Go Back  PPRuNe Forums > Flight Deck Forums > Rumours & News
Reload this Page >

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

Rumours & News Reporting Points that may affect our jobs or lives as professional pilots. Also, items that may be of interest to professional pilots.

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

Old 22nd Aug 2017, 23:34
  #961 (permalink)  
 
Join Date: Sep 2011
Location: earth
Posts: 1,084
"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.
There is a marked difference between seeking only disciplinary actions, mainly called punitive leadership, and doing all the seeking “why” and learning from an incident, while still holding the crew responsible.

I get the impression that the discussion on here goes too much in the direction of either/or.

Insinuating that those calling to hold the crew responsible for the incident only wanting to hang them, is calling the wrong shot. No one wants to crucify them, but we should acknowledge that they mad a grave mistake. Notwithstanding that there were contributing factors, we are in the cockpits to ensure safe flight and not to screw-up – point la ligne!

We can then go and do the soul searching about the "whys and how comes".
By doing this, we can then assist and help the concerned crew by pointing relentlessly to all the enemy factors we know so well. Simultaneously we should not let only accident boards, regulators, airlines and manufacturers go ahead with the inquiries and verdicts. We all know that therein lies the main problem: Collusion and corruption. In the name of the holy profit, too many interest groups and their beancounters go ahead with cutting all corners in assessments, training and equipment/tools for all the professionals involved in civil aviation. It makes our job more difficult and leaves access to too many ill-suited participants, which then makes the system more incident prone than necessary. Accident reports are more often than not very partially executed and their outcome is most often a lip service to safety, but a huge service to the aforementioned with new but mainly useless regulations and more gadgets for the industry to sell inflated to the taxpayer and airlines with little or no effect. It however definitely costs more than a better assessing and much better training of the aspiring young future employees.

In dollars and human losses.
glofish is offline  
Old 22nd Aug 2017, 23:46
  #962 (permalink)  
 
Join Date: Aug 2013
Location: PA
Age: 56
Posts: 34
refer to post http://www.pprune.org/9866948-post917.html

look at that NTSB report, and while there look at the others, and the findings.

We can then go and do the soul searching about the "whys and how comes".
By doing this, we can then assist and help the concerned crew by pointing relentlessly to all the enemy factors we know so well. Simultaneously we should not let only accident boards, regulators, airlines and manufacturers go ahead with the inquiries and verdicts.
This is a profession, with professional responsibilities.

In transportation, truck, rail, and ship accidents, the driver, captain, or responsible person is held accountable.
The train driver who missed the signal has his license taken away, the truck driver who ran the red light has his license taken away, the boat captain who misjudged the pier has his license taken away.
So the aircraft drivers who try to land on a taxiway full of aircraft should be just a learning lesson?

How about this as a learning lesson.

FIRE them. Did you see what happened to the drivers from the 777 crash at Dubai..FIRED.

Complain about hours and circadian rythmns, ENFORCE the rules. Make your airline follow the rules.

In reality, blaming it on circadian stuff is equivalent to claiming your parents abused you. It is a trending psychological term, that was never in aviation. Just another term to avoid responsibilty for ones actions.
Just a few years ago, drivers just knew how to fly the aircraft, and did so in adverse conditions with no automation.

Complain about lack of training and understanding of the aircraft systems. Drivers learn them or fire them. Did you see that the NTSB report showed the driver of the Cogan disaster repeatedly failed, yet was still driving. FIRE THEM.

Last edited by underfire; 23rd Aug 2017 at 00:08.
underfire is offline  
Old 22nd Aug 2017, 23:56
  #963 (permalink)  
 
Join Date: Jan 2004
Location: Here and there
Posts: 2,852
Originally Posted by underfire View Post
refer to post http://www.pprune.org/9866948-post917.html

look at that NTSB report, and while there look at the others, and the findings.
Is that directed to me? If so, what am I supposed to be looking for?
AerocatS2A is offline  
Old 23rd Aug 2017, 00:23
  #964 (permalink)  
 
Join Date: Nov 2007
Location: Texas, like a whole other country
Posts: 428
As my clay shooting instructor says, "don't use equipment as a solution for a training problem"
From one clay shooter to another.

you are correct, questioning an airline that flies international routes to major airports for not equipping an aircraft with GPS is just stirring.
Does AC actually consider ops within Canada and US "international"? Technically, they are -- I realize that -- but lots of things happen between the nations that blur that line, US Customs clearance in CA one of them.

