Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
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The pilots have, according to the prelim NTSB report, denied they saw aircraft on the taxiway, in fact, they denied being on the taxiway.
In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.
E.g.,
NTSB: "So now you're 4nm out, visual, making the first approach. Did you see the other aircraft lining up for take off?"
Pilot A: "No, we didn't see them, although something didn't look right on what we thought was the runway"
Pilot B: "Yeah, that's when we saw some lights, so we called tower, but he told us there's no one on 28R but us"
NTSB Update: "In postincident interviews, both incident pilots stated that, during their first approach... they did not recall seeing aircraft on taxiway C but that something did not look right to them."
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Then, the question is about AC's safety culture. Does it inhibit honest reporting of mistakes. Did the crew feel likely to be disciplined? Were they cognizant of the error and, if so, thought it could be hidden.
And, for all we know, the crew might have reported the incident through normal Air Canada channels.
I reviewed NTSB 830 again and surprisingly there is no requirement to immediately report this type of incident to the NTSB.
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And, the CVR tape was regrettably overwritten, just as it has been in many similar cases over the years. An honest mistake, right?
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Or, perhaps the tower called the company and told them to tell the pilots to give them a call. They may well have been in the blocks when they asked for the tower phone number on the ground control frequency.
I can imagine the conversation... "AC please ask the Captain to call me over the radio to ask me for my phone number". When the controller could've just radioed the pilots directly.
Apparently, right after the landing the Captain on his own initiative asked for the ATC's telephone number and called them to discuss the incident. That's not typical behavior of a crew attempting to hide anything.
And, for all we know, the crew might have reported the incident through normal Air Canada channels.
I reviewed NTSB 830 again and surprisingly there is no requirement to immediately report this type of incident to the NTSB.
And, for all we know, the crew might have reported the incident through normal Air Canada channels.
I reviewed NTSB 830 again and surprisingly there is no requirement to immediately report this type of incident to the NTSB.
GF
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Either way, if tower first notified Air Canada of a serious incident, then they too had a duty to preserve the CVR. It's not only the pilots.
I'm speculating that -- at the time -- neither the pilots, Air Canada, nor the controller had an appreciation of just how close they were to disaster, until the tapes were reviewed.
The pilots probably thought they'd just need to file a safety report in the morning and that would be the end of it.
I'm speculating that -- at the time -- neither the pilots, Air Canada, nor the controller had an appreciation of just how close they were to disaster, until the tapes were reviewed.
The pilots probably thought they'd just need to file a safety report in the morning and that would be the end of it.
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Peekay4 :
And I think you are probably right. Lining up with taxi way or wrong runway is not that unusual. It is the media coverage of one case that makes it sensational.
In Frankfurt ( Germany) for instance such incidents are a few per year, we even had an actual landing in the centre taxiway ( an Antonov 124 !) some 20 years ago, and a take off from the same centre one , a couple of years ago. In both cases as no-other aircraft was taxing at the time on it, no news coverage .
I'm speculating that -- at the time -- neither the pilots, Air Canada, nor the controller had an appreciation of just how close they were to disaster, until the tapes were reviewed.
The pilots probably thought they'd just need to file a safety report in the morning and that would be the end of it.
The pilots probably thought they'd just need to file a safety report in the morning and that would be the end of it.
In Frankfurt ( Germany) for instance such incidents are a few per year, we even had an actual landing in the centre taxiway ( an Antonov 124 !) some 20 years ago, and a take off from the same centre one , a couple of years ago. In both cases as no-other aircraft was taxing at the time on it, no news coverage .
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...
Entertain me, show me a screen shot you found on the internet for a 28L approach lighting at night. (with 28R active as well) of course, using the visual approach.
You appear to conflict with your own statement...do YOU see the approach lighting for 28R?
Very simple question....Is there any reason, even for you, or anyone....to line up on the taxiway?
Where would you land?
Entertain me, show me a screen shot you found on the internet for a 28L approach lighting at night. (with 28R active as well) of course, using the visual approach.
You appear to conflict with your own statement...do YOU see the approach lighting for 28R?
Very simple question....Is there any reason, even for you, or anyone....to line up on the taxiway?
Where would you land?
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Apologies for driftng off topic. When I was in Hong Kong tower we had at least 3 separate instances whereby aircraft that had been cleared for take-off on RWY 07L (it was early morning 1am to 3ish), lined up on TWY ALPHA parallel to RWY 07L. A Finnair A340, A Philippines A330 and a Hong Kong Airlines B738 and all three lined up on the taxyway "ALPHA" and commenced their take-off rolls. I know because I was the one that desperately instructed the PAL aircraft to "Stop immediately" as there was a 10 tonne sweeper operating on TWY ALPHA about 1500 meters down the TWY. Because these were departures there was no facility for immediately reporting and taking action regarding these transgressions. I could merely log the circumstances for management to action the next day. I guess the moral of the story is that there are a number of participants that keep the holes in the Swiss cheese from lining up so .... be careful, be alert, be suspicious (smell the rat) and respect SOP's.
