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As PJ2 rightly suggests, Transport Canada has not addressed the issue of fatigue in any serious way. I would add that this is just one manifestation of a much larger -- and very serious -- issue of civil aviation oversight in Canada. Put succinctly, Transport Canada is no longer funded, or even structured, in a way that ensures adequate safety levels and regulatory oversight in Canada. I`ll go even further and assert that Transport Canada is no longer meeting its mandate and obligations, under Canadian statutes and under its ICAO obligations.
There are many reasons but the two primary underlying causes are: 1. Resources. TC has been in a `death spiral` for many years. Example: Serious underfunding has led to too few inspectors to meet TC`s own schedule of surveillance. The added workload on those on that front line has led in turn to morale being lower than the Mariana Trench, which has led to further resignations and early retirements, which has led to even higher workload, which has led to TC reducing and even eliminating its mandated surveillance activities. And on and on and on. So, given that TC does not have the resources to meet its primary role and first responsibility, what do you think it`s doing about addressing issues like fatigue – and the multitude of other serious safety issues and concerns raised by CTSB, users, service providers, unions, ICAO, the public, etc.? Nada… 2. Structure. Transport Canada is NOT an independent, autonomous Civil Aviation Authority, as recommended (strongly) by ICAO, and as most countries have. TC is simply another department of the (Canadian) federal government. A few of TC’s areas of responsibility include: civil aviation, motor vehicles, railways, shipping and marine transportation, etc. As ICAO rightly asserts – and the experience of many countries attests – without an independent autonomous CAA, aviation safety issues are just another budget item for another branch of another department of a huge federal bureaucracy. Canada’s international reputation as a model of civil aviation safety is based on a philosophy, a structure, a commitment and an entity that existed in Canada in the late 20th century. That is all gone. Transport Canada’s logo should be the setting sun (an Avro Arrow disappearing into the sunset would be a nice touch…) |
Originally Posted by PukinDog
(Post 9836345)
A thorough briefing where both pilots pay attention to detail in order to emphasize correct and critical focal points is the primary tool/measure used by a crew to prevent blowing-it, minimize unworthy distractions, or being suckered in by illusion. Doing so purposely creates for the crew their own set of preconceived notion as to what the correct picture the approach and landing should look like. A proper briefing uses current, published information and NOTAMs, discusses what's to follow, and sets expectations/limits. It discusses what aids will be used to shoot the approach, what to expect and look for, what is to be confirmed, and limits set to wave themselves off the approach if they aren't met. SOPs are written so crews cover many of these things by following them....
Obviously, they didn't align themselves correctly when they transitioned. But how were they supposed to pick the correct string of lights way out there in the distance? Well, 28R has charted, visual lighting aids specifically designed and calibrated for that purpose; ALSF-II and PAPI. They're both designed to be seen from miles away for use by a crew to 1) visually align themselves with the centerline of the runway (ALSF-II) and 2) visually join the correct vertical path that within a given distance ensures obstacle clearance down to near the Touchdown Zone (PAPI). Given the existence of an ALSF-II and PAPI for 28R, let's start by throwing out the notion held by many that a visual approach at night to 28R is unreasonable or unsafe if it's based on the idea there's no ground-based guidance to use or back oneself up with if bog-s***t FMS equipment doesn't allow that back up to be an electronic ILS. ALSF-II and PAPI are ground-based guidance aids for 28R. Their existence should be noted, looked-for out the windscreen, and used for their intended purpose. Even in a briefing for an Instrument approach, the type of ALS is noted and visual sighting while on the approach itself prompts a callout. Just because this was an FMS approach to a long visual segment doesn't negate the need for reviewing and emphasizing the ALS for 28R. The fact it's a visual approach segment doesn't negate the need for the crew to verbally confirm when these visual guidance aids are acquired visually. On the contrary, the fact that the FMS portion of the approach doesn't align the aircraft with the centerline should only raise awareness and emphasize the visual aids' existence and the need to notice/confirm them. Again, it's what they are for; visually acquiring and guiding oneself to the runway. However, everything so far about the flight in question (ground track, altitudes, ,transmission) suggests the crew was oblivious to the existence of an ALSF-II and PAPI on 28R because, as it happened, they visually acquired, lined-up on, and overflew Taxiway C which has neither. As someone asked before, with the nearest PAPI being on the opposite side of RWY 28R from their position, what was this crew using for vertical path guidance for miles during the visual segment until reaching Taxiway C? Also, in addition to RWY 28L's closure being NOTAMed, 28L's approach light system, a MALSR (not an ALSF-II, which is the only ALS they would have seen that night), was also NOTAMed OTS. If the crew mistook Taxiway C for RWY 28R and RWY 28R (with it's operating ALSF-II blazing away to their left) for 28L, this suggests no review of current NOTAMS that could (and did) directly affect their operation and lack of knowledge (or review) regarding Approach Light System configurations. . Good points PD. Briefings are routinely interfered with by the real world, and are not infallible. Having a standardised process is of some value, however, that also fails when there is interruption. On lighting, I agree on the merit of briefing all of that, to the extent of what type of lighting, PAPI or VASI, is it asymmetric (L or R) etc. The downside is that every brief takes one crew member out of the loop, and the second crew member is in effect being distracted form monitoring by the brief itself. Correlation of brief with programming is a great method, but that works when tactical changes don't occur in close. The 'Bus display logic is annoying in the constraints on LS, compared to a Boeing, where you can track one thing and display another, and have different setups on either side.That has it's own set of issues but it is not a bad way of doing business. HUDs remove the problem in general, however I was involved in investigating a HUD equipped aircraft that landed on a taxiway, so there are always ways of getting hurt. HUD's become problematic in strong crosswind conditions where the lateral viewing angle may not show the track and target information well. As long as taxiways are parallel to runways, planes will get into strife. The current best tool in my kit is the foreflight moving map, that consistently will give a reliable guide of position vs the runway. The Boeing EFBs were good, but only when you were taxying. In this day and age, the FMS programming of approaches still leaves lots to be desired; It would be reasonable to have a legs programmed that actually is what you intend to fly, not abbreviated just when things get interesting by the G/A procedure taking it's place. The systems today comprehend a G/A occurs on large jets, by the selection of TOGA, at which point the G/A procedure should be active, but until that point, there is no need for it to be taking precedence over the actual approach to the actual runway that is intended. For aircraft without ATR or GA modes, then a sensed GA could be determined where descent alters to climb for a period of time or a minimum period of time/alt gain. If we continue to remove ground based nav aids, then the irritations that are inherent on the Airbus LS/FMC data for these types of approaches becomes moot. Again, Boeings have tried and succeeded in landing on the taxiways, so a better solution should be considered to the issue. |
Let's not forget the Phoenix payroll fiasco where many civil servants are being under- or over-paid.
