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-   -   Another wrong rwy close call at SFO (https://www.pprune.org/north-america/604092-another-wrong-rwy-close-call-sfo.html)

mkenig 11th Jan 2018 14:37

Another wrong rwy close call at SFO
 
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 11th Jan 2018 15:15

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

Ouch.

mkenig 11th Jan 2018 15:24

Is it the offset approach?
 
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 11th Jan 2018 17:33

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 11th Jan 2018 17:50

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

cossack 11th Jan 2018 18:23

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

HEMS driver 11th Jan 2018 18:26

"Confirmation bias?"

HEATHROW DIRECTOR 11th Jan 2018 18:34

Doesn't SFO Tower have radar?

DaveReidUK 11th Jan 2018 18:57

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

cossack 11th Jan 2018 20:28

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 11th Jan 2018 21:04

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 11th Jan 2018 22:27

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 12th Jan 2018 04:19

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 12th Jan 2018 07:12

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

RAT 5 12th Jan 2018 10:15

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

RAT 5 12th Jan 2018 12:35

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

galaxy flyer 12th Jan 2018 23:13

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 13th Jan 2018 02:25

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 13th Jan 2018 06:24

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 13th Jan 2018 12:05

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 13th Jan 2018 13:25

And, the airport configuration.

fleigle 13th Jan 2018 13:50

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 14th Jan 2018 07:11

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 14th Jan 2018 08:53

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 14th Jan 2018 12:43


Originally Posted by fleigle (Post 10018639)
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 14th Jan 2018 16:58

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 14th Jan 2018 17:20

another blind spot in the runway monitoring system?

jack11111 14th Jan 2018 23:31

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 15th Jan 2018 04:40

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 15th Jan 2018 06:31

FAA SAFO issued after AC759 at SFO

underfire 15th Jan 2018 15:11


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 15th Jan 2018 16:12

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 15th Jan 2018 17:14


Originally Posted by wingview (Post 10020582)
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 15th Jan 2018 18:24

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 15th Jan 2018 18:27

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 15th Jan 2018 18:40

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 15th Jan 2018 23:02

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 15th Jan 2018 23:40


Originally Posted by ZOOKER (Post 10020725)
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 16th Jan 2018 02:06


Originally Posted by fisher22 (Post 10020713)
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 16th Jan 2018 02:12

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


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