But that's not the question being asked.

The question being asked is could a controller with great training and deep experience have given a different initial response to a confused arriving aircraft, if time pressures on that controller were relaxed?

"Go around" is supposed to be safe. Safe enough at least that this controller subsequently issued it.

"There aren't any aircraft on the ground where you think you see them" isn't supposed to be safe.

So without suggesting blame, why was that response issued instead?

You are taking a screen shot BEFORE 28L was closed. You are aware that 28L was closed, correct?
Aside from that, are you expecting to believe that 28L was active for approach in the image that you provided? That aircraft would be on approach, near parallel, and yet no guidance on 28L?
http://i.imgur.com/SFnkGeh.jpg

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.


http://i.imgur.com/0GeMXqL.jpg



You appear to conflict with your own statement...do YOU see the approach lighting for 28R?

http://i.imgur.com/ZkDQqD0.jpg

Very simple question....Is there any reason, even for you, or anyone....to line up on the taxiway?

Where would you land?

I'm really late to this party
 

I have looked at many of the posts here, and looked at the approach plates for the Quiet Bridge Visual and the ILS to 28R.

For whatever reasons, they lined up on the taxiway instead of 28R.

Being from the "old school", but having used some of the most modern EFIS, I wonder why no one had at least raw data displayed with the ILS tuned and inbound heading set.

That would have alerted them of their visual mistake.

That picture was only to debunk your repeated assertion that:

You're fixated in asking the wrong question. The fact is, two experienced and presumably well trained pilots from a major North American airline tried to land on the taxiway. The question is: why?

That the active runway looks so obvious at night in comparison to the taxiway -- by design -- only deepens the puzzle of why this incident happened. We want to get to the root cause so we can attempt to prevent other incidents in the future.

Your mantra to simply "blame blame blame" the pilots contribute nothing to safety.

The thread is indeed long but take another look. The Air Canada crew was cleared for the FMS Bridge Visual to 28R, not the Quiet Bridge Visual. See earlier posts on why you might not find the FMS Bridge Visual in your Jepps.

And, as explained in previous posts, the ILS is not normally tuned on this approach in an A320 since there is FMS guidance to the runway and it is difficult to display raw ILS data in the 'bus without switching approach modes.

Thanks
 

Thanks. I went back and reviewed. Have a great day.

And, as explained in previous posts, the ILS is not normally tuned on this approach in an A320 since there is FMS guidance to the runway and it is difficult to display raw ILS data in the 'bus without switching approach modes.

Are you now saying the FMC guided them to the wrong runway/taxiway? I don't think you mean that, but as I've said, the FMS, no matter what kind of 'Bridge' approach they flew, brought them to a point where they then would took over visually to align themselves with the landing terrain. People have said they were not GPS equipped, so there could have been map-shift perhaps, but either way the last 4nm was visual alignment. If they did not have an ILS tuned, then they had PAPI's and full runway + approach lights for visual guidance.

There is still a mystery, and we are churning this around and around. Surely by now there are enough known facts from the crew, AC & FAA to publish a definitive report. There were no deaths and everyone is available to state their case. Have I missed it, or has an interim/final report been published. Sorry if that is the case.

Peekay4 : your question reminds me of something I read long ago : It was something like this : : !!!! happens for no reason sometimes. One day you do something irrational and no-one can understand why you did it, including yourself "
Fixation , fatigue, light hypoxia, mental distractions, micro-lapses, are for instance things you cannot measure with certainty , especially a posteriori.
Maybe it is one of these, maybe not.

As someone said, the crew is available and surely will be debriefed , but I bet you lots of beers that the PF will say : "I really thought we were aligned with the runway" . An where do you go from there ?

PF will say : "I really thought we were aligned with the runway" . An where do you go from there ?

You ask the PM what they thought & were doing.

Airbubba...FMS bridge visual final waypoint is on the extended runway centerline. (unlike quiet bridge visual which is not) They COULD have had the ILS tuned to check.
Map shift or not, the procedure is visual from 4.4 DME

I am not certain if it is common practice, but when flight validating RNP procedures, as a check, the #2 seat is tuned to the ILS to backcheck the alignment, so it is possible.

I agree...but. The pilots have, according to the prelim NTSB report, denied they saw aircraft on the taxiway, in fact, they denied being on the taxiway. They did not secure the CVR. They came within inches of aircraft sitting on the taxiway. As there was 'no incident', there was no mandatory substance test.

Would one expect the 2 drivers to be at least stood down pending the findings?

There is still a mystery, and we are churning this around and around. Surely by now there are enough known facts from the crew, AC & FAA to publish a definitive report. There were no deaths and everyone is available to state their case. Have I missed it, or has an interim/final report been published. [/QUOTE]

Good on yer, RAT5, I hope I got your handle right, and that I don't get kicked out on probation for incompetent quoting technique.

Even if there are no PhD rocket scientists currently available to work on this file, there is NO WAY it needs to take the customary 1 to 2 years for a credible investigation report. A really thorough, competent report on this near tragedy would be of tremendous benefit to countless people involved in aviation, both airborne and groundbound, but especially for younger pilots coming up. Even now, with few "details", it it appears to be a compelling example of a "there, but for the grace of God, go I" type of story.

It seems to me that this is an (unenviable) opportunity for the pilots involved to transition from (apparent) zero to hero if they summon all of the courage and integrity they have, and bare their souls to the investigators. Under the circumstances, few of us, myself included, would likely have the guts to do that, but I for one would deeply admire them if they got everything out into the open to help educate all of us about what not to do, and about what to watch for, both externally, and within ourselves.

