Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
As PJ2 rightly suggests, Transport Canada has not addressed the issue of fatigue in any serious way. I would add that this is just one manifestation of a much larger -- and very serious -- issue of civil aviation oversight in Canada. Put succinctly, Transport Canada is no longer funded, or even structured, in a way that ensures adequate safety levels and regulatory oversight in Canada. I`ll go even further and assert that Transport Canada is no longer meeting its mandate and obligations, under Canadian statutes and under its ICAO obligations.
There are many reasons but the two primary underlying causes are:
1. Resources. TC has been in a `death spiral` for many years. Example: Serious underfunding has led to too few inspectors to meet TC`s own schedule of surveillance. The added workload on those on that front line has led in turn to morale being lower than the Mariana Trench, which has led to further resignations and early retirements, which has led to even higher workload, which has led to TC reducing and even eliminating its mandated surveillance activities. And on and on and on.
So, given that TC does not have the resources to meet its primary role and first responsibility, what do you think it`s doing about addressing issues like fatigue – and the multitude of other serious safety issues and concerns raised by CTSB, users, service providers, unions, ICAO, the public, etc.? Nada…
2. Structure. Transport Canada is NOT an independent, autonomous Civil Aviation Authority, as recommended (strongly) by ICAO, and as most countries have. TC is simply another department of the (Canadian) federal government. A few of TC’s areas of responsibility include: civil aviation, motor vehicles, railways, shipping and marine transportation, etc. As ICAO rightly asserts – and the experience of many countries attests – without an independent autonomous CAA, aviation safety issues are just another budget item for another branch of another department of a huge federal bureaucracy.
Canada’s international reputation as a model of civil aviation safety is based on a philosophy, a structure, a commitment and an entity that existed in Canada in the late 20th century. That is all gone. Transport Canada’s logo should be the setting sun (an Avro Arrow disappearing into the sunset would be a nice touch…)
There are many reasons but the two primary underlying causes are:
1. Resources. TC has been in a `death spiral` for many years. Example: Serious underfunding has led to too few inspectors to meet TC`s own schedule of surveillance. The added workload on those on that front line has led in turn to morale being lower than the Mariana Trench, which has led to further resignations and early retirements, which has led to even higher workload, which has led to TC reducing and even eliminating its mandated surveillance activities. And on and on and on.
So, given that TC does not have the resources to meet its primary role and first responsibility, what do you think it`s doing about addressing issues like fatigue – and the multitude of other serious safety issues and concerns raised by CTSB, users, service providers, unions, ICAO, the public, etc.? Nada…
2. Structure. Transport Canada is NOT an independent, autonomous Civil Aviation Authority, as recommended (strongly) by ICAO, and as most countries have. TC is simply another department of the (Canadian) federal government. A few of TC’s areas of responsibility include: civil aviation, motor vehicles, railways, shipping and marine transportation, etc. As ICAO rightly asserts – and the experience of many countries attests – without an independent autonomous CAA, aviation safety issues are just another budget item for another branch of another department of a huge federal bureaucracy.
Canada’s international reputation as a model of civil aviation safety is based on a philosophy, a structure, a commitment and an entity that existed in Canada in the late 20th century. That is all gone. Transport Canada’s logo should be the setting sun (an Avro Arrow disappearing into the sunset would be a nice touch…)
A thorough briefing where both pilots pay attention to detail in order to emphasize correct and critical focal points is the primary tool/measure used by a crew to prevent blowing-it, minimize unworthy distractions, or being suckered in by illusion. Doing so purposely creates for the crew their own set of preconceived notion as to what the correct picture the approach and landing should look like. A proper briefing uses current, published information and NOTAMs, discusses what's to follow, and sets expectations/limits. It discusses what aids will be used to shoot the approach, what to expect and look for, what is to be confirmed, and limits set to wave themselves off the approach if they aren't met. SOPs are written so crews cover many of these things by following them....
Obviously, they didn't align themselves correctly when they transitioned. But how were they supposed to pick the correct string of lights way out there in the distance?
