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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 6th May 2018, 14:49
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Originally Posted by KingAir1978

From what I can see so far, the only thing the crew have been guilty of, is being human. It will be very interesting to see what the outcome of this investigation is. I'm sure it must have involved some kind of lapse of situational awareness due to some kind of visual illusion of some kind. The interesting question would be how to avoid this from happening again in the future.
The failure to preserve the CVR is quite significant to this aviation professional and has compromised, as you state, ..how to avoid this from happening again.
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Old 6th May 2018, 15:25
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@smott999 - It was a visual approach. Therefore theoretically flyable using only the Mk. 1 eyeball, without any ILS tuned (and the visual approach is at a slight converging angle to the ILS track, so one would not be using the ILS to the fullest extent). However, tuning the ILS can be a useful backup, but then one gets into specific airline policies (use it, don't use it) or aircraft operational differences.

@PaxBritannica - CVR was wiped before the NTSB could get to it. See numerous previous posts (including the one immediately above yours!). It is interesting that ,while SFO was supposedly quiet enough at midnight for one controller to handle things, there were four planes lined up for departure at this critical moment (gotta love those west-coast red-eyes!)

Trained, experienced commercial pilots line up with, and sometimes land on, taxiways on the order of once or twice a year. It happens. Usually, there is no traffic on the taxiway - or we'd have heard about it big-time before now. This time was different.

I can feel for the crew. They tried to do everything right (saw the NOTAM, noted the risks of an oh-dark-thirty arrival on their own human performance) - but in the end, they still "lost the picture" in a critical phase of the flight, were slow to respond to their own growing doubts, and nearly produced a major catastrophe. Things slipped through the cracks or "lined up in the cheese," and Murphy was riding in the jump-seat. An object lesson for everyone.
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Old 6th May 2018, 19:43
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Originally Posted by pattern_is_full
@smott999 - It was a visual approach. Therefore theoretically flyable using only the Mk. 1 eyeball, without any ILS tuned (and the visual approach is at a slight converging angle to the ILS track, so one would not be using the ILS to the fullest extent). However, tuning the ILS can be a useful backup, but then one gets into specific airline policies (use it, don't use it) or aircraft operational differences.

@PaxBritannica - CVR was wiped before the NTSB could get to it. See numerous previous posts (including the one immediately above yours!). It is interesting that ,while SFO was supposedly quiet enough at midnight for one controller to handle things, there were four planes lined up for departure at this critical moment (gotta love those west-coast red-eyes!)

Trained, experienced commercial pilots line up with, and sometimes land on, taxiways on the order of once or twice a year. It happens. Usually, there is no traffic on the taxiway - or we'd have heard about it big-time before now. This time was different.

I can feel for the crew. They tried to do everything right (saw the NOTAM, noted the risks of an oh-dark-thirty arrival on their own human performance) - but in the end, they still "lost the picture" in a critical phase of the flight, were slow to respond to their own growing doubts, and nearly produced a major catastrophe. Things slipped through the cracks or "lined up in the cheese," and Murphy was riding in the jump-seat. An object lesson for everyone.
Not only were there four planes lined up, there were a lot of flights landing. The report states that the UAL flight of 'He's on the taxiway' fame, had been waiting 30 mins at the time of the near-incident, and had made at least one query of ATC about whether a hole might be found in the the long queue of landing flights.

It would have made no difference to this particular flight, but I imagine passengers arriving at SFO might be surprised that ALL ops at the airport were being handled by just one person.
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Old 6th May 2018, 19:49
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Save me sifting through the thread, where is it said the local controller was also working ground, CD, etc?
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Old 6th May 2018, 21:03
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Originally Posted by West Coast
Save me sifting through the thread, where is it said the local controller was also working ground, CD, etc?
It's in crew statements in the recently opened NTSB docket. Several pilots of other aircraft said it was a cause for concern.
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Old 6th May 2018, 22:10
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Originally Posted by West Coast
Save me sifting through the thread, where is it said the local controller was also working ground, CD, etc?
From the 'Airplanes on taxiway C' attachment:

While the Air Canada 759 crew made a serious mistake that went unchecked for way too long. I believe that it is important to note that the tower controller was performing way too many functions, IE Ramp, Ground, Tower and at times ops vehicles. I believe that the audio from the 45-55 minutes prior to this event will support this belief. Sincerely, Robert S. Wallace United Airlines 737 Captain
It was clear from tower's comment to someone else on frequency seconds after this incident that there was only one controller working the tower and ground control functions. Greg L Sembower UAL 863 First Officer
Second, I feel the tower controller should not have been the only controller working the entire airport. He was working multiple frequencies, controlling tower duties for Take offs on 1L and 28R, and Landings 28R. He was also performing all ground control duties. I feel when Air Canada called with questions about the runway, this should have been the cue he needed to closely pay attention to that flight. That apparently did not happen. You can tell from the reaction time between when United 1 called "Where is this guy going? He is lined up on the taxiway" to when he told Air Canada to go around. It took a few seconds for him to evaluate the situation. Those few seconds were several more feet that Air Canada continued his approach down to around 100' Sincerely, First Officer Steve Shoquist United Airlines
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Old 7th May 2018, 01:04
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West Coast,

