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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 24th Jul 2017, 01:54
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Originally Posted by West Coast
As tragic as Colgan was, it was one accident and there are a lot of other pieces to that puzzle besides commuting.
I agree as to the pieces of the puzzle for that tragic crash. I didn't intend to suggest otherwise.

As to Part 117, that is speculative at best for the issue of commuting.
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Old 24th Jul 2017, 10:13
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How did this become a thread on FTL's & commuting?
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Old 24th Jul 2017, 12:01
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Motion seconded

Probably time for a lock down until further news are available.

Last edited by atakacs; 24th Jul 2017 at 22:14.
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Old 24th Jul 2017, 12:36
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Because the topic has run its course short of new information from the investigation.
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Old 24th Jul 2017, 14:33
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Originally Posted by RAT 5
How did this become a thread on FTL's & commuting?
Because cognitive misperceptions are far more likely if at the low performance end of the circadian cycle and fatigued. Often because the crew concerned are concentrating because they know they are at the low performance end of the circadian cycle and fatigued and this leads to cognitive (aka attentional) tunneling.
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Old 24th Jul 2017, 17:13
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excuses without foundation.
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Old 24th Jul 2017, 22:39
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Thank goodness they types like you out of safety departments a long time ago. If we didn't, we would still have the infallible 'Captain as God" types still flying the line, where we just sack people because they make mistakes and move on without trying to learn anything.

We are human, we are ALL screw up, and we don't get to choose when we do it. Landing on taxiways is a known phenomenon, this one just happened to be more populated than previous events.

The two guy's up the front didn't set out to screw up, the mere shame of ending up as the subject of a multi-page PPRuNe forum topic is horror enough. Let alone the true realisation of what might have been. These guys are likely to be irreparably psychologically damaged, and may even have their careers & families destroyed by this.

Aviation has moved on from previous era's of "just excuses, try harder, don't screw up", and it much safer for it. Aviation is a highly complex, stressed ecosystem with many more moving parts than just the pilots that concentrate large numbers of humans and dangerous goods into small areas at high velocity. It is a damn dangerous business, and we manage the risks exceptionally well because we have learnt that screwup can an do occur, even with the most simple and obvious task.

You can help improve the system, or you can just throw stones.

It's funny, as I am halfway through Fate is the Hunter [movie, 1964], everyone wants to hang the Captain Jack Savage out to dry...
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Old 24th Jul 2017, 23:06
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The last I heard, the reasons for the incident had not been determined, hence excuses without foundation.

Time to get off that pole you are sitting on.
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Old 24th Jul 2017, 23:29
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I've seen quite a few suggested contributing factors. Haven't seen a single thing proposed as an excuse.
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Old 25th Jul 2017, 00:36
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I guess I have a similar reaction to "excuse".

However that's directed at the system, not the individual.

I don't doubt the provenance of the human factors discussion above. It seems well formed.

Where I would choke is on considering those human factors a primary causal factor.

That implies we have to fix the human.

We might as well blame gravity.

We surely don't need to fix the human, and anyway let's be honest, we can't.

What we can do, and where I would hope any recommendations land, is in making circadian rhythms ever more irrelevant.

Last edited by pilot9249; 25th Jul 2017 at 13:22.
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Old 25th Jul 2017, 01:09
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Easy to laugh

I find it interesting that there is so much chat about the obvious. Poor airmanship and frankly an embarrassing moment for our profession. However I would venture a guess that these pilots where Toronto based and running on the back of the clock after a long day. AC was also involved in an incident of falling asleep at the controls only to wake up and violently manoeuvreing to avoid hitting a star. When will we band together and force laws to protect the flying public from tired pilots who are making life threatening decisions.
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Old 25th Jul 2017, 02:05
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Quote:
Originally Posted by BRDuBois .

Where I would choke is on considering those human factors a primary causal factor.

That implies we have to fix the human.

We might as well blame gravity.

We surely don't need to fix the human, and anyway let's be honest, we can't.
I disagree.
By identifying a human factor we don't have to fix the human, we have to fix the systems so that they are tolerant of that human factor.
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Old 25th Jul 2017, 02:27
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Well said.
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Old 25th Jul 2017, 03:14
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We have a choice whether to fix the system to accommodate the human frailty, or to avoid the human frailty entirely.

History is firmly on the side of the latter.
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Old 25th Jul 2017, 03:27
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Looks like 'the pilot' did not have the ILS tuned and displayed. This setup without the ILS would be normal for most operators on the A320 for this approach from our discussion here. Also, he went flying as scheduled the next day.

SFO close call: Air Canada pilot was not using guidance system, source says

By Matthias Gafni | [email protected] | Bay Area News Group
PUBLISHED: July 21, 2017 at 4:37 pm | UPDATED: July 24, 2017 at 4:35 am

SAN FRANCISCO — The wayward Air Canada pilot who nearly landed on a crowded SFO taxiway earlier this month did not activate his computer guidance system that would have helped guide his airplane onto the appropriate runway and not dozens of feet from a catastrophe, according to a source familiar with the federal investigation.

