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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 12th May 2018, 14:23
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Aterpster, I think I read somewhere that they didn't have GPS. Is the Airbus non-GPS RNAV system so accurate that it would be "perfectly aligned"? Further, I doubt their SOP would have allowed autoflight, in LNAV, down to 100ft, especially at night.

Again, only the crew will know: PF went manual flight some nm's out from touchdown. There has been discussion that they programmed the FMC for a 'Bridge visual approach' (I think). Going manual would they leave the FD's ON. If so they would be linked to the FMC. So when they lined up with the taxiway the lateral mode FD might/should have been showing a strong 'fly left'. Equally the magenta line would have been off to the left. And my earlier comments about the PAPI's for 28R being well off to the left is still valid. It would seem there were lots of clues. Curious. I can't believe 2 pilots would fly an approach from 3-4nm without some scan inside. Perhaps AB operators of this older model can help here.
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Old 12th May 2018, 14:40
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We used to do IRS alignment on all turnarrounds in my company, now we do not.
I always check for drift as I regularly fly 3 to 6 hrs legs: the drift is always great and in the range of 1\4 to 1 mile, so , dependent on DME DME triagulation update that Airbus did NOT have an accurate LNAV position after 4 to 5 hrs flt from Toronto!
The ILS drift ,on the other hand, is generally less then 1/10 degree per YEAR if I remember correctly from my Calibration Flights.

Oh, and they killed the FD when the Cpt disconnected , ca 4 miles.
Again I fly the odd visual, but generally with full automation to assure no OFDM trigger.
Come to think of it the last one was to CPH and the A/C two places ahead of me made a G/A from a botched visual?
If one wants to practice manual visual, providing the Company SOP let You, a busy International airport at night , at 03:00 BodyClock is not smart. As proven here.
Regardless WTF the clearance was!!!
Is this so hard to understand!
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Old 12th May 2018, 14:44
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RAT 5

We go F/D’s Off when going manual (All Airbus operator, Airbus SOP’s) and select the Bird on. They would have had no instrument back-up at that stage. As in, they’re visual and positioning the aircraft in accordance with what they see outside, not by what some lateral bar or needle is saying on the PFD.

The F/D’s would’ve come back on automatically when TOGA selected.

I’d be more interested to hear of their previous months roster, time asleep the previous 24hrs, etc. I think that is more applicable here in this incident.

That video is just, wow. So close to the second tail.
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Old 12th May 2018, 15:56
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Originally Posted by Capn Bloggs
Aterpster, I think I read somewhere that they didn't have GPS. Is the Airbus non-GPS RNAV system so accurate that it would be "perfectly aligned"? Further, I doubt their SOP would have allowed autoflight, in LNAV, down to 100ft, especially at night.
They didn't have GPS. When the lead carrier flight inspected the procedure before it was approved, they did it with and without GPS. The DME/DME environment on the entire approach was very good.

So, yes, a D/D/I airplane should be in as good as shape as a GPS/I airplane. 100 feet was to make a point. The rollout on final is at F101D at 1,200 msl. 3.5 miles from the AER. And, keep in mind this procedure is approved for IMC to as low as 1,000 and 3 with or without GPS provided: SFO Ceiling 1000' - VIS 3 With VIS 5 in Eastern Quadrant (030^ Clockwise 120^) and San Mateo AWOS Ceiling 2400' - VIS 5 [San Mateo AWOS info available from SFO Tower. If San Mateo AWOS inop, use San Carlos (KSQL) ceiling of 2400'-VIS 5; San Carlos ATIS on 125.9]
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Old 12th May 2018, 17:46
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If you'd indulge an SLF, I'm wondering about this:
The ALSF-2 was on at the time of the event according to the air traffic controller on duty except for the strobe in the white centerline bar lights
Had the runway sequenced flashing lights been on it would have defined the landing runway
From a cursory look on YouTube, it seems that some places have them on in CAVOK, and others (including KSFO's 28R) don't. Are there standard criteria dictating their use?
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Old 1st Sep 2018, 12:04
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NTSB to hold board meeting to determine probable cause of the Air Canada 759 near disaster:

https://www.ntsb.gov/news/press-rele...R20180831.aspx
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Old 7th Sep 2018, 18:36
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its a free for all!

