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Old 20th Aug 2017, 15:28   #941 (permalink)
 
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The NTSB's function was previously handled by the Civil Aeronautics Board, which was also the parent agency over the FAA's predecessor agency, the Civil Aeronautics Administration (CAA). But, the NTSB wasn't within the CAA.

In 1958 both the FAA and the NTSB were created as independent agencies. A few years later the Federal Aviation Agency was folded into the Department of Transportation and became the Federal Aviation Administration.
I should have originally written, "... a major reason of why the NTSB was separated from the DOT".

The NTSB wasn't created in 1958, but later in 1967 when the FAA was renamed and folded into the DOT. But back then, the NTSB was also (administratively) part of the DOT, which created some conflicts of interests.

So in 1974, the NTSB was separated from the DOT and became fully independent. The role of investigators to find probable causes of accidents and incidents -- instead of determining faults or to place blame -- is very central to NTSB's mandate as an independent safety board.

(As an aside, it seems that the Civil Aeronautics Board was never the parent agency of the Civil Aeronautics Administration either. Both were spun off from the Civil Aeronautics Authority.)

On possible administrative sanctions, if warranted, even the FAA may have limited recourse in seeking enforcement actions against the AC759 pilots since presumably the pilots only hold Transport Canada licenses and not FAA certificates. The FAA may refer possible violations to Transport Canada via the State Department and the Canadian Embassy; However, it would be up to Transport Canada to take matters further (or not).
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Old 20th Aug 2017, 15:36   #942 (permalink)
 
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Happens in Daylight as Well

At a certain Southern Ontario small airport, visiting aircraft often line up on the taxiway the first time in because it has more contrast to the terrain than the actual runway.

Illusions happen. At night much more often.
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Old 20th Aug 2017, 15:59   #943 (permalink)
 
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If it turns out the AC chaps failed to do a thorough briefing and missed the NOTAM, potentially increasing their chances for 28L/R confusion....is that grounds for dismissal?
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Old 20th Aug 2017, 16:14   #944 (permalink)
 
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If it turns out the crew said to each other, "hey look, there are four jets on C, lets give them a dust up!" Then absolutely, you fire them.
Except they confused C with 28R,
Quote:
...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.
The cockpit voice recorder had been overwritten.

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Old 20th Aug 2017, 18:49   #945 (permalink)
 
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Originally Posted by peekay4 View Post

On possible administrative sanctions, if warranted, even the FAA may have limited recourse in seeking enforcement actions against the AC759 pilots since presumably the pilots only hold Transport Canada licenses and not FAA certificates. The FAA may refer possible violations to Transport Canada via the State Department and the Canadian Embassy; However, it would be up to Transport Canada to take matters further (or not).
From what little I know those referrals often go nowhere. When I was still working I was being hooked up to a tow bar to be towed into a gate at LAX Terminal 3. A KAL 747 was lost in the smog on a visual to 24R. He did a 90 degree turn descending out of about 500 feet and rolled wings level just in time to prevent the right wing from hitting the ground. It make the local radio news.

An FAA friend told me that the tower was really upset. It was written up and sent via the State Department to the Korean equivalent. Nothing came of it. KAL could do no wrong.
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Old 20th Aug 2017, 19:10   #946 (permalink)
 
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Originally Posted by CurtainTwitcher View Post
llondel, how about taking it to the next level? Learning from others close calls & mistakes should be in our DNA

My hope is that there are many of us are now flying around with awareness of another potential "failure mode". I certainly am.

A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience.
True, I've always tried to learn from the mistakes of others because it's way less embarrassing that way (and when flying, way safer). However, a lot of people are in the "it can't happen to me, I'd never do that" camp until it does. I'm not saying this is one, but there are some mistakes you have to make personally before fully appreciating and understanding them.

I've always tried to blame "the system" for errors. Sometimes there is indeed gross negligence where the finger can be pointed at an individual or team, but for the most part they're following the routine where there are checks to spot mistakes and just occasionally something happens for which there isn't a check and we get a smoking hole. This one was saved because someone else thought it was wrong and spoke up in time, and that's probably another lesson to take on board, to keep an eye on what's in the air while you're anywhere near the landing point.
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Old 20th Aug 2017, 20:28   #947 (permalink)
 
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Originally Posted by CurtainTwitcher View Post
liondel, how about taking it to the next level? Learning from others close calls & mistakes should be in our DNA

My hope is that there are many of us are now flying around with awareness of another potential "failure mode". I certainly am.

A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience.
To those seeking discipline in this event, read the above--it describes how aviation became the safest means of transporting us around.
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Old 20th Aug 2017, 21:12   #948 (permalink)
 
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An FAA friend told me that the tower was really upset. It was written up and sent via the State Department to the Korean equivalent. Nothing came of it. KAL could do no wrong.
Yeah. It gets complicated because many countries prohibit domestic legal action based solely on foreign evidence / investigation by a foreign country. It gets into due process, sovereignty, etc.