Preliminary findings in the joint Federal Aviation Administration and National Transportation Safety Board investigation have determined that the pilot — who flew for his carrier again the next day after his aborted July 7 landing — did not activate his Instrument Landing System during his visual approach, the source said. The Wall Street Journal, citing two unnamed sources familiar with the investigation, also reported Air Canada flight 759 attempted to land manually with no back-up.

In what experts have called a near-disaster, the Airbus 320 passed over two fully loaded airplanes on the taxiway, as close as 51 feet to one, according to flight data information analyzed by this newspaper, before finally climbing to abort the landing and traveling over two more aircraft. The NTSB and FAA have interviewed the Air Canada flight crew and SFO air traffic controllers.

With the clear weather that night, retired United Airlines pilot Ross Aimer said that, based on air traffic audio, the Air Canada pilot was approved for a Flight Management System (FMS) visual to Runway 28-Right, which would not require him to use his computer guidance system [the FMS visual didn't require him to use his computer guidance system? - Airbubba]. That is an angled approach that would require adjusting the guidance equipment if he chose to use it.

Aimer said most pilots don’t use the guidance equipment under those conditions and that type of approach.
Predictably, the union paints the AC 759 pilots as heroes for doing a go-around when told to do so by the tower :

Union spokesman Chris Praught said that because of the ongoing probe, he was limited in his comments, and could not comment on the pilot’s status and flight hours.

“It is a testament to the expertise and professionalism of the highly trained crew that they were able to ensure that the flight arrived safely at its destination,” he said.
SFO: Source says Air Canada pilot not using computer system

From the WSJ:

Air Canada Pilots Reportedly Didn’t Use Normal Navigation Aids in Close Call at San Francisco


Pilots of an Air Canada jet failed to use a ground-based guidance system when they nearly landed by mistake on a taxiway at San Francisco International Airport two weeks ago, potentially coming within dozens of feet of airliners on the ground, according to people familiar with the investigation.

By Andy Pasztor

Updated July 21, 2017 7:55 p.m. ET

WASHINGTON—Pilots of an Air Canada jet failed to use a ground-based guidance system when they nearly landed by mistake on a taxiway at San Francisco International Airport two weeks ago, potentially coming within dozens of feet of airliners on the ground, according to people familiar with the investigation.

As more details emerge about the incident, these people said, investigators have tentatively determined the crew didn’t utilize the available instrument landing system U.S. carriers typically require pilots to rely on for precision approaches in similar circumstances. The issue hasn’t been reported before, and it isn’t known why the crew failed to call up the instrument system for backup during the visual landing prior to breaking off the approach.
https://www.wsj.com/articles/air-can...sco-1500667932
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Old 25th Jul 2017, 03:42
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Originally Posted by sptraveller
We have a choice whether to fix the system to accommodate the human frailty, or to avoid the human frailty entirely.

History is firmly on the side of the latter.
I assume you are talking about a totally automated system, are I correct?
If that is the case, who or what is the source of such coding for the automation?

Here is an old investigation, a "computer accident" & excellent write-up by Nancy Levison: Therac-25.

I doubt computer software is going to solve the systems problems. Sure, it will fix some obvious ones, and equally will embed new issues. There will still be human factors, however, the location of the failure will just shift from the flight deck to the coding cubicle.

Another very recent article: The Future of Artificial Intelligence: Why the Hype Has Outrun Reality. Soak that article up, realise the massive data acquisition & processing task we humans actually do. We are exquisitely adapted to such tasks, at cost of being 100% accurate of the time. The efficiency of our sensor bandwidth & processing vastly exceed that of current systems by a very large margin.

Last edited by CurtainTwitcher; 25th Jul 2017 at 04:03.
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Old 25th Jul 2017, 04:32
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No. Nothing of the sort.

Full automation is a holy grail and I can only refer you to Monty Python on that.

I fully expect that increased use of existing automation would have made this incident much less likely.

Even if not, I seriously doubt that increased sensitivity to circadian rhythms would be the logical next best step that anybody could possibly invent. That would be really really sad.

Let's see the report.
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Old 25th Jul 2017, 05:11
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Most of my stupid mistakes have been when I was foot dragin ,eyes bleedin.dead dog tired.
Solve that problem and the safety record will soar.
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Old 25th Jul 2017, 06:41
  #419 (permalink)  
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I fully expect that increased use of existing automation would have made this incident much less likely.
Would a automated system be capable of conducting a visual approach?
Would an automated system ask why aircraft appear to be on the runway?
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Old 25th Jul 2017, 06:48
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Originally Posted by sptraveller
Even if not, I seriously doubt that increased sensitivity to circadian rhythms would be the logical next best step that anybody could possibly invent. That would be really really sad.

Let's see the report.
You mean like a FRMS (Fatigue Risk Management System)? That is already industry standard in many areas of the world, and of course takes circadian rythm, disruptions of that and effect of previous duties into account.
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