insinuations would have been thunderously deafening! ' nuff said.

WillowRun 6-3

14th Jul 2017, 20:39

1. Precise and verified (as verified as possible) facts are not yet in hand - hopefully NTSB as well as TSB will produce. Sorry to be repeating a forum cliche in this sense. Yet this seems to need to be said, not so much because of various differing emphasis by knowledgeable posters about technical details - rather more due to a basic divergence, with some tending to take a view that "the system worked" (my paraphrasing) even despite evidence that the point of collision-no-return was looming imminent - or so it seems. Report, or Reports, we need these.
2. If. If the CVR could have been ditched - and I deplore, hate and loath having to imply fault or blame on the aviators - but IF they made things so that the CVR evidence no longer is available....wow. Big problem. If I were Civil Aviation Czar for a week, I'd get an immediate amendment to anything and everything to prevent this from taking place again (the CVR tamper, I mean).

PAXboy

14th Jul 2017, 20:43

JumpJumpJump

Here is the TSB Canada incident report ...

Thanks for the document AirBubba.

I'm not being flippant, I am interested to know the purpose of the "unknown" fields in the document. Can the number of unkown injuries ever exceed zero? What exactly is this field used for?It is true that the number of people on board aircraft is normally known. So, the Unknown field is for when an a/c collides with that famous school building or a large tower in the middle of a city. You can never know exactly how many people are in the school/offices/flats at impact as people might be visiting, be there illegally and so on.

Currently, in the UK, there are investigations of a terrible fire in a London block of flats that destroyed the building - the number of deaths will only ever be "At least nn" because no one knows who was there and some bodies will be far beyond recognition.

portmanteau

14th Jul 2017, 20:47

airbubba, by now you will have seen the posts between mine and yours. The impression given by ATC is that they instructed 759 to go around while still on the approach (thus averting a calamity). Not so according to TSB who say 759 was already overshooting and had passed over 0.25 miles of Twy C before ATC issued their go around call. Thus 759 was at least in control of his recovery actions. No criticism of ATC, theres not much else (useful) that you can say to an aircraft climbing out over a crowded taxiway.
Re expected report. We have been here before, Emirates, Lamia etc. Dont tell me the US does not comply with ICAO annex 13? Overshooting runway is an investigatable event and a Preliminary report ( not Interim) is mandated within 30 days. It won't apportion blame as per usual, just the facts , man. This is no ordinary overshoot of course and we would all really like to know how it came about.

Airbubba

14th Jul 2017, 20:58

airbubba Dont tell me the US does not comply with ICAO annex 13? Overshooting runway is an investigatable event and a Preliminary report ( not Interim) is mandated within 30 days.

Well, maybe they do it that way in England or wherever but I'm not rightly sure that's how it works here in America.

As aterpster says about that 30 day NTSB report:

News to me. NTSB investigated last December 16th EVA's near-CFIT departing LAX. As of this date nothing has been released. The NTSB is under no obligation to issue incident findings or reports. (The FOIA can force them to release to an individual.)

Maybe Canada will issue a 30 day report, can you find an example of one issued by the NTSB?

West Coast

14th Jul 2017, 21:50

To be clear on terms, if only for me, over shooting being the same as a go around and/or a missed approach?

DaveReidUK

14th Jul 2017, 22:02

Maybe Canada will issue a 30 day report, can you find an example of one issued by the NTSB?

Now that the NTSB has launched an investigation, the Canadian TSB's involvement will be as an accredited party to the investigation (as the domicile of the airline involved).

Protocol dictates that any further release of information will come from the NTSB.

Loose rivets

14th Jul 2017, 22:32

Summing feueraxt's pictures (taxiway with no traffic) #131 and the mental imagery of hilliard's post #138 suggesting aircraft lights on the taxiway might make a difference, I think this is where the answer lies.

There has to be some reason that not one, but two experienced crew fell for this imagery. Some kind of visual psychological trap.

As I said,

*When Tower said they had 28R to themselves, you could hear the continuing hint of bewilderment in the reply.

pilot9249

14th Jul 2017, 22:37

No criticism of ATC, theres not much else (useful) that you can say to an aircraft climbing out over a crowded taxiway.

