Nice sim - gulp

https://www.youtube.com/watch?v=ydUqfhNqUIc

Huh? This looks pretty damn close to a disaster.

Adoption of Forward Looking IR (Enhanced Flight Visibility Systems, EFVS in FAA speak) and Synthetic Vision Systems (SVS) would go a long way to eliminating night visual problems. The EFVS view, especially in a HUD, would have shown the line up planes as four large signatures and the lighting clearer, assuming it hadn't been converted to LED. The SVS would have shown the runway off line-up to the left in a daylight view and the taxiway in front of them. SVS is good enough to show you taxiing across a runway and the view on the PFD or MFD is identical to the outside view.

Per Annex 13, it will be categorised as a Serious Incident: "An incident involving circumstances indicating that there was a high probability of an accident ..."

Annex 13 goes on to explain, rather chillingly, that "The difference between an accident and a serious incident lies only in the result".

The damn AC aircraft likely did not even have GPS.....

If what the report states is true, that the AC drivers did not even recognize the taxiway was full, that implies they did not see the landing lights, nor hear UAL 1. (or are not telling the truth) There is enough intent in their statement alone, (forget the lack of CVR data) to prevent those 2 from rotating again.

Time to stop making excuses for the airline, the ac, and the crew. Let DHS get the true story out of them.

The 320 in question did not have GPS but is that really an excuse for a VFR approach at night under good visual conditions?

Besides that, not having GPS, the FMS would have used DME/DME for updating which is extremely precise enough to get you to the threshold of a runway.


I totally agree...

What bothers me is the fact they allowed the CVR to be over written perhaps purposely to cover their mistake(s).

Then in there statement to the NTSB they claim they never saw any aircrafts on taxiway C, so why did the initiate a "GO Around" at 85 feet AGL if they absolutely thought they were landing on RWY 28R?

Sounds to me like they are covering up, in other words lying about the whole incident, if so they should to be fired.

Does AC have the authority to use the special "FMS RNAV Quiet Bridge" procedure? I've not seen anyone post that bit of info--maybe they don't.

Maybe I am wrong but I believe that is not the approach they were cleared for.

Yes, it is clear in the audio, requested and cleared for FMS Bridge Visual. Some call it FMS Bridge visual, others call it RNAV bridge visual , some call it simply 28R visual in the ATC tape. Pretty loose given there is a Quiet Bridge Visual and Tipp Toe visual to 28R.

They would have to have DME/DME/IRU in lieu of GPS. They would have had to have it in the FMS to be approved to use it. Both the airline AND the crew have to be apprved. It is commonly used, so it is likely they were approved.

The response was to someone suggesting that Heads Up would be in order, hence my response that the ac does not appear to have GPS, so it is unlikely the airline would have the wherewithall to provide HU capabilites.

I agree, that was not the correct name for the approach AC 759 was given. The mixed up name on the D-ATIS doesn't help matters in my opinion. Perhaps the Quiet Bridge Visual and FMS Bridge Visual approaches were verbalized correctly on the voice version of the ATIS.

From an earlier post:

This link will time out soon when it hits the 30-day mark so download the clip from liveatc.net if you think you might want to review it later.

Hold on a minute
 

Quote: various posters subsequent to the NTSB information release yesterday, professing various conclusions about crew acts or omissions, and consequences, relative to sanctions, and system component reforms, and even ... causation.
Forum 11th Commandment: Must Have investigation report and those odd, pesky things, known as facts.
There is just too much left to be uncovered by the investigation process, and then still too much needing to be done to integrate the various and several factual elements into a coherent whole picture of the incident, before many of the assertions being made here would be justified and warranted. True, compared to investigations a couple of decades or so ago, places like this forum provide lots of access to relevant information - all the more so with all the tech gizmos which can show position, time-stamp, and more. But the thread is not the investigation. And before ya'all throw FCOM books at me, just think for a minute: once the facts are indeed known and integrated into a coherent whole picture of the incident, there will be plenty, plenty of time and opportunity to discuss probably dozens of system and subsystem reforms and changes. Wasn't the point, or one of the points, of poster Ian W.'s tutorial on attentional tunneling, a/k/a target fixation, that this could happen to anyone manning the flight controls? But let's hang the crew on suppositions here, heck, it's just the internet.

Agreed 100% WillowRun 6-3.

Also, we know that post-incident/accident statements are often very inaccurate -- not necessarily because anyone is lying but due to natural characteristics of human memory. Hence the lack of the CVR recording in this case is a big loss for the safety investigators.

