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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 4th Aug 2017, 11:33
  #601 (permalink)  
 
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Well said Deeceethree.
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Old 4th Aug 2017, 11:40
  #602 (permalink)  
 
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Originally Posted by Johnny Albert View Post
JA, you may wish to know that the images in your link were highlighted earlier in post #552, which itself led to this NTSB page where the images were first publicised, I believe.
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Old 4th Aug 2017, 13:10
  #603 (permalink)  
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My few posts have mostly been concerned with the psychology of the incident.

The tiniest hint of disbelief by the PNF when assured the runway was clear, is I feel, a very significant point. What they were perceiving has been well covered: a runway to their left and a set of lights that didn't look quite right - ringing an alarm bell in the mind of one pilot if not both.

Then there's the RT.

"Were going in the Hudson." is a sentence probably buried in the memory of every pilot in the Western World. As we all know, it did not convey the magnitude of the emergency and certainly not the intention.

"Wheres this guy going?" and "He's on the Taxyway!" brought things back into focus for AC759,
Without a second-by-second time-line into the thinking of the flying pilots, I rather think it didn't. Neither statement made the extent of the emergency totally clear - and from the holding pilot's viewpoint it was an imminent catastrophe.

If I'd been presented with that image, I like to think I'd have made it very clear - the very least, Landing aircraft. You are lined up with, or You are landing on the Taxiway. And yes, there would have been a lot of !!!!!!! to emphasise the point.

We know what was meant by He's on the Taxyway, but that was background noise in the ears of the flying pilots who were already presented with something that simply did not look right. Again, if I'd been presented with that image . . . well, I have no idea what I would have done. If the rows of lights fooled two experienced pilots, they may well have fooled me.

If we are to truly learn from this incident, the entire thing should be re-enacted, though I hasten to add I'd not have the camera aircraft overfly the holding hardware! Expensive, but it's vital to know how pilot perception can be slewed so dramatically.

N.B. I had a Boeing trundling towards me while at about 6 miles finals at night. I watched bemused as it seemed to be gathering extraordinary taxiing speed. When it rotated I asked if they'd like me to move out of the way. All good humoured. The point being, it was all so clear. I could even identify the aircraft. What was it about the row of holding aircraft that looked so different?
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Old 4th Aug 2017, 13:59
  #604 (permalink)  
 
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Originally Posted by deeceethree View Post

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.
If your premise is correct, then the crew had a subsequent lack of ethics and integrity by failing to secure the CVR and so advising their flight management at the end of the flight.

Now, stop being so bloody judgemental of the AC759 crew!
Why, given your premise and their failure to secure the CVR?
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Old 4th Aug 2017, 14:30
  #605 (permalink)  
 
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Yes, but.

Originally Posted by aterpster View Post
. . . . . . their failure to secure the CVR?
I'd like to be able to articulate a view which gives the AC crew some degree of credit for having flown the approach well enough - minus the misalignment obviously - so that the physical separation margin of error turned out to be enough. It might turn out to be shown that it was, mathematically and in terms of the physics of the situation, the minimum separation that could have existed, but we do not know that. And to be blunt, it can't really be said validly at this juncture, on the facts that are pretty much given, that the approach was operated in such a way so that what might have been a lower crossover of the threshold did not materialize. I sure can't say that, as much as I might want to.
But maybe there is another factor which should serve here to pull back on the reins dragging two fine aviator careers toward a rush to judgment. Specifically, that CVR content might have been pretty darn scary for the traveling public to hear. I have no idea what actually was on that segment. But it seems neither unrealistic nor unreasonable to include, as a possibility, that the segment no longer available was some pretty unnerved stuff. Now, that is not a reason for not preserving the CVR (double-duh!) in the eyes of the law. But before canards about ethics get taped to someone's jacket, should not reasonably possible mitigating factors be given their due?
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Old 4th Aug 2017, 14:46
  #606 (permalink)  
 
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Originally Posted by peekay4 View Post
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.
Actually a waypoint at the same position is designated as the SFO 095/20 on the Quiet Bridge approach. But you are right, if it is in the box it probably would be named with the FMS alphanumeric coding scheme.
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Old 4th Aug 2017, 15:02
  #607 (permalink)  
 