I'm neither a pilot nor a controller, but I'm 60 and I put in 37 years at QFE at a northern Canadian airport doing work that many controllers seemed to regard as being inferior, (but not the ones who had paid their dues themselves in the North).

That is assuming the pilots involved understand what went wrong. Perhaps they do not. If in their minds they did everything right, followed the correct approach, and only suddenly at the last moment saw they were on the taxiway, they may have no explanation for what happened. If they then go through the procedures they followed on the night of the incident, they will end lined up on the runway, because that's where they expected to be, and thought they were.

There is another waypoint, RW28R, on the chart, take a look. The FMS will provide path guidance between F101D and RW28R which may be faulty in what we think is a pre-GPS A320.

I heartily agree :ok:, this is a visual segment and any flight director or autoflight guidance should be strictly advisory.

Here are some earlier explanations on why A320 pilots normally don't have ILS raw data displayed on this approach:

I remember the admonition from a sim instructor in an A306 type rating course years ago: 'Use Rose Mode if you really want to get f***ed up on the approach!' ;)

za9ra22, your comment is a thoughtful one, but if the AC crew listened to the ATIS, they would have known that a "visual anomaly" was in place, and they logically would have been concerned about it, and would have briefed about it. For all of you pilots out there, if it's any consolation to you, it's even more mind numbingly mundane to record an ATIS than it is to have to listen to them. Plus on every one you record (mine - and I did thousands - were all non-digital), you had to go back and listen to yourself drone through the whole thing each and every time for quality control. Much like a pilot boo boo, it's easy to make a mistake on an ATIS if you're tired or distracted . . .

I have the answer. They were looking for the gorilla and forgot to keep their eye on the ball.

(for those not in the know it means a long search back)

I assumed one knew the differenece between the waypoint on the beginning of the final segment, and the runway endpoint (which defines a segment.) oi vey.

All of that explanation is why you only have this selected on the #2 system (ie copilot) as a backup.

This is not an RNP approach...it is RNAV visual.

Also, you will note on most RNP charts, glidepath is not coincident, so of course, you may get a noise.

I can see where you don't know enough about flying a plane to understand the explanations above from the A320 drivers. It's kinda technical.

I can see why you cannot understand that I was saying the exact same thing....you can do it, and it is not that technical, I do it all the time. As I stated, that is for flight validations, not in the commercial environment.

Pretty damning article...

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.

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.

Editorial: Air Canada, FAA hindered probe of SFO near-miss

I'm not a pilot, just an idiot academic PhD.

The interesting question seems, what would you see on approach *if you are lined up wrong*, not if you are lined up right. And whether by the time the pilot flying took his eyes off his instrument scan and looked out the window, tired after a long flight, his angle of visual awareness may have been reduced due to fatigue or blood sugar issues.

Also, I have a feeling there might be more to this story; some distracting factor, some approach lighting issue ... the usual holes in the cheese lining up. As someone here commented two pilots with decent vision did line up on a taxiway, and it shouldn't be possible.

Edmund

I find it hard to believe either the FAA or AC hindered the investigation at the outset. It was in middle of the night, if the crew didn't report it and the lone ATCO, busy with duties, didn't report it until shift change, the plane was probably being readied for departure before there was any hint of an incident. In the morning, the AC flight leaves for YYZ or YUL, bingo, no CVR recording. If anything is suspect, it is the crew's failure to report and trip the CVR circuit breaker. I'll admit it is possible they missed it all on the first approach, but I doubt a sentient crew didn't pick up their mistake on the second approach. Light bulbs had to be going off.

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. Their simple answers implies a " cover up" on their part that can't be uncovered now.

GFK

That's not exactly what the investigative report says:

What's missing is the context behind these statements. When during the first approach? On short final? Just prior to the go around? Even after the go around?

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."

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.

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. The tower controller had switched everyone else to the tower freq a few minutes earlier.

And, the CVR tape was regrettably overwritten, just as it has been in many similar cases over the years. An honest mistake, right? ;)

Seems a bit unlikely... if the tower called the company presumably the caller would've left his/her name and phone number for the callback.

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.

In this case, why didn't the captain act to prevent the CVR from being overwritten? If he called the tower, in request or own volition, clearly it was a significant incident. Earlier, it was stated the CAR 700 series requires action to preserve the CVR post serious incident.

GF

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.

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 .

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 ...

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.

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?

The article makes no specific claim about additional sources that I could see, so I am going to assume that they have about as much information as PPRuNe has found.

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.

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.

Maybe not as it was happening, but it's hard to avoid the conclusion that very soon afterwards all the parties involved would have been perfectly aware how potentially serious the incident had been.

The United crew might beg to differ.

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.

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.

Would have been interesting to hear the CVR from United and PAL! They were straight for PAL and only missed them by 3 feet of less....that must have been quite the conversation on the flightdeck.

UAL did report them on the TWY to the tower.

sure, there are all sorts of visual clues to land on the twy....

Interesting? Sure.

Useful to the investigation? Nope.

I seriously doubt that. 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. But they were low, granted.

Ahh, sorry folks for the delay, we went around due to traffic at the airport
 

Disclosure: not a pilot, nor a reporter or a media sympathizer, just a dude from downunder.

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.”

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?

That is correct, but we don't know with certainty that it was a 30 minute CVR.

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.

Really, you mean like trying to figure out why the 2 drivers were lined up on a taxiway, when there is absolutely no reason for that to occur at night with all of that lighting? According to the NTSB, they claim they were on the runway, and didnt see any aircraft. Perhaps the CVR would have shed some light on that.

The NTSB report showed the FDR data, when the began to climb, at the lowest point was 59 feet. That was after PAL aircraft whose tail is at 56 feet.

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.