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Originally Posted by Underfire
Pretty damning article…
Editorial: Air Canada, FAA hindered investigation of SFO near-miss
The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.
As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.
The fiasco highlights the need for new federal laws or regulations mandating immediate reporting of near-misses and the grounding of aircraft and pilots until after National Transportation Safety Board investigators are called in.
This could have been nearly the worst aviation disaster in history, second only to the two hijacked planes that plowed into the World Trade Center on September 11, 2001.
On July 7, pilots of an Air Canada plane landing minutes before midnight at SFO mistook a taxiway for the runway where they were supposed to land. The latest investigative findingsshow the plane dipped as low as 59 feet off the ground as the pilots aborted their landing, barely missing four fully-fueled aircraft with an estimated 1,000 passengers that were awaiting takeoff.
The FAA, which was responsible for having only one air controller working traffic in the tower at the time, took more than 24 hours to notify the NTSB. The delay allowed Air Canada to use the plane for three flights in which the cockpit recorder was taped over multiple times.
That recorder held potentially critical information about what the pilots were saying as they headed straight for the taxiway. The cockpit conversation between the pilots might have helped explain their confusion.
As for the pilots, a source familiar with the current NTSB investigation told reporter Matthias Gafni that they spent the night in the Bay Area and flew out the next morning on their normally scheduled flight.
It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded. United Airlines’ outrageous response after a passenger was dragged off a plane pales in comparison to this stonewalling.
Similarly, the FAA refuses to explain why it took more than a day to notify the NTSB. The NTSB, in turn, excuses all this by noting that federal rules did not require that it be notified because there was no collision.
That technical rationalization belies common sense. Air Canada Flight 759 came within a few dozen feet and a few seconds of creating an airport inferno the likes of which this nation has never seen.
Jim Hall, former NTSB chairman, told Gafni that those reporting guidelines should be addressed in the investigation. “This was probably the most significant near-miss we’ve had in this decade,” Hall said. “I think splitting hairs on this issue on an incident of this significance is a disservice to safety.”
He’s right. The investigation into this terrifying episode should have started immediately.
The U.S. Federal Aviation Administration and Air Canada hindered the investigation of last month’s near-catastrophe at San Francisco Airport by dragging their feet in the aftermath.
As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved.
The fiasco highlights the need for new federal laws or regulations mandating immediate reporting of near-misses and the grounding of aircraft and pilots until after National Transportation Safety Board investigators are called in.
This could have been nearly the worst aviation disaster in history, second only to the two hijacked planes that plowed into the World Trade Center on September 11, 2001.
On July 7, pilots of an Air Canada plane landing minutes before midnight at SFO mistook a taxiway for the runway where they were supposed to land. The latest investigative findingsshow the plane dipped as low as 59 feet off the ground as the pilots aborted their landing, barely missing four fully-fueled aircraft with an estimated 1,000 passengers that were awaiting takeoff.
The FAA, which was responsible for having only one air controller working traffic in the tower at the time, took more than 24 hours to notify the NTSB. The delay allowed Air Canada to use the plane for three flights in which the cockpit recorder was taped over multiple times.
That recorder held potentially critical information about what the pilots were saying as they headed straight for the taxiway. The cockpit conversation between the pilots might have helped explain their confusion.
As for the pilots, a source familiar with the current NTSB investigation told reporter Matthias Gafni that they spent the night in the Bay Area and flew out the next morning on their normally scheduled flight.
It was business as usual, despicable behavior on the part of Air Canada, which refuses to answer questions during the investigation, including whether the pilots have since been grounded. United Airlines’ outrageous response after a passenger was dragged off a plane pales in comparison to this stonewalling.
Similarly, the FAA refuses to explain why it took more than a day to notify the NTSB. The NTSB, in turn, excuses all this by noting that federal rules did not require that it be notified because there was no collision.
That technical rationalization belies common sense. Air Canada Flight 759 came within a few dozen feet and a few seconds of creating an airport inferno the likes of which this nation has never seen.
Jim Hall, former NTSB chairman, told Gafni that those reporting guidelines should be addressed in the investigation. “This was probably the most significant near-miss we’ve had in this decade,” Hall said. “I think splitting hairs on this issue on an incident of this significance is a disservice to safety.”
He’s right. The investigation into this terrifying episode should have started immediately.
- Is The Mercury News an authoritative source on air accident and investigation & safety?
- Do they have additional information that is generally not known the public?
Claim 1 AC and the FAA dragged their feet? Evidence, source? No it was based on the fact that the CVR was erased. Inferred in this statement is that this was a deliberate act. No mention that this is the default mode of operation for this device. Active steps must be taken to avoid erasure.
