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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, 21:58
  #201 (permalink)  
 
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Originally Posted by portmanteau
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
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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Old 14th Jul 2017, 22:50
  #202 (permalink)  
 
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To be clear on terms, if only for me, over shooting being the same as a go around and/or a missed approach?
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Old 14th Jul 2017, 23:02
  #203 (permalink)  
 
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Originally Posted by Airbubba
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.
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Old 14th Jul 2017, 23:32
  #204 (permalink)  
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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.
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Old 14th Jul 2017, 23:37
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Originally Posted by portmanteau
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?

Last edited by pilot9249; 19th Jul 2017 at 00:30.
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Old 15th Jul 2017, 00:58
  #206 (permalink)  
 
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Originally Posted by Kal Niranjan
"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.)
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Old 15th Jul 2017, 01:57
  #207 (permalink)  
 
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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.
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Old 15th Jul 2017, 03:43
  #208 (permalink)  
 
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Now Captain Aimer says that AC 759 was 'less than a second from a disaster'.

The article linked below has a graphic showing UA 1 holding past the Cat I hold line 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
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Old 15th Jul 2017, 04:39
  #209 (permalink)  
 
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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.
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Old 15th Jul 2017, 04:55
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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?
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Old 15th Jul 2017, 05:13
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Originally Posted by SDVFR
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:

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

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
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Old 15th Jul 2017, 05:28
  #212 (permalink)  
 
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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”

Last edited by _Phoenix; 15th Jul 2017 at 05:46.
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Old 15th Jul 2017, 07:17
  #213 (permalink)  
 
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Still?.... Eleven pages on this nearly non-incident.. Gawd! Get a life!!! Please move on train spotters...
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Old 15th Jul 2017, 07:52
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Originally Posted by Kewbick
Still?.... Eleven pages on this nearly non-incident..
Don't despair old boy, help is at hand.

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Old 15th Jul 2017, 09:10
  #215 (permalink)  
 
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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.
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Old 15th Jul 2017, 09:54
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https://s-media-cache-ak0.pinimg.com...okes-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.
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Old 15th Jul 2017, 09:57
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NTSB Preliminary Report in a somewhat more readable format:

DCA17IA148.pdf
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Old 15th Jul 2017, 09:59
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Originally Posted by JumpJumpJump
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.
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Old 15th Jul 2017, 10:37
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Originally Posted by NSTB
The flight descended below 100 feet above the ground...
two important clarifications in one little phrase.

Originally Posted by Kewbick
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
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Old 15th Jul 2017, 11:40
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NTSB preliminary report

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.
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