No criticism from me either, but I do wonder whether "Go around" would have been a better response than "Yes you are still cleared" when the aircraft reported that they weren't seeing on the ground what the controller would expect them to see.

Could it have been a runway incursion?

"Maintain runway heading and climb X" would at least have allowed time to diagnose the discrepancy.

This controller, who isn't to blame, just failed an intuition test.

Is it at all possible they were just too darned busy to add any superior value, leaving them acting as nothing more than a slow computer?

WillowRun 6-3

14th Jul 2017, 23:58

"Had this incident happened to a non western carrier, the amount of scorn and racial insinuations would have been thunderously deafening!"

Oh really now, Kal Niranjan. It would be easier just to say, when any particular "non Western" carrier you would care to name in particular, one which has in your view been subject to scorn, insinuations and so on (whether "thunderously deafening" or otherwise), compiles an overall safety record and a set of managerial and technical leadership qualities in the safety realm comparable to Air Canada, then maybe you could gripe. But that would be too easy; I like the challenge. When a "non Western" carrier fouls up, and it happens to be in a system, country or culture where substandard practices, lack of standard English, training and/or operational deficiencies, and other gross or significant deviations from SARPs are the norm, pointing these deviations out is not scornful or racism. If you think so, I certainly would enjoy learning about your educational background. Something clearly was missed. (I post this out of a sense of defending the forum, against your too-easily muttered bromides, which are nonsense - despite the stray or occasional off-point remark of a poster now or again.)

RAT 5

15th Jul 2017, 00:57

It would really do everyone a lot of good to read about visual perception and visual cognition.

I can understand PF becoming fixated on seeing what they wanted to see and not noticing 'the gorilla'. PM's brain is not so fixated and I'd expect more relaxed and neutral. PM is not being coached by PF into seeing the same thing. Therefore I'd expect PM to chirp up quite early on and challenge PF about where they were landing. But that brings the CVR back into the equation, and crew memory after the event.

There has to be some reason that not one, but two experienced crew fell for this imagery.

Indeed. That was also my curiosity, hence my comment above. There should have been 2 independent minds observing this event. I'm still curious whether they were in manual or autopilot flight down to e.g. 1000', and what guidance they were following. The report should discover that.

Airbubba

15th Jul 2017, 02:43

Now Captain Aimer says that AC 759 was 'less than a second from a disaster'. :eek:

The article linked below has a graphic showing UA 1 holding past the Cat I hold line :confused: and says 'the flight came within just 29 feet of one plane'.

Anyway, looks like this incident might not get swept under the rug with the media attention.

"Less than a second from disaster"; New details on near-collision at SFO

By Kris Van Cleave CBS News July 14, 2017, 7:13 PM

WASHINGTON -- It could have been one of the worst aviation disasters in history.

Last Friday night, an Air Canada flight lined up to land on a taxiway in San Francisco where four other airliners were waiting to take off. It pulled up just in time.

On Friday, Canada's Transportation Safety Board said early indications are the flight came within just 29 feet of one plane and "overflew the first two aircraft by 100 feet."

"We're talking less than a second from a disaster," said Ross Aimer, a retired airline captain and CEO of Aero Consulting Experts.

"Less than a second from disaster"; New details on near-collision at SFO - CBS News (http://www.cbsnews.com/news/less-than-a-second-from-disaster-new-details-on-near-collision-at-sfo/)

cappt

15th Jul 2017, 03:39

Flew into KSFO last night. Taxiway C has really bright green centerline lights, they are probably LED, they can appear white from a distance. With 28L dark (no approach lights and no centerline lights) the visual illusion of 28R being 28L and C being the 28R is certainly possible as has been demonstrated.
I'm not saying that's what happened, just relating what it looks like.

SDVFR

15th Jul 2017, 03:55

Why was there no giant white flashing "X" at the threshold of 28L? I've seen these several times at various GA airports; do large international airports not use them?

Airbubba

15th Jul 2017, 04:13

Why was there no giant white flashing "X" at the threshold of 28L? I've seen these several times at various GA airports; do large international airports not use them?

