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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 14th Aug 2017, 23:39
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Originally Posted by RAT 5
But as to the question : Would an extra controller had spotted the deviation earlier ?

It does seem an odd situation whereby people are asking if a second ATC controller, positioned at the side of an approach, at night, could have a better visual appreciation that a 2 man crew could be lined up, visually, on to the wrong runway.
But that's not the question being asked.

The question being asked is could a controller with great training and deep experience have given a different initial response to a confused arriving aircraft, if time pressures on that controller were relaxed?

"Go around" is supposed to be safe. Safe enough at least that this controller subsequently issued it.

"There aren't any aircraft on the ground where you think you see them" isn't supposed to be safe.

So without suggesting blame, why was that response issued instead?

Last edited by pilot9249; 15th Aug 2017 at 02:22.
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Old 15th Aug 2017, 00:41
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Here's a frame from a night visual approach to 28R while 28L was also operating. You can see the 28L lights (MALSR) are on:
You are taking a screen shot BEFORE 28L was closed. You are aware that 28L was closed, correct?
Aside from that, are you expecting to believe that 28L was active for approach in the image that you provided? That aircraft would be on approach, near parallel, and yet no guidance on 28L?


Entertain me, show me a screen shot you found on the internet for a 28L approach lighting at night. (with 28R active as well) of course, using the visual approach.






You appear to conflict with your own statement...do YOU see the approach lighting for 28R?



Very simple question....Is there any reason, even for you, or anyone....to line up on the taxiway?

Where would you land?

Last edited by underfire; 15th Aug 2017 at 02:48.
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Old 15th Aug 2017, 01:52
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I'm really late to this party

I have looked at many of the posts here, and looked at the approach plates for the Quiet Bridge Visual and the ILS to 28R.

For whatever reasons, they lined up on the taxiway instead of 28R.

Being from the "old school", but having used some of the most modern EFIS, I wonder why no one had at least raw data displayed with the ILS tuned and inbound heading set.

That would have alerted them of their visual mistake.
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Old 15th Aug 2017, 02:28
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That picture was only to debunk your repeated assertion that:

when the FMS Bridge visual or any of the visuals ar run on 28R, 28L cannot be used due to the close prox
Where would you land?
You're fixated in asking the wrong question. The fact is, two experienced and presumably well trained pilots from a major North American airline tried to land on the taxiway. The question is: why?

That the active runway looks so obvious at night in comparison to the taxiway -- by design -- only deepens the puzzle of why this incident happened. We want to get to the root cause so we can attempt to prevent other incidents in the future.

Your mantra to simply "blame blame blame" the pilots contribute nothing to safety.
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Old 15th Aug 2017, 03:55
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Originally Posted by Old Boeing Driver
I have looked at many of the posts here, and looked at the approach plates for the Quiet Bridge Visual and the ILS to 28R.

For whatever reasons, they lined up on the taxiway instead of 28R.

Being from the "old school", but having used some of the most modern EFIS, I wonder why no one had at least raw data displayed with the ILS tuned and inbound heading set.
The thread is indeed long but take another look. The Air Canada crew was cleared for the FMS Bridge Visual to 28R, not the Quiet Bridge Visual. See earlier posts on why you might not find the FMS Bridge Visual in your Jepps.

And, as explained in previous posts, the ILS is not normally tuned on this approach in an A320 since there is FMS guidance to the runway and it is difficult to display raw ILS data in the 'bus without switching approach modes.
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Old 15th Aug 2017, 12:39
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Thanks

Thanks. I went back and reviewed. Have a great day.
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Old 15th Aug 2017, 14:07
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And, as explained in previous posts, the ILS is not normally tuned on this approach in an A320 since there is FMS guidance to the runway and it is difficult to display raw ILS data in the 'bus without switching approach modes.

Are you now saying the FMC guided them to the wrong runway/taxiway? I don't think you mean that, but as I've said, the FMS, no matter what kind of 'Bridge' approach they flew, brought them to a point where they then would took over visually to align themselves with the landing terrain. People have said they were not GPS equipped, so there could have been map-shift perhaps, but either way the last 4nm was visual alignment. If they did not have an ILS tuned, then they had PAPI's and full runway + approach lights for visual guidance.

There is still a mystery, and we are churning this around and around. Surely by now there are enough known facts from the crew, AC & FAA to publish a definitive report. There were no deaths and everyone is available to state their case. Have I missed it, or has an interim/final report been published. Sorry if that is the case.
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Old 15th Aug 2017, 15:06
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Peekay4 :
The fact is, two experienced and presumably well trained pilots from a major North American airline tried to land on the taxiway. The question is: why?
your question reminds me of something I read long ago : It was something like this : : **** happens for no reason sometimes. One day you do something irrational and no-one can understand why you did it, including yourself "
Fixation , fatigue, light hypoxia, mental distractions, micro-lapses, are for instance things you cannot measure with certainty , especially a posteriori.
Maybe it is one of these, maybe not.

As someone said, the crew is available and surely will be debriefed , but I bet you lots of beers that the PF will say : "I really thought we were aligned with the runway" . An where do you go from there ?
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Old 15th Aug 2017, 15:54
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PF will say : "I really thought we were aligned with the runway" . An where do you go from there ?