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Originally Posted by WillowRun 6-3 View Post
I'd like to be able to articulate a view which gives the AC crew some degree of credit for having flown the approach well enough - minus the misalignment obviously - so that the physical separation margin of error turned out to be enough. It might turn out to be shown that it was, mathematically and in terms of the physics of the situation, the minimum separation that could have existed, but we do not know that. And to be blunt, it can't really be said validly at this juncture, on the facts that are pretty much given, that the approach was operated in such a way so that what might have been a lower crossover of the threshold did not materialize. I sure can't say that, as much as I might want to.
But maybe there is another factor which should serve here to pull back on the reins dragging two fine aviator careers toward a rush to judgment. Specifically, that CVR content might have been pretty darn scary for the traveling public to hear. I have no idea what actually was on that segment. But it seems neither unrealistic nor unreasonable to include, as a possibility, that the segment no longer available was some pretty unnerved stuff. Now, that is not a reason for not preserving the CVR (double-duh!) in the eyes of the law. But before canards about ethics get taped to someone's jacket, should not reasonably possible mitigating factors be given their due?
The CVR is for the serious purpose of investigation. It is not for the public's entertainment. Only this crew could have preserved the tape.
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Old 4th Aug 2017, 15:08
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On the CVR:

I believe the incident aircraft was C-FKCK, msn 265 delivered in 1992 -- so it may only have a 30 minute CVR installed in compliance with Canadian regulations.

The go-around happened by 02:56 UTC. After the circuit, AC759 then landed at 03:11 and arrived at the gate at 03:15. That's 19 minutes.

So unless the pilots pulled CBs within 10 minutes of the gate arrival (while passengers were still disembarking), the CVR might have been completely overwritten in any case.

And I'm not even sure it's standard procedure for AC pilots to pull CBs on their own after every possible reportable incident. Probably the pilots were told to "call the tower" at this point and were still wondering / discussing what had just happened amongst themselves.

25-hr CVR rule would have made a difference here.
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Old 4th Aug 2017, 15:08
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Originally Posted by WillowRun 6-3 View Post
Specifically, that CVR content might have been pretty darn scary for the traveling public to hear. I have no idea what actually was on that segment. But it seems neither unrealistic nor unreasonable to include, as a possibility, that the segment no longer available was some pretty unnerved stuff.
Are you seriously suggesting that would justify a conscious decision (if such was made) to allow the CVR to be overwritten?
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Old 4th Aug 2017, 15:21
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I would have thought by 1992 that solid state CVRs were being installed. The solid state units record two hours.
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Old 4th Aug 2017, 15:23
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Originally Posted by galaxy flyer View Post
Adoption of Forward Looking IR (Enhanced Flight Visibility Systems, EFVS in FAA speak) and Synthetic Vision Systems (SVS) would go a long way to eliminating night visual problems. The EFVS view, especially in a HUD, would have shown the line up planes as four large signatures and the lighting clearer, assuming it hadn't been converted to LED. The SVS would have shown the runway off line-up to the left in a daylight view and the taxiway in front of them. SVS is good enough to show you taxiing across a runway and the view on the PFD or MFD is identical to the outside view.
Unfortunately, HUDs and Synthetic Vision bring their own attentional tunneling effects which have been repeatedly demonstrated in human factors experiments in high fidelity simulations. You cannot 'cure' a feature of the human brain by adding more devices; except perhaps by automating out the crew entirely.
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Old 4th Aug 2017, 15:24
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I would have thought by 1992 that solid state CVRs were being installed. The solid state units record two hours.
No even brand new solid state CVRs today come with 30-minute and 120-minute options from the manufacturer.