Well, 28R has charted, visual lighting aids specifically designed and calibrated for that purpose; ALSF-II and PAPI. They're both designed to be seen from miles away for use by a crew to 1) visually align themselves with the centerline of the runway (ALSF-II) and 2) visually join the correct vertical path that within a given distance ensures obstacle clearance down to near the Touchdown Zone (PAPI).
Given the existence of an ALSF-II and PAPI for 28R, let's start by throwing out the notion held by many that a visual approach at night to 28R is unreasonable or unsafe if it's based on the idea there's no ground-based guidance to use or back oneself up with if bog-s***t FMS equipment doesn't allow that back up to be an electronic ILS. ALSF-II and PAPI are ground-based guidance aids for 28R. Their existence should be noted, looked-for out the windscreen, and used for their intended purpose.
Even in a briefing for an Instrument approach, the type of ALS is noted and visual sighting while on the approach itself prompts a callout. Just because this was an FMS approach to a long visual segment doesn't negate the need for reviewing and emphasizing the ALS for 28R. The fact it's a visual approach segment doesn't negate the need for the crew to verbally confirm when these visual guidance aids are acquired visually. On the contrary, the fact that the FMS portion of the approach doesn't align the aircraft with the centerline should only raise awareness and emphasize the visual aids' existence and the need to notice/confirm them. Again, it's what they are for; visually acquiring and guiding oneself to the runway.
However, everything so far about the flight in question (ground track, altitudes, ,transmission) suggests the crew was oblivious to the existence of an ALSF-II and PAPI on 28R because, as it happened, they visually acquired, lined-up on, and overflew Taxiway C which has neither. As someone asked before, with the nearest PAPI being on the opposite side of RWY 28R from their position, what was this crew using for vertical path guidance for miles during the visual segment until reaching Taxiway C?
Also, in addition to RWY 28L's closure being NOTAMed, 28L's approach light system, a MALSR (not an ALSF-II, which is the only ALS they would have seen that night), was also NOTAMed OTS. If the crew mistook Taxiway C for RWY 28R and RWY 28R (with it's operating ALSF-II blazing away to their left) for 28L, this suggests no review of current NOTAMS that could (and did) directly affect their operation and lack of knowledge (or review) regarding Approach Light System configurations.
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Obviously, they didn't align themselves correctly when they transitioned. But how were they supposed to pick the correct string of lights way out there in the distance?
Well, 28R has charted, visual lighting aids specifically designed and calibrated for that purpose; ALSF-II and PAPI. They're both designed to be seen from miles away for use by a crew to 1) visually align themselves with the centerline of the runway (ALSF-II) and 2) visually join the correct vertical path that within a given distance ensures obstacle clearance down to near the Touchdown Zone (PAPI).
Given the existence of an ALSF-II and PAPI for 28R, let's start by throwing out the notion held by many that a visual approach at night to 28R is unreasonable or unsafe if it's based on the idea there's no ground-based guidance to use or back oneself up with if bog-s***t FMS equipment doesn't allow that back up to be an electronic ILS. ALSF-II and PAPI are ground-based guidance aids for 28R. Their existence should be noted, looked-for out the windscreen, and used for their intended purpose.
Even in a briefing for an Instrument approach, the type of ALS is noted and visual sighting while on the approach itself prompts a callout. Just because this was an FMS approach to a long visual segment doesn't negate the need for reviewing and emphasizing the ALS for 28R. The fact it's a visual approach segment doesn't negate the need for the crew to verbally confirm when these visual guidance aids are acquired visually. On the contrary, the fact that the FMS portion of the approach doesn't align the aircraft with the centerline should only raise awareness and emphasize the visual aids' existence and the need to notice/confirm them. Again, it's what they are for; visually acquiring and guiding oneself to the runway.
However, everything so far about the flight in question (ground track, altitudes, ,transmission) suggests the crew was oblivious to the existence of an ALSF-II and PAPI on 28R because, as it happened, they visually acquired, lined-up on, and overflew Taxiway C which has neither. As someone asked before, with the nearest PAPI being on the opposite side of RWY 28R from their position, what was this crew using for vertical path guidance for miles during the visual segment until reaching Taxiway C?
