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

[Roger Greendeck]

The American practice of clearing aircraft to land when there is still traffic ahead to land or taking off doesn't help in this situation. If you only get your clearance when there is one finishin vacating or sure to have cleared the upwind threshold or turned then you've plugged another hole in the cheese.

[Bergerie1]

I am convinced that one day (in the not too distant future I hope) ADS-B In and Out will become a major part of the ATM environment. If information on other traffic is displayed on the moving map nav display, together with suitable warnings) the mis-perceptions that seemed to have played a part in this incident may be avoided.

https://www.skybrary.aero/index.php/..._Systems_(ASAS)

[ZFT]

Originally Posted by pfvspnf

The big red does it again , amazing how if it's them , these things are only a minor mishap, no problem at all .

If it happens in Africa or Asia , we have no clue what we are doing

Unfortunately true. Was thinking just the same earlier

[fox niner]

About one week ago, the NTSB released a video from the Asiana crash, viewpoint from the control tower. It was a security camera, I am sure that most of us have seen it. I'm sure that that particular camera is still in place. It must have caught this incident as well.
At Jacdec I saw a pic which indicated which other airplanes were involved:
UAL 1, UAL 1118, UAL 873 and Philippine airlines 115.

[DaveReidUK]

That's supported by the FR24 playback. At the time of the incident the queuing aircraft on twy C were (in order, from the front):

1. UAL1 B789 SFO-SIN
2. PAL115 A343 SFO-MNL
3. UAL863 B789 SFO-SYD
4. UAL1118 B739 SFO-MCO

Fortuitously, no 747s or (worse) A380s.

[EGLD]

Originally Posted by momo95

Humans are humans

Which is surely why there is at least two humans involved, backed up by some of the most sophisticated avionics available!

[DIBO]

Make that 3 humans, SFO TWR with all its equipment could also have picked up the misalignment much earlier. Not required to, but could/maybe should have...

[reubee]

Midnight in San Francisco = 3am in Toronto, it will be interesting to see the AC crew recent duties ...

[funfly]

Originally Posted by EGLD
I dunno what scares me more these days, the utter incompetence of pilots entrusted with the lives of their passengers, or their colleagues tendency to attempt to gloss over incidents like this as minor trivialities

As an ex pilot now a potential passenger, I totally agree with the above statement. What happened to Papy's, runway lighting etc. No excuse to close ranks.

[F-MANU]

There's no one on 2-8 Right but you !

T-00s 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?"

T-08s SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."

T-16s "Where's this guy going? He's on the taxiway," the other pilot said.

T-20s SFO TOWER: "Air Canada, go around."

T-22s AC759: "Going around. Air Canada 759."

T-23s SFO TOWER: Air Canada looks like you were lined up for Charlie there. Fly heading 280. Climb maintain 3,000."

T- 29s AC759: "Heading 2-8-0, 3,000 Air Canada 759."

T- 33s UA001 PILOT: "United One, Air Canada just flew directly over us."

T -42s SFO TOWER: "Yeah, I saw that."


From G/A instruction to 'they flew over us' => 13 seconds

Now remove from the equation: AC759 reaction time to initiate G/A + engine spool-up (inertia) + UA001 pilot reaction time to report the low pass...

[khorton]

CTV News has an interesting video with some background info and a bit of speculation:

CTV News Channel: 'Situation was unusual' | CTV News

[Basil]

That helps to explain a reason. Must say, it's a long time since I operated into SFO and don't recollect the offset.

SYD has close parallel runways but, IIRC, has lined up ILS but with a 'Breakout procedure' if an aircraft on approach deviates towards the other runway.

[FlyingCanuk]

I don't buy that explanation
The 28R approach is offset to the right, and at 4 miles, the aircraft on approach is to line up with the runway centerline.

This aircraft was lined up with taxiway Charlie until the go around at approx. 100'

[WillowRun 6-3]

Swiss cheese on your (significance) burger?

