Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
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Are you shocked by release of the training information?
Or release of the lifestyle information?
https://dms.ntsb.gov/public/61000-61...112/614631.pdf
Don't know how they do it in other countries but this seems to be pretty standard fare in the human performance section of an NTSB docket.
The first officer reported that he had attempted previously to upgrade to captain. After two unsatisfactory attempts, however, he elected to return to the first officer seat. Air Canada records showed that on February 6 and 7, 2017, the first officer had passed his command LOE training. On March 1, 2017, he had an unsatisfactory on his QOE27 and a second unsatisfactory QOE on March 16, 2017.
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. Some of the instructors and checkairmen categorized the incident first officer as “nervous” and “a weak candidate.”
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. Some of the instructors and checkairmen categorized the incident first officer as “nervous” and “a weak candidate.”
The First Officer’s Personal Background The incident first officer was 42 years old and lived in Toronto, Canada with his wife and children. He felt he needed 8 hours of sleep per night to feel rested and considered himself to be a heavy sleeper. He considered himself a “normal day person” as his children did not allow him to be a night person. He stated he is normally more alert in the evenings however, about 2300, he typically felt sleepy. He would have liked to sleep until 0800 to 0900 if he could. If he was flying a night flight, he normally took a nap in the afternoon for about 90 minutes. He slept well during naps and felt rested following them. He had no history of sleep disorders or changes to his health in the past year.
He reported no changes to his health, financial situation, nor personal life within the preceding year that affected his performance. He reported no issues with health or color vision, and although he passed his medical without wearing glasses but did use them when he flew. He had no issues with his hearing and was not taking any prescription medication. He drank alcohol 3-5 times per week usually consuming a glass of wine or beer with dinner. Prior to the incident he stated his last drink was likely with dinner on Monday or Tuesday, but he could not recall. He did not smoke tobacco nor use illicit drugs. He did not take any medication that would have affected his performance in the 72 hours preceding the incident flight.
He reported no changes to his health, financial situation, nor personal life within the preceding year that affected his performance. He reported no issues with health or color vision, and although he passed his medical without wearing glasses but did use them when he flew. He had no issues with his hearing and was not taking any prescription medication. He drank alcohol 3-5 times per week usually consuming a glass of wine or beer with dinner. Prior to the incident he stated his last drink was likely with dinner on Monday or Tuesday, but he could not recall. He did not smoke tobacco nor use illicit drugs. He did not take any medication that would have affected his performance in the 72 hours preceding the incident flight.
Don't know how they do it in other countries but this seems to be pretty standard fare in the human performance section of an NTSB docket.
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It's all fairly harmless until it isn't... Suppose he didn't live with his wife and children but had a slightly less 'traditional' living arrangement that could affect future job prospects, especially overseas in some less enlightened parts of the world. If exonerated completely by the report how is that cat going to be returned to the bag? Dodgy.
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I agree about the personal details being released - a big 'no-no' in my book..
On the other hand, someone either IS or IS NOT up to the job of commanding a flight. End of. There are people's lives at risk and the Captain of an aircraft has a huge responsibility. If he isn't up to the task then someone has to take responsibility and 'call him out' / fail him during sim or safety checks.
Sorry if that sounds harsh but I can't see any other way.
CS
On the other hand, someone either IS or IS NOT up to the job of commanding a flight. End of. There are people's lives at risk and the Captain of an aircraft has a huge responsibility. If he isn't up to the task then someone has to take responsibility and 'call him out' / fail him during sim or safety checks.
Sorry if that sounds harsh but I can't see any other way.
CS
Are you shocked by release of the training information?
Or release of the lifestyle information?
https://dms.ntsb.gov/public/61000-61...112/614631.pdf
Don't know how they do it in other countries but this seems to be pretty standard fare in the human performance section of an NTSB docket.
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And, go read NTSB accident reports before circa 1980. The name and age of the crew were always in the final report.
I'll guaranty you for sure that the only thing that saved the day was the fact that the PAL Airbus 340 pilots did flash their landing lights. Those two morons were going to land on top of those 3 aircrafts waiting inline on the taxiway.
