Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
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Wonderbusdriver - Quote
"BUT - they figured out they were wrong and went around - Problem solved." , 🤤🙄🤤
They missed their maker by a baw hair - so hardly problem solved .
They got got more luck than you need to get 6 numbers up on the lottery .
"BUT - they figured out they were wrong and went around - Problem solved." , 🤤🙄🤤
They missed their maker by a baw hair - so hardly problem solved .
They got got more luck than you need to get 6 numbers up on the lottery .
When you say hard limits please give some idea's i.e. no flying between 02-06LT or what?
Hard legal limits in the regulations, just like truck drivers and taxi drivers have.
Want to operate more than 8 hours stick time? Put a third crew member on.
Want crew to fly between 0200 and 0600? No problem, x hours free of duty prior and x hours free of duty after.
Max 28 hours duty in any 72 hour period.
Max 3 significant circadian shifts per 30 day roster. ( not earlies/ one day off/ lates/ one day off/ earlies etc etc)
Max of one single day off per roster, the rest as doubles etc etc etc
IMHV reducing fatigue is a three way process - CAA AOC and crewmembers
was the Captain commuting pre flight or are we not allowed to go there?
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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."
"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."
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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."
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."
5.1.14. The ACA759 flight crew were likely affected by some degree of WOCL/Fatigue.
5.1.22. The lack of onboard GPS, HUD or software tools to assist with alignment placed the crew in a position where they would be susceptible to illusions and biases.
Including erasing the CVR, it would appear that safety culture deficiencies are present up to the very top at ACA.
ACA, that is an unfortunate submittal to the NTSB investigation. The runway still had a full set of runway lights and approach lights, and a LLZ, GS etc. The crew presumably had a RWY 28R position on the ND, but of course that may be subject to position errors depending on the status of the MMR/GPS equipment, although the aircraft is presumably fully compliant with ADSB out/in GPS position accuracy. 10 out of 10 for supporting your flight crew, but it is a poor response. Suspect the NTSB will be more supportive of the flight crew and the constraints on human perception that exist.
It is understandable that the crew may have an expectation of the visual cues that differs from reality when the configuration of the runways is changed. The NOTAM itself may assist in ensuring that does not occur, but it is not a direct defence against misperception by the flight crew. The crew would eventually detect the differences in observed features as they approached the assumed runway end, but there are common cues that occur on every approach, and these were perceived late in the sequence, and apparently simultaneously by the Captain and the FO. The error appears to have been perceived earlier by the crew in the aircraft on the taxiway, which is also understandable, they are stationary and at a reasonably low level of cognitive load at that time, just observing a mess developing. Intervention by the flight crew on the ground is fraught with delay and confusion, and at 200FPS, that translates to quite a potential for the aircraft to get close to the taxiway before taking any action.
The controller had a pretty high workload, and appears to have never comprehended what the issue raised by the AC A320 crew really meant; the process of assimilating the A320 info, ascertaining the implications and responding takes time, probably much more than selecting TOGA on the ATS would have done. Even with multiple ATC officers, it is going to be an open question whether the interrogative from the A320 is going to trigger suspicions with the ATC officer that the flight crew have a S.A. error and are heading towards the weeds (and aluminium tubes).
Upgrading EGPWS systems is a possibility, with the improved accuracy of the nav systems that is associated with ADSB, that could give improved cueing to the flight crew of alignment. You get better information from FOREFLIGHT than the ND on the Boeings or Airbus aircraft at this time. The technology certification cycle and cost is close to being a negative to flight safety as much as it ensures safety through compliance.
Notice on the ATIS on the NOTAMS is of limited value, it may provide a cue to the visual aspect expected to be seen, but it is also subject to being lost in the noise of the rest of the operational information.
The AC submission makes the case for continued ground based nav aids to be maintained, which would be nice to have, but is opposite to the trend of progressing towards SBAS approaches. A RNP-AR type approach would have given adequate guidance to the actual runway, at least to the same level of reliability as a LLZ which is subject to its own errors and interferences. ASDE would assist, but it needs to be alerting the ATCCO in such instances, or it is a passive tool only.
