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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 13th Oct 2018, 07:16
  #1181 (permalink)  
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Originally Posted by JayMatlock
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.

Jay, congratulations, you would not have done what AC did, and you would not have been confused as the preceding aircraft had as well. Equally, you don't have the risk of making the error that occurs on average every few weeks in the rest of the world, english speaking and otherwise. The AC SOP is great for the QB approach, except that it is a major pain on an aircraft like an Airbus. The crew are asked to fly an approach to protect the tender ears of the dear people that have built properties to the south and east of the airfield, sine the jets have been used there. So the crews are set up to not have the best nav displays for a straight in approach, in fact we end up with converging flight paths with aircraft on an adjacent runway which is well below the standard for lateral separation, and so we are playing dodgems with other aircraft as well, and institute special procedures so that the "Risk" can be managed. Frankly, its about time to tell the world to stuff off on placing pax at risk for noise impact which results in increased risk to the crew and passengers. Globally, development has occurred around the approach paths and departure routes of airports, as the land was cheap, and then the restrictions have been applied.

We nearly ended up with 5 dead aircraft at SFO in this event, which would have added a bit of noise to the issue. About time to change the discussion, and start protecting the crew and pax rights.
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Old 13th Oct 2018, 08:02
  #1182 (permalink)  
 
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Originally Posted by jurassicjockey
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/
Two of the four Safety Recommendations made by the NTSB following the Hartsfield taxiway landing were adopted by the FAA and classed as acceptable action.
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Old 13th Oct 2018, 10:25
  #1183 (permalink)  
 
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Originally Posted by fdr
Jay, congratulations, you would not have done what AC did, and you would not have been confused as the preceding aircraft had as well. Equally, you don't have the risk of making the error that occurs on average every few weeks in the rest of the world, english speaking and otherwise. The AC SOP is great for the QB approach, except that it is a major pain on an aircraft like an Airbus. The crew are asked to fly an approach to protect the tender ears of the dear people that have built properties to the south and east of the airfield, sine the jets have been used there. So the crews are set up to not have the best nav displays for a straight in approach, in fact we end up with converging flight paths with aircraft on an adjacent runway which is well below the standard for lateral separation, and so we are playing dodgems with other aircraft as well, and institute special procedures so that the "Risk" can be managed. Frankly, its about time to tell the world to stuff off on placing pax at risk for noise impact which results in increased risk to the crew and passengers. Globally, development has occurred around the approach paths and departure routes of airports, as the land was cheap, and then the restrictions have been applied.

We nearly ended up with 5 dead aircraft at SFO in this event, which would have added a bit of noise to the issue. About time to change the discussion, and start protecting the crew and pax rights.
I would probably make many mistakes if I was in a state of fatigue.

You're going on and on about theoretical concepts but please.. Let me show you the illustration in the report

To me, the real problem is with runway lighting.
First, many airports, in their penny-wiseness, don't turn on all the available runway lighting.
For instance, I've landed at many international airports where you only had runway edge lights, PAPI, runway entry lights (the green line) and nothing else !
Then you can confuse it with a taxiway, because you can see on the picture it just looks like a green runway, which is confusing.
Second, airports could (and some do) use some ground lighting for taxiways. In Europe, many airfields have blue lighting that is completely invisible from the air.
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Old 13th Oct 2018, 13:33
  #1184 (permalink)  
 
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JayMatlock
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
Sooooo.......why did they try and land on a taxiway then?
Perception is a funny thing. People ( yourself included) regularly perceive things that aren’t there at all, ie they don’t exist.
What you see and what you perceive are two different things.

JayMatlock
To me, the real problem is with runway lighting.
So a runway isn’t clearly distinguishable from a taxiway at night? I’m confused.
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Old 13th Oct 2018, 14:31
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You have to put together all the elements I'm quoting :
- Taxiways should be completely invisible from the air. But at SFO they were very visible.
- A runway with complete lighting (approach lights, papi, touchdown zone lights, centerline) is easily distinguishable from a taxiway (even if lit)
- But airports often wanna save pennies and turn off approach lights, centerline lights, and touchdown zone light
- In these conditions, a runway is only left with papi, edge, and entry lights. And now a runway like this is closer to a lit taxiway.
- The safety margins are now reduced because a lit taxiway resembles a poorly lit runway
- But it still takes fatigue or another aggravating circumstance to mix up a white runway and a green taxiway