Claim 2 New laws to protect the CVR are required in the case of a series near miss. The assumption is that either the crew or the tower were aware that the incident was as series as it actually turned out to be. It may not have been clear to the crew just how close it actually was. Unless the tower controller was watching the radar altitude and been aware of the offset, he also may have been unaware the seriousness.
Claim 3 Potentially the second worst disaster ever. True
Claim 4 AC pilots attempted to land on a taxiway. True
Claim 5 Single tower controller. Appears to be true
Claim 6 FAA took 24 hours to notify NTSB. True
Claim 7 CVR overwritten caused by notification delay. True
Claim 8 CVR held vital information about the event. True
Claim 9 Pilots operated out as per schedule. Appears to be true.
Claim 10 AC non assistance with investigation. Appears to be true
Claim 11 FAA has not explained reporting delay. True
Claim 12 No immediate reporting requirement as no collision had occurred. True
Claim 13 Most serious near miss in a decade. True
Most of the specific detail of the article are technically correct. However, the entire assumption of this article and its criticism & tone of malicious intent by the crew & FAA rests on the assumption that there was the recognition of the seriousness of the event by either the crew or the tower controller. We have no way of knowing the state of mind of these three people, and what they believed about their perception of the seriousness of the event. There are only 3 people in the world who know.
Ten years ago, it is almost certain that this event would not have surfaced publicly, as the availability of the information from web based Flight Trackers and ATC recordings were just in their infancy without the widespread coverage and use by the public.
Would an NTSB investigation looked closely enough to also realise the seriousness of the event based on a crew or tower report? That is an unknowable answer.
The entire basis of the “damning” article appears to be about the judgement of how the crew & tower controller perceived the event. The inference from the article is the crew & tower would have been aware. On what basis could this view be formed? Pure assumption or actual knowledge?
To the general public reading this editorial, the crew & tower controller have been judged & convicted, case closed, throw away the key. To anybody with genuine insight, there are many more questions to be asked and information to gather. The truth is, we may never find the truth of this event. Likely this was true of many other near misses in the past that everyone in the system were unaware of. Absence of evidence is not evidence of absence.
The system is being judged through a different lens than existed in the past with the explosion of information available for open source analysis.
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Simple questions, and I apologise if they have already been answered. Had either pilot ever been to SFO before; had they ever landed on 28R; had they ever been there at night; had they ever flown any kind of 'bridge' approach?
If the answer if no to all then there is another slice of holy cheese to add to the puzzle. However, in which case you would expect extreme vigilance not a relaxed approach.
If the answer if no to all then there is another slice of holy cheese to add to the puzzle. However, in which case you would expect extreme vigilance not a relaxed approach.
Claim 2 New laws to protect the CVR are required in the case of a series near miss. The assumption is that either the crew or the tower were aware that the incident was as series as it actually turned out to be. It may not have been clear to the crew just how close it actually was. Unless the tower controller was watching the radar altitude and been aware of the offset, he also may have been unaware the seriousness.
There are only 3 people in the world who know.
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I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event. After all, that's what investigations are for aren't they? You mob sound like a bunch of vultures out for blood.
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The United crew might beg to differ.
Indeed, there has been little said about the state of mind of those 'holding a/c crews'. Their cockpit temps might have risen a few degrees and bodies been shaking. Imagine a near-miss, as in 100', at FL250 with a hard left avoidance and perhaps a push. The cockpit climate would have been disturbed for quite a while. These guys were about to get airborne. I would not be surprised if it took quite a while for them to calm down and feel ready to fly. Did they wait for the 2nd approach, or glean it safer to foxtrot-oscar while the runway was clear? Why sit in the sights for a 2nd time?
I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event.
It's not what was said, but rather what was not said: i.e. a brief about the state of the runway environment, how they were going to conduct the approach, what they expected to see in the dark, what threats were created by a closed runway and a visual approach etc. that is why the CVR would be helpful. The prevention process would be that a more thorough planning, briefing & understanding of the unusual circumstances could have been successful.
Remember a crash investigation of a landing over-run in rain storms, perhaps Little Rock? The CVR revealed that the auto speed brake had never been armed and they aqua-planed off the end. The NTSB never heard the 'click' of the lever being armed. CVR's can be more useful than FDR at times.
Indeed, there has been little said about the state of mind of those 'holding a/c crews'. Their cockpit temps might have risen a few degrees and bodies been shaking. Imagine a near-miss, as in 100', at FL250 with a hard left avoidance and perhaps a push. The cockpit climate would have been disturbed for quite a while. These guys were about to get airborne. I would not be surprised if it took quite a while for them to calm down and feel ready to fly. Did they wait for the 2nd approach, or glean it safer to foxtrot-oscar while the runway was clear? Why sit in the sights for a 2nd time?
