Another wrong rwy close call at SFO

[mkenig]

Aeromexico cleared to land on 28R, lined up on 28L with Virgin holding for takeoff. Tower issued G/A with AM 668 at 600 ft alt.

No incorrect procedure. Tower cleared for 28R, got correct readback.
Tuesday, 11:49.

Not saying it is tower, but third in a year? Something wrong with SFO?

[DaveReidUK]

FR24 confirms that the VRD A320 was on the piano keys as the AMX B738 went around.

Ouch.

[mkenig]

Admit I'm not a commercial pilot, I am a System Analyst. The incidents at SFO seem to have increased in frequency since the offset approach procedure was instituted. Could that be a contributing cause? Is it too different from approaches elsewhere? Are the 1950's RWYs too close and too similar? Comments from the pros?

[Hollywood1]

We landed 5 minutes ahead of this Aeromexico flight and heard the ground controller give the crew a phone number to call for a 'pilot deviation' incident. Was wondering what all that was about until I saw it here.

Well, SFO was using 28L ILS and 28R ILS approaches during that time of the day so it may well be that Aeromexico had the 28L ILS programmed in the box and wasn't expecting 28R. Especially since they arrived on the SERFR2 arrival just like we did, which 90% of the time, will have you land on 28L as the SERFR2 links in with 28L ILS approach at waypoint MENLO. But rarely do you fly straight in to the approach at SFO as ATC will radar vector you all over the place, before you intercept the localizer for the ILS.

Complacency perhaps was to blame here and possibly not updating the box with the 28R ILS when it was assigned. That's my guess anyway.

[rotorwills]

Pretty good plausible explanation. Let’s stay with that till something breaks.

[cossack]

How long was AMX on the "wrong" loc before the missed approach was called?

[HEMS driver]

"Confirmation bias?"

[HEATHROW DIRECTOR]

Doesn't SFO Tower have radar?

[DaveReidUK]

The lowest point that FR24 captured on the first approach was approximately 0.6 nm from the threshold.

[cossack]

Not what I meant. From how far out was he on the"wrong" loc? If it was say 10 miles, that would be at least 2 minutes for someone to notice, that didn't.

[DaveReidUK]

Ah, OK.

He was lined up with 28L from about 9 miles out, roughly abeam Bair Island and about 4 minutes from the threshold.

When you talk about noticing it presumably you mean on radar? It would be very difficult for the tower to discern which runway he was pointing at when that far out.

[cossack]

Maybe, maybe not. We have runways 1000' centreline to centreline. SFO's are 750'. Our tower radar displays the extended centrelines out to about 8 miles and because of the range of the display, we could (not saying we would) see if an aircraft is on the wrong centreline at 8 miles.

If SFO tower has a piece of radar equipment that we call Airspace Warning Feature, they would receive a visual and audible alert that he was incorrectly positioned at about 2 miles out. That would coincide with the issuance of missed approach instructions.

[cactusbusdrvr]

SFO has precision approach monitoring capability. Look at the PRM plates for SFO. Looks like they need to start using that capability a little more.

[JammedStab]

I suppose that it is always good to double check that ILS frequency as well. Or identify it and identify it properly.

[RAT 5]

What type was AMX? There was talk during the AC Incident that AB crews on FMC approaches did not always tune ILS.

[RAT 5]

Thanks Dave; in which case the/an ILS should have been tuned and ID'd.

[galaxy flyer]

How ‘bout looking at the airport critically and identifying BOTH runways and remembering what you read back to the tower. I can’t believe aviation has sunk to this level.

[RAT 5]

Let's not forget one of the principles of our industry. The general concept is to share information so that the mistakes of others are published to prevent reoccurrence. One would have hoped that previous events would have become known to all operators into SFO and warnings issued about the risk. To have multiple similar errors over such a short time frame is very disappointing. As well as commenting on each individual event it would be prudent to ask why they continued to reoccur. There seems to be a weakness somewhere that needs strengthening. If that weakness is in SFO's local procedures, that is one issue to address; however my initial comments are more focused on why crews are repeating this mis-identification.when they should be aware and extra vigilant.

[DaveReidUK]

We should be careful about making generalisations about "recurrence" - all three events were different (albeit two involved the same airline) and one of them (AC781) didn't feature a misidentification,

[Hotel Tango]

I would also think that with the SFO set up, it doesn't matter how aware one tries to be, it's ripe for a mistake to occur when there's the odd lapse of concentration once in a blue moon. I don't blame the crews, I blame the procedures and frequent last minute changes by approach or even the tower.

[aterpster]

And, the airport configuration.