A charter jet missed four taxiing airplanes by as little as 200 feet after it mistakenly lined up with a taxiway instead of the nearby runway, the National Transportation Safety Board said Thursday.

The Aug. 10 incident at Philadelphia International Airport is one of at least four similar cases since July 7, 2017, when an Air Canada plane missed four others on the ground in San Francisco by only a few feet. Collisions between airliners on the ground have been among the most deadly kinds of aviation accidents.

A Gulfstream IV charter jet operated by Pegasus Elite Aviation was cleared to land on runway 35, but instead pilots aimed for a parallel stretch of pavement just to the left, the NTSB said in a preliminary report. The pilot aborted the landing and started climbing about 1/10 of a mile before the runway. It flew just 200 feet (61 meters) above an Embraer SA regional jet and then passed above the three other planes, NTSB said.

In a 2017 incident, an Air Canada plane tried to land on a taxiway at San Francisco International Airport. The plane came within 59 feet (18 meters) of the ground and the first plane it passed over has a tail that is 56 feet high, according to NTSB and aircraft manufacturer data.

NTSB is holding a meeting on Sept. 25 to conclude the cause of the San Francisco incident.

The agency is also investigating an incident on Dec. 29 in which a Horizon Air flight landed on a taxiway in Pullman, Washington. No one was injured. Horizon is owned by Alaska Air Group Inc.

A Delta Air Lines Inc. plane also lined up with a taxiway instead of the runway in Atlanta on Nov. 29, according to the NTSB. It came within 60 feet (18 meters) of the ground before climbing.




https://www.bloomberg.com/news/artic...ine&yptr=yahoo
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Old 26th Sep 2018, 00:27
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Some excerpts from a synopsis of the NTSB's final report published at a hearing today, subject to editing.

Probable Cause

The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information.
Executive Summary

On July 7, 2017, about 2356 Pacific daylight time (PDT), Air Canada flight 759, an Airbus A320-211, Canadian registration C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), San Francisco, California, but instead lined up with parallel taxiway C.1 Four air carrier airplanes (a Boeing 787, an Airbus A340, another Boeing 787, and a Boeing 737) were on taxiway C awaiting clearance to take off from runway 28R. The incident airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before starting to climb. None of the 5 flight crewmembers and 135 passengers aboard the incident airplane were injured, and the incident airplane was not damaged. The incident flight was operated by Air Canada under Title 14 Code of Federal Regulations (CFR) Part 129 as an international scheduled passenger flight from Toronto/Lester B. Pearson International Airport, Toronto, Canada. An instrument flight rules flight plan had been filed. Night visual meteorological conditions prevailed at the time of the incident.

The flight crewmembers had recent experience flying into SFO at night and were likely expecting SFO to be in its usual configuration; however, on the night of the incident, SFO parallel runway 28L was scheduled to be closed at 2300. The flight crew had opportunities before beginning the approach to learn about the runway 28L closure. The first opportunity occurred before the flight when the crewmembers received the flight release, which included a notice to airmen (NOTAM) about the runway 28L closure. However, the first officer stated that he could not recall reviewing the specific NOTAM that addressed the runway closure. The captain stated that he saw the runway closure information, but his actions (as the pilot flying) in aligning the airplane with taxiway C instead of runway 28R demonstrated that he did not recall that information when it was needed. The second opportunity occurred in flight when the crewmembers reviewed automatic terminal information system (ATIS) information Quebec (via the airplane’s aircraft communication addressing and reporting system [ACARS]), which also included NOTAM information about the runway 28L closure. Both crewmembers recalled reviewing ATIS information Quebec but could not recall reviewing the specific NOTAM that described the runway closure.

The procedures for the approach to runway 28R required the first officer (as the pilot monitoring) to manually tune the instrument landing system (ILS) frequency for runway 28R, which would provide backup lateral guidance (via the localizer) during the approach to supplement the visual approach procedures. However, when the first officer set up the approach, he missed the step to manually tune the ILS frequency. The captain was required to review and verify all programming by the first officer but did not notice that the ILS frequency had not been entered.