Plus there were other cues, visual or instrumental.
The crew should have expected a taxiway to the right of the runways.
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Old 13th Oct 2018, 14:39
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Ok, I think I’m nearly with you.
Would you agree that
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
could more accurately be written as
“My opinion remains that a runway SHOULD BE clearly distinguishable from a taxiway at night.”?
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Old 14th Oct 2018, 13:15
  #1187 (permalink)  
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Originally Posted by JayMatlock

Plus there were other cues, visual or instrumental.
The crew should have expected a taxiway to the right of the runways.
Spot on, on both counts.
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Old 14th Oct 2018, 13:18
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This is about exactly what they saw...(save for the ac lined up) where would you land? Ignore that big white line of things pointing to the runway?
(where would one expect the VASI to be in regards to a runway?)


Last edited by underfire; 14th Oct 2018 at 13:41.
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Old 14th Oct 2018, 16:54
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Originally Posted by underfire
This is about exactly what they saw...(save for the ac lined up) where would you land? Ignore that big white line of things pointing to the runway?
(where would one expect the VASI to be in regards to a runway?)
I guess they should buy another red cross and stick it at the end of the taxiway.

Or just switch off taxiway centerline lights if they can't dim them like the runway lights.

Both of those solutions would be an obvious improvement, if it is the correct approach to solving the problem is another question.
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Old 14th Oct 2018, 18:15
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Other drivers had no problem landing. Stop making excuses for unqualified crew. Was this the same crew that failed to respond to ATC instruction to GA because the runway was still occupied

Last edited by underfire; 15th Oct 2018 at 04:43.
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Old 15th Oct 2018, 02:28
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Vice Chairman Bruce LandsbergConcurring Statement – Air Canada Taxiway Overflight InvestigationConcurring statements for SFO

This incident report should be required reading for all pilots. Only a few feet of separation prevented this from possibly becoming the worst aviation accident in history. I have some reservations about some of our recommendations where we may have gone farther than necessary in some cases and not far enough in others. Time will tell if we got it right.

Recommendation A-18-24 to the FAA on Preflight Information:
From a human factors perspective, the preflight briefing system is archaic and poorly designed. This Air Canada crew missed two warnings about the closed runway in SFO, first in pre-departure and secondly, via ACARS before landing. Concerns about legal liability rather than operational necessity, drive the current system to list every possible Notice to Airmen (Notam) that could, even under the most unlikely circumstance, affect a flight.

The current system prioritizes protecting the regulatory authorities and airports. It lays an impossibly heavy burden on individual pilots, crews and dispatchers to sort through literally dozens of irrelevant items to find the critical or merely important ones. When one is invariably missed, and a violation or incident occurs, the pilot is blamed for not finding the needle in the haystack!

GPS and TFR notices often fall into the same category of overly complex and geographically irrelevant. The legalistic descriptions of TFRs and poorly-descriptive GPS outage areas are worthless to pilots and dispatchers without tremendous and time-consuming effort. A graphic presentation of where a flight might be restricted or impacted should be easily found on FAA’s website and suffice as an official brief. It should also be disseminated to other preflight or electronic Flight bag providers and be both accurate and timely. FAA should not be allowed to hide behind FSS using this disclaimer which currently appears on the official FAA TFR website. “Depicted TFR data may not be a complete listing. Pilots should not use the information on this website for flight planning purposes. For the latest information, call your local Flight Service Station at 1-800-WX-BRIEF.”


VC Landsberg says 95% of what I was thinking.

My one addition would be to include runway lights will be off with all nighttime runway closure notams.
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Old 15th Oct 2018, 04:41
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A graphic presentation of where a flight might be restricted or impacted should be easily found on FAA’s website and suffice as an official brief
Instead of text, you want someone to create a cartoon to follow? Pilots need to go to the FAA website as part of a pre-flight or during flight check?
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Old 15th Oct 2018, 05:01
  #1193 (permalink)  
 
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Originally Posted by Underfire
Other drivers had no problem landing.
From the report:

Given that the general outline of airplane lights along taxiway C (in a straight line) had likely confirmed the crew’s expectation that the right-side surface was a runway, the omission of conflicting color cues in the crew’s assessment of the runway environment was consistent with the effects of expectation bias.105 The captain of DAL521 (the flight that immediately preceded the ACA759 into SFO) provided a similar assessment during postincident interviews. Specifically, the DAL521 captain stated that the airplane lights on taxiway C gave the impression that that surface could have been a runway.106
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Old 15th Oct 2018, 06:21
  #1194 (permalink)  
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Originally Posted by underfire
Other drivers had no problem landing. Stop making excuses for unqualified crew. Was this the same crew that failed to respond to ATC instruction to GA because the runway was still occupied
UF, the crew WERE qualified, that's the point. They didn't wake up that morning and decide to have a bad day, they were at the sharp point of the intersection of reality and practices. they probably wont do it again, but they are not the first, and will happen again. DId they make assumptions or have expectations that were different to the real world, absolutely, as almost all accidents outside of UA 232 etc have had.

