Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!

[Old Carthusian]

Holes lining up is actually not as relevant as some think. If one shifts one's perspective and looks at it from the point of passengers dying can you give the people who died their lives back? So though why is important the response to what is also important and in this case just as important.
Even in European countries there comes a point when a person is responsible for their actions. It becomes especially onerous if one also assumes the responsibility for other people as well. However, if one does assume this responsibility then one also should accept that there may be sanctions if one fails in that duty.

[BluSdUp]

old cartusian

You are not an Airline pilot are You!
And you do not understand how things work in the industry,do you?
It must be confusing for you.

[wiggy]

OC

You conveniently forgot to mention Yeager in your attempted riposte...was that an inconvenient truth?

Anyhow in an earlier post you stated:

1.

OK my flying experience is limited to grass airfields so I don't know commercial airports

Then in a subsequent post state:

2.

Seriously there is no excuse for trying to land on a taxiway instead of a runway.

I'll leave that observation hanging, others may care to comment.....

As for

You make sure that you do your best because other people trust you with their lives.

.... It's probably unlikely the crew in question pitched up at report for the duty and said to each other "lets not really do our best tonight"...in fact I wouldn't be surprised if the A C pilots actually thought they were doing their best.... as they came down the approach..

Not offering excuses but have you seen any of the Human Factors/ Human Perception videos others and myself have alluded to in this thread? I ask because it can come as a nasty shock, even to seasoned aviators, even in the calm of class room, to realise that in certain circumstances what you think your perceive may not actually what is out there in the real world, staring you in the face.

[underfire]

Without the CVR, we'll never know the truth sadly.

Equally, if the crew initiated the GA before ATC I wonder if it was PF or PM that called the GA. Remember they were studying the lights, and having doubts, for 2 minutes or more.

My thoughts and comments are basic on logic, and simple fact.

Do you really think the crew, after hearing UAL, seeing landing lights, and passing feet over aircraft, did not recognize it as the taxiway?

Did tower even say over the radio, you were lined up on the taxiway, and vector the GA?

Is it normal for aircraft to line up on the active runway for DEP? (facing backwards?)

IF what the NTSB stated is the case, that they stated they were lined up on 28R and did a GA because it didnt look right....

To answer other comments, they do the FMS bridge Visual, because all of the vector points and step downs are coded in, thus relieving ATC from all of that.

The CSPR procedures are a different lot.

A more constructive transmission would have been Air Canada you are lined up on the taxiway; or aircraft on approach to 28R you are landing on the taxiway.

How would UAL know its AC? One would assume that the drivers of all of those ac were busy with preflight, rather than stare out the windscreen plane spotting? In addition, if you are on Quiet Bridge visual, you approach the 28R TCH at an angle to extended centerline.

[Bergerie1]

wiggy,

I agree entirely. I spent most of my professional life as an instructor pilot and it is indeed very salutary to realise how vulnerable, we, as human beings, are to perceptual mistakes. Despite all the precautions we take there are still occasions when we can be caught out.

As many others who have posted here have said, the important things is to find out WHY.

[aterpster]

Originally Posted by underfire

The CSPR procedures are a different lot.

What's that?

[WillowRun 6-3]

Illusions, of both the optical and justification varieties

Pretty thoroughly, comprehensively, and rigorously indisputable that an air transport pilot is responsible for the safety of the people on board, certainly as a legal question. Does that mean that neither SARPs nor national laws pertaining - to pick an example at random - to training prior to licensure, including awareness of optical illusions existing (or prevalent) in airfield lighting could not be improved, because the Pilot is Responsible Ultimately? If a poster thinks that answer is "yes", I would strongly disagree.


And about summary dismissal: without asserting that summary dismissal could tend to weaken or mitigate the extent of co-operation and honesty on the part of the dismissed pilots, nevertheless, summary dismissal is presumptuous in this matter. The exploration of all the possibly causative and/or contributing factors is too important in this case to allow a kind of retaliatory lust to take over. If it indeed is warranted (and from information already in the NTSB record it very well could be warranted, but I do not know that) to dismiss the pilots, dismissal, like revenge, will be served better cold.

