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

[cappt]

There is way too much focus on the CVR here. There would be no "smoking gun" to point at. Of course they didn't catch the NOTAM, we know that.
The CVR would contain the usual descent check and brief, some chit-chat, I've got the airport in sight, call it? Yeah sure. Whats with the runway lights? yeah it looks like somethings on it? should I ask? yeah? WTH? lets go-around.

[BRDuBois]

Originally Posted by underfire

sure, there are all sorts of visual clues to land on the twy....

That wasn't the point being made.

[underfire]

There is way too much focus on the CVR here. There would be no "smoking gun" to point at.

Just another missing piece of the puzzle.

This will be a very interesting report when it does come out.

this video may explain some of the issues....AC A320-200 flightdeck tour...those screens would be difficult to use! I see why they lined up on the TWY now, after watching that for 6 hours!

https://www.youtube.com/watch?v=mj3Y0hyQrOA

Maybe the FO was flying and is left handed...

[llondel]

As I said earlier, they've reconstructed what happened, it's the 'why' that is important now, because understanding how they got so close is key to preventing it happening again. The CVR might have shed some light on that, I assume there was a cockpit discussion about the lights before the ATC call and a reason for the mistake might be found.

It was probably human error, but if so, the system needs to be changed to throw in an extra check somewhere to try to prevent it from happening again. The CVR might give a good hint as to the nature of that check and where to put it.

Until you understand why they did it, you can't honestly say for certain that you wouldn't have done the same thing.

[A320ECAM]

Have the AC pilots been dismissed yet?

[underfire]

..............................^ 28L...............................^28R..............^2 red/2 yellow perfect!

seems reasonable...easy mistake to make.

Until you understand why they did it, you can't honestly say for certain that you wouldn't have done the same thing.

Considering many, many aircraft used this approach and after, that same night, and did not try to land on the TWY......according to the drivers, they did not do anything wrong, just did a GA because "something didnt seem right"

[Obese]

On pages 78-79 of the Transportation Safety Board of Canada final report on Air Canada 624 (A320, Halifax, March 2015 - just Google Air Canada 624 report) it is indicated that ACA's remaining non-GPS A320's were to receive retrofitting. What bitter irony if C-FKCK (ACA759) was on the list, but hadn't made it into the hangar yet.


There have been intelligent, insightful comments re the inflexibility of the EFIS on the older A320's, especially if non-GPS, but here's a can of worms I haven't seen opened yet . . .


You are in an IFR aircraft, on an active IFR flight plan, inbound to SFO 28R, in VMC, cleared for the FMS Bridge, essentially an enhanced visual approach. If I remember correctly from my "Talk and Gawk" days, you had to have reasonable expectation of remaining visual to get approved for a visual approach, but you still had the option of "re-transitioning" back into IFR at any time, provided you didn't CANCEL IFR. Also, if I remember correctly, the controller still had to provide IFR separation for you, and also still had to protect the IFR missed approach area.


Now, I admit that, in the real world, if you were maintaining VFR in VMC, and a go-around became necessary for whatever reason, normally, you would be cleared for, and would execute, a VFR go-around, as ACA759 did. HOWEVER, in the given scenario, I submit that that would not have been your only option, again provided you had not cancelled IFR.


In the unlikely event that some unusual factor arose, such as fast-moving scud rolling in, migratory birds at circuit altitude, wind shear conditions, wake turbulence hazard, traffic, whatever, you would still be entitled to request clearance for an IFR missed approach, into the still-protected IFR missed approach airspace, despite your previous clearance for the FMS Bridge.


Sooo . . . (and I hope you're still awake, reading this) even if you are in a non-GPS beater A320, wouldn't you want your seat mate to be primed for, and/or tuned in for, immediate transition to IFR in case the IFR missed approach became necessary? If you were already prudently set up for that, would it involve all that much button pushing to quickly peek at ILS or VOR/DME data as a cross check while still on the FMS Bridge? Methinks not.

[jurassicjockey]

Originally Posted by underfire

Considering many, many aircraft used this approach and after, that same night, and did not try to land on the TWY......