Perhaps it's time to mandate the 25-hr CVR rule worldwide.

Again, I don't believe AC 759 ever 'requested' this approach. They were advised to expect it on the ATIS, told to join it by a NORCAL controller and later cleared for the approach by another controller. At least that's what I get off the LiveAtc.net tapes.

Can you provide a cite that says otherwise?

Your earlier post claiming planes were 'requesting' the FMS Bridge Visual 28R from the tower controller is total nonsense in my opinion:

As an outsider with some knowledge of aviation this real issue is possibly clearer to me than to those closer to things. The AC pilots are surely fine pilots and representative of their profession. The guys in the waiting planes, likewise. But literally everyone was asleep here. The entire system nodded off. Why?

Routine. There is so little freedom of action, and the the long day is so overgrown with necessary actions performed almost as an automaton would, that given a certain hour of the day, condition of lighting, etc. the truth can hide in plain sight. That can't be a plane coming at me - planes don't line up on taxiways! They are for taxiing! And those runway lights sure look strange - shrug. Can't wait to get down and get some sleep.

So much of the visual stimulus at night is hard to make out, even if colored like a Christmas tree. It must seem a wash of pretty lights sometimes, moving with hypnotic slowness. Every pattern has a significance, but maybe there are too many of them to keep immediately in mind because you are tired or just bored after a long day being a part of the machine. There are numerous cases of "how on Earth did they not hear that alarm? Why didn't they set the flaps? How can you mistake a frequency for an altitude?"

I don't know what you can do other than to make life more interesting for pilots so that they remain engaged. Let them - no require them - to do some hand flying. That's a start.

jeeezus...listen to the tape...they requested clearance to land for that approach...correct, just like all of the others on the tape...what, you want me to type out requests clearance to land for each line? I simply typed requests, not requested as you are stuck on.
I guess you did not listen to the tape, or you would have understood what was meant....there you go....

The taxiway is very near the runway on an offset angle approach. While waiting in line (for what appears an extended amount of time due to 28L closure), you are staring out the windscreen trying to figure out if the other ac are on RWY?
How often do lawyers sue other lawyers?

Who were asleep, were the pilots in command of the AC jet.

As much as drivers want to claim they are solely responsible for the command of the aircraft, here is the chance to put blame exactly where it belongs.

Children of the magenta line make excuses for poor performance. As noted, there is enough intent shown by the circumstances to show that it was an accident. It should and likely will be treated as such, and the responsible ramifications should be followed through.

There are systems that warn, but the bottom line. no matter what the warnings, ATC instructions, or aircraft , it is the PIC that makes and takes the responsibility.
Bottom line, that crew drove the ac down the taxiway on a clear night. Bright and very adequate approach lights...and a big white 'X' on 28L.

"jeez, looks like there is something on the runway, but ATC says there is nothing, so I will land anyways. Oh , I forgot to turn off the CVR and it got erased...really, we dont remember seeing any aircraft on the runway, those bright lights shining at me, or hear the radio saying I was on the taxiway....we just remember seeing something odd, and decided to GA.... "

How did AC 624 A320 plow into the dirt 300m short of threshold?

FFS, make all the excuses you want...time to cull this herd, with good reason.

So now they are requesting 'clearance to land for that approach'?

Like I said...

de-Sitter,

I wont comment on the "probable" causes leading to this incident, lot of speculation as usual, except for that regarding the local time this happened and how long their workday/night had been so far tiredness might have played a factor. My experience(25yr ww) is that boredom usually doesn't show up on approach and landing(complacency maybe).

Maybe it makes you feel better knowing that plenty of pilots still hand-fly, usually at lower levels and the flight departments encourage it. This depends on the(expected) workload though, flying into a challenging airport, or just a lot of traffic, weather, tiredness etc or a combination of all, yes, it can get interesting..(SEQM eg)

Seems the only thing clear from this thread is who are pilots and who are not.

Why I asked about AC's approval is their are TWO Quiet Bridge approaches--one public visual and one private, by specific approval FMS Quiet Bridge approach. Is AC approved for the approval required FMS Quiet Bridge or where the actually flying the public visual approach?

GF

FMS Quiet Bridge approach?

Here we go again... :)

You might want to check the name of that approach.

