Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
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I can't see that the AC759 aviators are being portrayed or defended here as having done nothing wrong.
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.
“that we punish people for making mistakes.”
-- Dr. Lucian Leape
Harvard School of Public Health
Testimony before US Congress.
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.
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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.
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.
Sometimes this approach is justified. When someone makes a mistake and it is subsequently identified that lots of other people almost make the same mistake but catch it in time, then a change in procedure is justified in my opinion. On the other hand if a mistake was made due to crew incompetence then I don't think procedures should change, instead the crew needs to be retrained or, in the most severe cases, removed from the industry.
The Colgan Capt should have been either dismissed or made a career FO a long time before their accident. A history of marginal performances is not a good sign.
I don't have a problem with considering punitive action against the Air Canada crew. My problem is that you are basing your "prosecution" on a very brief NTSB preliminary report that doesn't say what you think it says.
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peekay4 (no. 984): "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 [quotation omitted].
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."
A very thought-provocative post, peekay4. Perhaps you would comment on either or both of two further questions:
1) if there is a dividing line between different levels of accountability or responsibility - and also possibly between levels of sanction - is it not the case that such separating lines are adjusted over time? For example, the criminal offense of rape sometimes was a capital offense in the early 20th century. The point is, if a dividing line is accepted, its acceptance is understood to be subject to adjustment in a later time.
2) is there not a difference between mistake, on one hand, and what in laws and legal processes is identified as "gross negligence"?
I would not attempt, even, to argue with the fundamental premise that trust is a sine qua non of the safety system writ large; that blame and punishment are counter-productive. But I do question, is there not a point at which this rationale gets overtaken and thus becomes secondary to the level of "wrong action" by the aviators? -- and is not this line still a lower level than that which is sufficient to warrant (justify) criminal investigation and even more so, prosecution? I think there is such a point, and it exists in other areas of law, gradations between mistake or bare incompetence; and gross negliglence; gross misconduct; willful misconduct; criminal intent. But again, by these gradations being mentioned I do not mean to slight or ignore the concern over degradation of the safety culture.
In fact one of the most notable quotations about just culture was made by a physician [quotation omitted].
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."
A very thought-provocative post, peekay4. Perhaps you would comment on either or both of two further questions:
1) if there is a dividing line between different levels of accountability or responsibility - and also possibly between levels of sanction - is it not the case that such separating lines are adjusted over time? For example, the criminal offense of rape sometimes was a capital offense in the early 20th century. The point is, if a dividing line is accepted, its acceptance is understood to be subject to adjustment in a later time.
2) is there not a difference between mistake, on one hand, and what in laws and legal processes is identified as "gross negligence"?
I would not attempt, even, to argue with the fundamental premise that trust is a sine qua non of the safety system writ large; that blame and punishment are counter-productive. But I do question, is there not a point at which this rationale gets overtaken and thus becomes secondary to the level of "wrong action" by the aviators? -- and is not this line still a lower level than that which is sufficient to warrant (justify) criminal investigation and even more so, prosecution? I think there is such a point, and it exists in other areas of law, gradations between mistake or bare incompetence; and gross negliglence; gross misconduct; willful misconduct; criminal intent. But again, by these gradations being mentioned I do not mean to slight or ignore the concern over degradation of the safety culture.
Last edited by WillowRun 6-3; 25th Aug 2017 at 12:25.
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Almost every accident and incident that occurs was done flying a procedure that everyone does every day. And every time a change in SOP or regulation comes out in response to an incident, it is a case of a restriction being applied to the majority in response to a mistake by one person. This is nothing new.
The bulletin is negligent in its omission about the operating requirements and limitations of RVFPs. This is likely because the FAA doesn't have any criteria or operational guidance for the use of RVFPs. They are wholly a procedure developed by the airlines for the airlines. In this respect, the airlines are regulating themselves.
That's not the way the system is supposed to work.
Plastic PPRuNer
After a recent (obligatory) symposium on Medical Ethics, in the Q&A afterwards I suggested that we were moving away from Ethics-driven Ethics to Legal-driven Ethics.
IOW, do what you are least likely to be sued for rather than what is old-time ethically correct.
The Chairman was not happy, "I sincerely hope that you are wrong1"
She later cornered me and said that it was a very worrying statement.
So it goes.
Stick to the written SOPs and you're safe (but possibly dead - a much more desirable place to be than a Court of Law).
IOW, do what you are least likely to be sued for rather than what is old-time ethically correct.