Do you know that for a fact. There was a Delta go-around previous to this on the same night. Are you privy to the reasons for that

[peekay4]

Considering many, many aircraft used this approach and after, that same night, and did not try to land on the TWY......according to the drivers, they did not do anything wrong, just did a GA because "something didnt seem right"

The Asiana 214 crash at SFO happened in part due to a misunderstanding of a peculiar way the 777 Auto-Throttle worked in a set of circumstances the NTSB described as "very rare" -- after all, many many aircraft use auto-throttles on approaches all the time, without issue.

However, only after the accident did we start to look for other times crews made the same mistake. By analyzing historical FOQA data, one US airline reported that in their fleet pilots made the same mistake several times a day! Another US airline found seven instances that the same misunderstanding almost led to accidents, including one where the approach speed had deteriorated to almost 20 kts below Vref.

So while the vast majority of A/T approaches were incident free, mistakes were happening. An accident like Asiana 214 was just a matter of time, and likely could have happened to almost any 777 operator. The Asiana crew were simply the unlucky ones.

Similarly, in my view, through this AC759 incident we will find out many similar cases at SFO and/or other airports which had not been reported before. That many aircraft used the same night visual approach successfully that has no bearing to the fact that there might be an underlying cause such that a serious incident like this one might have been inevitable over time. Hence it's important for us to understand it, so we may try to prevent future occurrences.

[underfire]

Hence it's important for us to understand it, so we may try to prevent future occurrences.

What does circumstantial evidence say? (as the drivers have denied an incident)

All FDR evidence shows they tried to land on the TWY.
Video evidence shows they tried to land on the TWY
Crew denies they were on the TWY.
Crew denies they saw ac on the TW.
CVR not available.
As no incident, no substance testing?

Historically, how many other aircraft have tried to land on TWY C? EVER?

Do you believe the 2 drivers story?

What exactly do you feel will be learned from this?

Not allow visual approach for the other 99.99% that can figure out where the runway is?
Not to trust the drivers, and have 4 hour CVR's?
Have video recorders on the flightdeck?
Not allow visual for AC aircraft?

Exactly WHAT WILL BE LEARNED?

Every criminal in prison professes their innocence.

There was a Delta go-around previous to this on the same night. Are you privy to the reasons for that

Why was that, pray tell?

Perhaps they were behind the AC ac that tried to land on a few other aircraft?
Since you know, why be so coy?

[peekay4]

Do you believe the 2 drivers story?

As they perceived it, YES 100% WITHOUT RESERVATION.

[aterpster]

Originally Posted by peekay4

So while the vast majority of A/T approaches were incident free, mistakes were happening. An accident like Asiana 214 was just a matter of time, and likely could have happened to almost any 777 operator. The Asiana crew were simply the unlucky ones.

Disagree. Not for a pilot/crew that were trained in the fundamentals of flying. Unabated IAS below Vref would simply not happen to those who really understand how to fly.

[peekay4]

Plenty of airline pilots who were "trained in the fundamentals of flying" have stalled and crashed on approach. The NTSB has five decades worth of reports testifying as such.

The Asiana 214 commander was an elite pilot with the Korean Air Force. The PF had a 20-year career with Asiana flying the A320, 737, 747-400 before transitioning to 777s. The observer pilot sitting jumpseat flew F-16s. To suggest that they weren't "trained in the fundamentals of flying" is a bit of a stretch.

The fact that FOQA data shows that numerous similar deviations below Vref due to the same issue were happening at more than one US majors clearly suggest that this was an accident waiting to happen. If you read the NTSB final report, the statement by NTSB chairman Robert Sumwalt (starting at page 136) is quite illuminating.

I think many pilots will look at Asiana 214 or AC759 and simply think, "this can't happen to me, I'm a better pilot!". Don't be so sure.

[DaveReidUK]

Originally Posted by underfire

Crew denies they were on the TWY.

I must have missed that part. Where and when did they say that?