[fleigle]

Well, the airport configeration has been like that for a long time, what is changing is the volume of traffic and possibly the competence of the crews flying in. If for some reason a particular flight doesn't manage their spacing as anticipated then the crew in the tower have to deal with it.
Because of the closeness of 28L and R it is always a bottleneck for traffic flow when the weather is bad.
Back in the days of "steam" gauges the crew were paying attention 100% of the time, now, it seems, the FMS is programmed and if there is a last-minute runway change then rapid typing results, as the magic "follow the line" has to be displaced.
There is a youtube vid out there showing a Lufthansa 380 flight into SFO, naturally there was a runway change, the comment (from a Snr. Captain) was "typical"... so why was he surprised?.
Fly the aircraft, be prepared for the conditions and pay attention.
SFO isn't Denver.

[SquintyMagoo]

If you listen to the ATC tower recording, AMX 668 clearly contacts the tower stating he is inbound at "duyet." And the tower clears him for 28R. As we know, however, "duyet" is not a point on the ILS for 28R, but for 28L instead. (The correct point for 28R is "axmul.")

Why ATC didn't notice his call and make sure he was headed for 28R or give him the go around then is a question to be answered.

Additionally, two seconds after clearing AMX to land, ATC clears a Delta to land on the same runway.

Finally, about 15 seconds after clearing AMX, there is a blocked transmission on the recording where the tower and a pilot are talking at the same time. Could AMX have been blocked when asking for clarification on the runway assignment? (There is a call of "blocked" on the Norcal Approach recording, see below, but not for this one.)

[SquintyMagoo]

The Norcal Approach recording is no more reassuring. The transmission instructing AMX 668's turn onto its final runway heading is cut off so that the airline and flight number is not heard. And the repeat omits the runway designation.

ATC: "...maintain 4,000, turn left heading 3-1-0, intercept 28R localizer."
Unknown aircraft: "Blocked"
ATC: "Aeromexico 668 turn left heading 3-0-0."

Although later AMX 668 is directed to report established on the 28R localizer and the read back is correct. Then AMX 668 is cleared to 2,500, but after read back that is corrected to 4,000.

This exchange didn't help matters any:

AMX 668 " ..."are we clear for the ILS?"
ATC: "Aeromexico 668, uh, stand by....
AMX 668: "Roger."

ATC: "Aeromexico 668, four miles from DUYET, cleared to runway 28R
appr...correction, four miles from AXMUL, cleared to runway 28R
approach."
AMX 668: "okay the ILS runway 28R approach."

If the controller said DUYET rather than AXMUL because he noticed AMX 668 was lined up for 28L, he should have given a clearer instruction to get on the correct localizer. (SFO's own noise-abatement flight tracker indicates AMX 668 was lined up for 28L from when it first turned onto heading 290, at least 10 miles out.)

Finally, I note that at least two prior arrivals had trouble capturing the localizer and had to continue turns to re-intercept.

Combined with the tower recordings, it seems there were multiple clues for ATC that AMX 668 was not aligned properly for the approach and runway assigned, despite read backs to the contrary. Why these clues were missed is perhaps something that warrants investigation.

[aterpster]

Well, the airport configeration has been like that for a long time, what is changing is the volume of traffic and possibly the competence of the crews flying in. If for some reason a particular flight doesn't manage their spacing as anticipated then the crew in the tower have to deal with it.
Because of the closeness of 28L and R it is always a bottleneck for traffic flow when the weather is bad.
Back in the days of "steam" gauges the crew were paying attention 100% of the time, now, it seems, the FMS is programmed and if there is a last-minute runway change then rapid typing results, as the magic "follow the line" has to be displaced.
There is a youtube vid out there showing a Lufthansa 380 flight into SFO, naturally there was a runway change, the comment (from a Snr. Captain) was "typical"... so why was he surprised?.
Fly the aircraft, be prepared for the conditions and pay attention.
SFO isn't Denver.
Agree, especially that SFO isn't Denver.

[costalpilot]

all those long, straight lines on the ground, close up, against each other.

atlanta comes to mind, dfw..but those app's are generally strung out, progressive, turns to final, (strung way out), gently turned into with mothering radar vectors.

sfo can be way different

now that i think about it, thats why i liked it. it was just a little different, not always the same.

sfo required a little more attention.

otoh, pilots been landing on taxi ways ever since there has been taxi ways. not to mention wrong runways, wrong airports, wrong airports in cities, hell, wrong countries.

[underfire]

another blind spot in the runway monitoring system?

[jack11111]

The close spacing of the 28's plus the distance from the tower and sight angle make it very difficult to determine the runway the arrival is lined-up upon.

A video camera situated between the 28's at the approach end and tower monitor would be cheap, easy and effective final check on arrivals.

Without some change this will happen again.