From an earlier post on this thread, emphasis mine:

From the Mercury News article "’11 seconds to impact’: Expert calculates how close SFO near-miss was to disaster" :eek::

Pilots receive NOTAMS — notices to pilots — regularly alerting them to closed runways or other changes in normal flight procedures, and Air Canada would have dispatchers alerting their pilots of a closed runway, Trescott said.

SFO spokesman Doug Yakel said that Runway 28L closed down at 10 p.m. Friday [isn't 0600Z 11 p.m. in SFO? -Airbubba], about two hours before Air Canada was scheduled to land. A NOTAM was sent alerting pilots of the closure until 7 a.m. Saturday [8 a.m. local?], and the airport had a large, flashing “X” at the landing area to reinforce the closure, he said.

The FAA and NTSB, which have launched investigations into the event, declined to provide further details of the incident Wednesday.

“We may have investigators in the Bay Area within the next few days,” said NTSB spokesman Keith Holloway. “It is possible that part of the NTSB investigation going forward will be to review (air traffic control) procedures and practices for that airport.”

SFO near-miss: Air Canada pulled up with 11 seconds to spare (http://www.mercurynews.com/2017/07/12/11-seconds-to-impact-expert-calculates-just-how-close-air-canada-plane-at-sfo-was-to-disaster/)

_Phoenix

15th Jul 2017, 04:28

I can understand PF becoming fixated on seeing what they wanted to see and not noticing 'the gorilla'. PM's brain is not so fixated and I'd expect more relaxed and neutral.
I don't understand how you can line up on a taxiway….
IAN W wrote a very good post # 167 about cognition experiment and Bergerie1 posted the video. Worth to see it, you’ll see the gorilla, but…
https://www.youtube.com/watch?v=IGQmdoK_ZfY

This incident must be related to visual perception and visual cognition.
The players start the passes:
altimeter set, speed brake armed, flaps position, lights on, so on…
They expect to see two runways, so from far they see two lines of lights as expected. Then oops!! PF see a gorilla, strobe lights stand out from the 28R runway. He talks to PM, but he sees three gorillas. They continue passing the ball: gear down, flaps full, but keep the eyes on the gorillas, the curtain color change from bright white light to green lights, the PAPI is leaving the scene but nobody notice. The gorillas are four now and the time of the game is running out fast: "Tower, just want to confirm [for you, because for us is pretty clear] This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?” “Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you." “OK, [if you insist, let’s buzz them a little], Air Canada 759”

Kewbick

15th Jul 2017, 06:17

Still?.... Eleven pages on this nearly non-incident.. Gawd! Get a life!!! Please move on train spotters...

DaveReidUK

15th Jul 2017, 06:52

Still?.... Eleven pages on this nearly non-incident..

Don't despair old boy, help is at hand. :O

http://www.avgen.com/Postsperpage.jpg

portmanteau

15th Jul 2017, 08:10

National Transportation Safety Board Aviation Incident Preliminary Report
Location:
Date & Time:
Aircraft:
Flight Conducted Under:
San Francisco, CA 07/07/2017, 2356 PDT AIRBUS 320
Part 129: Foreign
Incident Number: Registration: Injuries:
DCA17IA148 C-FKUK N/A
On July 7, 2017, about 2356 Pacific daylight time, Air Canada flight 759, an Airbus A-320, C- FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), San Francisco, California, but instead lined up on parallel taxiway C, which had four air carrier airplanes on it awaiting takeoff clearance (a Boeing 787 that was first in line followed by an Airbus A340, another Boeing 787, and a Boeing 737). The flight descended below 100 feet above the ground and initiated a go-around after overflying the first airplane on the taxiway. The flight was operating under 14 Code of Federal Regulations Part 129 as an international scheduled passenger flight from Toronto/Lester B. Pearson International Airport, (YYZ), Toronto, Canada. Night visual meteorological conditions prevailed at the time of the incident.
Aircraft and Owner/Operator Information
Aircraft Manufacturer: AIRBUS Registration: C-FKUK
Model/Series: 320 211 Aircraft Category: Airplane
Amateur Built: No
Operator: Air Canada Air Carrier Operating Foreign Air Carrier (129) Certificate:
Page 1 of 2 DCA17IA148
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.
Meteorological Information and Flight Plan
Conditions at Accident Site: Condition of Light:
Observation Facility, Elevation: Observation Time:
Distance from Accident Site: Temperature/Dew Point:
Lowest Cloud Condition: Wind Speed/Gusts, Direction:
Lowest Ceiling: Visibility:
Altimeter Setting: Type of Flight Plan Filed: IFR
Departure Point: Toronto, FN (YYZ) Destination: San Francisco, CA (SFO)
Wreckage and Impact Information
Crew Injuries: N/A Aircraft Damage: None
Passenger Injuries: N/A Aircraft Fire: None
Ground Injuries: N/A Aircraft Explosion: None
Total Injuries: N/A Latitude, Longitude: 37.615278, -122.358056
Administrative Information
Investigator In Charge (IIC): John W Lovell
Additional Participating Persons:
Note: The NTSB traveled to the scene of this incident.
Page 2 of 2 DCA17IA148
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