[DIBO]

Closely Spaced Parallel Runways

[peekay4]

It's really CSPO (Operations) to airports with CSPR, e.g., the procedures already described in post #898.

[aterpster]

Originally Posted by DIBO

Closely Spaced Parallel Runways

Thanks! Too many acronyms.

They've been doing that at SFO so many years I even flew them. It really backed things up when the weather was "200 and 1/2."

[peekay4]

What's "new" at SFO is the 1.5nm spacing between aircraft on parallel runways. Only introduced in the past 5 years or so.

[underfire]

It's really CSPO (Operations) to airports with CSPR, e.g., the procedures already described in post #898.

Unfortunately, not quite correctly discribed.

From 2010 CSPR https://www.faa.gov/documentLibrary/...308CHG3inc.pdf this modified the 2008 order, which modified the etc order.

CSPR is the concept, it has been around for many years in several different formats and names, so yes, if you were in there since about 2000, you did fly one of the variants. This is not only at SFO, but many others...I think some of the first were at ATL (1000' feet between rwys) and STL (1300') in 1998! (with 3 III runways)

Recently, the FAA has added a spacing based on prevailing wind direction and strength, for mitigate wake turbulence issues. This is pioneered at SFO.

(terpster) The theory: Different interpretation of DA from the FAA AIM...(SAMUL would be the DA on FMS Bridge Visual) Can you tell from your database if SAMUL is a flyover as shown in this diagram, or a flyby as I have in mine?


EDIT: terpster, the FAA calls SAMUL a DA.... what is the Jepp definition of SAMUL?

[peekay4]

CSPR is the concept, it has been around for many years in several different formats and names

What? CSPR is not a "concept". CSPR just means Closely Spaced Parallel Runways, defined as parallel runways closer than 2,500ft.

And .308 did not define a new approach concept, just a change in policy (authorization) on conducting dependent approaches on CSPR pairs, specifically allowing 1.5nm parallel aircraft separation on dependent approaches to CSPRs.

Notice the phrasings in .308 (quoting the latest revision):

Simultaneous Dependent Approaches to Closely Spaced Parallel Runways[/B] ...
7. Procedures.
a. Airport Criteria Allowing Conduct of Simultaneous Dependent Approaches on CSPR ...
b. Procedures for Dependent Approaches to CSPRs. ...
Specific Airports/Runway Geometries Approved for Dependent Approaches to CSPRs

You'll find the same definition used by ICAO, Eurocontrol, etc.

so yes, if you were in there since about 2000, you did fly one of the variants.

Umm, no. Dependent approaches have been around since at least the 1970s, but until 2008 they were not authorized on runways spaced closer than 2,500 ft. The old separation criteria meant approaches to close parallel runways were effectively equivalent to conducting approaches to a single runway only.

And at SFO the 1.5nm separation did not take effect until 28L glideslope changes were made in 2013, as previously discussed.

Different interpretation of DA from the FAA AIM...(SAMUL would be the DA on FMS Bridge Visual)

DA on a visual approach... right...

[underfire]

DA on a visual approach... right...

Argue with the FAA AIM on the subject. As shown in the diagram, for example, does an RNP AR procedure have a DA?

What? CSPR is not a "concept". CSPR just means Closely Spaced Parallel Runways,

Since you love to argue, that comment was in response to your CSPO comment.

And at SFO the 1.5nm separation did not take effect until 28L glideslope changes were made in 2013, as previously discussed.

Arguing with yourself again...

So, moving forward.

NTSB's formal investigations.

There is an Executive Section and Probable cause section.

https://www.ntsb.gov/investigations/...s/AAR1402.aspx

Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain.

Contributing to the accident were (1) the flight crew's failure to properly configure and verify the flight management computer for the profile approach; (2) the captain's failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured; (3) the flight crew's expectation that they would break out of the clouds at 1,000 feet above ground level due to incomplete weather information; (4) the first officer's failure to make the required minimums callouts; (5) the captain's performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and (6) the first officer's fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.