The Chairman was not happy, "I sincerely hope that you are wrong1"
She later cornered me and said that it was a very worrying statement.
So it goes.
Stick to the written SOPs and you're safe (but possibly dead - a much more desirable place to be than a Court of Law).
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I don't have a problem with considering punitive action against the Air Canada crew. My problem is that you are basing your "prosecution" on a very brief NTSB preliminary report that doesn't say what you think it says.
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
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
I also agree that it is a bit of a basket case with allowing sub-standard aircraft to use it. Is there is a problem with allowing non GPS aircraft to use the procedure? the intent of the procedure was to reduce workload, I simply cannot see that with a non-GPS aircraft.
They should all be restricted, or just this crew/airline?
I mean really, how many non-GPS equipped ac are flying international these days?
The bulletin is negligent in its omission about the operating requirements and limitations of RVFPs. This is likely because the FAA doesn't have any criteria or operational guidance for the use of RVFPs. They are wholly a procedure developed by the airlines for the airlines. In this respect, the airlines are regulating themselves.
That's not the way the system is supposed to work.
That's not the way the system is supposed to work.
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This fixation with GPS (on a visual approach!) and the level of misinformation in this thread about RVFPs are getting ridiculous.
1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.
3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.
4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.
It's not like UAL designed the procedure on the back of a napkin and had Jepp print it up without FAA's involvement, reviews and approval.
1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.
3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.
4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.
It's not like UAL designed the procedure on the back of a napkin and had Jepp print it up without FAA's involvement, reviews and approval.
No. You continually state that the crew deny being on the taxiway. The only source for this information is a brief statement in the NTSB report, but it doesn't say what you keep claiming it says.
This thread has been made unbareable by someone who isn't even qualified to fly a visual approach let alone anything more complicated. Waste of time even checking it now days.
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Stick to the written SOPs and you're safe (but possibly dead - a much more desirable place to be than a Court of Law).
Indeed. At various interviews with differing operators a common question was "what do you think about SOP's?" There were some standard answers that 2 pilots who did not know each other would know what the other was going to do and when etc. etc. Then an old TRE, 15 years ago, told me another reason to be studious in following SOP's. It was to cover your backside in the event of................
I thought that to be rather sad, if you could see the SOP was not the best thing to do a that moment. Perhaps it would work, but there was a better way. However, if during your alternative technique Sod's law came into play you were on your own. Under Plan A rules you had a defence.
Indeed. At various interviews with differing operators a common question was "what do you think about SOP's?" There were some standard answers that 2 pilots who did not know each other would know what the other was going to do and when etc. etc. Then an old TRE, 15 years ago, told me another reason to be studious in following SOP's. It was to cover your backside in the event of................
I thought that to be rather sad, if you could see the SOP was not the best thing to do a that moment. Perhaps it would work, but there was a better way. However, if during your alternative technique Sod's law came into play you were on your own. Under Plan A rules you had a defence.
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4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.
To me this means and includes that the active runway must be clearly identified.
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1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.
3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.
4. And let's not forget since RVFPs are visual approaches they must be flown in VMC. Aircraft can be routed through waypoints in RVFPs in IMC all day long, but before they're actually cleared for the RVFP the pilots must have the airport environment (or preceding aircraft) in sight and be able to remain clear of clouds. Thus the level of safety of RVFPs is no less than a CVFP.
It's not like UAL designed the procedure on the back of a napkin and had Jepp print it up without FAA's involvement, reviews and approval.
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I found the order 8260.55. Really nothing more than an outline. Criteria it is not. Having read it, it would be beyond the RAPT's mandate to get involved in approving these RVFPs.
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1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
2. RVFPs are developed in close coordination with the FAA's procedures team (RAPT), and must be individually approved by FAA's Procedures Review Board.
3. RVFPs are also designed to meet FAA's RNAV standards to the extent possible for a visual approach. In fact, it is the FAA's RNP and RNAV groups, together with FAA's regional All Weather Operations specialist, that makes the final determination if there's sufficient DME/DME infrastructure for the procedure or if GPS will be required.
The AWO is not a decision maker, but simply the focal point in the process as a manager, assisting in routing the documents to the respective groups.
This thread has been made unbareable by someone who isn't even qualified to fly a visual approach let alone anything more complicated. Waste of time even checking it now days.
Last edited by underfire; 25th Aug 2017 at 16:29.
systemic of our dysfunctional FAA (on a corporate level