RAT 5

15th Jul 2017, 08:54

https://s-media-cache-ak0.pinimg.com/736x/6e/e8/30/6ee8300a7abb62fa0aa162a1e7382229--funny-jokes-for-adults-jokes-adult.jpg

As Ian W has enlightened us, we do not always see the reality that is in front of our nose.

This incident must be related to visual perception and visual cognition.
They expect to see two runways, so from far they see two lines of lights as expected. Then oops!!

The official report will shed the light.

DaveReidUK

15th Jul 2017, 08:57

NTSB Preliminary Report in a somewhat more readable format:

2572

AerocatS2A

15th Jul 2017, 08:59

Instead of thinking of new runway lighting layouts, which would induce a huge financial layout. Is there any merit in simply not turning the lights out on a closed runway? There seems to be a lot of speculation with regards to the possible illusions this Crew may have seen..... If both runways were lit, these illusions would most likely have been mitigated.

Then you will be reading a thread about how someone lined up on the wrong runway. It doesn't really matter whether the other runway lights are on or off, just make sure the crews know the status so they can get the right picture in their head. And I don't mean a NOTAM, put it on the ATIS.

DIBO

15th Jul 2017, 09:37

The flight descended below 100 feet above the ground...two important clarifications in one little phrase.

on this nearly non-incident.. at 0.6nm out, it still could have been only that... at below 100ft AGL, with 55ft tails sticking out in rather close proximity, another qualification might be more appropriate.

Regarding LED lighting, it's not just the same light with low power consumption. No idea how these greens look like at a distance, but don't underestimate the side effects of LEDs

F-MANU

15th Jul 2017, 10:40

The flight descended below 100 feet above the ground and initiated a go-around after overflying the first airplane on the taxiway.

NTSB wording sounds like AC759 overflew UA1 below 100ft while descending or floating above the taxiway. And once UA1 was behind them they applied go-around.

What I can't grasp is that UA1 saw AC:
"He's [litterally] on the taxiway !"
But, until flying past UA1, AC didn't noticed that the lights on the "runway" were those of the 4 taxiing A/C ??

Hopefully CVR and FDR were downloaded in time by the authorities.

underfire

15th Jul 2017, 10:51

Do we know whether the NTSB is even looking at this SFO incident?

A pooched AR procedure by a foreign carrier, one would certianly hope so! Especially the AR part.

This 'near miss', 'almost the worst airline crash in history' kindof stories all over the press.

It looks like the heights being quoted have a ±50' resolution,

With the quoted 100' clearance, with accuracy/latency, wheels and tail down a bit..damn

Video from Youtube, not very good, but one can see the runway lights vs taxiway (green lights) pretty clearly at 3:44 This is on Quiet Bridge Visual.
https://youtu.be/O3LTYeZrzH8
http://i63.tinypic.com/1zldmwx.jpg

another night landing
http://i64.tinypic.com/1zc1kdu.jpg

Ian W

15th Jul 2017, 11:15

Wow you are all so knowledgeable and so very kind.

Had this incident happened to a non western carrier, the amount of scorn and racial insinuations would have been thunderously deafening! ' nuff said.

