Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
An FRMS is supposed to do those things, whether it does or not depends upon the people running it. People can tick along fatigued to the point of depression within an FRMS, knowing full well that if they call fatigued one too many times it will be a mandatory visit to the company doctor. Legislated hard limits are the only real way to keep a lid on fatigue.
Provides surveillance data with an accuracy and update rate suitable for:
- Situational awareness in all weather conditions
- Departure queuing
- Conflict detection and alerts
- Taxi route conformance monitoring
Still a looong way to go before automation catches most of the incidents before they become one...
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Hasn't it been established that the flight was cleared for the FMS Bridge Visual 28R? If so, seems that would supersede using the ILS 28R, contrary to Andy Pasztor's assertion.
I believe someone stated earlier in this thread that the FMS Visual 28R could be coupled to autoflight and A/T and track a solid 3D (LNAV/VNAV) path to roll out on final at WP F101D (4.4 DME SFO VOR), which is aligned with the runway at 3.6 nautical miles.
From those of you who have flown this FMS procedure, right or wrong?
I believe someone stated earlier in this thread that the FMS Visual 28R could be coupled to autoflight and A/T and track a solid 3D (LNAV/VNAV) path to roll out on final at WP F101D (4.4 DME SFO VOR), which is aligned with the runway at 3.6 nautical miles.
From those of you who have flown this FMS procedure, right or wrong?
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Correct me if I am wrong, but I recall someone stating that its "either/or" with the Air Bus.
Also, I have no idea how an FMS visual is coded. If it is coded to go to LVAV approach alerting and sensitivity (RNP 0.30), perhaps at F101D, the lateral and vertical guidance should be more than adequate for the circumstances.
Also, I have no idea how an FMS visual is coded. If it is coded to go to LVAV approach alerting and sensitivity (RNP 0.30), perhaps at F101D, the lateral and vertical guidance should be more than adequate for the circumstances.
Why do I find it hard to believe that we, as pilots in clear weather, need an ILS to find a runway plainly visible? The pilots on the AC flight questioned the controller, but did not question themselves, there's the problem.
I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.
I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.
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For the controller types, would not ADSE-X or ASSC have given a warning on this event, or do these technologies work on ground traffic only. One would think combined surveillance inputs could see this developing.
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In the A320 the display of ILS GS and LOC symbology on the PFD is incompatible with using the autoflight system to fly a non-precison approach. The ILS may be hard-tuned but the crew will not see the data unless they select the LS pushbutton or switch the Nav Display over to ROSE LS mode. If they do press the LS pushbutton after loading an approach with vertical guidance, they will get a flashing amber V/DEV message on the PFD to highlight the incompatible selection.
Why do I find it hard to believe that we, as pilots in clear weather, need an ILS to find a runway plainly visible? The pilots on the AC flight questioned the controller, but did not question themselves, there's the problem.
I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.
I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.
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Figuring out causal links (plus a question)
A set of factors led up to this incident, and obviously not all of those factors yet are identified, let alone integrated into an overall narrative - but will the end result of the Board report be fully satisfactory? To explain . . .Reference has been made by several posts to the Colgan accident, as I understood it, for context for suggestions that effects of fatigue, or circadian rhythms (or both), played a role in the SFO incident. Someone posted the NTSB report on Colgan which I took as an invitation to start reading said report. Immediately the role of probabilistic assessment leapt out from its pages:
"The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions." Report Sec. 3.2 (p. 155).
Note also, Finding no, 9, the reason the captain failed to recognize the impending onset of stick shaker “could not be determined from the available evidence”; Finding no. 15 (“the reasons the F/O retracted the flaps and suggested raising the gear could not be determined from the available information); and Finding no. 24 (“The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined”).