That aside, I'm just inquiring about how the airlines view these operations and if that might affect outfitting. Thanks.
Carbon Bootprint is offline  
Old 23rd Aug 2017, 06:39
  #965 (permalink)  
 
Join Date: Oct 2014
Location: Qatar
Posts: 89
underfire,

There is definitely a position in airline management for you out in this part of the world, any of the ME carriers would welcome you with open arms. As to whether your approach would make the industry safer, well that's another debate.
320goat is offline  
Old 23rd Aug 2017, 07:26
  #966 (permalink)  
 
Join Date: Sep 2015
Location: Germany
Posts: 42
Originally Posted by underfire View Post
This is a profession, with professional responsibilities.

In transportation, truck, rail, and ship accidents, the driver, captain, or responsible person is held accountable.
The train driver who missed the signal has his license taken away, the truck driver who ran the red light has his license taken away, the boat captain who misjudged the pier has his license taken away.
So the aircraft drivers who try to land on a taxiway full of aircraft should be just a learning lesson?
Frequently, these events occur because the driver was distracted doing stuff not related to driving/docking/whatever. If that is the case, he should rightfully have his license suspended/revoked and get fired. The same if he did what he did because he couldn't be bothered to obey the law "because he is more important than that".

However, if he is doing his level best to avoid the event, he should be allowed to keep it. E.g. you run a red light to make room for the ambulance behind you. If there is no crash, nobody will blame you.

Even in aviation, if you break the rules because you feel like it or because you can't be bothered to do proper preparation, you should be prosecuted. To my knowledge, you are. This impinges on this case - they should have been aware of the issue with the runway lighting. They did download the NOTAMs, read them, etc. How come they missed this? I don't think they were just going through the motions. There is a gap in there somewhere that should be fixed.

I cannot imagine these pilots were trying to die. They were doing their best to land the aircraft safely. They (hopefully) had a sterile cockpit, they noticed something amiss and even queried ATC about it. IMHO, they should not be fired.

I'm sure they will never make that mistake again, they will go around much earlier if something looks wrong (imagine a 380 had been waiting there...). They triggered a discussion that may save someone else in the future (remember, a landing is an approach that doesn't end in a go-around!).

(Disclaimer: just an SLF)
RealUlli is offline  
Old 23rd Aug 2017, 10:42
  #967 (permalink)  
 
Join Date: Jun 2009
Location: Newcastle
Age: 50
Posts: 585
Originally Posted by aterpster View Post
I'll stick with the NTSB.
OK, then check the update on their website and refrain from popping on here.
MATELO is offline  
Old 23rd Aug 2017, 14:44
  #968 (permalink)  
 
Join Date: Apr 2009
Location: On the Beach
Posts: 3,299
Quoting me out of context. That doesn't help the discussion.
aterpster is offline  
Old 23rd Aug 2017, 15:27
  #969 (permalink)  
 
Join Date: Apr 2009
Location: On the Beach
Posts: 3,299
FAA issues safety alert because of this incident.
Attached Images
File Type: jpg
SAFO17010-1.jpg (376.1 KB, 164 views)
File Type: jpg
SAFO17010-2.jpg (315.2 KB, 161 views)
File Type: jpg
SAFO17010-3.jpg (111.2 KB, 157 views)
aterpster is offline  
Old 23rd Aug 2017, 21:57
  #970 (permalink)  
 
Join Date: Jul 2013
Location: Within AM radio broadcast range of downtown Chicago
Age: 68
Posts: 393
Meanwhile ...

I'd like to offer some defense of underfire . . . about sanctions of crew, and whether anyone other than drivers situated in what they refer to as pointy ends can hold responsibility at the system and systemic level.

First, it is akin to civilian control of the military (notwithstanding any deficits in current U.S., uh, personages). The civil aviation system in the U.S. and Canada and really now, in probably a significant majority of ICAO member states, exists organically within a legal structure, a governmental structure. As supreme as the aviators are within their realm and in certain respects outside of it, they are not the ultimate responsible parties, by themselves, at the system and governmental level. I don't think this is a controversial view. Or, it shouldn't be controversial.

Second, there actually is no reason to impute to underfire's views - or to the views of anyone who advocates at the very least, for consideration of the most severe sanction available - any disregard for the safety inquiry and improvement processes. As a prior post quite nicely said, it is not either/or. Is there even a single example which can be provided where, because a crew with stuffed-up results on their record were given a heavy sanction rather than a milder one, safety inquiry and system improvement suffered, even suffered at all?