I'm going to correct myself a bit: I've been told that Canada is a "special case" and the FAA has a "direct line" to Transport Canada for referrals (so the State Department doesn't have to get involved). However, it would still be Transport Canada's decision to pursue the matter further or not.
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Old 21st Aug 2017, 00:33   #949 (permalink)
 
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Originally Posted by _Phoenix View Post
Except they confused C with 28R,
I know. I was just giving an example of behaviour that would result in dismissal. I didn't mean to suggest that this is what happened.

Quote:
Originally Posted by Smott999
If it turns out the AC chaps failed to do a thorough briefing and missed the NOTAM, potentially increasing their chances for 28L/R confusion....is that grounds for dismissal?
That would depend on why they didn't do a thorough briefing and missed the NOTAM.
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Old 21st Aug 2017, 05:23   #950 (permalink)
 
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Where do you find the FAA calling SAMUL anything?

The airline TARGETS source shows SAMUL as a FB step-down within the intermediate segment. This is all "story board" stuff, since the source designer is using a program intended for IFP design to design a FMS visual approach track.

I hope the NTSB really opens this can of worms, although I seriously doubt they will.
That is what I was getting at. We had discussed before the FAF definition on Jepp charts. This is very close to the FMS Bridge visual procedure.

This is the mixed bag visual detailled out, and given that, I was surprised to see a DA listed. Was interesting to see the RNP AR to visual.
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Old 21st Aug 2017, 08:25   #951 (permalink)


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In the long run, if it turns out that the pilots and airline in question are truthful and cooperative, that means that they place a high value on contributing to aviation safety for the greater good, and that they deserve to be respected and treated fairly. If, on the other hand, it were to turn out that the whole thing morphed into a cynical, sick, worthless charade, well then, I think that passengers, regulators, and insurers could perhaps take note. Over time, the prestige of airline aviation will die a death of a thousand cuts, if it is demonstrated to young and aspiring airline pilots, and to the flying public, that it is bean counters, mouthpieces, and deal makers who are really, in effect, the ones in the cockpit.
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Old 22nd Aug 2017, 00:26   #952 (permalink)
 
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n the long run, if it turns out that the pilots and airline in question are truthful and cooperative, that means that they place a high value on contributing to aviation safety for the greater good, and that they deserve to be respected and treated fairly.
Well, the airline HAS made a decision to equip its aircraft with GPS, a known safety equippage. That being said, it does not appear to be implemented yet on this ac that flew this international route.

Does that put the airlines contribution to safety in context? Perhaps the money the airline is willing to spend on the aircraft, and the upkeep of the aircraft?

As a passenger, are you be happy to know that the airline did not even spend enough money to put a GPS system in the AC? You have one in your car, your phone, and your watch, but the airline didnt even get around to putting one in the the aircraft you are riding in.

Last edited by underfire; 22nd Aug 2017 at 00:52.
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Old 22nd Aug 2017, 00:30   #953 (permalink)
 
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As someone who claims to design approaches for a living you know better than that Underfire, are you just stirring?
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Old 22nd Aug 2017, 01:22   #954 (permalink)
 
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you are correct, questioning an airline that flies international routes to major airports for not equipping an aircraft with GPS is just stirring.
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Old 22nd Aug 2017, 01:41   #955 (permalink)
 
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As someone who claims to design approaches for a living you know better than that Underfire, are you just stirring?
He is spot on.
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Old 22nd Aug 2017, 01:50   #956 (permalink)
 
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Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.
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Old 22nd Aug 2017, 09:28   #957 (permalink)
 
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Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.

This was a Mk.1 eyeball & Mk.2 brain created problem not a technological one.
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Old 22nd Aug 2017, 14:47   #958 (permalink)
 
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Originally Posted by galaxy flyer View Post
Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.
True enough if they don't have RNAV. But, the early RNAV FMS birds that do not have GPS are subject to small inaccuracies when the DME geometry is not good. Those small inaccuracies can become a significant factor flying an FMS visual, especially down low and close in.

We do not know if that happened in this case. But, the potential is there using DME updating instead of GPS for position determination, particularly as the airplane gets low and loses good DME geometry.

With the tight spacing of Runways 28L/R and especially 28R and Taxiway Charlie, this 28R FMS Visual should mandate GPS. Look at the RNAV IAPs to 28R. They state "DME/DME RNP-0.30 not authorized." The FMS 28R Visual should have the same restriction, particularly since it uses RNP 0.30 from F101D inbound.
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Old 22nd Aug 2017, 14:48   #959 (permalink)
 
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Originally Posted by RAT 5 View Post
Not having GPS equipment is probably the least important factor in this incident. Plenty of planes fly safely w/o GPS.

This was a Mk.1 eyeball & Mk.2 brain created problem not a technological one.
Do you have an authoritative cite for that conclusion?
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Old 22nd Aug 2017, 15:34   #960 (permalink)
 
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Originally Posted by aterpster View Post
Do you have an authoritative cite for that conclusion?
Isn't the whole thread the authoritative?
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