Collectively, we as a group have been dealing with KSFO and it's oddities for a long time. While we appreciate the geographic issues that exist for this airport, it is remarkable how many bandaids exist in giving approaches to the airport. As much fun as Quiet Bridge and similar approaches are to fly, I'm not sure that they are collectively in the best interest of the public, they provide expediency but with a substantial increase in complexity of the task the crews face. At what point do the airlines and flight crew call it quits with dealing with simops, dependent parallel non aligned approaches, etc? Operating a cross runway for departure and two non compliant spaced parallel approaches and departures at the same time suggests it's time to get a new airport. This is not the first incident that came close to crews sharing cockpits, and it is unlikely to the the last at this airport. As much as I like Lefty O'Douls, the fare payers probably deserve a better infrastructure, or one that manages the operating tempo with more margin for error.
It is understandable that the crew may have an expectation of the visual cues that differs from reality when the configuration of the runways is changed. The NOTAM itself may assist in ensuring that does not occur, but it is not a direct defence against misperception by the flight crew. The crew would eventually detect the differences in observed features as they approached the assumed runway end, but there are common cues that occur on every approach, and these were perceived late in the sequence, and apparently simultaneously by the Captain and the FO. The error appears to have been perceived earlier by the crew in the aircraft on the taxiway, which is also understandable, they are stationary and at a reasonably low level of cognitive load at that time, just observing a mess developing. Intervention by the flight crew on the ground is fraught with delay and confusion, and at 200FPS, that translates to quite a potential for the aircraft to get close to the taxiway before taking any action.
The controller had a pretty high workload, and appears to have never comprehended what the issue raised by the AC A320 crew really meant; the process of assimilating the A320 info, ascertaining the implications and responding takes time, probably much more than selecting TOGA on the ATS would have done. Even with multiple ATC officers, it is going to be an open question whether the interrogative from the A320 is going to trigger suspicions with the ATC officer that the flight crew have a S.A. error and are heading towards the weeds (and aluminium tubes).
Upgrading EGPWS systems is a possibility, with the improved accuracy of the nav systems that is associated with ADSB, that could give improved cueing to the flight crew of alignment. You get better information from FOREFLIGHT than the ND on the Boeings or Airbus aircraft at this time. The technology certification cycle and cost is close to being a negative to flight safety as much as it ensures safety through compliance.
Notice on the ATIS on the NOTAMS is of limited value, it may provide a cue to the visual aspect expected to be seen, but it is also subject to being lost in the noise of the rest of the operational information.
The AC submission makes the case for continued ground based nav aids to be maintained, which would be nice to have, but is opposite to the trend of progressing towards SBAS approaches. A RNP-AR type approach would have given adequate guidance to the actual runway, at least to the same level of reliability as a LLZ which is subject to its own errors and interferences. ASDE would assist, but it needs to be alerting the ATCCO in such instances, or it is a passive tool only.
Collectively, we as a group have been dealing with KSFO and it's oddities for a long time. While we appreciate the geographic issues that exist for this airport, it is remarkable how many bandaids exist in giving approaches to the airport. As much fun as Quiet Bridge and similar approaches are to fly, I'm not sure that they are collectively in the best interest of the public, they provide expediency but with a substantial increase in complexity of the task the crews face. At what point do the airlines and flight crew call it quits with dealing with simops, dependent parallel non aligned approaches, etc? Operating a cross runway for departure and two non compliant spaced parallel approaches and departures at the same time suggests it's time to get a new airport. This is not the first incident that came close to crews sharing cockpits, and it is unlikely to the the last at this airport. As much as I like Lefty O'Douls, the fare payers probably deserve a better infrastructure, or one that manages the operating tempo with more margin for error.
Last edited by fdr; 28th Sep 2018 at 02:03.
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Ok, for narrow bodies with no bunk;
Hard legal limits in the regulations, just like truck drivers and taxi drivers have.