It seems more than just reasonable to say that the analysis of causes in the AC 759 SFO incident also will involve a set - a complex, a list - of factors. What is the standard for "probable cause" as opposed to a "contributing factor" as opposed to some factor that a large or even vast majority of ATPs will say was a relevant one but which the available evidence or information does not warrant making a firmer conclusion or finding about? More than a pedantic query, the standard for assessing causal linkage relates directly to identifying priorities for rule-making, technological system assessments, and other factors. (And is formal assessment of cause one which assumes that all of the factors would take place in the next potential incident or does the remedial and preventative effort proceed with an understanding that several different combinations of most, but not necessarily all, of the factors would result in an accident the next time?)
The glib reason for being curious about this is that as Congress and other interested parties take a shot at separating the ATC and Safety functions of FAA, the agency's ability to respond to NTSB recommendations certainly cannot be allowed to be degraded, downgraded or otherwise reduced, and should instead - in such a legislative initiative - be significantly improved.
Now, does anyone who actually flies such an aircraft on such an approach as was involved in this incident think that the actual physics of the situation - the amount of actual distance between two potential points of contact - was a result of some lingering doubt in the mind of the PF that maybe the approach had been screwed up, misaligned? In other words, did PF possibly fly the approach just a little bit higher, out of some kind of PF muscle memory, let's call it, just because something didn't seem quite right? The margin was so small, was it not? - but was it "enough" because the PF left a tiny bit of extra margin, subconsciously if that is what you want to call it?
Edit: Statement of Chairman Hersman, concurring (Colgan report): "We . . . do not require that any causal or contributing factor equate to a percentage or share of the cause of an accident."
(Notation 8090A, pg. 3)
"The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions." Report Sec. 3.2 (p. 155).
Note also, Finding no, 9, the reason the captain failed to recognize the impending onset of stick shaker “could not be determined from the available evidence”; Finding no. 15 (“the reasons the F/O retracted the flaps and suggested raising the gear could not be determined from the available information); and Finding no. 24 (“The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined”).
It seems more than just reasonable to say that the analysis of causes in the AC 759 SFO incident also will involve a set - a complex, a list - of factors. What is the standard for "probable cause" as opposed to a "contributing factor" as opposed to some factor that a large or even vast majority of ATPs will say was a relevant one but which the available evidence or information does not warrant making a firmer conclusion or finding about? More than a pedantic query, the standard for assessing causal linkage relates directly to identifying priorities for rule-making, technological system assessments, and other factors. (And is formal assessment of cause one which assumes that all of the factors would take place in the next potential incident or does the remedial and preventative effort proceed with an understanding that several different combinations of most, but not necessarily all, of the factors would result in an accident the next time?)
The glib reason for being curious about this is that as Congress and other interested parties take a shot at separating the ATC and Safety functions of FAA, the agency's ability to respond to NTSB recommendations certainly cannot be allowed to be degraded, downgraded or otherwise reduced, and should instead - in such a legislative initiative - be significantly improved.
Now, does anyone who actually flies such an aircraft on such an approach as was involved in this incident think that the actual physics of the situation - the amount of actual distance between two potential points of contact - was a result of some lingering doubt in the mind of the PF that maybe the approach had been screwed up, misaligned? In other words, did PF possibly fly the approach just a little bit higher, out of some kind of PF muscle memory, let's call it, just because something didn't seem quite right? The margin was so small, was it not? - but was it "enough" because the PF left a tiny bit of extra margin, subconsciously if that is what you want to call it?
Edit: Statement of Chairman Hersman, concurring (Colgan report): "We . . . do not require that any causal or contributing factor equate to a percentage or share of the cause of an accident."
(Notation 8090A, pg. 3)
Last edited by WillowRun 6-3; 25th Jul 2017 at 17:37. Reason: Found a partial answer
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Why on earth do the edge lights on the runway out of use have to be switched off, given they are part of the visual cues for a visual approach ?
Last edited by WHBM; 26th Jul 2017 at 07:42.
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It's not hard to image someone landing on a lit runway...
