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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 24th Aug 2017, 01:27
  #981 (permalink)  
 
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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.
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Old 24th Aug 2017, 01:38
  #982 (permalink)  
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Originally Posted by underfire
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.
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Old 24th Aug 2017, 01:40
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Indeed the SAFO almost hints that the FMS wasn't being used for the latter parts of the approach...
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Old 24th Aug 2017, 04:33
  #984 (permalink)  
 
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Originally Posted by underfire

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.
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.

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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Old 24th Aug 2017, 12:27
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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.

Last edited by WillowRun 6-3; 25th Aug 2017 at 13:25.
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Old 24th Aug 2017, 14:50
  #986 (permalink)  
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Originally Posted by AerocatS2A
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 so-called safety bulletin the FAA issued is a knee-jerk reaction of a somewhat dysfunctional aviation regulatory agency. The bulletin doesn't even mention the airline-rolled (as in, roll your own cigarettes) Flight Management System RNAV database visual flight procedure (RVFP), which was Air Canada's approach clearance.

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.
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Old 24th Aug 2017, 21:56
  #987 (permalink)  

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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).
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Old 24th Aug 2017, 23:07
  #988 (permalink)  
 
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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.
I actually did not rely on the NTSB findings, but what I saw and heard. The NTSB data simply confirmed what virtually everyone already saw and knew.

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
Exactly on point. This procedure has been flown every few minutes for years.

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.
Opening the procedure designed by UAL to other operators is the issue. Does Air Canada go back to UAL for the issues, or to the FAA which allowed them to do it?
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Old 24th Aug 2017, 23:25
  #989 (permalink)  
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Originally Posted by underfire


Opening the procedure designed by UAL to other operators is the issue. Does Air Canada go back to UAL for the issues, or to the FAA which allowed them to do it?
The FAA should be holding the dime, not UAL. UAL's design is fine, at least for GPS aircraft.
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Old 25th Aug 2017, 06:20
  #990 (permalink)  
 
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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.
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Old 25th Aug 2017, 06:41
  #991 (permalink)  
 
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Originally Posted by underfire
I actually did not rely on the NTSB findings, but what I saw and heard. The NTSB data simply confirmed what virtually everyone already saw and knew.


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.
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Old 25th Aug 2017, 06:56
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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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Old 25th Aug 2017, 08:32
  #993 (permalink)  
 
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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.
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Old 25th Aug 2017, 09:21
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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.
Bears the question what 'airport environment' effectively means.
To me this means and includes that the active runway must be clearly identified.
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Old 25th Aug 2017, 13:35
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Originally Posted by peekay4
This fixation with GPS (on a visual approach!) and the level of misinformation in this thread about RVFPs are getting ridiculous.
You are certainly entitled to that opinion. However, since the procedures go to approach mode for the final portion of the database procedure, the standard for accuracy should be the same as that required for an RNAV IAP; i.e., GPS required. This isn't about obstacle clearance containment areas, it is about assured alignment with the runway when that is the design objective. There are no notes about the critical DMEs for D/D/I, unlike on LEETZ SIX RNAV SID at KSLC, as an example.

1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
Are these criteria in a public order? I'm not disagreeing, I just don't know.
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.
I participated in the monthly RAPT telecons for AWP and ANM for four years until recently. I don't recall any discussion or vote about RVFPs, but I could have missed it.
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.
Without notes on the chart about critical DMEs they aren't doing a stellar job. And, what are these FAA RNP and RNAV groups? I do know that AIS in OKC (the folks who design SIAPs, etc.) are not in any way involved in the process.

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.
As I've stated previous I have no issue with the IMC phase because it is really a radar route predicated on MVAs at that point. It's the visual portion without GPS that concerns me.

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.
I never suggested that the design wasn't carefully done by UAL. I have the TARGETS package. It is all fine for FMS/GPS aircraft. As to the extent of the FAA involvement and approval, you know more about that then I do. What I do know is that there is no small skepticism about the process in certain quarters of the FAA.
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Old 25th Aug 2017, 14:06
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Originally Posted by glofish
Bears the question what 'airport environment' effectively means.
To me this means and includes that the active runway must be clearly identified.
Of course. And I'm sure that at some point they thought they had clearly identified the runway. Turned out they were wrong.
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Old 25th Aug 2017, 15:07
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Originally Posted by peekay4

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.
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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Old 25th Aug 2017, 17:17
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1. The criteria for RVFPs are developed by the FAA Flight Standards Service.
Incorrect. The procedures are simply designed to emulate existing visual procedures. There is no other guidance or criteria on how this is accomplished. You can use TF/TF or even TF/RF/TF legs. There is no criteria which is why it is considered a tailored approach.

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.
Incorrect. RAPT is only involved in a cursory manner. Only if there are conflicts with the design is the procedure even routed to RAPT for review. When a procedure is designed, it can be a good idea to route it through RAPT, especially if one wants to delay approval.

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.
Incorrect. These groups are only involved if the procedure requires. If you have RNP to visual, the RNP group is involved, if you have RNAV GPS required, the RNAV group is involved. If if is DME/DME/IRU, only the AWO is involved. The operator submitting the procedure, uses RNAV-Pro to evaluate the DME coverage. That program decides if it is sufficient, not the AWO. The operator supplies the results to the AWO with the findings. There is no decision, it is simply the results of the program analysis. The procedure approval path is then determined, and routed accordingly to the different groups by the AWO for review/approval.
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.
I certainly hope you are not foolish enough to be talking about me in this case. You would be completely wrong. As a tech pilot, I would be willing to bet I am typed on far more aircraft than you are.

Last edited by underfire; 25th Aug 2017 at 17:29.
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Old 25th Aug 2017, 21:02
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systemic of our dysfunctional FAA (on a corporate level
If you think this on a "corporate" level, try working with them at the FSDO. 6-8 months for a LOA anyone. If it isn't an airline issue, it doesn't exist.
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Old 25th Aug 2017, 21:54
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I didn't mean to exclude them.
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