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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!

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Old 17th Jul 2017, 21:26
  #301 (permalink)  
 
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Originally Posted by fox niner View Post
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.
81 feet

Federal investigators on Monday revealed startling new information about the July 7 close-call at SFO. The Air Canada pilot that mistook a crowded taxiway for his approved runway actually flew over at least one plane on the ground before aborting his landing.

National Transportation Safety Board investigators said in an initial report that Air Canada flight 759 from Toronto descended below 100 feet and aborted the landing “after overflying the first airplane on the taxiway.”

New data show that the Air Canada plane was just passing over a second aircraft – Philippine Airlines jet – at 106 ft in the air and continued his descent when an SFO air traffic controller finally warned him to abort his landing.

The Transportation Safety Board of Canada said in their initial report that the Air Canada pilot did not begin his “go-around” until the air traffic controller told him to pull up.

The plane continued to drop to as low as 81 feet, as aviation experts say such a late aborted landing takes a moment to stop the jet’s inertia and climb again.
post too short
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Old 17th Jul 2017, 21:51
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NTSB: Air Canada close-call at SFO was even worse than first reported

See more detailed discussion of fly-over heights and when the go-around was ordered. It gets even more frightening. Although given the positions and heights involved, AC would not have hit first two aircraft, only numbers 3, 4 and 5.
SFO near-miss: Air Canada flew over plane before aborting
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Old 17th Jul 2017, 21:58
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3J, I know, it was a thought question, not a question...

Aside from that, its looking worse all the time...


face it, they were landing...DAMN UAL 863 is a 789 at about 56' tall, PAL 115 is an A343 at 57' tall

Whoever said they are on the taxiway was not kidding!

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Old 17th Jul 2017, 22:12
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That contradicts both the TSB and FAA accounts, and of course assumes accurate time synchronisation between FlightAware and (presumably) LiveATC.net.
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Old 17th Jul 2017, 22:19
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Dave, it is a datapoint. FA has been getting pretty good these days, and has quite the offering for tracking, I would not discount the accuracy.
The GA call is one thing, and the driver may have not reacted to the call, but still, the altitude track is damning. PAL must have had quite the ringside seat....
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Old 17th Jul 2017, 22:35
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Perhaps they are correct, and that is where I'm wondering if we have just over complicated things on what should be the most basic of manoeuvres; a visual approach.
This is a basic procedure, and was used by quite a few operators just preceeding these guys. With all of the angle points/stepdown fixes on the approach, it actually is easier for everyone involved.

It is a RNAV visual approach, and visual from 4 DME. The driver even questioned if there were aircraft on the runway, and still decided to land. From what everyone is saying, this is an old A320 that may have not been GPS capable, so it appears they werent relying on the automation anyways...
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Old 17th Jul 2017, 23:26
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Those sky gods advocating tuning the ILSs when given a non precision or charted visual approaches clearly do not understand the policies of modern major air operators where big aunty FOQA is sifting through post flight data.
Also it is mandatory in some operators' policies to execute an unnecessary go around if the glide slope GPWS warnings are triggered.

Damn, it is a night landing and you are a dot right of localizer at 999ft AGL..and you didn't go around? Gee, auntie FOQA will get you taken off the roster, get to the safety office to explain. All your very convincing explanations will be met by very sceptical and cynical interruptions, the so called FOQA gatekeeper will let you stew before s/he let it on that you indeed did no wrong. Your week or days is already ruined, your blood pressure up and you probably pissed off more nincompoops inadvertently with your enthusiastic defence of your actions. You know now that more eyes are now watching you, waiting for your next social or technical faux pas.

Small hassle? Yes or no. Go figure.
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Old 17th Jul 2017, 23:34
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Just heard on the radio that the NTSB is going to release a video of the incident.

What will happen to the pilot at AC?
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Old 17th Jul 2017, 23:37
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Originally Posted by SeenItAll View Post
Although given the positions and heights involved, AC would not have hit first two aircraft, only numbers 3, 4 and 5.
Before we get too far with this one, weren't there only four aircraft holding short of 28R on C?