Not least, there is a case to be made for something that sounds harsh, and is harsh. Sometimes the unjustness which appears to be visited upon one or a small handful of individuals is, when weighed in a significantly larger context, justified. It is being emphasized, over and over here, that the set of causal factors likely to be found and reported by the formal and official investigation will include a number of things; . . . . the lighting obviously on the taxiway and runway, the attentional tunneling problem that has been aped about, maybe the approach set-up in the airspace architecture and as specified in procedures and for equipment lacking certain avionics, and even the bugaboo fatigue and "daily timeclock routine" (aka rhythm of circadian type). So, if one believes these factors were present or might have been present, in some combination or even all of them, then maybe the right approach is to make an example out of this crew. The unfairness to them, such as it might be, could be worth the slap-across-the-chops the example would give to others. This is not what I am saying obviously must be done or needs to be done. Still it is a case to be stated and pondered. This was a very, very close call, was it not? And if it had gone into accident mode, I don't think anyone yet can say "well the physics of the situation show us that the extent of needless death and destruction would have been no more or less than X" - but we can say with reasonable confidence that if it had gone into accident mode there would have been at least many serious injuries if not fatalities. So, from this standpoint, underfire's clamor for the most severe sanction is a reasonable point of view, and the option must be in the mix of possible outcomes. In sum, a near-accident that has the appearance - at the very least - of having been horrible had it turned into an accident, may warrant severe sanction, once all the facts are determined and officially charged rapporteurs have had their day in print.
WillowRun 6-3 is offline  
Old 23rd Aug 2017, 23:49
  #971 (permalink)  
 
Join Date: Sep 2014
Location: Canada
Posts: 1,257
How do you know I do not have the qualifications to drive the aircraft?
Sorry, but it's pretty obvious.

Is there even a single example which can be provided where, because a crew with stuffed-up results on their record were given a heavy sanction rather than a milder one, safety inquiry and system improvement suffered, even suffered at all?
Unfortunately there are many.

E.g., the "most severe" sanctions, to borrow your words, would be criminal ones. As such, in many countries accident investigations fall into purview of the criminal justice system, along with very strict rules of evidence, etc., required by that system. Yet this focus to "criminalize" pilot conduct has had an impact to safety:

1. After the ValuJet crash in the everglades, employees of ValuJet's maintenance company SabreTech were charged in Florida with 110 counts of 3rd degree murder and 110 counts of manslaughter -- one for each crash victim. A few years later, when the NTSB investigated the 1999 pipeline rupture in Bellingham, everyone "lawyered up". And worse, prosecutors prevented the NTSB from doing their job. Statement from NTSB Chairman Jim Hall at the time:

"The NTSB wants the answers to all of these questions, and we need to know them as soon as feasible. But, my investigators have been stymied by the prospect of criminal prosecutions . . . A number of our investigative activities has been suspended because most of the central players will not talk to us. And, prosecutors have asked that we not test the valve of the pipeline until their concerns regarding evidence preservation can be allayed. "
2. In 2009, a Cessna Citation crashed near Rome. The judicial authorities immediately seized the CVR & FDR and refused to release them to the Italian Transportation Safety Board (ANSV), for months!

3. Similarly after the XL Airways / Air New Zealand A320 crash in the Mediterranean sea, French judicial investigators took custody of the FDR and interfered with the safety investigation, preventing the damaged FDR from being sent to the US for read out at the manufacturer (Honeywell) until a compromise was found.

4. Indonesian authorities wanted to "send a message" after the Garuda Flight 200 crash in Yogyakarta by criminally sentencing the Captain and sending him to jail. Afterwards, dozens of the Indonesia's most senior pilots and ATCO left to other countries rather than work in an environment where there's constant fear of criminal prosecution. If anything, the country's safety situation only worsened further.

5. I recall at least one case where the CVR was lost to fire because judicial investigators refused to give timely access to safety investigators who wanted to secure the blackboxes in the aftermath of a crash.

These are inevitable consequences from the urge to "throw the book" and impose "severe sanctions" for unintended operational errors.