The interview with the controller is here:

https://dms.ntsb.gov/public/61000-61...112/614678.pdf
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Old 7th May 2018, 02:01
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That's a pretty ugly schedule the controller is working. I've done one similar to that before and didn't care for it. Maximises your days off though.
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Old 7th May 2018, 05:32
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Some NTSB docket analysis in this Mercury News article:

5 feet?! Shocking SFO video, data reveal Air Canada plane came perilously close to aircraft on taxiway

By MATTHIAS GAFNI [email protected] Bay Area News Group
PUBLISHED: May 2, 2018 at 10:50 am UPDATED: May 4, 2018 at 10:49 am
SAN FRANCISCO — Federal aviation investigators released stunning video footage and data Wednesday showing the near-disastrous landing ofan Air Canada flight at San Francisco International Airport came as close as 5 feet from striking a Philippine Airlines jet lined up on a taxiway last July — much closer than previously reported.

In its lengthy report Wednesday on one of the most troubling close calls in SFO’s history — an Air Canada jet almost landing on top of four passenger jets awaiting takeoff — the National Transportation Safety Board found the crew felt fatigued during the flight, that the first officer was twice rejected in his application for promotion, and that another pilot landing at SFO that night complained about too-bright construction lights that made it difficult to find the proper runway.

Aviation experts have said the close call could have led to one of the worst aviation disasters in history with the fully loaded planes carrying upward of 1,000 passengers and crew.

The documents were released a day after the Federal Aviation Administration released its own investigatory findings into other take-off and landing mishaps at SFO, highlighted in a series of reports first detailed by the Bay Area News Group.

The new NTSB report includes never-before-seen SFO surveillance video that shows Air Canada Flight 759, an Airbus A-320, mistakenly aligned with Taxiway C the night of July 7. The black-and-white video shows the Air Canada jet descending perilously close to — and flying directly over — the planes awaiting takeoff before pulling up at the last second. It had been cleared to land on runway 28R, but pilots told the NTSB they got confused because a parallel runway was closed for construction that night.

The new data from NTSB shows the plane dropped to only 60 feet above the ground at its lowest point — much lower than previously thought — as it passed over a Philippine Airlines Airbus A340 waiting to take off on the taxiway. The tail of the Airbus model — the tallest point — is 55 feet, six inches.

When asked to confirm that Air Canada passed within 5 feet of the other jet based on the NTSB chart, a spokesman said they would have to consult the investigators. While the federal agency could not confirm the distance, in its performance study report the NTSB estimated the distance between the two planes at 13.5 feet.

Former United pilot Ross Aimer reviewed the NTSB data and said it appeared the planes got incredibly close.“If the tail of (Air Canada) was directly above the A340’s rudder (which may not be the case) the direct vertical distance would be 5 (feet)!” Aimer wrote in an email.

The NTSB report also presents a much clearer idea of what happened in the cockpit during those final crucial moments on approach and named the pilots involved for the first time.

Air Canada Capt. James Kisses switched off the autopilot once the plane reached the final approach and took over flying. As they neared the airport, he saw lights on the runway and asked his co-pilot Matthew Dampier to verify the runway was clear.

At about 11:55 p.m., radio traffic indicates that Dampier asked the SFO air traffic controllers: “Just want to confirm this is Air Canada 759 we see some lights on the runway there across the runway. Can you confirm we’re cleared to land?”

The tower, believing the plane was lined up for the correct Runway 28R, said the runway was clear, not realizing the plane was actually lined up on the crowded parallel taxiway.



The first officer described how in the moments before radioing the tower for clarification he had been “looking more inside the cockpit than out because” he was focused on preparing the plane for landing, according to the NTSB report.

When Dampier looked up from his chart as the captain asked him to query the tower, he looked outside and saidit “didn’t look right” and he had a “bad feeling in his stomach,” according to the report.

“Although he was not certain what was incorrect, he was unable to process what he was seeing. He subsequently commanded the go around to the captain by saying ‘go around go around,’ ” according to the report. Kisses told investigators “things were not adding up” and that it “did not look good,” and as he got even closer it “still felt odd” and he aborted the landing.

The pilot and co-pilot had never flown together before that night. Dampier, 42, said they both began to feel tired while still an hour away from SFO. While neither man had a previous incident or accident, Dampier had two “unsatisfactory” attempts to become a captain.