Whoa, hold on a mo, I think there is some fundamental misunderstanding going on here. The Air Canada 759 crew did see something on what they thought was Rwy 28R (but was actually Taxyway C), and queried it with the Tower:The Tower replied:AC759 quickly replied:Consequentally, whatever the reasons for AC759 being incorrectly lined up with Taxyway C, the crew had just had their (unknowingly) erroneous visual and mental model apparently reinforced by the Tower. Neither side of that radio conversation knew yet that things were badly wrong (the 4 aircraft crews on Taxyway C may have already had hairs standing on the back of their necks). The AC759 crew did have some initial unease about their odd visual picture, and queried it, but Tower (through no fault of his own), seemingly dispelled it.

United Airlines 1, right in the 'line of fire', seemed to be the first to raise real alarm, and did so by quickly transmitting (right on the end of AC759's reply to Tower):I believe it was those calls from UAL1 that probably then provided the serious startle factor for AC759. Very shortly thereafter they commenced a go-around, and Tower, now also aware of the potential disaster, ordered a go-around. A final report will, no doubt, clarify the precise timings and order for those latter events.I don't believe that the AC759 crew statements "that they did not recall seeing aircraft on taxiway C but that something did not look right to them" mean that they did not see anything on Taxyway C - they did see something there - lights - and queried it with Tower. When Tower told them the runway was their's to land on, in their mental/visual model they then had even less reason to think that the lights were aircraft.

For people here to express astonishment that the AC759 crew did not see this or that, or demand that heads roll because the AC759 crew might be lying, is really jumping the gun! AC759 did see lights, and had their verbal query apparently satisfied by Tower's reply. I suspect that it may have been UAL1's calls which suddenly brought the visual and mental models inside the AC759 cockpit into very stark focus, and the crew must have been frightened and then embarrassed in the space of a handful of seconds.

Give them some space people, for goodness sake! All we know, and they now know, is that something went terribly wrong. Only a final report will give us more insight into the reasons for AC759 lining up with Taxyway C and not the real Rwy 28R. In the latter stages there seems to have been a serious disconnect between where they thought they were and what they saw, when compared to where they actually were.

Human Factors studies are being devolped and refined all the time, and the subject is part of pilot license qualification and training. It also forms part of ongoing license requalification and retraining - we study it it because we are erring humans subject to sometimes insidious phenomena. If it wasn't important, we wouldn't need to consider the subject, would we? It could be that this incident is a variation on something already known about mental/visual pictures being mixed up, but whatever it is, quit the flipping armchair judge-and-jury nonsense. It sucks, and some of you do yourselves no favours by behaving like a lynching mob.

Dollars to donuts, the contents of the CVR following the GA weren't printable anyway.

Well said.

This is so much like Comair at Lexington.

There has been much 'red herring' chat about the type of approach offered/requested/accepted. IMHO that has nothing to do with this incident, and I do not wish to open that discussion again. This incident started to occur at less than 3nm visual finals to RW28R. How they arrived at that point has nothing to do with it. It is what the crew did after that point that is relevant. Please, let us see the wood for the trees.

I can't help wondering that the gap after PAL and prior to the UAL 3rd in line, wound up as hugely important to the safe result? If UA had been right behind PAL....would the bottom end of that flight path during GA cleared everyone?

Terrifying to think about.

Is it possible that they were flying the "Quiet Bridge Visual 28L/R" without FMS guidance? That approach follows the SFO 095 radial inbound, which happens to cross the airport boundary just at Taxiway C. They would have to offset left a bit after crossing the San Mateo Bridge to line up on 28R.

Sorry if this has been shown. Just some daytime shots of the approach.


About 7mins in.


https://www.youtube.com/watch?v=ENe89j89tBA

Let me add another scenario. If you listen to the ATC tape, I am dumbfounded by the nonchalant transmission from AC saying that they are in the go-around. I am not sure that even then they realized what a f-up had just occurred and how close they were to disaster. At least we have the FDR. They should be able to synchronize it with the ATC tapes to see exactly when the go-around was commenced.

Good reason to stick to ILS. ;)
If ILS out of service, the RNP would line you up with the runway.

Yes it is, done so many times. Workload is much lower on the FMS bridge however.

The crew were cleared for the FMS Bridge but of course at this time we don't know what approach they actually flew and how they did it.

I don't see the expected turns to/from F101D in the (admittedly sparse) ADS-B data from FlightAware.

I've also wondered if somehow they had the wrong approach in the box or were looking at the wrong one on their tablets? Did they build a path or incorrectly heal a discontinuity that gave faulty guidance on final?