Remember the Taipei SQ accident? He used a lit runway that had construction equipment halfway down it. For every countermeasure, closing off one accident scenario seems to open up another.
As I explain to my kids, its all about identifying the failure modes and making yourself aware of the traps as best as you can. Perhaps we have got to the point where introducing more defences actually become counterproductive.
Remember the Taipei SQ accident? He used a lit runway that had construction equipment halfway down it. For every countermeasure, closing off one accident scenario seems to open up another.
As I explain to my kids, its all about identifying the failure modes and making yourself aware of the traps as best as you can. Perhaps we have got to the point where introducing more defences actually become counterproductive.
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Why do I find it hard to believe that we, as pilots in clear weather, need an ILS to find a runway plainly visible? The pilots on the AC flight questioned the controller, but did not question themselves, there's the problem.
I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.
I don't think the ILS being tuned and displayed or the FMS approach would, or could have, made the slightest difference. Once locked into the the visual picture, the crew wasn't going to change. What's surprising is they did NOT go around when they believed the runway was blocked.
Had one of those queued aircraft switched on its landing lights the 'illusion' would have been destroyed. Similarly, had ATC switched on the 28L lights the illusion would have been destroyed, had ATC added to the approach clearance 'runway 28L is out of use unlit and marked with a red cross' - the illusion would have been destroyed. But all the players were happy with the holes in the cheese as they were and didn't think to try to close them.
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As to your other point that would have been in NOTAMs and broadcast on the KSFO ATIS frequency.
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This is exploding into realms that are.........
The lighting of a runway, including the approach lights is very clear, well defined and well known. The lighting of a taxiway is completely different, and there are no approach lights. The lighting systems & colours were done this way to avoid mistaken identification. Runways have white & red lights; taxiways have blue & green. Pilots have colour-blindness tests and eye-sight tests. Added to this are NOTAMS when anything is amiss.
Pilots were expected to know these things and look out of the window and use Mk.1 eyeball to determine they were landing on an OK bit of tarmac.
Now, there are techies who are designing systems to alert ATC & crews when they are lined up with the wrong bit of tarmac. Another automatic back-up to human error. Agreed, there is a system to alert the crew when they are encroaching onto an active runway. At some very confusing airfields this seems to have saved the day a few times. However, their need might have been contributed to by non-standard lighting and lack of stop bars. (it should be difficult to cross reds).
It has been surmised that over-automation might become counter productive. Humans will stop thinking, plough on regardless, and wait for the warning system alerts to wake them up. I saw this in a young company when they transitioned from B727 to B757. The instructors were scolding the pilots to "stop scanning the overhead panel. The EICAS will tell you when something is wrong." I see it in a friend's new car with lane control, reactive braking & cruise control; his attention is reduced and he says how relaxing it is. i.e. his alertness level is reduced. I look a few cars ahead to anticipate traffic flow, not at the bumper in front of me. He sets his cruise/brake control to 3 car lengths and switches off.
If a crew can not distinguish between a well lit runway & a taxiway, at night, then I'm not sure an automatic system is the answer. That is a sticking plaster on a deeper problem.
The lighting of a runway, including the approach lights is very clear, well defined and well known. The lighting of a taxiway is completely different, and there are no approach lights. The lighting systems & colours were done this way to avoid mistaken identification. Runways have white & red lights; taxiways have blue & green. Pilots have colour-blindness tests and eye-sight tests. Added to this are NOTAMS when anything is amiss.
Pilots were expected to know these things and look out of the window and use Mk.1 eyeball to determine they were landing on an OK bit of tarmac.
Now, there are techies who are designing systems to alert ATC & crews when they are lined up with the wrong bit of tarmac. Another automatic back-up to human error. Agreed, there is a system to alert the crew when they are encroaching onto an active runway. At some very confusing airfields this seems to have saved the day a few times. However, their need might have been contributed to by non-standard lighting and lack of stop bars. (it should be difficult to cross reds).