Originally Posted by underfire View Post
It is a RNAV visual approach, and visual from 4 DME. The driver even questioned if there were aircraft on the runway, and still decided to land. From what everyone is saying, this is an old A320 that may have not been GPS capable, so it appears they werent relying on the automation anyways...
And it appears that the A320 will give you path guidance all the way to touchdown in this case, even if the nav is not accurate due to a map shift of some sort. But you are absolutely right, this is a visual approach with a four mile line up, they should not have relied on the FMS for anything more than advisory guidance on the visual segment.

Originally Posted by RAT 5 View Post
Perhaps they are correct, and that is where I'm wondering if we have just over complicated things on what should be the most basic of manoeuvres; a visual approach.
I know of one erstwhile operator who has a mandatory VNAV/LNAV FMS WPT programmed visual circuit profile for a basically equipped airfield. It's been there a longtime, and I flew into it with B732. Somehow, 35 years later in a more sophisticated jet, it needs magenta lines, both later & vertical, to fly a visual circuit.
The world has gone mad, and I enjoy my stressless retirement. I got out just in time. Straight jackets & handcuffs are useless in a cockpit, sometimes.
Years ago I flew for an airline that wore white hats and had acquired a regional carrier to provide a domestic feed to their legendary international routes. Folks from the domestic carrier weren't too keen on book learning but they had honed their flying skills doing several sectors a day around the southeastern U.S. in a 727 or L-188. The pilots from the international airline could quote chapter and verse of all the manuals but didn't do that many landings flying long haul. The domestic airline types joked that the other folks would someday write a book called The Dreaded Visual Approach.

Three decades of glass cockpit flying has probably made us ready for that bestseller.
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Old 17th Jul 2017, 23:57
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Originally Posted by rotornut View Post
Just heard on the radio that the NTSB is going to release a video of the incident.
From today's Mercury News article, looks like it will be a while before the video is released in the NTSB incident docket:

According to the NTSB initial findings, federal investigators interviewed the Air Canada captain on Friday and will interview the first officer on Tuesday. Air traffic controllers were interviewed at SFO and Northern California TRACON, the regional hub, on Sunday and those will continue through Wednesday.

Federal officials have recovered the aircraft’s flight data recorder and security camera video from SFO of the incident approach. The NTSB says that video will be released once the public docket for this incident is opened in the next several months.
SFO near-miss: Air Canada flew over plane before aborting

Conspicuously absent is any mention of the cockpit voice recorder, my guess is that the crew 'forgot' to pull the circuit breaker. An honest mistake.

Originally Posted by rotornut View Post
What will happen to the pilot at AC?
Far as we know there were at least two pilots. If their union dues are up to date they probably will get some extra sims and a line check and resume their scheduled trips. If the CVR is missing they can't gig them for missing checklists and callouts, right?
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Old 18th Jul 2017, 00:36
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Far as we know there were at least two pilots. If their union dues are up to date they probably will get some extra sims and a line check and resume their scheduled trips. If the CVR is missing they can't gig them for missing checklists and callouts, right?
As an international carrier from a bit of an unfriendly nation these days, IF the airline was not authorized to use that procedure, and/or if that ac was not authorized, and/or if that crew was not authorized to use that procedure, I am afraid the ramifications will be a bit more than a few extra sims.

As a driver sitting in that lineup, what would you want for that crew, see them on the next rotation and hope? When AC aircraft are around will SOP be "cabin crew prepare for impact"?

Is this per chance, the same AC crew that tried to land in the water a while back?

Last edited by underfire; 18th Jul 2017 at 01:16.
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Old 18th Jul 2017, 00:54
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Originally Posted by Airbubba View Post
Conspicuously absent is any mention of the cockpit voice recorder, my guess is that the crew 'forgot' to pull the circuit breaker. An honest mistake. ...
If the CVR is missing they can't gig them for missing checklists and callouts, right?
While we don't know yet whether the CVR was preserved, not pulling the CVR circuit breaker seems often to be item #1 on the After F*ck Up checklist. While I understand the motivation, the only real solution appears to be the installation of memory chips that hold 24+ hours -- rather than the 30 minute or 2-hour jobs that are now relics of the magnetic tape era.
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Old 18th Jul 2017, 01:47
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Conspicuously absent is any mention of the cockpit voice recorder, my guess is that the crew 'forgot' to pull the circuit breaker. An honest mistake.
I'm fascinated by this.