Criminal prosecutions are warranted in cases of where there's willful violations of the law. Otherwise, pilots, mechanics, ATCO, everyone else involved in aviation will simply "plead the fifth" on any incident or accident. There will be no self-reporting and coverups will become the norm. Safety will greatly suffer.
peekay4 is offline  
Old 24th Aug 2017, 00:01
  #972 (permalink)  
Moderator
 
Join Date: Aug 2006
Location: Ontario, Canada
Age: 59
Posts: 4,796
Posters, please play the ball, not the players.
Pilot DAR is offline  
Old 24th Aug 2017, 00:02
  #973 (permalink)  
 
Join Date: Jul 2013
Location: Within AM radio broadcast range of downtown Chicago
Age: 68
Posts: 393
Severity

peekay4, good thing I couldn't assess interest charges on borrowing my words. I was imprecise.
The most severe sanction to which reference was made, or within context of the argument by underfire, was termination of employment. But I left the door open to criminal prosecution being understood as within the question as I wrote it.
I believe there is some body of legal research (academic, mostly) on the impact of criminal prosecutions (and even criminal investigations) on safety investigations and, while it is not something I have read closely or thoroughly, I think the quite dominant view aligns closely with your litany of examples.
But termination of employment, as the most severe sanction in this incident -- seems far-fetched even to think about any possibility of a prosecution or criminal inquest here. So, are there examples in your lexicon of employment termination, as opposed to some milder sanction, impeding either safety investigation or implementation of any recommended system modifications?
WillowRun 6-3 is offline  
Old 24th Aug 2017, 00:04
  #974 (permalink)  
 
Join Date: Aug 2013
Location: PA
Age: 56
Posts: 34
FAA issues safety alert because of this incident.
Thank you terpster...very interesting SAFO.

"due to the severity of the incident a review and incorporation of these recommendations is strongly encouraged"

EDIT: Willow. with all due respect, why should a pilot be afforded such luxury on incompetence? What other profession, given life safety issues, is afforded such luxury?
The question of punative sanction on the individual is veiled on the impact of aviation in general?
While there is certainly a lesson to be learned, how does that somehow releave the responsiblity of the perpetrator?

Bottom line, the individuals have been removed, and the impact has been mitigated, both present and future. Interesting , when people see a crime, and the perpetrator has previous offenses, everyone wonders why they still able to commit more crimes.....why didnt enforcement prevent this from happening.

tale of the tape:
FMS Bridge Visual is flown every few minutes into SFO on a daily basis.
One operator decides to land on the taxiway.
Lesson to be learned or punative action?

Last edited by underfire; 24th Aug 2017 at 00:43.
underfire is offline  
Old 24th Aug 2017, 00:13
  #975 (permalink)  
 
Join Date: Sep 2014
Location: Canada
Posts: 1,257
So, are there examples in your lexicon of employment termination, as opposed to some milder sanction, impeding either safety investigation or implementation of any recommended system modifications?
Not a great example but one that immediately pops into my mind is Capt. Kinzer's firing at Allegiant we've previously discussed, WillowRun 6-3.

If you'd recall, the Captain's employment was terminated after he allegedly did not follow company SOP on evacuations. I can't speak for Allegiant pilots but it seems to me that if another were put into a similar situation after the firing, he/she might think twice about ordering a needed evacuation, and who knows what the safety repercussions would've been?

Similar to criminal prosecutions, threat of termination over operational mistakes (vs. willful misconduct, gross negligence, etc.) will simply encourage many to cover up safety issues. Is this what we really want?

Incidentally, the Allegiant case is now scheduled for jury trial in October.
peekay4 is offline  
Old 24th Aug 2017, 00:52
  #976 (permalink)  
 
Join Date: Aug 2013
Location: PA
Age: 56
Posts: 34
So, are there examples in your lexicon of employment termination, as opposed to some milder sanction, impeding either safety investigation or implementation of any recommended system modifications?
PK, how does your example, and explanation answer the question?

So, in your opinion, the threat of punative action will typically cause a coverup?

How far does this go?

What about a FOQA bust? A wake encounter?
All of the other mistakes and lack of aircraft system knowledge and capabilites, that we see outlined in posts here on PPRuNe?
Where is the learning experience if everyone covers their mistakes or covers lack of aircraft system knowledge?

Wait for an accident?

Again, FMS Bridge Visual is flown every few minutes into SFO on a daily basis.
One operator decides to land on the taxiway.
Lesson to be learned or punative action?

Should the restrictive (punative) action be against all operators? If you were United, would you want to be restricted due to Air Canada?

I think everyone can see from the FAA SAFO terpster provided, where this is going.