It has been surmised that over-automation might become counter productive. Humans will stop thinking, plough on regardless, and wait for the warning system alerts to wake them up. I saw this in a young company when they transitioned from B727 to B757. The instructors were scolding the pilots to "stop scanning the overhead panel. The EICAS will tell you when something is wrong." I see it in a friend's new car with lane control, reactive braking & cruise control; his attention is reduced and he says how relaxing it is. i.e. his alertness level is reduced. I look a few cars ahead to anticipate traffic flow, not at the bumper in front of me. He sets his cruise/brake control to 3 car lengths and switches off.
If a crew can not distinguish between a well lit runway & a taxiway, at night, then I'm not sure an automatic system is the answer. That is a sticking plaster on a deeper problem.
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I believe someone stated earlier in this thread that the FMS Visual 28R could be coupled to autoflight and A/T and track a solid 3D (LNAV/VNAV) path to roll out on final at WP F101D (4.4 DME SFO VOR), which is aligned with the runway at 3.6 nautical miles.
Previous comments stated that the ac may not have been GPS equipped. This would negate them even using the procedure, so who knows.
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Except that this experienced crew _did_ make an approach to a taxiway marked with centerline greens rather than the well lit runway alongside and with several widebodies queued on it which they also saw. Restating the reasons they shouldn't is like saying in that in the research I posted earlier the observers should have seen the gorilla. Research repeatedly shows how easy it is to get human brains to have these misperceptions.
The more this crew concentrated the more their attentional tunneling made them convinced they were making an approach to 28R. Sure we all know airport marking and lighting but once that misperception kicks in it will be difficult to remove. So the first thing is to make misperception less likely and then to break the misperception if it does occur.
The more this crew concentrated the more their attentional tunneling made them convinced they were making an approach to 28R. Sure we all know airport marking and lighting but once that misperception kicks in it will be difficult to remove. So the first thing is to make misperception less likely and then to break the misperception if it does occur.
SFO 06/017 SFO RWY 28L ALS OUT OF SERVICE 1706021357-1707211500
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It requires radar from the old plate posted earlier on the thread.This approach has been in use for at least 20 years, long before most A320's and B-757's had GPS. But I'm sure you knew that, right?
At the time of the SQ006 crash runway 05R was an odd pseudo-runway in my observation. It had green centerline lights since it was usually used as a taxiway. Also, the touchdown zone markings were faded and non-standard with rows of white circles instead of piano keys and solid fixed distance markers. Seems like I landed on 05R once (75 feet wide?
) when 05L was notamed out of service for rubber removal years ago.It appears that the edge lights to 05R were not lit when the SQ whale lined up on it by mistake:
On the night of the accident, the information available to the flight crew regarding the orientation of the aircraft on the airport was:
- CKS Airport navigation chart
- Aircraft heading references
- Runway and Taxiway signage and marking
- Taxiway NI centerline lights leading to Runway 05L
- Color of the centerline lights (green) on Runway 05R
- Runway 05R edge lights most likely not on
- Width difference between Runway 05L and Runway 05R
- Lighting configuration differences between Runway 05L and Runway 05R
- Para-Visual Display (PVD) showing aircraft not properly aligned with the Runway 05L localizer
- Primary Flight Display (PFD) information
The flight crew lost situational awareness and commenced takeoff from the wrong runway.
- CKS Airport navigation chart
- Aircraft heading references
- Runway and Taxiway signage and marking
- Taxiway NI centerline lights leading to Runway 05L
- Color of the centerline lights (green) on Runway 05R
- Runway 05R edge lights most likely not on
- Width difference between Runway 05L and Runway 05R
- Lighting configuration differences between Runway 05L and Runway 05R
- Para-Visual Display (PVD) showing aircraft not properly aligned with the Runway 05L localizer
- Primary Flight Display (PFD) information
The flight crew lost situational awareness and commenced takeoff from the wrong runway.