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

[PuraVidaTransport]

Flying a night visual approach, wouldn't the lack of PAPI lights on the "runway" while looking to the left and seeing PAPI for the "other" runway, be a rather large clue? And by the time the AC pilots got to the gate, they knew they had lined up on the taxiway and overflown at least one aircraft from the radio traffic alone. UA1 reported it (both 'on the taxiway' and 'right over us'), tower acknowledged it AND tower told AC they'd lined up on Charlie. To not immediately secure the CVR and notify the proper authorities seems a major misjudgement. And why not allow a small commercial drone to "fly" and video that night approach with similar aircraft on the taxiway, the last 3 miles or so? It could provide crucial evidence at minimal risk.

[tubby linton]

Galaxy flyer, He should not have been tried . If you search for topics about it on here, there was a lot more to the incident

[slast]

G-AWNO event

The underlying reason for the trial was that the event came close to being a "worst ever transport disaster" (full 747 impacting a full hotel, wreckage path would have taken out the airport rescue, firefighting, emergency communications and police facilities and hit the the access routes to the airport which were full of rush hour traffic etc.) Normally the UK AIB would have investigated it but they were fully occupied with dealing with the PanAm Lockerbie bombing plus British Midland. Kegworth crash, so since there were no injuries and no damage it was left to a internal investigation.

Powers that be in the CAA felt (quite rightly IMHO) that this was severely flawed and resulted in little effective action to prevent repetition. They then pursued the prosecution route which in itself only succeeded in proving what an inadequate tool criminal prosecutions are for investigating complex matters like this.
(See event 3 on this link which also links to a substantial article on the event)
Appendix: Internal culture and resistance to change. | PicMA

Also well covered in Matthew Syed's book "Black box thinking".

[WHBM]

AC759: "Tower, just want to confirm. This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?"

SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."

I wonder why the tower just nonchalantly said there's nothing there if a crew reports seeing unexpected lights. How did they know a runway incursion, even by a vehicle, had not taken place ?

It's the old adage "If it doesn't look right, assume it's wrong".

[DIBO]

To not immediately secure the CVR and notify the proper authorities seems a major misjudgement.

Well, they were requested to contact an FAA supervisor, and even given the phone no., before switching off. When did they call the FAA supervisor? What was discussed?
Not implying anything, but looking at the 'EK / Seychelles' incident, where it was discussed something in the line of "we don't file a report, if you don't either", we simply don't know what the AC crew and FAA super. discussed and what actions followed from that discussion.

[DIBO]

I wonder why the tower just nonchalantly said there's nothing there if a crew reports seeing unexpected lights. How did they know a runway incursion, even by a vehicle, had not taken place ?

Well, because their tower is full of the latest, fancy equipment, so the single, very busy controller handling both GND and TWR, with 2 crossing active rwy's in use and a lot of activity going on even that late at night, will most likely has checked the rwy "incursion status" on his fancy equipment and seen that all was as it should have been. And visual checking at night, at a 30-40° angle to the centerlines, would not have helped him easily spotting the misalignment... until AC actually overflew the acft's on C. And the fancy equipment 'loosing sight' of AC for about 15 sec's, surely won't have helped him either.

[Loose rivets]

And why not allow a small commercial drone to "fly" and video that night approach with similar aircraft on the taxiway, the last 3 miles or so? It could provide crucial evidence at minimal risk.

I suggested this, albeit not with a drone*, some posts back. The problem is, all the expenditure of an exact simulation would be expensive and - in the minds of the funders - primarily for a defence argument**. Also, how does one achieve an exact simulation? Every aircraft would have to be very near to the same place and have precisely the same lights on. I gather one at least put on main landing lights. Could all the crews remember their light settings at any given moment?

I can't express how strongly I feel about the RT wording used. A clear, addressed, and forceful message would have been a much better tool to warn that a major mistake was being made. But then, the issue of disbelief is as true for the crews in the firing line as it is for the landing pilots.

Tiredness. I can't count the times I've felt miserably tired during a flight - especially in the days before a quick shut-eye was allowed - but always the approach and landing were so stimulating, so much the absorbing part of why I was in the profession, that the tiredness was put on hold by brain chemistry.


*A camera aircraft with a couple of Fed guys on board is the only way.

**While it would seem primarily a flight for defence mitigation, the all-important learning issue is still valid and I feel this case is so important because it is so unexplainable.

[AerocatS2A]

Originally Posted by underfire

They did let the CVR go, and certainly had time to rehearse the story.

How can this be in anyway mistaken?

Well, obviously it can. Or are you suggesting that they correctly identified the taxiway and decided to try and land on it anyway?

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.

Not at all. If the NTSB report is correct then they didn't recall seeing aircraft. That doesn't mean they saw no aircraft, it just means that what they did see didn't look like aircraft, it probably looked like a bunch of confusing lights. Obviously they didn't think they were on the taxiway because if they did they wouldn't have been there . No doubt they realised afterwards they were on the taxiway, but hindsight is an awesome thing.