Thanks Kal, not being kind - being realistic. Pilots should all learn from this incident because the same WILL happen to them at some time. Unfortunately, as you will have seen many of the posts on this thread have started with: cannot believe that it is possible for professional pilots etc etc

It is absolutely nothing to do with professionalism or capability it is all to do with cognition and perception - human factors experiments Repeatedly show the brain has limits and cannot work in some ways.

Try to read this post and recite a nursery rhyme and listen to what someone is saying and read it back you cannot. Your brain has only one verbal 'cognitive channel'. A huge amount of research has been carried out in visual perception yet that is all forgotten when airports are designed. Everyone gets a degree of cognitive tunneling (focusing on a problem) when doing something challenging and that is when mis-perception can occur. This has been repeatedly demonstrated in research and happens continually in real life.

_Phoenix

15th Jul 2017, 11:21

Underfire, see the video in post here (http://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo-11.html#post9831275)
I didn't see the curtain changing color (first time, while counting the passes). Second time I was amazed that I missed the curtain as big as the screen size. I'm sure that AC 759 pilots were amazed too during the second approach.

Ian W

15th Jul 2017, 11:32

OK now put a line of widebodies onto that taxiway and you will have a set of wingtip lights that are all around 100ft either side of the center line at close to 300ft apart along the 'taxiway'. Not unlike runway lights on a 200ft wide runway at 300ft intervals......

That is enough to trigger the 'illusion' of it being a runway - then the anti-collision lights on the aircraft would look like someone on the 'runway'.

You are not comparing like with like.

DIBO

15th Jul 2017, 11:54

It looks like the heights being quoted have a ±50' resolutionRaw mode S data (available to NTSB) should have a resolution of 25ft

one can see the runway lights vs taxiway (green lights) pretty clearly at 3:44I'm pretty sure that being perfectly aligned with twy C, might result in a substantial difference in brightness of the green centerline.

...will have a set of wingtip lights ... ... Not unlike runway lightsa couple of reds & greens <-> rwy lights? Nah, don't think so.

Loose rivets

15th Jul 2017, 12:16

This is what I've been trying to get across.

PM is not being coached by PF into seeing the same thing. Therefore I'd expect PM to chirp up quite early on and challenge PF about where they were landing.

But apart from that hesitation in his voice when ATC told him they had the runway - he too seemed locked on to a false reality.

It is absolutely nothing to do with professionalism or capability it is all to do with cognition and perception - human factors experiments Repeatedly show the brain has limits and cannot work in some ways.

IMHO Those rows of aircraft lights fooled them both. Tiredness factor to add perhaps, but despite the magnitude of the incident, my heart goes out to those two guys.

Bergerie1

15th Jul 2017, 12:34

Having studied workload, stress and visual illusions in aviation, I believe Ian W's posts are along the right lines. Under some conditions, human perception can be very fragile. Even the best professionals can be fooled.

BluSdUp

15th Jul 2017, 12:58

Professional pilots tune the ILS and xcheck.
At 500`on loc on gs 2 white 2 read stabelized . PNF : "500 feet continue"
It is simple.
Positive identification, always! If not GA, try again.

Airbubba

15th Jul 2017, 13:48

National Transportation Safety Board Aviation Incident Preliminary Report

I did not know this existed, thanks for finding this portmanteau. :ok:

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

If the CVR wasn't impounded in time, maybe the FDR was. It should have radar altitude data to correlate the descent and go around profiles over the taxiway.

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

There seems to be a consensus that most A320 crews wouldn't tune the ILS for this RNAV approach and even if you did, the data would not be displayed unless you switched approach modes.

I'm guessing that the AC A320 may have had old style radio nav without GPS, does this sound right? You often get map shifts from what I've seen, especially down low in places with higher surrounding terrain like SFO and KIX.

ironbutt57

15th Jul 2017, 13:54

Professional pilots tune the ILS and xcheck.
At 500`on loc on gs 2 white 2 read stabelized . PNF : "500 feet continue"
It is simple.
Positive identification, always! If not GA, try again.

are you familiar with an FMS approach?? it is also flown multiple times daily by many professional pilots

aterpster

15th Jul 2017, 14:15

are you familiar with an FMS approach?? it is also flown multiple times daily by many professional pilots

I flew only one airplane with an FMS, the 767 in its early days. We didn't have an FMS approach procedure at the time. We were required to bring up the ILS on a visual, no different than with the old round-dial airplanes.