Is it not still the case, where fundamentals as well as operational practices and methods are concerned, that the basic model for safety is stated as "not having the holes in the Swiss cheese line up" - at least for the traveling public, and the legions of governmental, manufacturer, and other interested parties who never have held an airliner in their hands in the left seat, the right seat, or anywhere else conceivable? I think it's still a darn good way of explaining a rather (!) complex set of variables with so many possibilities that the word "infinite" might even be warranted. Lighting, visual fixating, crew rest, reaction time, height of lined-up aircraft tail, plus CRM, plus familiarity with SFO, and let's not forget (amorphous though it certainly tends to be) automation on the airliner flight deck.


This was way too close for categorization as "the system worked, no sweat, pipe down SLF." True, a catastrophe was avoided - but the margin of error was approaching (pun intended or not, I don't care) holey Swiss.

[eckhard]

That helps to explain a reason. Must say, it's a long time since I operated into SFO and don't recollect the offset.

There is an offset LDA and LDA (PRM) approach to RW28R. FAC 281. (RWY QFU 284.)
There is also a regular straight-in ILS approach to RW28R with FAC 284.

My understanding is that the Air Canada was cleared for the "Quiet Bridge" visual approach to RW28R. This involves an initial course of 275 towards the SFO VOR (centre-field) and then an alignment at 6D (5nm from THR) to the RWY QFU of 284. The 28R ILS GS is available for vertical guidance.

[glofish]

There are many possible factors that explain how it can come to such a situation. Fact is, that such offset visual procedures, be they LDA or RNAV feeded, are known to be tricky. There are numerous briefings available and many required to perform such approaches, outlining the dangers, the visual illusions, the possible holes in the Swiss cheese.
What bothers me in this particular incident, is the non-reaction of the crew after recognising that something is not quite right. Many of us might have experienced a bad line-up, an initial heading for the wrong piece of concrete, a wrong approach setting, etc., at least I have. The important part is to A) recognise an error and B) mitigate it, take action.
The query by this crew about funny lights on the runway shows that they suspected something’s not right. By just continuing once the tower told them the runway was clear and only initiating a go-around on input by a taxiing aircraft and subsequently the tower, and especially how low they passed over the taxiing aircraft once started the G/A, shows how long (too long) the passivity of the crew was ongoing.
In any uncomfortable situation that is highly unprofessional and even frightening.

[slack]

Don't know where Mackey comes up with 30 kts from the north. Tower reported winds 270\08. Some expert.

[Airbubba]

Originally Posted by fleigle

In no way, shape or form would they use F for anything but taxying.

Taxiway F was not involved in this incident, the aircraft were lined up on C waiting to take off on 28R.

Originally Posted by eckhard

My understanding is that the Air Canada was cleared for the "Quiet Bridge" visual approach to RW28R.

Not the Quiet Bridge Visual, they were cleared for the FMS Bridge Visual approach to 28R.

[JumpJumpJump]

Where are you going with this? Are you saying that after 13 Seconds AC should have been/was higher than what is being clainmed here, or are you sugesting that AC took a long time to react? Or something else?

13 seconds seems reasonable between "go around" being said and UA001 commenting; given the exchange after the go around was initiated between AC and ATC, and then a pause to check that there was nothing else to be said between AC and ATC by ua001 to not step on AC/ATC.

[OldLurker]

Originally Posted by glofish

What bothers me in this particular incident, is the non-reaction of the crew after recognising that something is not quite right. Many of us might have experienced a bad line-up, an initial heading for the wrong piece of concrete, a wrong approach setting, etc., at least I have. The important part is to A) recognise an error and B) mitigate it, take action.
The query by this crew about funny lights on the runway shows that they suspected something’s not right. By just continuing once the tower told them the runway was clear and only initiating a go-around on input by a taxiing aircraft and subsequently the tower, and especially how low they passed over the taxiing aircraft once started the G/A, shows how long (too long) the passivity of the crew was ongoing.
In any uncomfortable situation that is highly unprofessional and even frightening.

The crew's response surely indicates that somehow they were certain that they were lined up on the runway and had become fixated on that certainty, despite the various visual indications to the contrary. They queried the lights on the runway, but the tower said the runway was clear, so since they were sure they were heading for the runway, it must be clear despite the funny lights ... Nothing in that radio conversation triggered a realisation that they were looking at the taxiway, not the runway.