Can you pull up the Quiet Bridge Visual on the A320 FMS? Will it give guidance on final?

Some earlier opinions:

You can see how much confusion there is on this thread about the two visual approaches to 28R with 'Bridge' in the name.

Since the dog ate the CVR tape, will the legacy FDR data show much about what was in the FMS?

Actually there was an accident three decades ago where an airliner taxiing for takeoff did swerve when seeing a commuting Eastern captain in an Apache coming out of the fog lined up on the taxiway. The Pan Am 727 moved enough to avoid a direct hit and took a glancing blow. The Apache was totaled with fatal results but everybody in the 727 evacuated successfully and the plane was repaired and flew again.

https://www.washingtonpost.com/archi...=.a2fbba62c493

I think the approach is actually this one: https://www.youtube.com/watch?v=LO12oGJPrPY

Seems they did select the correct approach, flew direct TRDOW to join before being cleared for the visual. This waypoint doesn't exist on the Quiet Bridge.

yup, not sure how one could confuse the two when they went to TRDOW. Non player to me.

Dumbfounded? I have listened, and am not dumbfounded.

You assert that you are "... not sure that even then they realized what a f-up had just occurred and how close they were to disaster" but are also surprised they made a supposedly nonchalant transmission? If, and this is a big 'if', it is true that the AC759 crew were still unaware of the disaster that had just been averted, why would you expect them to be anything other than calm? They can't be frightened by something they don't know has happened, surely? But I sincerely don't think that is going to be the case uncovered here.

As I indicated in my earlier post (#584), it is highly likely that UAL1's calls of "Wheres this guy going?" and "He's on the Taxyway!" brought things back into focus for AC759, with fear and embarrassment in equal measure in the following seconds. The radio conversation that ensues is:"In the go-around ..." implies that AC759 has already begun his go-around (as you state, the NTSB will undoubtedly be able to pinpoint precisely what was done and what was said, to the fraction of a second ...). If you currently believe AC759's reply transmission as "nonchalant", would you be willing to alternately consider it might be that, having been startled by UAL1s calls, the crew realised the enormity of what was unfolding, and were now working extremely hard not to let the emotions, fear almost certainly being one of them, overwhelm their recovery from the near disaster? They were 'boxing the chimp' and hanging on to their sensibilities - try a websearch for Dr Steve Peters and 'The Chimp Paradox' if you are not familiar with the term.

Whilst AC759's go-around reply is short and crisp, I beg to differ about it being at all "nonchalant"! I believe we will eventually learn that by then the crew did realise that a disaster had only just been averted, by the narrowest of margins, and they were desperately trying focus on recovering as calmly and professionally as they could, not making things any worse whilst they did so. Throughout the go-around and beyond, a nagging thought of "What the hell just happened?" would likely have been distracting them.

Despite the CVR loss, we are fortunate that there is still plenty of data available for the NTSB to reconstruct this serious incident, and we will learn in fine detail what went on and, hopefully, why. It seems clear that the crew of AC759 had a mental/viusal model that was disparate from what others involved could see, so it really is important to learn how and why they got there. As I declared in my earlier post, stop with the unnecessary character-bashing and rush to judgement - it isn't seemly without all the facts to hand. The NTSB final report will give us those.

If anyone is concerned I might be biased in favour of the AC759 crew, I am happy to openly declare my position:
1. I have no connection with Air Canada, or the crew members involved, whatsoever.
2. Neither do I have any connections to any of the other crew, SFO ATC, or the investigators.
3. I fly longhaul passenger aircraft, and have 38 years of professional flying experience.
4. I have operated in and out of SFO.

Now, stop being so bloody judgemental of the AC759 crew!

If I had to bet I would say that this incident started well before that. There is only one way that I can see that this occurred. The expectation of both pilots had to be that there would be a runway to the left of their final approach track and that they wanted the second one in. This expectation had to be pretty strong in order for "expectation illusion" to 'overpower' what they actually sensed when looking out the window.
It could have been a strong expectation because they had both flown into that airport at night from the East on many occasions, or because they briefed that that is what they would see, or both. Either way I can't see how it could have been such a strong expectation in both of them if they had read and understood the notam and the ATIS.
So when the report comes out ( and I may be wrong of course) , I think we will read that the nuts and bolts of this incident are to be found a long way prior to 3nm final.

Well said Deeceethree.