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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, 18:21
  #621 (permalink)  
 
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Even better, notams are checked before flight including the arrival airport and it is good practice to check again before starting the arrival/approach. There is no excuse for not knowing about arrival notams except when they are issued after departure which is possible given the long haul flight times.
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Old 4th Aug 2017, 18:27
  #622 (permalink)  
 
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Originally Posted by peekay4 View Post
No even brand new solid state CVRs today come with 30-minute and 120-minute options from the manufacturer.

FA2100:

They could be recording essentially unlimited times, given the cost of storage chips now. This is totally amazing. 30 minutes appears to be the capacity of the first CVR from 1961, if we can trust Wikipedia.
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Old 4th Aug 2017, 18:53
  #623 (permalink)  
 
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TWA installed them in 1964. Tape recorder, 30 minute loop. That 30 minutes was invaluable in the 1974 TWA 514 CFIT investigation. Much more so than the FDR.
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Old 4th Aug 2017, 19:20
  #624 (permalink)  
 
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I'd give a body part to have had one in my dad's plane. It would have kept the CAB from making such a hash of their investigation.

http://www.pprune.org/accidents-clos...tra-crash.html
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Old 4th Aug 2017, 19:36
  #625 (permalink)  
 
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Not that you guys and gals need more crap to look at, but why not put a big illuminated yellow X at the ends of Txwy C...out in front of the seawall?

Yeah, GenDynamics actually paid me a lot of $ for ideas like this.
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Old 4th Aug 2017, 19:47
  #626 (permalink)  
 
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Old 4th Aug 2017, 20:34
  #627 (permalink)  
 
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ATIS information Q

NTSB states in preliminary report.:

Atis info Q active, stating standard stuff, PLUSS : Runway 28L Closed, approach lights and runway lights OFF.

So if they forgot the Notam they read i Canada X hrs earlier, there is no excuse now.
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Old 4th Aug 2017, 21:18
  #628 (permalink)  
 
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Originally Posted by Ian W View Post
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.
IanW,

First, I completely agree with your post 616--whatever illusion in both pilots view could have been confirmed by the ATC comment and remained until the second approach. Anyone who's been thru visual illusion training knows how diificult it is "break" the illusion and how compelling it is.

WRT, HUD/EFVS/SVS, I haven't seen the studies you mention but a couple thousand hours using the equipment demonstrates its value. Yes, initially it is very compelling and causes tunneling of attention, but with experience it becomes another firm information that requires the pilot to properly channel his attention.
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Old 4th Aug 2017, 22:06
  #629 (permalink)  
 
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I think it is worth remembering that what we perceive, and what we sense, are two different things.
If you think that you percieve things exactly as they are seen ( sensed) , then you are wrong, and you are more susceptible to this kind of illusion than those who understand that the human brain has a particular area of weakness here. I say weakness but 99.99% of the time when your brain takes the visual information sensed and modifies it prior to presenting it to you, it works to your advantage. Your brain is quite capable of adding things that don't exist to a picture prior to presenting it to you.
These guys had a lot of successful flying experience, we should assume that a combination of factors came together which resulted in them both developing a mental picture that was different from reality and search for each of those factors. We should determine how we can reduce the likelihood of this combination of factors aligning again.
Notams are good if you read and understand them, ATIS information is good if you read and understand it. A shared mental model is good if it is correct. We will never 'fix' the trait that caused this incident, but we might guard against further mishaps if we educate about the importance of having more than one source of information, about the susceptibility of the brain to these illusions, and research how circadian lows and busy rosters affect our susceptibility to them.
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Old 4th Aug 2017, 22:25
  #630 (permalink)  
 
Join Date: Aug 2017
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Mistaking a taxiway for a runway

Good day all, I'm an AC ramp employee and new to this board.
I've become fascinated with this incident and all the possible explanations as to why it occurred.

I've seen the pictures of what a nighttime approach into SFO looks like, and it seems to me that with the runway approach lights extending well out into the water, it should be pretty obvious to see where the runway is...but the crew lined up with the taxiway instead and the still unanswered question is why?

Here's a theory I'll throw out for consideration..
Assuming the crew had forgotten about the closure of 28L, they would be expecting to see two parallel sets of approach lights; so I wonder if the light from the nose gear of the aircraft first in line on the taxiway, pointing straight out into the bay, may have been mistaken for the approach lighting for 28R from a couple of miles out?