Want to operate more than 8 hours stick time? Put a third crew member on.
Want crew to fly between 0200 and 0600? No problem, x hours free of duty prior and x hours free of duty after.
Max 28 hours duty in any 72 hour period.
Max 3 significant circadian shifts per 30 day roster. ( not earlies/ one day off/ lates/ one day off/ earlies etc etc)
Max of one single day off per roster, the rest as doubles etc etc etc
I agree 100% .
We can go there. If you commute and know it means you will have been awake for 19 hours on arrival then you are irresponsible imho. I have no idea if anyone commuted in this case.
Thanks for posting that, I watched five or six minutes.
All three (Regulator, Airline, Individual) appear to be dropping the ball in his story.....Captain as well. If that is anywhere near normal over there then no wonder people are making errors that well rested folk can’t comprhend.
Regulator needs to set hard limits Airline needs to create/enforce commuting rules, Individuals need to live where they are based and if that is too expensive.....quit like that guy did. The wages would rise pretty quick.
All three (Regulator, Airline, Individual) appear to be dropping the ball in his story.....Captain as well. If that is anywhere near normal over there then no wonder people are making errors that well rested folk can’t comprhend.
Regulator needs to set hard limits Airline needs to create/enforce commuting rules, Individuals need to live where they are based and if that is too expensive.....quit like that guy did. The wages would rise pretty quick.
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Thanks for posting that, I watched five or six minutes.
All three (Regulator, Airline, Individual) appear to be dropping the ball in his story.....Captain as well. If that is anywhere near normal over there then no wonder people are making errors that well rested folk can’t comprhend.
Regulator needs to set hard limits Airline needs to create/enforce commuting rules, Individuals need to live where they are based and if that is too expensive.....quit like that guy did. The wages would rise pretty quick.
All three (Regulator, Airline, Individual) appear to be dropping the ball in his story.....Captain as well. If that is anywhere near normal over there then no wonder people are making errors that well rested folk can’t comprhend.
Regulator needs to set hard limits Airline needs to create/enforce commuting rules, Individuals need to live where they are based and if that is too expensive.....quit like that guy did. The wages would rise pretty quick.
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Canada is presently reviewing the daily maximum hours duty time/flying time rules. Truckers in Canada have better rules than Canadian aircraft pilots. The U.S. flight time rule is more favorable to the pilots.
Commuting will not go away. Airlines open and close crew domiciles. Also, family and other personal commitments usually prevent moving.
People don’t normally commute to Airline jobs in the countries I’ve lived and flown in. Maybe 1% tops.
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Jump seating makes it much easier. That came about in the mid-1980s when I was still working. Prior to that, on my airline at least, a commuter had to use his pass. Full airplane meant no ride on that flight.
Q
Depends where you are but that’s not really the driver now where I am....at a guess we have rather more than 1% that commute by air, and it certainly isn’t jumpseat access that has caused it (and FWIW due to our regs we pay even for a jumpseat ride, unless it’s a domestic flight), it’s more that fares structures have made it more viable economically.
A basic standby on our own airline possibly costs more than a full fare with the Loco which often serves the same city pair, and a discounted full fare with our own airline can sometimes be only marginally more expensive than the staff standby,possibly jumpseat ticket, on the same flight....so I’d suggest lifestyle choices/base closures/employer changes plus the need for family stability have probably caused many to commute.
A basic standby on our own airline possibly costs more than a full fare with the Loco which often serves the same city pair, and a discounted full fare with our own airline can sometimes be only marginally more expensive than the staff standby,possibly jumpseat ticket, on the same flight....so I’d suggest lifestyle choices/base closures/employer changes plus the need for family stability have probably caused many to commute.
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People don’t normally commute to Airline jobs in the countries I’ve lived and flown in. Maybe 1% tops.
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At Pan Am I remember having a Delta pilot on the jumpseat over the pond. The Clipper Skipper asked the Deltoid why they didn't take other airlines' pilots on the jumpseat. 'We don't consider it professional' was the reply.