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.

Obviously we don't know if this crew were tired or fatigued or whatever, however, your statements on the issue betray a large amount of ignorance on the subject. Fatigue is not black and white. You are not either fatigued or not fatigued. Likewise with being tired or just having low arousal levels. If pilots refused to fly whenever they were the slightest bit fatigued, tired, or in a low point in their circadian rhythm, half the flights in the world would be grounded.

We must accept some deterioration in our performance on a regular basis otherwise we would all stay home and the aviation industry would stop. The question then is how much fatigue/tiredness/etc is acceptable? There are no hard and fast rules, everyone is different, and a big problem is that it is very difficult to predict at the start of a duty, how you will feel by the end of it.

I fly back of the clock freight all of the time and know my personal signs of fatigue. Things like asking for a checklist associated with the last type I flew rather than the current one, being slower, having a narrower focus on a task leading to poorer situational awareness, and being less critical of my own performance and that of my colleague. I do my very best to only work if I believe I am fit for duty but I don't have a crystal ball and cannot predict my future performance with 100% accuracy. One consequence of fatigue of course is a decline in the ability to make good decisions. The fatigued pilot is therefore more likely to make a poor decision about whether they are in fact fit to fly.

I am not making excuses for the AC crew, I don't know how they mistook a taxiway for a runway any more than you do, but I'm pretty sure they didn't deliberately attempt to land on a taxiway. I'm also pretty sure that if this crew were told about this incident happening to someone else they'd be just as disbelieving as we are. Something screwed up their mental model and it is much more valuable to be open to explanations (not excuses) so that we can learn something from it, rather than just sitting back, pointing, and saying "you screwed the pooch!"

[AerocatS2A]

Originally Posted by Loose rivets

*A camera aircraft with a couple of Fed guys on board is the only way.

The real problem with doing this is that it doesn't simulate the mental state of the pilots. It would be like watching the gorilla video when you know the gorilla is there.

[WillowRun 6-3]

Five-a-Side (or, the Law Schools teach how to emplace words - the course is Evidence)

Originally Posted by underfire

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

1. underfire, let's assume your factual picture is painted with complete accuracy. Nonetheless, it is based only on what has emerged in the preliminary phases of the investigation. Further assume that the severity of sanction you evidently believe is deserved by the AC crew is in fact justified and deserved. Nonetheless, AC could be due for sanction too, and so could FAA if a more damaging event had occurred which fortunately it did not. So, in at least hurrying if not rushing to judgment about crew responsibility, you are short-circuiting the full process. The disagreement is not with your conclusion that the crew, if erring the way you state they erred, is due for sanction (or will be due, once all the facts are known). Nor is it necessarily with your assessment of their errors. The brutal truth is, though, we do not yet know all the facts, and the process for finding those facts has been derived over time and proven more reliable than short cuts. It's about the process. And that's for the sake not just of a decent and reasonable result for crew (and other involved parties, if any), it's also about two other factors. (AerocatS2A in #671 seemed to be making a similar kind of point.)
2. No one taking the time to write posts on this forum (posts of any seriousness, that is) fails to hold a strong desire to know the WHY: why did this sequence of events, acts and omissions, take place, and how did it all take place, as exactly as possibly determined afterwards. But preliminary - or less nicely, half-baked - conclusions about responsibility based on a very early stage of factual development strikes this poster as a good way to interfere with defining and understanding the why and the how.
3. And then there's the "what needs to be changed" discussion. One can anticipate the NTSB issuing a pretty lengthy list of stuff that needs to be changed (probably some pretty complex stuff, too). Again, premature conclusory assertions as to crew culpability and the clarity with which they deserve to be tarred and keel-hauled is a good way to interfere with attaining the necessary clarity about system modifications and the broad understandings needed to restructure system elements, if any need to be restructured (like approach airspace architecture, and runway and taxiway lighting, just to name two candidates).
4. I really don't think reference to an aviator who "drove it into the mountain" adds much here, underfire. But, it's free expression.
5. Once upon a time, a lawyer had a case in which a client had re-enacted an alleged safety violation (not involving airliners, alas). The re-enactment went very well, so the lawyer was told, in establishing the wrong-doing of the dismissed employee. Ah, but the notes taken by some of the participants....which led to the lawyerly wisdom, "you think I'm putting words in someone's mouth? Actually, they teach that art, in law school - take the course in Evidence and find out!"

[fjordviking]

@underfire.
I`ve love to have the opportunity to work alongside such a flawless individual as yourself. I Would just sit in amazement and watch and Learn from the skygod never making mistakes and never having to mitigate.