“According to the simulator instructors and checkairmen that conducted the incident first officer’s upgrade attempt, the reason for the unsatisfactory upgrade was the first officer’s lack of situational awareness, failure to correctly identify a mandatory altitude on an arrival, non-precision approaches, and a lack of performance to the Transport Canada required performance standards,” according to the report.

Some instructors described Dampier as “nervous” and a “weak candidate.”

Air Canada has not said if either man was disciplined. The 56-year-old captain has 20,000 flying hours, and the first officer has 10,000 flying hours. Both men live in Toronto, meaning their body clock was at 3 a.m. during the landing.

Dampier told investigators it was not until they left the plane that night — after a second, successful landing — that they remembered about the runway closure at SFO.

Dampier told investigators as they taxied to the gate at SFO that night he realized the result “could have been bad.”

The NTSB also interviewed the flight crews who got buzzed by the Air Canada plane as they sat on the taxiway. Many pointed to the quick thinking of United Airlines Flight 1 Capt. Keith Freeberg, who had been first in line at the end of Taxiway C waiting to take off. He saw the Air Canada plane headed toward them and radioed: “Where’s that guy going, he’s on the taxiway!”

Steve Shoquist, a relief first officer on United 863, which was third in line on the taxiway, said the plane turned on all its lights in a last ditch effort to warn the Air Canada plane it was about to land on them.

“Air Canada went around, and a huge disaster that would have many fatalities, including myself was avoided,” Shoquist told investigators.

Another pilot told investigators that the air traffic controller that night was overburdened with work directing air, ground and other radio traffic. The FAA has since ordered two controllers to be in the tower at SFO at all times during the night rush hour. At the time of the landing, one controller was in the tower, and the second was on break.

The air traffic controller that night, Brian Delucchi, also was interviewed by the NTSB and recalled talking to the “shaken” Air Canada pilot shortly after the incident.

“He (said the pilot) had not realized how close the aircraft had gotten to each other … and (he) did not want to ‘freak the guy out since he seemed shaken,’ ” according to the report.

The Air Canada pilots were not the only ones confused by runway configuration that night, when Runway 28L was closed for construction. Another airline’s flight crew that landed on Runway 28R four minutes before the Air Canada flight reported to investigators the “construction lights were so bright we could not determine the location of the inboard runway, 28L,” according to the report.

That crew said they too questioned whether they were properly lined up for Runway 28R but checked with their instruments to confirm the right path.
https://www.mercurynews.com/2018/05/...four-aircraft/
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Old 7th May 2018, 06:39
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As a radio altimeter will return the closest obstacle in the signal path, one could suggest the 60 foot lowest recorded reading is actually from the top of the A340, not the ground.
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Old 7th May 2018, 07:18
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Unfortunately unless there’s been a major foul up in the document with regard to definitions I don’t think you can suggest that..

The performance study table in the docket/Airbubba’s post specifically labels the fourth column “altitude” and the amplifying text refers to “altitude” , not “ height” or “radio height” or “radio altitude”.
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Old 7th May 2018, 09:44
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I begin this post by apologizing for not completely reviewing the thread again before commenting. I did read it while the incident unfolded in the months afterward, but the thread is now so long it precludes the ability to find specific information for memory refreshment.

There has been discussion about the controller's workload; at the time this individual was coordinating aircraft flight and ground operations as well as the movement of ground vehicles.

My thoughts on the issue:

The aircraft was cleared to land and on a visual approach. It therefore seems to me the controller's workload had little bearing on the crew's lineup on the taxiway rather than the runway. Similarly, the controller's go around call was based on his interpretation of a radio transmission from the crew of UAL 1, not information that was available from his equipment.

It seems quite reasonable to state the controller's increased workload had little effect on the situation.

As for the crew's perception of the last seconds of the approach, the situation was undoubtedly confusing.

"The NTSB reported that in post flight interviews both pilots of AC-759 reported they were convinced the lighted runway to their left was runway 28L and they were lined up with runway 28R. They did not recall seeing aircraft on taxiway C, however, something did not look right to them."

Runway 28L had been closed for five months at the time of the incident. It seems reasonable to assume the crew might have flown into SFO during those months, and therefore on the date of the incident might have been aware 28L had been closed for some time. The NOTAM regarding the runway closure was part of the data the crew reviewed that day, and the ATIS broadcast also contained the information.

In spite of this, it seems the crew did not fully integrate this knowledge into their approach briefing and actions during the approach. The NTSB statement above says the crew mistook the lights of Runway 28R for the closed Runway 28L. But as they should have expected, the closed runway did not have approach lights, PAPI, edge lights, and centerline lights in operation. It did have an elevated brightly lit "X" placed on the centerline of the runway. Why would they make this elementary mistake?