I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event.
It's not what was said, but rather what was not said: i.e. a brief about the state of the runway environment, how they were going to conduct the approach, what they expected to see in the dark, what threats were created by a closed runway and a visual approach etc. that is why the CVR would be helpful. The prevention process would be that a more thorough planning, briefing & understanding of the unusual circumstances could have been successful.
Remember a crash investigation of a landing over-run in rain storms, perhaps Little Rock? The CVR revealed that the auto speed brake had never been armed and they aqua-planed off the end. The NTSB never heard the 'click' of the lever being armed. CVR's can be more useful than FDR at times.
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The United crew might beg to differ.
UAL did report them on the TWY to the tower.
what you should be showing is a photo from the perspective of being lined up on the taxiway, and ask the question what visual clues are there that make you think you aren't where you are supposed to be ...
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Would have been interesting to hear the CVR from United and PAL!
Useful to the investigation? Nope.
They were straight for PAL and only missed them by 3 feet of less
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Ahh, sorry folks for the delay, we went around due to traffic at the airport
Quote:
Originally Posted by Underfire
Pretty damning article…
Editorial: Air Canada, FAA hindered probe of SFO near-miss
This article raises several questions:
- Is The Mercury News an authoritative source on air accident and investigation & safety?
- Do they have additional information that is generally not known the public?
Claim 1 AC and the FAA dragged their feet? Evidence, source? No it was based on the fact that the CVR was erased. Inferred in this statement is that this was a deliberate act. No mention that this is the default mode of operation for this device. Active steps must be taken to avoid erasure.
etc
Can't see that The Mercury News ever claimed to be an authority on air accidents or near misses. However, the news outlet in question has had an investigative reporter on the case since the story broke. This is at least the second editorial they’ve written as followup to his several stories about the incident. And in a previous editorial, on 17 July, commenting on the reporter's story that day after the NTSB published it’s initial findings, yes, they were calling then for someone’s head. But can we blame them for wanting answers, after all it’s become a big story in their backyard?
Regarding the unavailability of CVR evidence, you are wrong (in your Claim 1 paragraph) to accuse the editors of implying deliberate destruction of evidence, because the original online story of the text you quoted had a clickable link to the reporter’s article describing how CVR’s work.
Incidentally, what that same reporter did unearth was an account by a passenger on AC 759, the first that I have seen since this whole sorry saga broke. Unfortunately for AC and the regulators - 3 of whom he wrote - he happens to be California’s top insurance public official. See a facsimile of his letter to Air Canada at the bottom of the story on this page:
SFO near-miss: Air Canada flew over plane before aborting
And my favorite quote from his description? “…the pilot made a nonchalant announcement that he had to go around due to traffic at the airport.”
Last edited by SLFstu; 16th Aug 2017 at 13:45. Reason: added quote from AC 759 passenger
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Some of the CVR
About several hundred posts ago peekay4 (IIRC) showed an analysis of the CVR 30-minutes duration after the go around (using evidently reliable time-stamp information). Wasn't it shown that of the 30 minutes of recorded data potentially available, 19 of those minutes had been consumed by necessity in the go around, second approach, landing and taxiing to the gate? This is not meant to excuse or otherwise deflect attention away from the fact that the CVR such as it was, was not preserved. But it is important as a matter of factual background and context to include this detail, that only roughly the final one-third of the 30 minutes would have been available in any event, just because of the aborted landing. Is this not so?
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About several hundred posts ago peekay4 (IIRC) showed an analysis of the CVR 30-minutes duration after the go around (using evidently reliable time-stamp information). Wasn't it shown that of the 30 minutes of recorded data potentially available, 19 of those minutes had been consumed by necessity in the go around, second approach, landing and taxiing to the gate? This is not meant to excuse or otherwise deflect attention away from the fact that the CVR such as it was, was not preserved. But it is important as a matter of factual background and context to include this detail, that only roughly the final one-third of the 30 minutes would have been available in any event, just because of the aborted landing. Is this not so?
And, assuming it was a 30 minute recording, the dialogue from ARCHIE inbound would have been preserved, as well as the dialogue during the go-around and subsequent approach and landing.
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I find it hard to believe there would have been anything on the CVR that would be useful in preventing a repeat of this event.
The NTSB never said that. That's been inferred by posters on here. Without having seen the raw data, radio altimeters report the closest obstacle in the signal path, including an aircraft fuselage.
Yes, you are correct, they did not say 3 feet. (but 59-56 is well...)
I think that given where the ac measures altitude from, even the radalt, the landing gear is below that...actually, it is a bit of a miracle they missed them.
It is interesting that the report shows screen shots from a video, but does not show a shot when the AC was directly over the PAL ac....they do have it though.