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.
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The crew names are customarily in the docket but not in the final report from what I see in recent mishaps. Things like addresses (physical and email), phone numbers, SSN's and employee numbers seem to be mostly redacted in the online docket.
You would think the NTSB would be extra cautious after the infamous 2013 OZ214 crew name debacle. An NTSB summer intern was fired and four non-Asian producers at KTVU involved were let go as well. Managing Editor Michelle Toy who OK'd the crew list kept her job.
Is there any mention of the missing CVR in the docket documents? I haven't had a chance to flip though them very thoroughly yet.
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.
Perhaps at some point on the approach that could be true, but at 100 AGL approaching the end of a taxiway full of aircrafts waiting for takeoff? Sorry, but I'm not buying it.
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As SLF I'm not able to understand everything I read in the docket....but was curious about the failure to tune the ILS. The FO expressed being upset to note that he'd forgotten to do that on the initial approach (they tuned it for the second approach).
Many of the AC interviewees mentioned that they routinely tune the ILS.
How big (or small) an error is something like that given the difficulties of SFO....?
Many of the AC interviewees mentioned that they routinely tune the ILS.
How big (or small) an error is something like that given the difficulties of SFO....?
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Regardless of the above - civil aviation pilots generally carry hundreds of pax in airplanes worth over $100m. That carries a responsibility. If you don't like the idea that in the case of a serious incident, relevant personal factors are included in the formal accident report, then don't fly. It's been part of the job for decades and any responsible flyer should completely agree with it.
If the details are irrelevant, then fine, but home life and rested status are directly relevant to human factor safety.
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There's a FDR analysis, but I can find no mention of the CVR.
Several of the crew witness statements from the a/c on the taxiway comment that there was only one air traffic controller, working air traffic, ground and even vehicles. They observe that the single controller had a heavy workload, and was slow to respond to UAL's call of "He's on the taxiway".
For a major airport like SFO, isn't this a bit lightly staffed?
Several of the crew witness statements from the a/c on the taxiway comment that there was only one air traffic controller, working air traffic, ground and even vehicles. They observe that the single controller had a heavy workload, and was slow to respond to UAL's call of "He's on the taxiway".
For a major airport like SFO, isn't this a bit lightly staffed?
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As for the video, words fail me. Well they don't fail me, but if I used the words that come to mind I would get severely moderated.
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This was a serious incident that could have resulted in loss of life approaching 1,000 souls. And there was considerable ethical malpractice in the CVD being deleted at the end of a flight involving such a serious incident. These factors alone necessitate a full enquiry. Not a scratch? Yes - based on the actions mainly of alert pilots on the taxiway. This was a horrendous incident with 60 feet separation or less between fully loaded aircraft.
Regardless of the above - civil aviation pilots generally carry hundreds of pax in airplanes worth over $100m. That carries a responsibility. If you don't like the idea that in the case of a serious incident, relevant personal factors are included in the formal accident report, then don't fly. It's been part of the job for decades and any responsible flyer should completely agree with it.
If the details are irrelevant, then fine, but home life and rested status are directly relevant to human factor safety.
Regardless of the above - civil aviation pilots generally carry hundreds of pax in airplanes worth over $100m. That carries a responsibility. If you don't like the idea that in the case of a serious incident, relevant personal factors are included in the formal accident report, then don't fly. It's been part of the job for decades and any responsible flyer should completely agree with it.
If the details are irrelevant, then fine, but home life and rested status are directly relevant to human factor safety.
If your start the investigation with the intention to 'hang them high', you'll never learn anything because the crew will simply refuse to cooperate. Publishing their names has already been tremendously damaging to the people involved.
This is why ICAO is trying to investigate incidents and accidents with the explicit intention NOT to apportion blame.
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.
Only if the investigation reveals some kind of carelessness or recklessness, should this go to a court of law. Only AFTER the crew have been convicted of some wrongdoing (and that is questionable at best), should their names have been made public knowledge.