In general terms how is an FMS approach set up?

ironbutt57

15th Jul 2017, 14:29

an FMS approach is based on information in it's own database, some provide lateral and vertical guidance, others only lateral...the 767 was different as the ILS could be tuned independently with the tuner on the centre pedestal as I remember, since this particular approach is offset, manually tuning the ILS was probably not a part of their SOPs, it is possible in the Airbus, but generally only used during downgrading of the FMGS system...the FMS approach is displayed as an LNAV track on the nav display..

BluSdUp

15th Jul 2017, 14:39

Iron butt
If you bother to read the thread , you would see I already covered this.
As for your condescending tone, please!
There is few types of approaches invented I have not flown.

As for the specific selection on THIS AC A320 , I would be interested to know what AC mandate for a visual night approach.
I can not recall how any Lnav/vnav approaches are specifically entered and executed, as it is 13 years since I was qualified on A320.

But , any FMS based approach active, it will give you a strong full fly left FD at this point.

Another thing: Who has mapshift these days?

I say again: Visual Night , tune and follow approach aid for runway landing. AP on.

ironbutt57

15th Jul 2017, 14:52

Aterpster asked, I answered, simple...take it as condescending, thats up to you..havent seen any pic of the MCDU of that approach..I can get one...it could well be the database ends prior to the runway...following the ILS for that runway may well put you outside the lateral path for the assigned approach, most likely they would have flown the assigned and published approach which is the "Quiet Bridge" fms approach...slightly offset over the bay for noise abatement procedures..in later stages of the approach it joins the ILS track, but not sure if that late portion is coded into the database, or it's flown "out the window" from that point, so being professional pilots, they did indeed fly their assigned, published approach...

RAT 5

15th Jul 2017, 14:53

I've only flown various Boeings, the latest being B738NG. LNAV/VNAV & RNAV approaches were authorised, BUT any ground based aids that helped confirm the FMS guided approach had to be tuned and monitored as back-up. Why would Airbus not tune and monitor a back-up aid, whether it be manually tuned or automatic? Is not a common standard in aviation to have back-up systems for most critical areas. If there are 2 fuel pumps, 2 hydraulic pumps, 2 braking systems, 2 gear & flap systems, 2 pilots......then why not have 2 independent NAV systems in use if they are available? Why rely on only 1 to bring you in close proximity with a concrete grave?

Shore Guy

15th Jul 2017, 15:29

Honeywell "Smart Runway" ....

from this document: https://aerospace.honeywell.com/en/~/media/aerospace/files/technical-articles/060-4564-001d-product-description.pdf

4.3.8 Taxiway Landing
The purpose of the Taxiway Landing caution is to provide crew awareness that the aircraft is not lined up with a runway at low altitudes.
4.3.8.1 Annunciation Criteria
The caution is generated if:
Aircraft is airborne between 150 and 250 feet AGL (Radio Altitude), and Aircraft climb rate is less than 450 FPM, and
Aircraft is within 5 NM of a runway and is not lined-up with a runway.
NOTE: RAAS functions are based on a database of runway locations. The system does not have knowledge of the location of taxiways.
4.3.8.2 Message Content
The aural message string “Caution Taxiway, Caution Taxiway” is annunciated once each time the caution is generated. Refer to Figure 4-13.
4.3.8.3 Audio Level
The aural message is generated at the EGPWS Cautions and Warnings volume level.

Lonewolf_50

15th Jul 2017, 17:04

SFO, two different incidents:
1) crew approaching a runway, something doesn't look right, they go along and are 30+ knots slow on final, crash, 3 dead, many injured, Asiana. GA decision too late.

2) Crew approaching runway, something looks wrong, someone speaks up, someone calls tower, and a GA decision is made in a timely fashion. Air Canada.

Cockpit culture and willingness to say "this doesn't look right" and speak up (confess to confusion) is to me a crucial difference, and why there is egg on face, and no dead bodies.

