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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 3rd Aug 2017, 20:20
  #581 (permalink)  
 
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FMS Quiet Bridge approach?

Here we go again...

You might want to check the name of that approach.
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Old 3rd Aug 2017, 20:41
  #582 (permalink)  
 
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Originally Posted by BluSdUp View Post
The CVR is overwritten and the crew can not recall overflying 4 aircraft!
WOW!
Originally Posted by underfire View Post
If what the report states is true, that the AC drivers did not even recognize the taxiway was full, that implies they did not see the landing lights, nor hear UAL 1. (or are not telling the truth) There is enough intent in their statement alone, (forget the lack of CVR data) to prevent those 2 from rotating again.

Time to stop making excuses for the airline, the ac, and the crew. Let DHS get the true story out of them.
Whoa, hold on a mo, I think there is some fundamental misunderstanding going on here. The Air Canada 759 crew did see something on what they thought was Rwy 28R (but was actually Taxyway C), and queried it with the Tower:
NTSB 2nd August 2017 Update:
At 2355:46 PDT, when ACA759 was about 0.7 mile from the landing threshold and about 300 ft above ground level (agl), the flight crew contacted the ATC tower, mentioned seeing lights on the runway, and requested confirmation that the flight was cleared to land.
The Tower replied:
"Air Canada 759, confirmed, cleared to land Runway 28 Right, there is no one on 28 Right but you."
AC759 quickly replied:
"Okay, Canada 759."
Consequentally, whatever the reasons for AC759 being incorrectly lined up with Taxyway C, the crew had just had their (unknowingly) erroneous visual and mental model apparently reinforced by the Tower. Neither side of that radio conversation knew yet that things were badly wrong (the 4 aircraft crews on Taxyway C may have already had hairs standing on the back of their necks). The AC759 crew did have some initial unease about their odd visual picture, and queried it, but Tower (through no fault of his own), seemingly dispelled it.

United Airlines 1, right in the 'line of fire', seemed to be the first to raise real alarm, and did so by quickly transmitting (right on the end of AC759's reply to Tower):
"Wheres this guy going?"
"He's on the Taxyway!"
I believe it was those calls from UAL1 that probably then provided the serious startle factor for AC759. Very shortly thereafter they commenced a go-around, and Tower, now also aware of the potential disaster, ordered a go-around. A final report will, no doubt, clarify the precise timings and order for those latter events.
NTSB 2nd August 2017 Update:
"In post incident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them."
I don't believe that the AC759 crew statements "that they did not recall seeing aircraft on taxiway C but that something did not look right to them" mean that they did not see anything on Taxyway C - they did see something there - lights - and queried it with Tower. When Tower told them the runway was their's to land on, in their mental/visual model they then had even less reason to think that the lights were aircraft.

For people here to express astonishment that the AC759 crew did not see this or that, or demand that heads roll because the AC759 crew might be lying, is really jumping the gun! AC759 did see lights, and had their verbal query apparently satisfied by Tower's reply. I suspect that it may have been UAL1's calls which suddenly brought the visual and mental models inside the AC759 cockpit into very stark focus, and the crew must have been frightened and then embarrassed in the space of a handful of seconds.

Give them some space people, for goodness sake! All we know, and they now know, is that something went terribly wrong. Only a final report will give us more insight into the reasons for AC759 lining up with Taxyway C and not the real Rwy 28R. In the latter stages there seems to have been a serious disconnect between where they thought they were and what they saw, when compared to where they actually were.

Human Factors studies are being devolped and refined all the time, and the subject is part of pilot license qualification and training. It also forms part of ongoing license requalification and retraining - we study it it because we are erring humans subject to sometimes insidious phenomena. If it wasn't important, we wouldn't need to consider the subject, would we? It could be that this incident is a variation on something already known about mental/visual pictures being mixed up, but whatever it is, quit the flipping armchair judge-and-jury nonsense. It sucks, and some of you do yourselves no favours by behaving like a lynching mob.

Last edited by deeceethree; 4th Aug 2017 at 11:29. Reason: Some formatting had disappeared - Mods seem to have trimmed some recent posts at the same time.
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Old 3rd Aug 2017, 20:50
  #583 (permalink)  
 
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Dollars to donuts, the contents of the CVR following the GA weren't printable anyway.
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Old 3rd Aug 2017, 20:55
  #584 (permalink)  
 
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Well said.