Over time reciprocal jumpseat agreements spread but as always there is no good deal that a pilot gets that somebody doesn't abuse. Some folks would get must ride positioning tickets issued on another carrier, ride the jumpseat and refund or rewrite the ticket for personal use. And some non-sked cargo outfits would use the jumpseat to position crews for free. Or, so I'm told.
Some carriers were better to me riding free internationally as a jumpseat rider than they were riding on a pass or a full fare positioning ticket it seemed.
9-11 messed up jumpseats, especially internationally, but with many U.S. airline domiciles over half of the pilots still commute more than 100 miles to the base.
The commuting issue was kinda swept under the rug in the last revision of FAR rest rules but it should be part of the discussion in my opinion since some folks really push the envelope. Again, might not be a player in this SFO incident but I submit that it is an element of fatigue in many cases.
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Back in the 1980's there were jumpseat airlines like Pan Am, TWA and Northwest that would take other carriers' pilots and in some cases dispatchers and mechanics. Other airlines, like United, would only take their own pilots and I believe Delta would not even take their own pilots at one time.
We couldn't ride our own jump seat without management authorization until late 1970s. Then, TWA-ALPA got the jump seat for TWA commuters only. Not for me since I lived within the defined local distance of LAX.
Then, in early 1980s, with the retirement of pioneer "black knight" senior VP of Flight Ops, it became wide open. Some of it made me a bit uncomfortable. I never refused but insisted they take a cabin seat unless we were full.
Interestingly, the "black knight" placed controllers ahead of TWA commuters in the late 1970s. Then, the PATCO strike and the controllers went behind TWA commuters and subsequently behind all commuters.
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The commuting issue was kinda swept under the rug in the last revision of FAR rest rules but it should be part of the discussion in my opinion since some folks really push the envelope. Again, might not be a player in this SFO incident but I submit that it is an element of fatigue in many cases.
In 1983 I got bounced to STL for several months. I always went from LAX to STL the day before and rented a hotel room. I was part of a small minority.
From the Australian Civil Aviation Safety Authority website;
We need to be aware of how long we will have been awake for when our duty ends.
The FAA (2012, p. 359), reference to a 13 hour FDP could result in periods of wakefulness in excess of 16 hours before their FDP resulting in a human performance similar to that of an individual over the legal limit for alcohol consumption.
• In their study quantifying the performance impairment associated with fatigue Lamond and Dawson (1999) identified that being awake for approximately 17 hours has a similar impairment on many aspects of performance as having a Blood Alcohol Concentration (BAC) of 0.05%. Being awake for approximately 21 hours has a performance impairment equivalent to 0.10% BAC.
• In their study quantifying the performance impairment associated with fatigue Lamond and Dawson (1999) identified that being awake for approximately 17 hours has a similar impairment on many aspects of performance as having a Blood Alcohol Concentration (BAC) of 0.05%. Being awake for approximately 21 hours has a performance impairment equivalent to 0.10% BAC.
Why this is so should be a matter of an independant, objective examination say, of a Royal Commission like the Moshansky Commission way back in '89. so Canadians can know why their Ministry of Transport has succeeded in avoiding addressing this scientifically-established issue for so long.
Virgil P Moshansky; Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario (Canada)
and another: Moshansky comments to the Transport, Infrastructure and Communities Committee, February 2007
It appears that no matter what happens, Canada is not serious about fatigue issues.
PJ2
It is easy to tackle safety issues like CFIT, mid air collisions, loss of control, and so on. They typically have a fairly obvious cause and affect. Fatigue is a bit more nebulous. It is often a contributing factor but rarely, if ever, a sole cause of an accident. It can therefore be shuffled down the priority list when it invariably turns out that fixing fatigue issues is commercially inconvenient. There is also the fact that a pilot must not present to work in an unfit state. Whenever fatigue rears it’s head the authorities can always just say that the pilot was at fault for not getting adequate rest or standing themselves down.