Granted, one would hope that all of the details and airmanship issues discussed for the last few hundred posts would prevent it getting that close.
I am glad someone spoke up and said "this doesn't look right" and then the GA happened in a timely fashion.(well, maybe not timely, given how close this was).
No approach is too beautiful to wave off.

gwillie

15th Jul 2017, 18:04

This story was referenced on a Canadian (air cadet caliber) forum.......an interesting read (not previously mentioned here, afaik).........and, it features a not-unfamiliar actor !

Pilots mistake taxiway for runway at Sea-Tac | The Seattle Times (http://www.seattletimes.com/business/pilots-mistake-taxiway-for-runway-at-sea-tac/)

From.....2005 !

RAT 5

15th Jul 2017, 18:22

manually tuning the ILS was probably not a part of their SOPs, it is possible in the Airbus, but generally only used during downgrading of the FMGS system...the FMS approach is displayed as an LNAV track on the nav display..

I'm still waiting for an answer from the Airbus gurus: You've answered the lateral aspect of an FMS approach, if indeed they were doing one inside 4nm, but what were they using (what do you expect) for vertical guidance?

Airbubba

15th Jul 2017, 18:29

Another thing: Who has mapshift these days?

From a discussion on another thread about the Air Canada Halifax crash:

In reality, a large number of A320s (and even A330s/A340s) do not have even vanilla GPS installed as part of the navigation system! No GPS units. No MMR. These A320s depend solely on radio updating (VOR/DME) or manual IRU alignment before takeoff.

(I believe the Air Canada aircraft involved in this accident [YHZ - Airbubba] was not equipped with GPS.)

Also, some of these aircraft have dual FMS which are not GPS compatible. Total upgrade price == very costly.

I'm wondering if the AC A320 at SFO was in this legacy no-GPS configuration.

Still, even if the setup is FMS with no raw data displayed, at the end of the day this is supposed to be a visual approach. Does AC turn off the flight directors on the visual segment of this approach?

Kewbick

15th Jul 2017, 19:17

Possibly...especially at the end of the day..

If not already self evident, I am no longer able to tolerate non-professional pilot comments on this forum. Good night.

Airbubba

15th Jul 2017, 20:55

I can see you're probably not a pilot, apologies for the shop talk.

Some carriers have a policy of turning off a flight director if it wasn't giving pertinent guidance e.g. on a visual approach without navaid path guidance. Others leave the flight director on but use caution because the information displayed may be misleading, especially on older nav systems without GPS or WAAS. I believe I used flight path vector years ago on visuals at a couple of carriers in the A306, but as I said, I've never flown the A320.

Sorry if we confused you, hope this helps explain what we're talking about, have a good night. :ok:

Chuck Canuck

15th Jul 2017, 21:23

Oh really now, Kal Niranjan. It would be easier just to say, when any particular "non Western" carrier you would care to name in particular, one which has in your view been subject to scorn, insinuations and so on (whether "thunderously deafening" or otherwise), compiles an overall safety record and a set of managerial and technical leadership qualities in the safety realm comparable to Air Canada, then maybe you could gripe. But that would be too easy; I like the challenge. When a "non Western" carrier fouls up, and it happens to be in a system, country or culture where substandard practices, lack of standard English, training and/or operational deficiencies, and other gross or significant deviations from SARPs are the norm, pointing these deviations out is not scornful or racism. If you think so, I certainly would enjoy learning about your educational background. Something clearly was missed. (I post this out of a sense of defending the forum, against your too-easily muttered bromides, which are nonsense - despite the stray or occasional off-point remark of a poster now or again.)

I don't agree with Kal 100% but after rereading the EVA LAX near CFIT incident, I sympathise with non-Western pilots who are almost always painted as incompetent by a broad brush.

Hassan Bok

15th Jul 2017, 21:34

Thanks Kal, not being kind - being realistic. Pilots should all learn from this incident because the same WILL happen to them at some time. Unfortunately, as you will have seen many of the posts on this thread have started with: cannot believe that it is possible for professional pilots etc etc

It is absolutely nothing to do with professionalism or capability it is all to do with cognition and perception - human factors experiments Repeatedly show the brain has limits and cannot work in some ways.