This is so much like Comair at Lexington.
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Old 3rd Aug 2017, 21:35
  #585 (permalink)  
 
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Originally Posted by nolimitholdem View Post
*sigh*

What breathless nonsense.
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Old 3rd Aug 2017, 21:43
  #586 (permalink)  
 
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There has been much 'red herring' chat about the type of approach offered/requested/accepted. IMHO that has nothing to do with this incident, and I do not wish to open that discussion again. This incident started to occur at less than 3nm visual finals to RW28R. How they arrived at that point has nothing to do with it. It is what the crew did after that point that is relevant. Please, let us see the wood for the trees.
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Old 3rd Aug 2017, 23:13
  #587 (permalink)  
 
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I can't help wondering that the gap after PAL and prior to the UAL 3rd in line, wound up as hugely important to the safe result? If UA had been right behind PAL....would the bottom end of that flight path during GA cleared everyone?

Terrifying to think about.
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Old 4th Aug 2017, 01:41
  #588 (permalink)  
 
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Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance? That approach follows the SFO 095 radial inbound, which happens to cross the airport boundary just at Taxiway C. They would have to offset left a bit after crossing the San Mateo Bridge to line up on 28R.
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Old 4th Aug 2017, 03:17
  #589 (permalink)  
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Sorry if this has been shown. Just some daytime shots of the approach.


About 7mins in.


https://www.youtube.com/watch?v=ENe89j89tBA
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Old 4th Aug 2017, 03:22
  #590 (permalink)  
 
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Let me add another scenario. If you listen to the ATC tape, I am dumbfounded by the nonchalant transmission from AC saying that they are in the go-around. I am not sure that even then they realized what a f-up had just occurred and how close they were to disaster. At least we have the FDR. They should be able to synchronize it with the ATC tapes to see exactly when the go-around was commenced.
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Old 4th Aug 2017, 03:28
  #591 (permalink)  
 
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Good reason to stick to ILS.
If ILS out of service, the RNP would line you up with the runway.
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Old 4th Aug 2017, 04:26
  #592 (permalink)  
 
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Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance
Yes it is, done so many times. Workload is much lower on the FMS bridge however.
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Old 4th Aug 2017, 04:45
  #593 (permalink)  
 
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The crew were cleared for the FMS Bridge but of course at this time we don't know what approach they actually flew and how they did it.

I don't see the expected turns to/from F101D in the (admittedly sparse) ADS-B data from FlightAware.
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Old 4th Aug 2017, 04:45
  #594 (permalink)  
 
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Originally Posted by MarcK View Post
Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance?
I've also wondered if somehow they had the wrong approach in the box or were looking at the wrong one on their tablets? Did they build a path or incorrectly heal a discontinuity that gave faulty guidance on final?

Can you pull up the Quiet Bridge Visual on the A320 FMS? Will it give guidance on final?

Some earlier opinions:

Originally Posted by ironbutt57 View Post
there are two, BOTH in the FMS database
Originally Posted by aterpster View Post
Two FMS Visuals to 28R?
Originally Posted by West Coast View Post
Only one FMS bridge visual in my database. You'd have to build the quiet bridge visual yourself.
Originally Posted by cappt View Post
Just one, the RNV28R in our FMS.
You can see how much confusion there is on this thread about the two visual approaches to 28R with 'Bridge' in the name.

Since the dog ate the CVR tape, will the legacy FDR data show much about what was in the FMS?

Originally Posted by deSitter View Post
Why didn't the first two planes bail off the taxiway? I can't imagine I'd just sit there and let someone land on my nose. What are your driver's instincts here?
Actually there was an accident three decades ago where an airliner taxiing for takeoff did swerve when seeing a commuting Eastern captain in an Apache coming out of the fog lined up on the taxiway. The Pan Am 727 moved enough to avoid a direct hit and took a glancing blow. The Apache was totaled with fatal results but everybody in the 727 evacuated successfully and the plane was repaired and flew again.

Jet at Tampa Airport Hit By Small Plane

By Bill McAllister November 7, 1986

A small twin-engine plane, flown by a senior airline pilot, crashed into a taxiing Pan American World Airways jet in dense fog at Tampa International Airport yesterday morning, killing the small-plane pilot as his aircraft broke apart in a fireball.

Officials said the death toll in the Florida accident would have been higher if the pilot of the Pan Am 727 had not spotted the approaching plane seconds before impact and swerved to avoid a head-on collision.

"That maneuver . . . prevented what could have been a much more serious accident," Pan Am spokesman Alan Loflin said. Two of the jet's 17 passengers and one of its six crew members suffered minor sprains sliding down the aircraft's emergency chutes.
https://www.washingtonpost.com/archi...=.a2fbba62c493
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Old 4th Aug 2017, 05:29
  #595 (permalink)  
 
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Originally Posted by Loose rivets View Post
Sorry if this has been shown. Just some daytime shots of the approach.