The crew was aware the 28L was closed, and the difference in the sight picture between a fully lit active runway and a taxiway, illustrated by an earlier post of a sim program screencap, is so obvious it seems inexplicable the crew made the misidentification described in the NTSB document.

The inquiry the crew made to the controller about their confused sight picture seconds before the planned touchdown indicates they were aware something was amiss. But because of their alignment on the taxiway, the ASDE-X/ASSC data link did not show the position of AC-759 for several seconds, leaving the controller unaware of the impending collision.

The assertion by both pilots they were "convinced" the aircraft was aligned with Runway 28R seems to be a bit too emphatic to me. If so, why were they confused enough to contact the controller about the situation? "Convinced" conveys the image that they had a clear understanding of what was in front of them, and that characterization seems to be, perhaps, rehearsed.

While giving sufficient weight to human factors, particularly fatigue, the actions of the crew seem to indicate inattention or complacency were also present. This should not be a surprise, human endeavours are often affected by such traits. I have not made the above observations to heap unwarranted criticism on the crew, I am suggesting behavior, though unintentional, that may have played a part in the incident.
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Old 7th May 2018, 09:59
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I'm shocked that two controllers were paid to be on duty, but after 30 minutes one of them went off on an extended 3 hour break, a break from what? As the United Pilots said, they were waiting 30 minutes on the ground for departure. How much did this cost the airlines, whilst one controller napped on the sofa or played Minecraft?

G
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Old 7th May 2018, 14:57
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Originally Posted by PaxBritannica
It would have made no difference to this particular flight, but I imagine passengers arriving at SFO might be surprised that ALL ops at the airport were being handled by just one person.

Speaking as SLF, when I first read that back in July I was utterly shocked that a major international airport could have just one ATC on duty no matter what the time of day -- what about sudden incapacitation?
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Old 7th May 2018, 15:13
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Originally Posted by Ambient Sheep
Speaking as SLF, when I first read that back in July I was utterly shocked that a major international airport could have just one ATC on duty no matter what the time of day -- what about sudden incapacitation?
It wouldn't be a big deal. Those jets on the ground would stay there, and those in the air would land in an orderly fashion. There are places where passenger jets operate in and out of airports that don't have any controllers at all. Despite what they might like you to think, we don't really need them .
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Old 7th May 2018, 15:16
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Originally Posted by groundbum
I'm shocked that two controllers were paid to be on duty, but after 30 minutes one of them went off on an extended 3 hour break, a break from what? As the United Pilots said, they were waiting 30 minutes on the ground for departure. How much did this cost the airlines, whilst one controller napped on the sofa or played Minecraft?

G
Having another controller isn't going to magically increase the flow rate.
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Old 7th May 2018, 15:19
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Originally Posted by ThreeThreeMike
I begin this post by apologizing for not completely reviewing the thread again before commenting...

...The crew was aware the 28L was closed, and the difference in the sight picture between a fully lit active runway and a taxiway, illustrated by an earlier post of a sim program screencap, is so obvious it seems inexplicable the crew made the misidentification described in the NTSB document.

You may therefore have missed the following:

Originally Posted by AerocatS2A
It is interesting that the previous landing also questioned to themselves if they were lined up on the correct runway stating that the construction lights were very bright and made it impossible to see the closed runway, also that the lack of lights on the jets on the taxiway contributed to their confusion. Of course they sorted things out fine, but it certainly suggests that the visual environment was not good.

May I thus venture to suggest that the actual situation as seen through the cockpit window on that particular night may not have tallied with the "sim program screencap" -- 28L not dark, and red-X drowned out by construction floodlights perhaps?
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Old 7th May 2018, 15:22
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Originally Posted by AerocatS2A
It wouldn't be a big deal. Those jets on the ground would stay there, and those in the air would land in an orderly fashion. There are places where passenger jets operate in and out of airports that don't have any controllers at all. Despite what they might like you to think, we don't really need them .

Ok, thank you for the info. And yes I am aware that some small airfields don't have them at all, was just shocked regarding a place as large as SFO, that's all. Again, thank you for replying.
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Old 7th May 2018, 17:27
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Originally Posted by Derfred
As a radio altimeter will return the closest obstacle in the signal path, one could suggest the 60 foot lowest recorded reading is actually from the top of the A340, not the ground.
Did you see the pictures? it was reading the ground...
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Old 7th May 2018, 18:15
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SFO should have better equipment and more staff on duty. This was almost a disaster but everybody seems to forget Asiana which would have been prevented with the right radar. To have a blanc spot on very very short final is not acceptable for an airport like SFO with runways used for parallel landings and take off.
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