I am pointing the phraseology used in this and most of the other reports the NTSB has formally issued

First off, the NTSB report wording put the fault directly with the flight crew?

It then goes on with the Contributing factors. Specifially notice (5) and especially (6) in bold.

In reference to "fatigue, distraction, or confusion,"..."acute sleep loss resulting from her ineffective off-duty time management and circadian factors."

https://www.ntsb.gov/investigations/...s/AAR1603.aspx
https://www.ntsb.gov/investigations/...s/AAR1603.aspx

Asian SFO...similar phraseology

The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the PF's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances.

Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing's documentation and Asiana's pilot training, which increased the likelihood of mode error; (2) the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the PF's inadequate training on the planning and execution of visual approaches; (4) the PM/instructor pilot's inadequate supervision of the PF; and (5) flight crew fatigue, which likely degraded their performance.

[peekay4]

First off, the NTSB report put the fault directly with the flight crew.

From the report (and in all NSTB reports), page 3:

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

[aterpster]

Originally Posted by peekay4

From the report (and in all NSTB reports), page 3:

That is carefully crafted language to keep NTSB investigators and Board members immune from being dragged into endless tort litigation.

I am not sure, but I believe the NTSB regulations are backed up by public law (acts of Congress, signed into law by the president). I have no doubt a competent aviation litigator could provide further enlightenment.

[aterpster]

Originally Posted by underfire

EDIT: terpster, the FAA calls SAMUL a DA.... what is the Jepp definition of SAMUL?

Where do you find the FAA calling SAMUL anything?

The airline TARGETS source shows SAMUL as a FB step-down within the intermediate segment. This is all "story board" stuff, since the source designer is using a program intended for IFP design to design a FMS visual approach track.

I hope the NTSB really opens this can of worms, although I seriously doubt they will.

[SalNichols]

If assigning fault for an error in judgement or procedure is unimportant, I wonder why the Navy has no problem cashiering ship captains that run into other objects, be it an underseamount in an LA class attack sub, or a container ship in the case of the USS Fitzgerald. I can't think of a single instance in which a Navy captains career has survived his or her poor judgement that resulted in damage to their ship and/or loss of life.

I have over 3M miles sitting back there, and frankly...29' is cutting things a little bit close for me. 20-30K hours and all the bloody swiss cheese in the world doesn't make this better, it was a major screw up. Fix it.

[galaxy flyer]

Sal

There are two tracks--safety investigation aimed at "fixing it" and disciplinary track aimed at uncovering criminal responsibility. It is entirely possible there is no criminal negligence here, humans make mistakes that are not criminal negligence after all. Go around firing or jailing people will not fix the problem, as the USN has proved.

[SLFstu]

In response to Old Carthusian's most recent post you wrote:

Originally Posted by BluSdUp

You are not an Airline pilot are You!
And you do not understand how things work in the industry,do you?
It must be confusing for you.

Disclosure - non-pilot opinion. Oh and I work in a life/death safety critical industry too. I signed up knowing that if I stuff up, people may die. And a known consequence is being tossed out of the gig.

Old Carthusian is calling for the crew’s heads to roll because mistakes were made that should not have been made by competent drivers. Is it relevant whether he knows “how things work in the industry”?

As a pilot you do of course, and we know what you mean because in earlier posts you said you hope that AC and the union take care of the 2 pilots. You know that only with an understanding employer and a protective union will these guys’ jobs be preserved. You yourself have banged on and on that there is no excuse for what these guys did.

Here’s some of your choice language pertaining to the incident, excerpted from your 18 posts, crafting a picture of what you called your “rather harsh description of the crew”:
…“near disaster; pure madness; fire chief pilot and head of training; this mess; FAA overdue for a big one; no excuses whatsoever; incompetent crew; it is simple, positive identification, always; severe incompetence of the crew; crew should get new glasses; aghast; conveniently developed amnesia; too lame; selective memory, at best; so there is no excuse now; my money is on complacency.”

What is there to be confused about?