About 7mins in.


https://www.youtube.com/watch?v=ENe89j89tBA
I think the approach is actually this one: https://www.youtube.com/watch?v=LO12oGJPrPY
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Old 4th Aug 2017, 05:41
  #596 (permalink)  
 
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You can see how much confusion there is on this thread about the two visual approaches to 28R with 'Bridge' in the name.
Seems they did select the correct approach, flew direct TRDOW to join before being cleared for the visual. This waypoint doesn't exist on the Quiet Bridge.
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Old 4th Aug 2017, 05:54
  #597 (permalink)  
 
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Seems they did select the correct approach, flew direct TRDOW to join before being cleared for the visual. This waypoint doesn't exist on the Quiet Bridge
yup, not sure how one could confuse the two when they went to TRDOW. Non player to me.
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Old 4th Aug 2017, 06:09
  #598 (permalink)  
 
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New images of Air Canada near miss
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Old 4th Aug 2017, 11:22
  #599 (permalink)  
 
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Originally Posted by SeenItAll View Post
Let me add another scenario. If you listen to the ATC tape, I am dumbfounded by the nonchalant transmission from AC saying that they are in the go-around. I am not sure that even then they realized what a f-up had just occurred and how close they were to disaster. At least we have the FDR. They should be able to synchronize it with the ATC tapes to see exactly when the go-around was commenced.
Dumbfounded? I have listened, and am not dumbfounded.

You assert that you are "... not sure that even then they realized what a f-up had just occurred and how close they were to disaster" but are also surprised they made a supposedly nonchalant transmission? If, and this is a big 'if', it is true that the AC759 crew were still unaware of the disaster that had just been averted, why would you expect them to be anything other than calm? They can't be frightened by something they don't know has happened, surely? But I sincerely don't think that is going to be the case uncovered here.

As I indicated in my earlier post (#584), it is highly likely that UAL1's calls of "Wheres this guy going?" and "He's on the Taxyway!" brought things back into focus for AC759, with fear and embarrassment in equal measure in the following seconds. The radio conversation that ensues is:
Tower: "Air canada, go-around."
AC759: "In the go-around, Air Canada 759"
"In the go-around ..." implies that AC759 has already begun his go-around (as you state, the NTSB will undoubtedly be able to pinpoint precisely what was done and what was said, to the fraction of a second ...). If you currently believe AC759's reply transmission as "nonchalant", would you be willing to alternately consider it might be that, having been startled by UAL1s calls, the crew realised the enormity of what was unfolding, and were now working extremely hard not to let the emotions, fear almost certainly being one of them, overwhelm their recovery from the near disaster? They were 'boxing the chimp' and hanging on to their sensibilities - try a websearch for Dr Steve Peters and 'The Chimp Paradox' if you are not familiar with the term.

Whilst AC759's go-around reply is short and crisp, I beg to differ about it being at all "nonchalant"! I believe we will eventually learn that by then the crew did realise that a disaster had only just been averted, by the narrowest of margins, and they were desperately trying focus on recovering as calmly and professionally as they could, not making things any worse whilst they did so. Throughout the go-around and beyond, a nagging thought of "What the hell just happened?" would likely have been distracting them.

Despite the CVR loss, we are fortunate that there is still plenty of data available for the NTSB to reconstruct this serious incident, and we will learn in fine detail what went on and, hopefully, why. It seems clear that the crew of AC759 had a mental/viusal model that was disparate from what others involved could see, so it really is important to learn how and why they got there. As I declared in my earlier post, stop with the unnecessary character-bashing and rush to judgement - it isn't seemly without all the facts to hand. The NTSB final report will give us those.

If anyone is concerned I might be biased in favour of the AC759 crew, I am happy to openly declare my position:
1. I have no connection with Air Canada, or the crew members involved, whatsoever.
2. Neither do I have any connections to any of the other crew, SFO ATC, or the investigators.
3. I fly longhaul passenger aircraft, and have 38 years of professional flying experience.
4. I have operated in and out of SFO.

Now, stop being so bloody judgemental of the AC759 crew!
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Old 4th Aug 2017, 11:32
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This incident started to occur at less than 3nm visual finals to RW28R.
If I had to bet I would say that this incident started well before that. There is only one way that I can see that this occurred. The expectation of both pilots had to be that there would be a runway to the left of their final approach track and that they wanted the second one in. This expectation had to be pretty strong in order for "expectation illusion" to 'overpower' what they actually sensed when looking out the window.
It could have been a strong expectation because they had both flown into that airport at night from the East on many occasions, or because they briefed that that is what they would see, or both. Either way I can't see how it could have been such a strong expectation in both of them if they had read and understood the notam and the ATIS.
So when the report comes out ( and I may be wrong of course) , I think we will read that the nuts and bolts of this incident are to be found a long way prior to 3nm final.
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