Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!

[b1lanc]

Plan Continuation Bias

Interesting paragraph in the AC624 AIR Section 2.5 cited as a cause/contributing factor. Who knows what an individuals "salient triggers" are. Replace "too low" with "lined up on taxiway" and the paragraph fits.

[Loose rivets]

How can this be in anyway mistaken?

Well, of course it can't. The only way to truly assess the slewing of their perception would be the re-enactment I mentioned. Sadly, I feel this would be deemed seriously OTT, given 'that's no excuse' outcome where there is still a major difference between 28R and C even with the taxi lights of the holding aircraft. And that's another point: most crews would turn off any light that might be distracting for a landing aircraft. Is there any information about the real quantity of the 'mass of lights' on C?

IMHO, this aberration is only bewildering because, as far as we know, both pilots were affected.

Of course, it may turn out that there was a much greater stream of protests on the flight deck than we know about.

[DaveReidUK]

Originally Posted by Loose rivets

Of course, it may turn out that there was a much greater stream of protests on the flight deck than we know about.

No it won't, because the only conclusive evidence of that would have been the CVR.

[framer]

How can this be in anyway mistaken?

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

IMHO, this aberration is only bewildering because, as far as we know, both pilots were affected.

That both pilots were affected is the greatest clue that whatever programming of their expectations that had occurred prior to turning final was strong enough to influence both of their perceptions.
On a different tack, have you ever been so knackered that you slur your speech and can't construct sentences properly? I wonder if we will find out that the combination of rostered duties and the individual home lives of these two meant we had two fatigued pilots up front.
I know I'm not the only one to wonder.

[underfire]

No it won't, because the only conclusive evidence of that would have been the CVR.

Concur.

Take them both off line, they will turn on each other, that is the only way.

I wonder if we will find out that the combination of rostered duties and the individual home lives of these two meant we had two fatigued pilots up front.

more excuses....

[tubby linton]

Underfire, can you send your contact details to your president as he doesn't need the expemsive NTSB when he has you. You have solved what has happened , I am just waiting for the report. Also call the chiefl pilot at AC and have both pilots sacked based on your testimony and investigation.Perhaps you would like to do their dismissal hearings. Don't bother looking at any of the contributing causal factors which may have contributed to this.In your eyes they are guilty and should never fly again.Have you ever heard of Swiss cheese?
You probably don't remember this incident, but the Captain committed suicide after his trial. He certainly hadn't started his day thinking I must try and land on a road.
https://aviation-safety.net/wikibase/wiki.php?id=147119

[framer]

Underfire, wondering if the pilots cognitive performance was reduced due to their workload and hours of wakefulness and sleep history and the stage of their circadian rhythms isn't an excuse, it is common sense. The job they were doing at the time of the incident requires a certain rate of cognitive processing, any neuro scientist will tell you that the rate of processing can be affected by the above factors.

We have an incident where the cognitive process clearly failed, to not look at something that is known to affect the process is irresponsible.

[deSitter]

Originally Posted by wiedehopf

@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."

That is the essential point. Considering Western at Mexico City, the lesson to be learned is how to close a runway in a way that is utterly obvious and clear.

[Ironman1331]

Hype and concern.

Originally Posted by hitchens97

Huh? This looks pretty damn close to a disaster.

I strongly dislike commentators stating this could have been "the worst aviation disaster in history", hyping for dramatic effect, BUT, one of the aircraft on the taxiway turned on his landing lights!!! as the errant aircraft approached, the aircraft approaching asked about lights on the runway, reports said the aircraft was down to 100 feet, others said lower.

[Ironman1331]

Originally Posted by nolimitholdem

*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.

There was a fair amount of hype from commentators, BUT, said the approaching airliner was down to 100 feet OVER the taxiway, incorrect, as to planes on the ground were ear the threshold. There were five large airliners, one of whom turned on his landing lights as the aircraft approached. The incoming pilot re-checked for clearance to land and said there were lights on the runway. To not be there or see it yourself, and state it wasn't close, and state the aircraft were clearly visible is faulty. The approacing aircraft was, reported, 100 feet above the AC on the taxiway, some said lower, hito evidence seen, pilot asked about his cleared to land status, said there were LIGHTS, not that he saw aircraft. There was clise proximity w AC at 150 knits 100 feet over other AC. I don't like the dramatic statements of worse accident in history, but you are dismissing this incident carelessly.

[West Coast]

the lesson to be learned is how to close a runway in a way that is utterly obvious and clear

To clarify, are you inferring the current process isn't sufficient? in this case, NOTAMs, runway lights off, a lighted X on the closed runway, a clearance to land on the lighted proper runway, an instrument procedure that provides positive lateral and vertical course guidance to the runway in conjunction with an approach lighting system, differing colored lighting between runways and taxiways. likely a lot more safety nets as well. We should always focus on improving the system, but somewhere we need to focus on the most fallible part of the entire system, the humans.

I'm sympathetic to the AC crew and hope much is learned from this and that there's no negative long term consequences to their careers.

[underfire]

Don't bother looking at any of the contributing causal factors which may have contributed to this.In your eyes they are guilty and should never fly again.Have you ever heard of Swiss cheese?

Guilty with an explanation is still guilty.

They allowed the CVR to be erased, and from the preliminary NTSB statement, both denied seeing any aircraft on the 'runway' , but simply did a GA because "something didnt look right"

While those two may have suicidal tendencies, it is not fair to take out 400 others.

Yes, I feel very strongly they should be removed.