You ask the PM what they thought & were doing.
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Old 15th Aug 2017, 16:20
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Airbubba...FMS bridge visual final waypoint is on the extended runway centerline. (unlike quiet bridge visual which is not) They COULD have had the ILS tuned to check.
Map shift or not, the procedure is visual from 4.4 DME

I am not certain if it is common practice, but when flight validating RNP procedures, as a check, the #2 seat is tuned to the ILS to backcheck the alignment, so it is possible.

That the active runway looks so obvious at night in comparison to the taxiway -- by design -- only deepens the puzzle of why this incident happened. We want to get to the root cause so we can attempt to prevent other incidents in the future.
I agree...but. The pilots have, according to the prelim NTSB report, denied they saw aircraft on the taxiway, in fact, they denied being on the taxiway. They did not secure the CVR. They came within inches of aircraft sitting on the taxiway. As there was 'no incident', there was no mandatory substance test.

Would one expect the 2 drivers to be at least stood down pending the findings?

Last edited by underfire; 15th Aug 2017 at 16:32.
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Old 15th Aug 2017, 17:14
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There is still a mystery, and we are churning this around and around. Surely by now there are enough known facts from the crew, AC & FAA to publish a definitive report. There were no deaths and everyone is available to state their case. Have I missed it, or has an interim/final report been published. [/QUOTE]

Good on yer, RAT5, I hope I got your handle right, and that I don't get kicked out on probation for incompetent quoting technique.

Even if there are no PhD rocket scientists currently available to work on this file, there is NO WAY it needs to take the customary 1 to 2 years for a credible investigation report. A really thorough, competent report on this near tragedy would be of tremendous benefit to countless people involved in aviation, both airborne and groundbound, but especially for younger pilots coming up. Even now, with few "details", it it appears to be a compelling example of a "there, but for the grace of God, go I" type of story.

It seems to me that this is an (unenviable) opportunity for the pilots involved to transition from (apparent) zero to hero if they summon all of the courage and integrity they have, and bare their souls to the investigators. Under the circumstances, few of us, myself included, would likely have the guts to do that, but I for one would deeply admire them if they got everything out into the open to help educate all of us about what not to do, and about what to watch for, both externally, and within ourselves.

I'm neither a pilot nor a controller, but I'm 60 and I put in 37 years at QFE at a northern Canadian airport doing work that many controllers seemed to regard as being inferior, (but not the ones who had paid their dues themselves in the North).
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Old 15th Aug 2017, 18:55
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Originally Posted by Obese
It seems to me that this is an (unenviable) opportunity for the pilots involved to transition from (apparent) zero to hero if they summon all of the courage and integrity they have, and bare their souls to the investigators.
That is assuming the pilots involved understand what went wrong. Perhaps they do not. If in their minds they did everything right, followed the correct approach, and only suddenly at the last moment saw they were on the taxiway, they may have no explanation for what happened. If they then go through the procedures they followed on the night of the incident, they will end lined up on the runway, because that's where they expected to be, and thought they were.
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Old 15th Aug 2017, 19:41
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Originally Posted by underfire
Airbubba...FMS bridge visual final waypoint is on the extended runway centerline.
There is another waypoint, RW28R, on the chart, take a look. The FMS will provide path guidance between F101D and RW28R which may be faulty in what we think is a pre-GPS A320.

Originally Posted by underfire
Map shift or not, the procedure is visual from 4.4 DME
I heartily agree , this is a visual segment and any flight director or autoflight guidance should be strictly advisory.

Originally Posted by underfire
I am not certain if it is common practice, but when flight validating RNP procedures, as a check, the #2 seat is tuned to the ILS to backcheck the alignment, so it is possible.
Originally Posted by Old Boeing Driver
Being from the "old school", but having used some of the most modern EFIS, I wonder why no one had at least raw data displayed with the ILS tuned and inbound heading set.
Here are some earlier explanations on why A320 pilots normally don't have ILS raw data displayed on this approach:

Originally Posted by Brain Potter
In the A320 the display of ILS GS and LOC symbology on the PFD is incompatible with using the autoflight system to fly a non-precison approach. The ILS may be hard-tuned but the crew will not see the data unless they select the LS pushbutton or switch the Nav Display over to ROSE LS mode. If they do press the LS pushbutton after loading an approach with vertical guidance, they will get a flashing amber V/DEV message on the PFD to highlight the incompatible selection. I do not have experience of any 'FMS coded' visual approaches (RNAV visuals in other parlance?) but I expect that the FMGS behaviour is the same.

In the case of a classic visual approach, with just the runway selected in the FMGS, the ILS will have auto-tuned (the FMGS will know that it is an ILS runway) and the data can be displayed on the PFD without any advisory messages; the selections are compatible. However, by coding the visual approach trajectory into the FMGS it has effectively been transformed into a non-precison approach, and the selection of supporting ILS information is not as straightforward.
I remember the admonition from a sim instructor in an A306 type rating course years ago: 'Use Rose Mode if you really want to get f***ed up on the approach!'