Also, in addition to RWY 28L's closure being NOTAMed, 28L's approach light system, a MALSR (not an ALSF-II, which is the only ALS they would have seen that night), was also NOTAMed OTS. If the crew mistook Taxiway C for RWY 28R and RWY 28R (with it's operating ALSF-II blazing away to their left) for 28L, this suggests no review of current NOTAMS that could (and did) directly affect their operation and lack of knowledge (or review) regarding Approach Light System configurations.
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Good points PD.
Briefings are routinely interfered with by the real world, and are not infallible. Having a standardised process is of some value, however, that also fails when there is interruption.
On lighting, I agree on the merit of briefing all of that, to the extent of what type of lighting, PAPI or VASI, is it asymmetric (L or R) etc. The downside is that every brief takes one crew member out of the loop, and the second crew member is in effect being distracted form monitoring by the brief itself. Correlation of brief with programming is a great method, but that works when tactical changes don't occur in close. The 'Bus display logic is annoying in the constraints on LS, compared to a Boeing, where you can track one thing and display another, and have different setups on either side.That has it's own set of issues but it is not a bad way of doing business. HUDs remove the problem in general, however I was involved in investigating a HUD equipped aircraft that landed on a taxiway, so there are always ways of getting hurt. HUD's become problematic in strong crosswind conditions where the lateral viewing angle may not show the track and target information well.
As long as taxiways are parallel to runways, planes will get into strife. The current best tool in my kit is the foreflight moving map, that consistently will give a reliable guide of position vs the runway. The Boeing EFBs were good, but only when you were taxying.
In this day and age, the FMS programming of approaches still leaves lots to be desired; It would be reasonable to have a legs programmed that actually is what you intend to fly, not abbreviated just when things get interesting by the G/A procedure taking it's place. The systems today comprehend a G/A occurs on large jets, by the selection of TOGA, at which point the G/A procedure should be active, but until that point, there is no need for it to be taking precedence over the actual approach to the actual runway that is intended. For aircraft without ATR or GA modes, then a sensed GA could be determined where descent alters to climb for a period of time or a minimum period of time/alt gain.
If we continue to remove ground based nav aids, then the irritations that are inherent on the Airbus LS/FMC data for these types of approaches becomes moot. Again, Boeings have tried and succeeded in landing on the taxiways, so a better solution should be considered to the issue.
Let's not forget the Phoenix payroll fiasco where many civil servants are being under- or over-paid.
If over-paid you can be asked to return the entire amount, but Canada Revenue Agency received a big chunk of that overpayment and it will take a bunch of paperwork, time and effort to get that money out of their claws
Any other employer would long ago have been taken to a labor tribunal and ordered to pay up pronto.
Is it any surprise that a bunch of Transport Canada staff have departed to other employers
If over-paid you can be asked to return the entire amount, but Canada Revenue Agency received a big chunk of that overpayment and it will take a bunch of paperwork, time and effort to get that money out of their claws
Any other employer would long ago have been taken to a labor tribunal and ordered to pay up pronto.
Is it any surprise that a bunch of Transport Canada staff have departed to other employers
Last edited by RatherBeFlying; 3rd Oct 2018 at 03:27.
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And I have to add that this level of investigation used to occur in Canada as well, but (sadly for aviation safety) the Canadian TSB is not the agency it once was. If this incident had occurred at Toronto, Montreal or Vancouver the resultant report by the Canadian TSB would have been a short ineffective report after a shallow investigation.
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Canadian TSB is not the agency it once was. If this incident had occurred at Toronto, Montreal or Vancouver the resultant report by the Canadian TSB would have been a short ineffective report after a shallow investigation.
Both crewmembers recalled reviewing ATIS information Quebec but could not recall reviewing the specific NOTAM that described the runway closure.
Multiple events in the National Aeronautics and Space Administration’s aviation safety reporting system database showed that this issue has affected other pilots, indicating that all pilots could benefit from the improved display of flight operations information.
Only half a speed-brake
Notams and their presentation to airline crew have a lot to be desired. If the incident is used as a wedge to move into 21 century, an applause would be due. But are we surely not wagging the dog here?
My best judgement is that the crew knew rather well they should be landing on the starboard side the deck, and that's exactly what was almost achieved.