[SquintyMagoo]

Or when a plane for 28R reports he's at DUYET, the controller could pay attention and redirect the wayward aircraft before a go around is necessary.

[DaveReidUK]

FAA SAFO issued after AC759 at SFO (https://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2017/SAFO17010.pdf)

[underfire]

A video camera situated between the 28's at the approach end and tower monitor would be cheap, easy and effective final check on arrivals.

and just who would monitor this?

There is already a system in place to monitor the approach, it is the first installed, and was to be used as the pilot for other airports. This system was detailed in the AC thread.

According to the FAA, the system was successful and was going to be implemented at other airports.

The first 'blind spot' found was the AC that tried to land on the taxiway...now this?

It does not appear that the system works, or is ready for distribution

[wingview]

No idea how it's called but you have a system that monitors the complete approach. Too low and off track gives a warning. Should be a nice idea at SFO to use it after 3 times wrong run or taxi way and 1 time the T7 being too low.

[DaveReidUK]

Too low and off track gives a warning.

So in this case, did it or didn't it?

Either way, questions need to be asked.

[RAT 5]

No idea how it's called but you have a system that monitors the complete approach. Too low and off track gives a warning.

Sounds like an ILS to me. I wonder if a ground based system, so close to the runway, to tell the airborne guys that they are off track is the best way to go to solve the problem. There are enough bells & whistles on board, plus 2 sets of eyes, that should be enough. We are sometimes finding that the more back-up error beeping systems there are the less the pilots do their job of monitoring. I saw this attitude in the 80's when an operator graduated from a 3 crew cockpit, needles & dials, to a 2 crew LNAV/VNAV EFIS a/c. We had many cadets coming on board and they were being drummed to "follow the Flight Director" and "there's no need to keep scanning the panels as there are bells & whistles & beepers and flashers to tell you when things go wrong". Oh dear. I tried and failed to stem that heresy. That was 30 years ago & things seems to have evolved to worse not better.

[fisher22]

How about the advanced system monitoring the flight called a pilot? They were given a clearance, read it back correctly several times, and ended up messing up. Simple confusion and lack of situational awareness, simple as that, has happened before, probably will happen again.

And the controller DID notice what happened and called for a go around, what else is there to see?

[ZOOKER]

I'm fairly certain EGCC has an electronic 'gizmo' that sets off a hooter if a/c deviate from the ILS centre-line. Although the runways are staggered by 1850m, they are much closer together than KSFO. Apologies, but I can't remember the technical name of the piece of kit.

[bekolblockage]

Sounds like APM (Approach Path Monitoring).
Our system has it (as well as DPM- Departure Path Monitoring) but not activated yet.
Basically 3-D polygons adapted that trigger an alert if the a/c strays laterally or vertically from the defined path.
Would have thought very difficult to adapt separate approach paths with such close spacing as SFO has, that didn’t set off nuisance alerts often.

[ion_berkley]

I'm fairly certain EGCC has an electronic 'gizmo' that sets off a hooter if a/c deviate from the ILS centre-line. Although the runways are staggered by 1850m, they are much closer together than KSFO. Apologies, but I can't remember the technical name of the piece of kit.

Errr, quite the opposite, SFO runway centreline separation on 28 L/R is on the order of 750 feet...Manchester is more like 1250 feet. Operationally they are completely dissimilar

[Hollywood1]

How about the advanced system monitoring the flight called a pilot? They were given a clearance, read it back correctly several times, and ended up messing up. Simple confusion and lack of situational awareness, simple as that, has happened before, probably will happen again.

And the controller DID notice what happened and called for a go around, what else is there to see?

Absolutely! And well said. It was a simple case of the Aeromexico crew not doing the 'pilot thing'. SFO literally has hundreds of movements a day that go without incident. Professional pilots in a multi-crew environment should be capable enough to follow ATC instructions and clearances without incident.

[The Banjo]

Qiute easy really. Rename 28R as 29R or 28L as 27L. Similar concept to not having RWY 02/20 such at YPPH.

[ZOOKER]

ion,
apologies, yes of course, the KSFO C/L separation is quoted in feet, 'CC is of course in metres. All the more reason to buy a 'gizmo' then.

[underfire]

This is installed at SFO NextVue | Harris Symphony CDM (http://www.symphonycdm.com/Pages/product/nextvue)

At SFO the AC ac was not tracked for several seconds (the blind spot referenced in reports) and appeared at the end of the taxiway...still no alert (that has been reported)

There is also the PRM radar system which is supposed to track the close spaced parallel runway ops...

[vapilot2004]

How ‘bout looking at the airport critically and identifying BOTH runways and remembering what you read back to the tower. I can’t believe aviation has sunk to this level.

