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

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

Old 14th Jul 2017, 17:26
  #181 (permalink)  
 
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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)
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Old 14th Jul 2017, 17:47
  #182 (permalink)  
 
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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.
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Old 14th Jul 2017, 17:53
  #183 (permalink)  
 
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@trw

if anything i'd rather have flashing leadin lights for every runway.
way easier to implement ...
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Old 14th Jul 2017, 18:05
  #184 (permalink)  
 
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@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.
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Old 14th Jul 2017, 18:09
  #185 (permalink)  
 
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It's been done literally hundreds of times in the US alone.
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Old 14th Jul 2017, 18:15
  #186 (permalink)  
 
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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.....
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Old 14th Jul 2017, 18:39
  #187 (permalink)  
 
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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.
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Old 14th Jul 2017, 18:53
  #188 (permalink)  
 
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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?
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Old 14th Jul 2017, 19:07
  #189 (permalink)  
 
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..... 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
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Old 14th Jul 2017, 19:10
  #190 (permalink)  
 
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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!
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Old 14th Jul 2017, 19:18
  #191 (permalink)  
 
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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.
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Old 14th Jul 2017, 19:27
  #192 (permalink)  
 
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Originally Posted by aterpster View Post
Do we know whether the NTSB is even looking at this SFO incident?
Yep, they are:

Originally Posted by Airbubba View Post
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/st...21284513959936
Originally Posted by RAT 5 View Post
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.

Originally Posted by llondel View Post
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.
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Old 14th Jul 2017, 19:34
  #193 (permalink)  
 
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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?
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Old 14th Jul 2017, 20:08
  #194 (permalink)  
 
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Originally Posted by wingview View Post
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...
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Old 14th Jul 2017, 20:19
  #195 (permalink)  
 
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CVR

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.
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Old 14th Jul 2017, 20:28
  #196 (permalink)  
 
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Originally Posted by Ian W View Post
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/caps...e_movement.pdf )



(See http://www.drjoebio.com/uploads/1/8/..._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
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.
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Old 14th Jul 2017, 20:39
  #197 (permalink)  
 
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CVR, Safety Management, & Facts

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).
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Old 14th Jul 2017, 20:43
  #198 (permalink)  
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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.
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Old 14th Jul 2017, 20:47
  #199 (permalink)  
 
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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.
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Old 14th Jul 2017, 20:58
  #200 (permalink)  
 
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Originally Posted by portmanteau View Post
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:

Originally Posted by aterpster View Post
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?
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