Pulling the CVR circuit breaker following an incident is not procedure in my jurisdiction, nor in my airline.

Is it really policy in that part of the world?

CVRs were introduced for accident analysis. Not for incident blame game.

What is USALPA's position on this?
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Old 18th Jul 2017, 02:18
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Originally Posted by underfire View Post

Is this per chance, the same AC crew that tried to land in the water a while back?

No, if you are referring to the Sint-Maarten incident... That would have been WestJet.
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Old 18th Jul 2017, 03:38
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Originally Posted by Derfred View Post
Pulling the CVR circuit breaker following an incident is not procedure in my jurisdiction, nor in my airline.

Is it really policy in that part of the world?
The NTSB has lobbied for a couple of decades for turning off the power to the CVR after a 'reportable' incident or accident.

See:

THE NTSB RECOMMENDS THAT THE FAA: REQUIRE ALL AIRLINES TO REVISE THEIR PROCEDURES TO STIPULATE THAT FLIGHTCREWS TURN OFF POWER TO THE COCKPIT VOICE RECORDER AS PART OF THE ENGINE SHUTDOWN PROCEDURE IN THE EVENT OF A REPORTABLE INCIDENT/ACCIDENT.
https://ntsb.gov/safety/safety-recs/...x?Rec=A-96-170

Several airlines have put the CVR breaker on the shutdown checklist ('as required') so if the pilots 'forget' to pull it in case of a safety related event, the feds can go after them for not properly completing the checklist. Or, maybe it's just a memory aid.

§ 121.359 (h) mentions NTSB part 830, if you don't hit anything and no one swerves out of the way, you might be OK buzzing four planes holding short of the runway and not pulling the cb:

(h) In the event of an accident or occurrence requiring immediate notification of the National Transportation Safety Board under part 830 of its regulations, which results in the termination of the flight, the certificate holder shall keep the recorded information for at least 60 days or, if requested by the Administrator or the Board, for a longer period. Information obtained from the record is used to assist in determining the cause of accidents or occurrences in connection with investigations under part 830. The Administrator does not use the record in any civil penalty or certificate action. [trust me, we're here to help you etc. - Airbubba]
https://www.law.cornell.edu/cfr/text/14/121.359

On the Canadian side it looks like the CVR is supposed to be disabled after an accident or incident. Again, maybe AC 759 could claim they didn't hit anything so they didn't know the cb was supposed to be pulled:

3.0 BACKGROUND
Following recent incidents, flight crews have either disabled the wrong circuit breaker or neglected to pull the circuit breaker for a CVR, resulting in the loss of critical information. The Transportation Safety Board (TSB) has recommended that steps be taken to ensure that the necessary information and guidance is made available to flight crews to properly safeguard on-board recordings following an occurrence.

4.0 REQUIREMENTS
Subsection 605.34(2) of the CARs states: No person shall erase any communications pertaining to the flight being undertaken that have been recorded by a cockpit voice recorder.

Paragraphs 725.135(i), 724.121(i), 723.105(1)(aeroplane) 723.105(j)(helicopter) of the CASS require the inclusion of FDR and CVR procedures in the Company Operations Manual. It is expected that the appropriate steps for disabling of a FDR and/or CVR following an accident or incident will be included in these procedures.

Clauses 705.124(2)(a)(iv)(C), 704.115(2)(a)(v)(C), and subparagraph 703.98(2)(c)(iii) of the CARs require that an air operator’s training program include initial and annual training on emergency procedures. This training should include procedures for disabling the FDR/CVR following an accident or incident, and must be provided to flight crew members and ground personnel.
https://www.tc.gc.ca/eng/civilaviati...00-013-131.htm
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Old 18th Jul 2017, 05:28
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crowded taxiway in a perfectly airworthy aircraft in visual conditions