The notams change might be a win, but without shining the light on the real cause, the job of preventing the next occurrence has not even started.
My best judgement is that the crew knew rather well they should be landing on the starboard side the deck, and that's exactly what was almost achieved.
The notams change might be a win, but without shining the light on the real cause, the job of preventing the next occurrence has not even started.
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The report raises the "need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use" and seems to focus on a more conspicuous X marking, and the ludicrously antiquated NOTAM which goes without saying. It seems the DAL521 FO's recommendation to ATC to "turn on the lights for RWY 28L" would have averted this incident. But that seems to have been overlooked in the report as a strategy. The other thing I don't understand in that respect is the DAL521 captain stated that the sequenced flashing lights were not operating on 28R. The report covers the incidence of runway lighting colouring being mistaken in other incidents, and talks about the possibility of aircraft lighting being mistaken for runway lighting. Despite all that, the report rules out airport lighting as a factor in the incident stating it was compliant with regulations. It seems to me airport lighting is a significant factor in this incident. The report quite rightly talks about expectation and confirmation bias but it seems the lighting aspects have not been given adequate emphasis. It's hard to imagine this incident would have occurred if 28L lights were on and 28R sequenced flashing lights were operating.
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The report raises the "need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use" and seems to focus on a more conspicuous X marking, and the ludicrously antiquated NOTAM which goes without saying. It seems the DAL521 FO's recommendation to ATC to "turn on the lights for RWY 28L" would have averted this incident. But that seems to have been overlooked in the report as a strategy. The other thing I don't understand in that respect is the DAL521 captain stated that the sequenced flashing lights were not operating on 28R. The report covers the incidence of runway lighting colouring being mistaken in other incidents, and talks about the possibility of aircraft lighting being mistaken for runway lighting. Despite all that, the report rules out airport lighting as a factor in the incident stating it was compliant with regulations. It seems to me airport lighting is a significant factor in this incident. The report quite rightly talks about expectation and confirmation bias but it seems the lighting aspects have not been given adequate emphasis. It's hard to imagine this incident would have occurred if 28L lights were on and 28R sequenced flashing lights were operating.
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If all landings were to Cat 3b these incidents would not occur either is this a case where automation is safer than human pilots? While visual approaches are allowed setting up "confusing lighting" would appear to be a fundamental flight safety risk. Expectation of two lit runways led to the right hand runway and the taxiway being assumed to be the runways. Once that expectation is fulfilled it is difficult to correct. There are many antiquated ways of signalling on airports that need some human factors testing and psychological reassessment - or as you allude to, automate out the human error.
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How can someone confuse a taxiway lighting with a runway lighting ?
Is there a proper reconstitution of what the pilots saw that night ?
My guess, before reading the report, is that both of them had a busy schedule and were fatigued. Fatigued enough that they forgot how a runway looked like.
Is there a proper reconstitution of what the pilots saw that night ?
My guess, before reading the report, is that both of them had a busy schedule and were fatigued. Fatigued enough that they forgot how a runway looked like.
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The report actually do points out crew fatigue, due to late duty.
The report also describes confusion in the cockpit, with the first officer not even looking at the runway during final approach, and the captain going around just to be sure. Because things did not add up. He did not really understood he was on the taxiway until after the event.
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
The report also describes confusion in the cockpit, with the first officer not even looking at the runway during final approach, and the captain going around just to be sure. Because things did not add up. He did not really understood he was on the taxiway until after the event.
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
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The NTSB, doing what they do, have made some recommendations on how this all might have been avoided. Hopefully some will be adopted, but the record of NTSB recommendations being put into FAA regulations has not always been stellar.
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Doesn't really look like any of the recommendations from 7 years ago have been implemented, so I don't really anticipate any short term changes.
https://flightsafety.org/asw-article/blue-edge-lights/
https://flightsafety.org/asw-article/blue-edge-lights/
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Your opinion is a bit moot actually because these competent pilots did not clearly distinguish the taxiway from the runway. The visual clues were not strong enough and the poor implementation and existing deficiencies of a number of safety barriers led to the incident.
It's a very informative case of human factors and multiple root causes.
Last edited by bud leon; 13th Oct 2018 at 05:10.