[RAT 5]

As per the Westjet near crash into the sea at St. Maarten, and again here the crew made a GA then flew the same approach again and succeeded. I've wondered & asked in both cases what they did differently the 2nd time. By knowing that we might learn, from them, how they screwed up the 1st time.
I read somewhere, I think, that AC's 2nd approach was via a straight in ILS; is that correct? If so we may not learn their fundamental mistake, but what the crew can say, without any doubt, is that the picture they saw on the 2nd approach was vastly different from that on the 1st. In which case how can they say they were not lined up on the taxiway for the 1st attempt. If "something didn't look right" on their 1st visual then it sure a heck looked normal on the 2nd, or they wouldn't have landed.

[AerocatS2A]

They didn't say they were not lined up with the taxiway, they said they "believed they were lined up with 28R". Well duh! Obviously they thought they were lined up with the runway, they're not going to line up with a taxiway on purpose just for ****s and giggles. This is not the same as denying they were lined up on the taxiway as Underfire keeps banging on about. They also don't recall seeing aircraft. Again that doesn't mean they didn't see the aircraft, it just means they didn't recognise what they were looking at as aircraft, instead it "just didn't look right".

Nowhere does it say that the crew deny the fact they were lined up with the taxiway or that they overflew aircraft, they are talking about what they perceived at the time.

[AerocatS2A]

Originally Posted by DaveReidUK

I must have missed that part. Where and when did they say that?

They didn't.

The quote from NTSB is this:

...both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.

Maybe they misunderstood the ATIS and NOTAM and thought the approach lighting was out for 28R. I've been into Sydney many times after curfew when the closed runway 34R is lit up like a bonfire while the in use runway 34L has a displaced threshold, no approach lights, temporary PAPIs hiding behind taxiway signs and a couple of vehicles on the runway doing an inspection. If you did an approach on what looked like a runway you'd balls it up (and it has been done), instead you are expected to make an approach on to a mess of lights that don't look much like a runway. Granted, Sydney is not SFO, but perhaps these guys had talked themselves into expecting to see 28R with no approach lights next to a 28L with approach lights. Who knows? I don't know. What I do know is that they didn't set out to purposefully land on a taxiway, something screwed up their expectations.

[aterpster]

Originally Posted by peekay4

The fact that FOQA data shows that numerous similar deviations below Vref due to the same issue were happening at more than one US majors clearly suggest that this was an accident waiting to happen. If you read the NTSB final report, the statement by NTSB chairman Robert Sumwalt (starting at page 136) is quite illuminating.

I think many pilots will look at Asiana 214 or AC759 and simply think, "this can't happen to me, I'm a better pilot!". Don't be so sure.

I am familiar with Sumwalt's statement. He was upset that the Board wouldn't recommend that Boeing modify the 777 A/T system. I share that concern. Automation has created a generation of "children of the magenta line." Sumwalt also went on to say:

The above remarks are an attempt to explain how the pilot flying may have relied on the aircraft to maintain a safe airspeed. Despite his reliance on the automated system, there is no doubt that he should have monitored airspeed. The investigation found that the pilot flying didn’t monitor for 24 seconds, and the instructor pilot didn’t monitor for 17 seconds. These were critical errors that were causal to the crash.

As far as the PIC's experience is concerned, that and $10 will get you coffee at Starbucks. The KAL PIC at Guam (KAL800) also had lots of merit badges.

[underfire]

When they passed 3 feet over PAL (with their lights on), do you think they realized they were on the taxiway?

Did they hear UAL radio they were on the taxiway 5 seconds before GA? Did they see UAL pass under them?

To continue to say they thought they were on the runway is disengenuous to say the least.

They never said we did the GA because we saw we were landing on the taxiway.

Again, denial of the simple facts.

[DaveReidUK]

Originally Posted by underfire

When they passed 3 feet over PAL (with their lights on), do you think they realized they were on the taxiway?

Did they hear UAL radio they were on the taxiway 5 seconds before GA? Did they see UAL pass under them?

To continue to say they thought they were on the runway is disengenuous to say the least.

They never said we did the GA because we saw we were landing on the taxiway.

Again, denial of the simple facts.

You seem to be going round in circles.

Are you still asserting that the crew denied they were on the taxiway ?