an night...all aircraft stationary, most likely taxi lights off...hard to see...now not seeing runway lights , thats another human factor to be explored...it's not about the crew "blowing it", it's about WHY, so measures can be taken to minimize chances of it happening again...
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Old 18th Jul 2017, 09:22
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The old adage of "when there's doubt there is no doubt" comes to mind. That helps you decide that if you are not 100% certain you really are where you want to be, when close to damaging concrete, it is a good idea to get the hell out of it and start again.
This incident raises many issues from technology to human behaviour, both that of the individual and as a team; and local airport procedures. These events rarely happen in isolation. They will repeat until they are fully understood and mitigated against. May be not in the exact same place or circumstances; could be elsewhere, but Murphy is always sniffing around.
This event requires much more than just a few extra sims: it also has to include local airport & ATC procedures, plus AC's own. This occurrence might well have contributing parameters outsides the flight-deck.
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Old 18th Jul 2017, 10:25
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Rat5, confusion is what we humans will always do!

Another way of looking at it, cognitive biases and heuristics are the mental equivalent of the way a lens bends light. Our mindis the lens, it literally bends what we see based on our preconception. Stated another way, our perception is dependant upon what we believe. We process randomness until we "understand" the chaos AND THEN STOP PROCESSING, and move on to the next task. We superb pattern recognition machines, and we will always attempt to make sense and interpret what we perceive. Watch the short video below.


Did you attribute intention and make up a story to go along with these geometric shapes moving around a board? That is our faulty cognitive machinery at work.

A smart guy once remarked that the first impulsive thought to a GPWS "PULL UP" is likely to be utter disbelief, followed by "nah, its spurious" because by definition we are confused about where the aircraft is if we get this warning.

Our mental model says we are one place, the aircraft knows we aren't. We would not be in the approaching terrain willingly, so we are confused! Our instinctive response is to blame the machine for it's confusion, we aren't confused! I suspect this is the case with most CFIT, the crew are very happy with where they think they are, until they aren't

I made a similar post over on the Dubai B777 accident, post#1371 with some more thoughts on confusion. I don't believe this mental state is well understood or researched.

A soft entry into this is Michael Lewis's recent book, "The Undoing Project". If you like this, then move onto Daniel Kahneman's "Thinking Fast and Slow" and even Nassim Taleb's "Fooled by Randomness". Those books are the more general cases, not aviation specific, however there is lots that we can take away as pilots.
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Old 18th Jul 2017, 10:43
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Originally Posted by DIBO View Post
... SFO TWR with all its equipment could also have picked up the misalignment much earlier. Not required to, but could/maybe should have...
Nope, they should NOT have noticed the misalignment.
Having listened to comm's before and well after the incident, he (as in only one) was too d#mned busy handling arriving/departing traffic 28R, interleaved with many departures 01L, combining GND/TWR positions, explaining to people he was the only one up there, getting everybody over and over again on TWR freq., handeling gate position not yet free, people uncertain about their gate having to call OPS, people messing up taxi instructions, English procifiency levels with room for improvement, .... Well the usual stuff...but all this with still a lot of traffic, enough to keep one person very busy.
Contributing factor maybe? ATCO staffing levels not allowing an extra pair of eyes to monitor things and even for visual approaches to do a spot check on the radar screen, knowing that the rwy config (dark 28L) was not 100% "as usual"?
I know, keep on dreaming, we are in the age of cost cutting...
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Old 18th Jul 2017, 10:53
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1. AC 759 queries lights on runway.
2. Atco, no matter how busy he was would have looked along runway before reassuring aircraft it was safe to land. ( Atco doesn't say, by the way you are lined up on the taxiway because that fact is not apparent to him. It's night remember).
3. AC 759 believes what ATC tells him and prepares to land.
4. AC 759 gets the shock of his life when he realises that the lights he saw actually WERE aircraft, pours on the power and narrowly gets away with it. i.e. he was right and so was ATC. They were just talking about two different "runways".

5. I am a bit puzzled about the almost light-hearted " he's on the taxiway" which suggests 759 still had some way to go and therefore time to correct his error. ( I doubt if the 759 PF needed any prompting from anybody. It must be possible that he didn't even hear it, what with the flight deck suddenly becoming a hive of activity).
6. Is there not a case for wondering if Visual approaches AT NIGHT to several close parallel runways and taxiways such as occurs at SFO are a suitable option when accurate instrument aids are available? Distance between 28R and taxiway C for example is only around 480 feet (centreline to centreline).
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