If this was the case, then the lights from the other aircraft on the taxiway could have been what prompted the AC crew's query to ATC about traffic on the runway.
I'd be curious to hear feedback from the professionals on this board if this is a plausible explanation. It's definitely disappointing that we will never hear what was actually said in the flight deck that night.
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Old 4th Aug 2017, 23:57
  #631 (permalink)  
 
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Had they been coupled to the FMS28R "George" would have prevented all those variables.
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Old 5th Aug 2017, 01:05
  #632 (permalink)  
 
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I disagree. At some point an approach has a visual segment unless you are going to autoland in low visibility. Airbus has recently changed the minimum height for autopilot disconnection after a non-precision approach but on a cavok night the temptation would be to disconnect the autopilot, select the Bird ,align with the runway centreline and fly the papis by looking out the window. The problem is that if the visual picture is confusing with lots of lights on the airfield environment and the lights of the city beyond, there will be nothing inside the aircraft to tell you as the ILS will not have been tuned by the aircraft.
With a non-gps aircraft the map on the ND would could also have a small error.
Perhaps as part of the approach briefing the threats of the runway closure and what the correct visual picture will be for landing could have been discussed.
Gatwick has two strobes on the runway threshold when the standby runway is in use, and nobody is allowed to occupy the parallel taxiway.
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Old 5th Aug 2017, 01:47
  #633 (permalink)  
 
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This entire approach was a visual segment, albeit one with guidance that provides 3D alignment almost 4 mile out. If there was a map shift, which hopefully will come out in the investigation, then D/D/I should be prohibited from FMS Visuals.

The standards folks in the FAA have not been exactly fond of these FMS Visuals.
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Old 5th Aug 2017, 02:17
  #634 (permalink)  
 
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Originally Posted by underfire View Post
Underfire...

Who made this cross section diagram and how accurate is it?
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Old 5th Aug 2017, 02:41
  #635 (permalink)  
 
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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.
I've been thinking about the above... I'm not sure it's accurate, partly because wrong info from one pilot can affect the judgement of the other pilot, and from that point forward the two pilots may actually reinforce & amplify each other's incorrect perceptions.

Scenario fulfillment can happen to entire crews. The most extreme example is perhaps the shooting down of Iran Air 655 by USS Vincennes.
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Old 5th Aug 2017, 02:55
  #636 (permalink)  
 
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Even better, notams are checked before flight including the arrival airport and it is good practice to check again before starting the arrival/approach. There is no excuse for not knowing about arrival notams except when they are issued after departure which is possible given the long haul flight times.
Not better, rather in conjunction to reading them prior to departure. Easy to overlook something you read many hours before which is why you do it as a part of the approach briefing.
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Old 5th Aug 2017, 09:45
  #637 (permalink)  
 
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@Raingear

not only has this theory been posed on the first page of this quite long thread, also it's been confirmed by interviews with the pilots:

"The NTSB reported that in post flight interviews both pilots of AC-759 reported they were convinced the lighted runway to their left was runway 28L and they were lined up with runway 28R. They did not recall seeing aircraft on taxiway C, however, something did not look right to them."
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Old 5th Aug 2017, 09:52
  #638 (permalink)  
 
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Our airline has HW RASS system when they close a runway open new one etc we get false alarms until the data base is fixed, That said it will advise if you attempt to land or depart on a taxi way
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Old 5th Aug 2017, 10:32
  #639 (permalink)  
 
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Oh for the old days, with a runway caravan, and someone to fire off a few reds is something looks wrong.
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Old 5th Aug 2017, 13:33
  #640 (permalink)  
 
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Who made this cross section diagram and how accurate is it?
I made it using the NTSB image and altitude information in the NTSB report. It includes the information from the 3 images, the altitude data at several points on the profile, which correlates very well with the 2.5 seconds at around 140 kts distance.
Aircraft images are to scale with the profile and altitude information.

PAL 115 A340 tail is 56.5' tall, and the AC ac descended to 59 feet. Where that altitude provided is measured from, I am not certain, so the profile is the best scernario at bottom of wheel.
If this is measured from a different point on the ac, then the situation becomes worse.

I have the 3D aircraft for a profile, with the fligthpath, and can do a fly thorough, like a desktop sim, but just did not want to spend the time to generate that.

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