Originally Posted by cactusbusdrvr
I have done many FMS Bridge visuals in the A320 family. You do not have the ILS raw data because it is an FMS approach. You have VASI and the electronic glidepath. You can hard tune the lLS through the RMP but no one ever does.
Originally Posted by CurtainTwitcher
We have a crazy policy recomendation to de-tune the ILS for an RNP approach when the runway is equiped with an ILS, why? Because of occasional GPWS glideslope alerts if the ILS is tuned! The GPWS is valid, but because some approaches are 2.8 degree (due hot weather), if it is cold and with enough barometric error you are actually low on path compared to the ILS. Better to turn the noise off than acknowledge the issues. Reminds me of "Shut up Gringo".
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Old 15th Aug 2017, 20:04
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za9ra22, your comment is a thoughtful one, but if the AC crew listened to the ATIS, they would have known that a "visual anomaly" was in place, and they logically would have been concerned about it, and would have briefed about it. For all of you pilots out there, if it's any consolation to you, it's even more mind numbingly mundane to record an ATIS than it is to have to listen to them. Plus on every one you record (mine - and I did thousands - were all non-digital), you had to go back and listen to yourself drone through the whole thing each and every time for quality control. Much like a pilot boo boo, it's easy to make a mistake on an ATIS if you're tired or distracted . . .
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Old 15th Aug 2017, 21:08
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I have the answer. They were looking for the gorilla and forgot to keep their eye on the ball.

(for those not in the know it means a long search back)
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Old 15th Aug 2017, 22:07
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Originally Posted by underfire View Post
Airbubba...FMS bridge visual final waypoint is on the extended runway centerline.
There is another waypoint, RW28R, on the chart, take a look. The FMS will provide path guidance between F101D and RW28R which may be faulty in what we think is a pre-GPS A320.
I assumed one knew the differenece between the waypoint on the beginning of the final segment, and the runway endpoint (which defines a segment.) oi vey.

Here are some earlier explanations on why A320 pilots normally don't have ILS raw data displayed on this approach:
All of that explanation is why you only have this selected on the #2 system (ie copilot) as a backup.

We have a crazy policy recomendation to de-tune the ILS for an RNP approach when the runway is equiped with an ILS, why?
This is not an RNP approach...it is RNAV visual.

The GPWS is valid, but because some approaches are 2.8 degree (due hot weather), if it is cold and with enough barometric error you are actually low on path compared to the ILS.
Also, you will note on most RNP charts, glidepath is not coincident, so of course, you may get a noise.
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Old 15th Aug 2017, 22:21
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Originally Posted by underfire
All of that explanation is why you only have this selected on the #2 system (ie copilot) as a backup.
I can see where you don't know enough about flying a plane to understand the explanations above from the A320 drivers. It's kinda technical.
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Old 15th Aug 2017, 23:13
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Originally Posted by Airbubba
I can see where you don't know enough about flying a plane to understand the explanations above from the A320 drivers. It's kinda technical.
I can see why you cannot understand that I was saying the exact same thing....you can do it, and it is not that technical, I do it all the time. As I stated, that is for flight validations, not in the commercial environment.

Pretty damning article...

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.

As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.


It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded.

Editorial: Air Canada, FAA hindered probe of SFO near-miss

Last edited by underfire; 15th Aug 2017 at 23:42.
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Old 16th Aug 2017, 00:46
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I'm not a pilot, just an idiot academic PhD.

The interesting question seems, what would you see on approach *if you are lined up wrong*, not if you are lined up right. And whether by the time the pilot flying took his eyes off his instrument scan and looked out the window, tired after a long flight, his angle of visual awareness may have been reduced due to fatigue or blood sugar issues.

Also, I have a feeling there might be more to this story; some distracting factor, some approach lighting issue ... the usual holes in the cheese lining up. As someone here commented two pilots with decent vision did line up on a taxiway, and it shouldn't be possible.

Edmund


Originally Posted by underfire
I can see why you cannot understand that I was saying the exact same thing....you can do it, and it is not that technical, I do it all the time. As I stated, that is for flight validations, not in the commercial environment.

Pretty damning article...

The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.

As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.


It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded.

Editorial: Air Canada, FAA hindered probe of SFO near-miss
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Old 16th Aug 2017, 02:03
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I find it hard to believe either the FAA or AC hindered the investigation at the outset. It was in middle of the night, if the crew didn't report it and the lone ATCO, busy with duties, didn't report it until shift change, the plane was probably being readied for departure before there was any hint of an incident. In the morning, the AC flight leaves for YYZ or YUL, bingo, no CVR recording. If anything is suspect, it is the crew's failure to report and trip the CVR circuit breaker. I'll admit it is possible they missed it all on the first approach, but I doubt a sentient crew didn't pick up their mistake on the second approach. Light bulbs had to be going off.

Then, the question is about AC's safety culture. Does it inhibit honest reporting of mistakes. Did the crew feel likely to be disciplined? Were they cognizant of the error and, if so, thought it could be hidden. Their simple answers implies a " cover up" on their part that can't be uncovered now.

GFK
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