In aviation, we deal with the Swiss Cheese model all of the time. You just had 2 idiots drive over the cheese, not through the holes.

[WillowRun 6-3]

Said it all better than I can

underfire, when you get a chance, you *could* look up and read NTSB Chair Hersman's separate statement which they made part of the Board report on the Colgan accident. It was linked in a prior post in this thread. Then again, it makes a pretty articulate case for fatigue, when fairly raised by facts, to be a contributing factor. Facts, underfire, are not so easily swept away, as mere excuses. Then too, perhaps the Chair of the NTSB just plain ol' didn't know what they were writing about?

[underfire]

As a professional, is it not your responsibility to deal with the conditions and recognize issues such as fatique? This is the same for any high risk profession.

Look what they do to the train drivers in accidents where fatique was blamed, or truck drivers? Why is it that pilots feel they are exempt from punishment?

Does anyone assume that the pax expect a disaster because the driver has to commute or works too many hors and is tired? What about the other drivers sitting on the ground, are they responsible for being on the taxiway the AC was trying to land on?

If you cannot handle the job, then move on. If you dont move on, you should be removed.

[Loose rivets]

Well, not having a long term consequences will have a lot to do with the Feds having some sympathy with the reasoning - which surely has to be based more on imagery rather than electronics.

Me:

Of course, it may turn out that there was a much greater stream of protests on the flight deck than we know about.

Dave Reid

No it won't, because the only conclusive evidence of that would have been the CVR.

The overall time bracket wasn't very long, so yes, 'stream of protests' was too strong a statement but I suspect there may have been a mounting 'realization differential' and doubt both then realised the truth at the same instant.

I for one hope there is an agreed visual trap that will to some degree mitigate this puzzling incident. I re-read the 747 incident and recall how sad I felt at the time for the skipper.

[llondel]

As a professional, is it not your responsibility to deal with the conditions and recognize issues such as fatique? This is the same for any high risk profession.

OK, so you're half an hour from landing, you realise you're dog-tired, you're not in a position to stop. Sure, you can try to double-check everything from then on, but that just slows everything down, including the thought processes and decision-making. They were on final, realised something wasn't quite right but failed to understand exactly what, so they called ATC and found a solid piece of cheese as a result.

In the absence of the CVR and with a consistent story from the pilots, that's probably about the best you'll get. NTSB has come up with a good reconstruction of what happened, but 'why' is going to take a lot longer and may never yield a verifiable answer.

[galaxy flyer]

Originally Posted by tubby linton

Underfire, can you send your contact details to your president as he doesn't need the expemsive NTSB when he has you. You have solved what has happened , I am just waiting for the report. Also call the chiefl pilot at AC and have both pilots sacked based on your testimony and investigation.Perhaps you would like to do their dismissal hearings. Don't bother looking at any of the contributing causal factors which may have contributed to this.In your eyes they are guilty and should never fly again.Have you ever heard of Swiss cheese?
You probably don't remember this incident, but the Captain committed suicide after his trial. He certainly hadn't started his day thinking I must try and land on a road.
https://aviation-safety.net/wikibase/wiki.php?id=147119

Tubby,

I've read of that BA incident, he should never have been tried. Would you agree?

Underfire,

The pics from the sim, I presume, make it look ridiculously obvious, but it can't be as simple as shown. Surely, two highly experienced pilots didn't suddenly decide to land on the taxiway, there must be much more to it--illusion, both very fatigued, etc. 3 am body time is tough and, despite it being and everyday schedule, sometimes things just go wrong.

[underfire]

All these excuses, and for both drivers!

No incident =no drug or alcohol test?

What about opinion of the UAL 1 driver, he did not appear too impressed?

What about the PAL drivers?

OK, so you're half an hour from landing, you realise you're dog-tired, you're not in a position to stop.

As professionals, you are both so dog tired after a 6 hour flight that you are incoherant to land the aircraft? What part of being a professional is that?

Forget about the 400 pax, right? They all have the expectation that the people driving will get them there and are professionals. According to all the posts with excuses, the drivers were tired because it is such a lousey profession, great excuse. Its okay, just like the one who drove it into the mountain on purpose, he was real tired too.

[WillowRun 6-3]

Reminds me of an expert witness I once cross-examined.....

No don't fret, that header was just an attention-getting device.
underfire, I think everyone concerned with safety and its improvement where and when improvement is shown to be needed agrees: excuses have no place. But you're reaching for the disciplinary rod before enough facts have been determined. Again, after Colgan, the Board chairman strongly advocated for recognition of fatigue as a contributing factor. Obviously the Colgan crew paid a kind of disciplinary penalty of the ultimate kind. But you seem to be saying, "to identify all the facts and to find all the causal links and causal factors is the same as just sloughing off crew responsibility". You didn't use those words of course, but why the insistence that relentlessness in finding all the facts means anyone wants to shrug off the crew's responsibility?

[underfire]

But you're reaching for the disciplinary rod before enough facts have been determined.

On direct:
If the NTSB report is correct, in essence;
the crew has denied being on the taxiway,
denied seeing aircraft on the taxiway, and
denied outside input that influenced their decision to go around. (UAL 1 saying they were on the taxiway, nor PAL turning on their lights)

On cross:
The crew then exaserbated the situation by not securing the CVR, which could have substantiated their "story".

To date, the crew has not stated they were tired, have not claimed anything other than they went GA because it didnt look right.

You make the call, and stop putting words in their mouths as they have already spoken.