FA2100:

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Old 4th Aug 2017, 15:39
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Originally Posted by DaveReidUK View Post
Are you seriously suggesting that would justify a conscious decision (if such was made) to allow the CVR to be overwritten?
No. A mitigating factor is one which tempers a sanction, typically in support of reducing a sanction (but sometimes only in a pro forma manner). Not justification. And secondly, here the inquest is intended (or should be intended) to extract as much information as is relevant to the sequence of events. Asking what possibly could have caused one of those events is an established means of assuring that an investigation process does not gloss over or miss anything (as much as this can be assured).
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Old 4th Aug 2017, 15:43
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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.
You are approaching what you are convinced is the runway you have been cleared to land on. As you reach short finals you see lights on 'the runway' you tell ATC who tell you there is nothing on the runway you are clear land. But you _still_ see those lights and think I am going around there _is_ something on the runway. Just as you start to go around tower tells you to go around. You say to Tower "In the go around" and you are thinking those guys in the tower screwed up! There _were_ vehicles on the runway! ....

Perhaps the illusion that the taxiway was the runway actually lasted all the way around the circuit after the go around until a straight in approach made them realize that their first approach had been to the taxiway.

Just a thought.
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Old 4th Aug 2017, 15:47
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Originally Posted by deeceethree View Post

Now, stop being so bloody judgemental of the AC759 crew!
They seemed to have performed very well when they realized what was going on.
It's the fact they nearly thumped it into a crowded taxiway that is the issue.

The error was rectified, but whatever caused the initial problem needs to be fixed.
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Old 4th Aug 2017, 16:03
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DC3: If you read carefully my post, you will note that I drew no conclusions as to what actually did happen. All I did was propose another possibility. And as I noted, whether or not this possibility is correct will come out as the investigation continues. While I cannot opine as to the composure that these pilots might have been able to muster in the face of a situation that 3 or 4 seconds prior was going to be beyond catastrophic, I know that I (and I think most people, even pilots) would have been a little rattled.

Further, I can't recount the number of times I have asked my kids to come home for dinner, and received a response that "I am on my way," even when they had not started or were only beginning this process. It's a face-saving response to which many (myself included) are prone.

Again, I do not know what exactly did happen and I apologize if you thought that my raising of this possibility was disrespectful. In any event, you may wish to reread your post and decide whether it needs to be scrubbed of some judgements.
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Old 4th Aug 2017, 16:12
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Originally Posted by peekay4 View Post
So unless the pilots pulled CBs within 10 minutes of the gate arrival (while passengers were still disembarking), the CVR might have been completely overwritten in any case.

And I'm not even sure it's standard procedure for AC pilots to pull CBs on their own after every possible reportable incident. Probably the pilots were told to "call the tower" at this point and were still wondering / discussing what had just happened amongst themselves.
At many U.S. carriers the CVR circuit breaker is on the shutdown checklist and should be pulled in the event of an NTSB Part 830 reportable incident or an accident. That procedure has been in place in the U.S. for several years, I'm sure someday it will be SOP in Canada as well if it is not already.

But, as you can see from my earlier comments, I'm not too surprised that the CVR recording was somehow unavailable for the NTSB investigation of an incident that occurred around midnight on a Friday evening.
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Old 4th Aug 2017, 16:45
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Having lived in the same house for 54 years, and having parked outside it some 50,000 times, I recently parked outside the wrong house. Excuse was a defunct street light, plus I "latched" on to the wrong facade, which I thought looked slightly "funny". 1 in 50,000 is AOK for a parking location error, but totally unacceptable for a life threatening error.
HOWEVER
F Type pretty soon put me right.
Which means that the probability of two pilots getting it wrong is not my 1 in 50,000, but 1 in 50,000 squared, or 1 in 2,500,000,000. Which is much better, but still a bit scary.
A good argument for having two pilots.
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Old 4th Aug 2017, 17:49
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As a non-pilot, this intrigues me and I would like to know what pilots think about this situation -- it appears obvious from the discussion that one of two things is true, either

(a) the pilots did not receive the NOTAM concerning runways in use, or

(b) the pilots forgot the information from the briefing presumably four to six hours earlier.

Either way, is there no system in place to remind pilots of NOTAM information at a useful time such as 30 minutes before arrival?

If not, should there not be one? Just some sort of computer-generated message like reminder of NOTAM of closed runway at SFO, with the actual details in the message. This would avoid both possibilities above.
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Old 4th Aug 2017, 17:54
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Either way, is there no system in place to remind pilots of NOTAM information at a useful time such as 30 minutes before arrival?
Possibly. Many airlines make a checking NOTAMS a part of the approach briefing.
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