The captain stated that, as the airplane approached the airport, he thought that he saw runway lights for runway 28L and thus believed that runway 28R was runway 28L and that taxiway C was runway 28R. At that time, the first officer was focusing inside the cockpit because he was programming the missed approach altitude and heading (in case a missed approach was necessary) and was setting (per the captain’s instruction) the runway heading, which reduced his opportunity to effectively monitor the approach. The captain asked the first officer to contact the controller to confirm that the runway was clear, at which time the first officer looked up. By that point, the airplane was lined up with taxiway C, but the first officer presumed that the airplane was aligned with runway 28R due, in part, to his expectation that the captain would align the airplane with the intended landing runway.

The controller confirmed that runway 28R was clear, but the flight crewmembers were unable to reconcile their confusion about the perceived lights on the runway (which were lights from airplanes on taxiway C) with the controller’s assurance that the runway was clear. Neither flight crewmember recognized that the airplane was not aligned with the intended landing runway until the airplane was over the airport surface, at which time the flight crew initiated a low-altitude go-around. According to the captain, the first officer called for a go-around at the same time as the captain initiated the maneuver, thereby preventing a collision between the incident airplane and one or more airplanes on the taxiway. However, at that point, safety margins were severely reduced given the incident airplane’s proximity to the ground before the airplane began climbing and the minimal distance between the incident airplane and the airplanes on taxiway C.

The flight crewmembers stated, during postincident interviews, that the taxiway C surface resembled a runway. Although multiple cues were available to the flight crew to distinguish runway 28R from taxiway C (such as the green centerline lights and flashing yellow guard lights on the taxiway), sufficient cues also existed to confirm the crew’s expectation that the airplane was aligned with the intended landing runway (such as the general outline of airplane lights—in a straight line—on taxiway C and the presence of runway and approach lights on runway 28R, which would also have been present on runway 28L when open). As a result, once the airplane was aligned with what the flight crewmembers thought was the correct landing surface, they were likely not strongly considering contradictory information. The cues available to the flight crew to indicate that the airplane was aligned with a taxiway did not overcome the crew’s belief, as a result of expectation bias, that the taxiway was the intended landing runway.

The flight crewmembers reported that they started to feel tired just after they navigated through an area of thunderstorms, which radar data indicated was about 2145 (0045 eastern daylight time [EDT]). The incident occurred about 2356, which was 0256 EDT according to the flight crew’s normal body clock time; thus, part of the incident flight occurred during a time when the flight crew would normally have been asleep (according to postincident interviews) and at a time that approximates the start of the human circadian low period described in Air Canada’s fatigue information (in this case, 0300 to 0500 EDT). In addition, at the time of the incident, the captain had been awake for more than 19 hours, and the first officer had been awake for more than 12 hours. Thus, the captain and the first officer were fatigued during the incident flight.

Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident. Although the National Transportation Safety Board (NTSB) identified significant safety issues during our investigation into this incident, CVR information, if it had been available, could have provided direct evidence about the events leading to the overflight and the go-around. For example, several crew actions/inactions during the incident flight demonstrated breakdowns in crew resource management (CRM), including both pilots’ failure to assimilate the runway 28L closure information included in the ATIS information, the first officer’s failure to manually tune the ILS frequency, and the captain’s failure to verify the tuning of the ILS frequency. However, without CVR information, the NTSB could not determine whether distraction, workload, and/or other factors contributed to these failures.
https://www.ntsb.gov/news/events/Doc...8-Abstract.pdf

Pictures from the hearing:
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Old 26th Sep 2018, 05:21
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Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?
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Old 26th Sep 2018, 07:58
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Originally Posted by rmac2
https://youtu.be/u59bJZEitRI

Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?
Not, according to Murphy.😉
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Old 26th Sep 2018, 08:20
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A lot of pilots are flying around with degraded performance capabilities due to rostering practices now days.
A lot of pilots are reporting same.
Nothing will change until reasonable hard legal limits are put in place to prevent fatigue.
Will Canada take real steps to reduce fatigue?
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Old 26th Sep 2018, 09:19
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Originally Posted by rmac2
Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?
When you say "every runway", do you mean "every runway" or "every open runway", or perhaps different variations of the two options at different airports, just to keep the pilots awake and alert?
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Old 26th Sep 2018, 13:02
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Originally Posted by Airbubba
Some excerpts from a synopsis of the NTSB's final report published at a hearing today, subject to editing.
A damning report, on a number of levels.
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Old 26th Sep 2018, 17:12
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Video of yesterday's NTSB hearing posted here:

National Transportation Safety Board
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Old 26th Sep 2018, 17:29
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Originally Posted by rmac2
https://youtu.be/u59bJZEitRI

Too much to ask to just put running rabbit approach lights at the end of every runway. Should be impossible to screw it up then ?
Doesn't do anything for a crew who think the one on the left, with lots of lighting, is the one closed, and the strip visible on the right is the one to go for. As here.

Similar situation happened at London Gatwick TWICE, one with a based operator, with jets actually landing on the (fortunately vacant) taxyway, before some changes were made to procedures when a runway is advised as closed. I trust the enquiry here has looked closely at those cases. They also put a joggle in the relief taxyway so it looks crooked from the air.
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Old 26th Sep 2018, 18:07
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A visual approach at night is no laughing matter.
Flying one into SFO due to all the local aural and visual chatter does not make it easier.
And then they were tired and/or became a bit complacent and were then way behind in setting up the airplane (i.e. putting the correct ILS app into the FMS, as soon as the ATIS said so, etc.) and being on the same page as a crew.

It has happened to all of us in one way or the other - the sudden question: "WTF? How did I get here?!"

BUT - they figured out they were wrong and went around - Problem solved.

That - does not happen to all of us.
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Old 26th Sep 2018, 23:09
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Docket Updated

A significant number of new reports were posted yesterday on the NTSB Docket.
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Old 27th Sep 2018, 06:41
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Originally Posted by Zeffy
A significant number of new reports were posted yesterday on the NTSB Docket.
Includes a 37-page submission from Air Canada: Air Canada Submission to the NTSB in the Investigation of the Overflight of a Taxiway at San Francisco International Airport on July 7, 2017

ACA-determined Probable Cause:

"The Probable Cause of the ACA759 overflight incident was the flight crew’s misperception of SFO Taxiway C as Runway 28R during the approach. Contributing to the incident were: (1) San Francisco International Airport’s inadequate lighting of the runway environment, including lighting of the ongoing construction, to distinguish the normally-configured parallel runways from runway 28R and Taxiway C given the closure of runway 28L; (2) failure of the sole, combined local controller/controller-in-charge (LC/CIC controller) in the KSFO tower to provide any direction or information to the flight crew, following the flight crew’s request, until after the flight crew had already initiated the go-around; and (3) insufficient training and knowledge by the combined LC/CIC controller on use of available lighting resources and ADSE-X/ASSC capabilities."

NTSB-determined Probable Cause:

"The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information."
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Old 27th Sep 2018, 07:00
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Originally Posted by 73qanda
A lot of pilots are flying around with degraded performance capabilities due to rostering practices now days.
A lot of pilots are reporting same.
Nothing will change until reasonable hard legal limits are put in place to prevent fatigue.
Will Canada take real steps to reduce fatigue?
Difficult to get a bigger picture unless you see the full roster - for all we know the Crew could have had 4 days off prior.
When you say hard limits please give some idea's i.e. no flying between 02-06LT or what?
IMHV reducing fatigue is a three way process - CAA AOC and crewmembers - what will you do e.g. was the Captain commuting pre flight or are we not allowed to go there?
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Old 27th Sep 2018, 07:15
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Originally Posted by Mr Angry from Purley
Difficult to get a bigger picture unless you see the full roster - for all we know the Crew could have had 4 days off prior.
We do know - and no, they hadn't.
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