Try to read this post and recite a nursery rhyme and listen to what someone is saying and read it back you cannot. Your brain has only one verbal 'cognitive channel'. A huge amount of research has been carried out in visual perception yet that is all forgotten when airports are designed. Everyone gets a degree of cognitive tunneling (focusing on a problem) when doing something challenging and that is when mis-perception can occur. This has been repeatedly demonstrated in research and happens continually in real life.

:ok: Well said.
Didn't some Delta pilots land on some taxiway in ATL some years ago. Well a China Airlines crew took off from taxiway in ANC before.

So pilots from both hemispheres made mistakes. The only difference you don't see Oriental pilots coming over to Pprune gloating ( with pride about their superiority ) over the mistakes made by westerners.

ratpackgreenslug

15th Jul 2017, 22:16

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

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

West Coast

15th Jul 2017, 22:32

Time to close this one for awhile. It's a rush to admonish pilots to use the ILS or a rant on non western pilots.

ratpackgreenslug

15th Jul 2017, 23:09

Time perhaps to let it run for a while. Even for a visual, input the ILS freq as a matter of standard procedure and common sense. Otherwise it's all too easy to land on the parallel taxiway.

underfire

15th Jul 2017, 23:22

I'm wondering if the AC A320 at SFO was in this legacy no-GPS configuration.

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

Otherwise it's all too easy to land on the parallel taxiway.

Just how many ac use that procedure every day, yet one ac pooches it, and it is too easy to screw up?!?!

WillowRun 6-3

16th Jul 2017, 00:59

I don't agree with Kal 100% but after rereading the EVA LAX near CFIT incident, I sympathise with non-Western pilots who are almost always painted as incompetent by a broad brush.
Let's back up. Kal's assertion was made in context of carriers, not individual pilots. Reply I posted likewise was completely in context of carriers, also - not individual pilots.
The facts are pretty easy to discern. Without scorn or racist overtones, and also without accusations of incompetence on the part of any pilot involved in any given incident, the overall system of a good many countries all over the world - not just outside a conventional concept of the West - have deficiencies in their NAS, or pilot qualification or recurrent training, or operational methods. Although it speaks blandly the ICAO USOAP - Universal Safety Oversight Audit Programme - provides massive increments of data to this effect in the specific context of safety oversight systems (https://www.icao.int/safety/CMAForum/Pages/default.aspx).
It is not about individual aviators. The Asiana pilots in the SFO incident would have checked out, individually, very highly in the simulator, would they not? But despite their skills and abilities, the system within which they operated left something to be desired. The system deserves to be painted with the brush it has earned.
Traveling out of Tokyo Narita to New York on JAL a couple of years ago, a JAL flight crew were having breakfast near my table at the airport hotel. As crisp, precise, and polished looking crew as I ever have seen. Maybe the Japanese cultural imperatives for respect for seniority and hierarchy, and in general, and a kind of immediacy in response to stimuli, at times can be superior to standard Americana/Brit attitudes?

Airbubba

16th Jul 2017, 01:12

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

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

I believe the FMS Bridge Visual is sometimes described as an RNAV/Visual hybrid approach. You certainly don't always need GPS for RNAV without RNP in my experience.

In fact, in some places with some aircraft you can do an RNP 0.3 approach without GPS using DME/DME when authorized.

From the Jepps:

Some aircraft have RNP approval in their AFM without a GPS sensor. The lowest level of sensors that the FAA will support for RNP service is DME/DME. However, necessary DME NAVAID ground infrastructure may or may not be available at the airport of intended operations. For those locations having an RNAV chart published with LNAV/VNAV minimums, a procedure note may be provided such as “DME/DME RNP-0.3 NA”; this means that RNP aircraft dependent on DME/DME to achieve RNP-0.3 are not authorized to conduct this approach.

Where FAA flight inspection successfully determines the availability and geometry of DME facilities will support RNP-0.3 and that the DME signal meets inspection tolerances, a note such as "DME/DME RNP-0.3 Authorized” will appear on the chart. And where DME facility availability is a factor, the note may read “DME/DME RNP-0.3 Authorized; ABC and XYZ Required”; meaning that ABC and XYZ facilities have been determined by flight inspection to be required in the navigation solution to assure RNP-0.3.

http://www.jeppesen.com/download/briefbull/den00-arnav.pdf