I agree, GF. It's all fairly obvious, even with the sidestep maneuver.

I'm not one to blame the guys up front, but how hard is it to apply the knowledge that L means the ribbon of concrete on the left and R, the right? It is the cockpit's responsibility to confirm ATC instructions. Garbled or keyed mike breakup on the frequency is not an excuse for getting it wrong. If in doubt, you ask again.

Well, the airport configeration has been like that for a long time, what is changing is the volume of traffic and possibly the competence of the crews flying in.

Check. :ok:

[ZOOKER]

If this 'hot-spot' is difficult to observe from the VCR, can't they put a camera/remote VCR/Portakabin closer to the thresholds?

There's a RVCR adjacent to the Polderbaan at EHAM.

Come on KSFO, it's not rocket-science to solve this one.

[wiedehopf]

why would you all talk video cameras if a PRM radar system provides better data than any eye ever could.

the problem with that is maybe that the system is independent and the data is only ever displayed on a special PRM station in the TRACON which is likely unmanned when PRM approaches are not in use.

and with automated systems predicting conflicts maybe they don't even get the input which runway the plane is approaching. it only gives an alert if the runway is occupied which might not happen until short final as the departing traffic is lining up.

anyway after a certain history for the airport getting PRM data into the tower can't be that hard. and much better than putting a video monitor there. should even be possible to just deduce right or left side from the PRM and just display RIGHT LEFT or UNDECIDED and miles from touchdown for the relevant targets. that would also work on a small extra screen because as always integrating in the existing radar system might prove impractical.

[ZOOKER]

Portakabin between the 2 runways, manned by a qualified chap with a radio.

[RAT 5]

Ah. The old human RVR measuring device returns. Strange that in this day of super accurate GPS nav systems, and old fashioned accurate ILS, guys can still screw up. There could be a guy on the threshold with ‘bats’ guiding you in. More gizmos ain’t the answer. More professionalism might just be, and that includes the ground based links in the chain. The fault can lie in designed procedures as well as their execution.

[Ian W]

Well back in the day I used to have a 'runway controller' in a 'caravan' just offset from the runway threshold with a flare pistol that worked extremely well. :ok:

In the near future expect your aircraft trajectory to be known to the system and it will be apparent from a long way out which runway the aircraft expects to land on. SFO and the operators using it are showing how necessary trajectory based operations are becoming.

[ZOOKER]

There has to be a simple solution to this one.
Without digging around to find the details of each incident, and the Wx conditions occurring at the time of each one, could you not put a large illuminated 'L' and 'R' somewhere adjacent to each runway's approach lighting system?
I was thinking about the large LH and arrow that was painted on the Southall Gas-Holder when EGLL had R/W 23 and Pan Am landed at EGWU in error. As far as I'm aware, it never happened again?

[DaveReidUK]

Idiot's guide to the PRM (Precision Runway Monitor) at SFO:

SFO Fact Sheet - PRM/SOIA (https://media.flysfo.com/PRM_SOIA_version_1_0.pdf)

No mention of its use as an automated safety-net, other than a reference to the TRACON controller who monitors the No Transgression Zone (NTZ) between the two approaches and will send you around if you infringe it (which the AC probably didn't).

[underfire]

Dave,

The PRM is just one of the feeds into nextvue. While nextvue tell you where the ac is, it appears it doesnt warn or coordinate with where it is supposed to be.

NextVue is a web-accessible application that provides visualization of all flights in the National Air Space along with operational monitoring, taxi delay alerts, diversion management and management of irregular operations. Combined with trusted airline prediction models and collaborative decision-making (CDM) functionalities, users can proactively manage congestion and efficiently interface with the FAA’s Traffic Flow Management System (TFMS). NextVue leverages the Exelis NextGen commercial flight traffic surveillance data feed, to provide the most complete, accurate and timely picture of all aircraft in the air and on the ground, throughout and beyond the NAS.

[DaveReidUK]

Yes, I'm not seeing anything in that description that sounds like a real-time safety-net.

[VONKLUFFEN]

SFO/LAX/JFK etc ATC is always in a rush to get rid of traffics. Always using non standard phraseology, pushing pilots to make visual approaches, giving challenging shortcuts and so on. Even english speaking pilots complain about the wording and speed of controllers.
They want to save a second but waist 3 or 4 when the have to repeat the clearance at times.
SFO is and airport where RWYs are so close to each other that it is easy to make a mistake in high work load environment( follow the traffic, clear visual "maintain 180 till outermarker...bla bla bla). Would be easier and safer if they just stick to a safe vectoring philosophy and not to a cowboy stile one. Its not a rodeo!

[aterpster]

To me, SFO is the worst of the lot.