The QB APPR is less than desirable with the Airbus architecture. Why are we doing them at all?

The AC crew didnt design the lights of the taxiways, nor did they design the airport that places runways too close together.
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Old 15th Oct 2018, 06:22
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Originally Posted by underfire
Other drivers had no problem landing. Stop making excuses for unqualified crew. Was this the same crew that failed to respond to ATC instruction to GA because the runway was still occupied
I'm not making excuses for anyone.
The fact is you will always get a percentage of fatigued and/or distracted and/or incompetent pilots.
You can reduce that percentage by providing regulations. Cutting it to zero will be next to impossible.

The by far easiest improvement to night landings on parallel taxiways is to buy a few more LEDs when lighting the taxiway and putting a red cross at the end.
When something is long and straight some people will think it's a runway. You can't change that. There is a reason for the big TAXI markings on the taxiway pavement in BOSTON.

You could argue that's the cost of doing visual approaches at night, you have to install additional lighting.
I'm not arguing something super expensive to cater for rare events. I'm not even arguing to install such red crosses everywhere.
Just saying it's not that costly and after a warning shot like this incident why not defuse that hopefully rare situation.

Do you think it would not help or introduce other dangers?
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Old 15th Oct 2018, 06:44
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I think that this report shows a very interesting fact. The fatigue and the human error a strongly correlated to the fact that fatigue + human perception are very strong and can led to confuse both pilots. I think that with all the info (NOTAM, ATIS) and also the visual clues, it's was really obvious which was the RWY and which one was the TWY but with the fatigue together with some bias about the airport rwy configuration, led to this almost tragic event.

I am also really surprise about the visual approaches during night, i think it could add another level of difficulty.

We need to really be careful about fatigue, especially in the future where I can see pressure coming to reduce level of cost on crew side, with the increase of fuel price!
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Old 15th Oct 2018, 07:19
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Originally Posted by underfire
Other drivers had no problem landing.
Isn't that always the case in an accident? Everybody before and everybody after do not crash.
Or do you expect hundreds to crash at the same time and place?
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Old 15th Oct 2018, 07:21
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Originally Posted by spoon84
it was really obvious which was the RWY and which one was the TWY
Except that it clearly wasn't, to two people at least.
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Old 15th Oct 2018, 07:31
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Question Runway identifiers

Originally Posted by 787PIC
Anyone with more info or possibly the ATC tapes of an incident in SFO, on Friday July 07, just before midnight local time?
Apparently an Air Canada jet cleared to land on 28R had lined up with the parallel taxiway "C".
There were up to 5 "heavies" full of fuel and pax waiting for T/O on that taxiway.
Unconfirmed reports indicate that the Captain of UA 001, (a 787 bound for SIN) may have said something on the Tower frequency to get the pilot's attention and causing them to go around!
Perhaps averting the most horrific aviation disaster in history!
I'm interested in aviation but only a (lapsed) microlight pilot. So a simple question: why is it not mandatory for lit runways to have a pattern of lights that spells out the runway name that can be seen by landing aircraft? e.g. "28R"
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Old 15th Oct 2018, 08:33
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Originally Posted by msjh
I'm interested in aviation but only a (lapsed) microlight pilot. So a simple question: why is it not mandatory for lit runways to have a pattern of lights that spells out the runway name that can be seen by landing aircraft? e.g. "28R"
You don't always get to see the runway until a few seconds to touchdown. We are doing about 65 to 75 metres per second, and operating in visibilities down to 200m visibility. Not a lot of time to see the runway and confirm everything is where is should be. A picture is worth a thousand words:




Most approaches aren't in conditions like this. However, we have something far better than some new runway identifier, the ILS beam with ident specific to the runway that is good for at least 25nm. In this incident, Airbus doesn't display the ILS for some types of approach by default, extra steps need to be taken, and they weren't. Not mandatory to have it displayed for the approach they were flying, but it would have given additional cues earlier that there was a problem.

Last edited by CurtainTwitcher; 15th Oct 2018 at 08:47.
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