[DIBO]

The real problem with doing this is that it doesn't simulate the mental state of the pilots. It would be like watching the gorilla video when you know the gorilla is there.

A re-enactment of the approach will not have the simulation of the mental state as goal, but will look and try to find other clues besides the gorilla aka twy C. You can't miss the gorilla once you know it's there, so nobody will mistake C for 28R no matter how many simulation or re-enactment flight are done. But maybe, just maybe, other factors will be discovered, by the human eye on board of an investigation plane. That's why drone camera's or simulators won't be do the job. Many post back, I mentioned differences in 'perception' of classic and LED lighting. At that time I thought LED were at a disadvantage, after updating my knowledge, it's LEDs that are better in this case, the twy centerline greens, remain 'greener' at long distance compared to classic bulbs. Not sure what twy C is equipped with (seem to remember somebody mentioning LED's), but classic bulbs in the twy centerline, might have appeared less green/more white from a distance, and maybe the AC pilots locked their minds on "visual with a white centerline" (although, knowing the gorilla, it's remains hard to comprehend that all the rest of available lighting didn't give the right clues). If twy C is already equipped with LEDs however, then one less argument in favor for the AC pilots...

[BluSdUp]

Fatigue , Tired or complaisant?

To accuse the crew of flying fatigued is serious stuff today. And for Aircanada.

Some of you confuse pure tired with fatigue, different animal.
They most likely did only one sector before this one ,if any at all.
That is as easy as it gets.
Anyway, we know NOTHING about their personal state,so fare.

My money is on complacency , a common thing after 30 and, or 10 000hrs.

So that is always in my Threat and Error Brief.

I trust that The Union and AirCanada is taking proper care of the crew.
I would imagine the Crew contacted their Union and AirCanada asap after deboarding.
Someone wrote they were told to contact a FAA rep asap.
I shure as **** would pull that CVR Cb to prevent it being over written, if I got that message. Can always push it in if all are happy.

Now, that is Company procedure were I work.

Not in AirCanada as we have seen. It is going to be most interesting to see what communication took place between the different partys that evening , and morning. Before someone clued in and phoned NTSB.

Every year I write a handfull of reports, and never hear a thing back.
No news is good news.

In this case it was uttered at least 3 times on an open channel, full of nerds listening,that he was about to land on Taxiway C.
Did they think it was going to go away, seriously dude!

Gather the facts, call the Boss , tea no crakkers! Or not!

For now, if You are tired:
Fly the ILS

[aterpster]

Originally Posted by BluSdUp

For now, if You are tired:
Fly the ILS

You simply cannot do that when cleared for the FMS Bridge Visual 28R. When 28L is open that would have the tower screaming at you.

[Carbon Bootprint]

It's the old adage "If it doesn't look right, assume it's wrong"

Indeed, much like "Whenever there is any doubt, there is no doubt"

(Which has probably been posted already in this thread, sorry if it's redundant.)

I'm just glad this turned out the way it did.

[BluSdUp]

Aterpster

Hey, Not even I fly approaches I am not cleared for!

On first contact with Approach I request vectors for ILS 28R, negative visual.

On another note, You mention in post #635 map shift etc.
I have been thinking about this.

Is it possible they had a slight MFD drift to the right. The A320 they flew not having GPS, we are looking at DME DME VOR triangulation.
The IRS being off by at least a mile after 5 hrs, how does the A320 mix the position presented and flown on the MFD ?With the FMS (visual Bridge)28R in?

If the track presented was off by just 100 meters right, they would think they were on CL.

I most certainly see FAA not loving some of these money saving , half baked so called procedures.

[WHBM]

Originally Posted by DIBO

Well, because their tower is full of the latest, fancy equipment, so the single, very busy controller handling both GND and TWR, with 2 crossing active rwy's in use and a lot of activity going on even that late at night.

AS I understand it, neither of the crossing runways were active, nor was 28L. Only 28R was in use, hence they were landing on it (with several having just preceded them) with four to depart. This is why there were so many holding to depart.

For now, if You are tired:
Fly the ILS

You simply cannot do that when cleared for the FMS Bridge Visual 28R.

So how was it that when they came round again for their second approach they could be cleared for the ILS without issue.

[DaveReidUK]

Originally Posted by WHBM

AS I understand it, neither of the crossing runways were active, nor was 28L. Only 28R was in use, hence they were landing on it (with several having just preceded them) with four to depart. This is why there were so many holding to depart.

No, there were also departures from 1L immediately prior to the incident.

[DIBO]

And also after the incident 'crossing' departures 28R / 1L continued.

And a while later, this created the recipe for a new swiss cheese on the table, with already one hole lined up. But luckily this cheese was countered as quickly as it appeared...

[Carbon Bootprint]

So what difference does it make who is departing from where? Another distraction from what could have been a huge mess, judging from the photos, animations and other resources that have sought to illustrate this incident.