Last edited by underfire; 24th Aug 2017 at 01:17.
underfire is offline  
Old 24th Aug 2017, 00:53
  #977 (permalink)  
 
Join Date: Jul 2013
Location: Within AM radio broadcast range of downtown Chicago
Age: 68
Posts: 393
PPRuNe should cover the trial....

peekay4, good point. But. The Allegiant pilot was, if I am recalling correctly, defended in the forum thread pretty stridently or at least consistently, for having done the right thing. And the carrier management scored, again stridently or consistently (in same thread), for having tanked the man, predicated on his not having done anything wrong. Do you recall differently (and yes, it was a, uh, spirited exchange previously). I can't see that the AC759 aviators are being portrayed or defended here as having done nothing wrong.
(Perhaps the Allegiant trial will contribute to a growing, if still nascent, body of advocacy for an overhaul of massive proportions of US federal labor and employment law applicable to air carrier operations.)
WillowRun 6-3 is offline  
Old 24th Aug 2017, 01:11
  #978 (permalink)  
 
Join Date: Jul 2013
Location: Within AM radio broadcast range of downtown Chicago
Age: 68
Posts: 393
Originally Posted by underfire View Post
......why should a pilot be afforded such luxury on incompetence? What other profession, given life safety issues, is afforded such luxury?
The question of punative sanction on the individual is veiled on the impact of aviation in general?
While there is certainly a lesson to be learned, how does that somehow releave the responsiblity of the perpetrator?

Bottom line, the individuals have been removed, and the impact has been mitigated, both present and future. Interesting , when people see a crime, and the perpetrator has previous offenses, everyone wonders why they still able to commit more crimes.....why didnt enforcement prevent this from happening.......
Really there are two things at work here, aren't there? I think your position tends to emphasize a kind of preventative as well as punitive purpose. These two pilots stuffed up so obviously and so badly that they cannot be trusted to operate an air transport category aircraft again - that's me paraphrasing you, and I hope accurately and fairly. Then there is the system view. And the point I was trying to make is that even if someone in the ultimate authority seat for decisions on such a termination of employment might decide on a lesser sanction based on the degree of stuffed-up-edness, that decision-maker might instead opt for termination, to make an example of them. Rather than affording luxury, I was trying to say, make it more severe, even if not as convincingly warranted in these two individual cases, to signal to everybody else that this is a dangerous set of conditions or circumstances and vigilance needs to be increased. Or to consider this option -- as I originally posted, this should be considered, but until the facts are known, I am not inclined, at all, to hold any certainty.
WillowRun 6-3 is offline  
Old 24th Aug 2017, 01:27
  #979 (permalink)  
 
Join Date: Sep 2014
Location: Canada
Posts: 1,257
I can't see that the AC759 aviators are being portrayed or defended here as having done nothing wrong.
When we talk about punishment, we need to look at the bigger picture, not just this specific instance -- because punishment for operational mistakes sets a precedent regardless if others are supportive of the pilots or not.

Just culture is becoming the predominant safety culture, at least in North America (I can't really speak about elsewhere.) It's not just about pilots, but in all safety critical fields, including all forms of transportation (under the NTSB, Canadian TSB, etc.), nuclear safety (see IAEA's stance on open reporting of errors), medicine, etc.

In fact one of the most notable quotations about just culture was made by a physician:

The single greatest impediment to error prevention in the medical industry is
“that we punish people for making mistakes.”

-- Dr. Lucian Leape
Harvard School of Public Health
Testimony before US Congress.
A culture of safety must be based on trust. Pilots are human beings asked to make real-time, split-second decisions. Mistakes will happen. The solution is not punishment but to improve the system as a whole.

Some posters here (ahem) seem to be of the opinion that because many planes land successfully at SFO, that means nothing can be learned and nothing needs to be improved. This type of thinking is very dangerous.

Aviation is very safe because we are continuously learning and improving. Once we start blaming, trust will be lost, and the consequences will be severe.
peekay4 is offline  
Old 24th Aug 2017, 01:38
  #980 (permalink)  
 
Join Date: Apr 2009
Location: On the Beach
Posts: 3,299
Originally Posted by underfire View Post
Thank you terpster...very interesting SAFO.

"due to the severity of the incident a review and incorporation of these recommendations is strongly encouraged"
Alas, not any mention of the FMS database visual they were cleared for. (almost hypocritical.)

Properly executed (airplane and/or flight crew) it (the FMS Visual) would have satisfied all the flight guidance requirements of the SAFO.

I believe this SAFO is systemic of our dysfunctional FAA (on a corporate level) trying to get out in front of what I suspect is a very angry NTSB.
aterpster is offline  

Thread Tools
Search this Thread

Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service - Do Not Sell My Personal Information -

Copyright 2021 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.