If over-paid you can be asked to return the entire amount, but Canada Revenue Agency received a big chunk of that overpayment and it will take a bunch of paperwork, time and effort to get that money out of their claws:sad: Any other employer would long ago have been taken to a labor tribunal and ordered to pay up pronto. Is it any surprise that a bunch of Transport Canada staff have departed to other employers:} |
Originally Posted by RatherBeFlying
(Post 10264134)
Is it any surprise that a bunch of Transport Canada staff have departed to other employers. |
NTSB Report Issued
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Originally Posted by Zeffy
(Post 10271542)
And I have to add that this level of investigation used to occur in Canada as well, but (sadly for aviation safety) the Canadian TSB is not the agency it once was. If this incident had occurred at Toronto, Montreal or Vancouver the resultant report by the Canadian TSB would have been a short ineffective report after a shallow investigation. Grizz |
Canadian TSB is not the agency it once was. If this incident had occurred at Toronto, Montreal or Vancouver the resultant report by the Canadian TSB would have been a short ineffective report after a shallow investigation. |
Both crewmembers recalled reviewing ATIS information Quebec but could not recall reviewing the specific NOTAM that described the runway closure. Multiple events in the National Aeronautics and Space Administration’s aviation safety reporting system database showed that this issue has affected other pilots, indicating that all pilots could benefit from the improved display of flight operations information. |
Notams and their presentation to airline crew have a lot to be desired. If the incident is used as a wedge to move into 21 century, an applause would be due. But are we surely not wagging the dog here?
My best judgement is that the crew knew rather well they should be landing on the starboard side the deck, and that's exactly what was almost achieved. The notams change might be a win, but without shining the light on the real cause, the job of preventing the next occurrence has not even started. |
Originally Posted by FlightDetent
(Post 10271793)
The notams change might be a win, but without shining the light on the real cause, the job of preventing the next occurrence has not even started.
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The report raises the "need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use" and seems to focus on a more conspicuous X marking, and the ludicrously antiquated NOTAM which goes without saying. It seems the DAL521 FO's recommendation to ATC to "turn on the lights for RWY 28L" would have averted this incident. But that seems to have been overlooked in the report as a strategy. The other thing I don't understand in that respect is the DAL521 captain stated that the sequenced flashing lights were not operating on 28R. The report covers the incidence of runway lighting colouring being mistaken in other incidents, and talks about the possibility of aircraft lighting being mistaken for runway lighting. Despite all that, the report rules out airport lighting as a factor in the incident stating it was compliant with regulations. It seems to me airport lighting is a significant factor in this incident. The report quite rightly talks about expectation and confirmation bias but it seems the lighting aspects have not been given adequate emphasis. It's hard to imagine this incident would have occurred if 28L lights were on and 28R sequenced flashing lights were operating.
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Originally Posted by bud leon
(Post 10272011)
The report raises the "need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use" and seems to focus on a more conspicuous X marking, and the ludicrously antiquated NOTAM which goes without saying. It seems the DAL521 FO's recommendation to ATC to "turn on the lights for RWY 28L" would have averted this incident. But that seems to have been overlooked in the report as a strategy. The other thing I don't understand in that respect is the DAL521 captain stated that the sequenced flashing lights were not operating on 28R. The report covers the incidence of runway lighting colouring being mistaken in other incidents, and talks about the possibility of aircraft lighting being mistaken for runway lighting. Despite all that, the report rules out airport lighting as a factor in the incident stating it was compliant with regulations. It seems to me airport lighting is a significant factor in this incident. The report quite rightly talks about expectation and confirmation bias but it seems the lighting aspects have not been given adequate emphasis. It's hard to imagine this incident would have occurred if 28L lights were on and 28R sequenced flashing lights were operating.
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Originally Posted by aterpster
(Post 10272078)
Nonetheless failure to use available lateral guidance is a lot higher on the fault tree than any confusing lighting.
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How can someone confuse a taxiway lighting with a runway lighting ?
Is there a proper reconstitution of what the pilots saw that night ? My guess, before reading the report, is that both of them had a busy schedule and were fatigued. Fatigued enough that they forgot how a runway looked like. |
Originally Posted by JayMatlock
(Post 10272250)
My guess, before reading the report, is that both of them had a busy schedule and were fatigued. Fatigued enough that they forgot how a runway looked like.
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Originally Posted by aterpster
(Post 10272078)
Nonetheless failure to use available lateral guidance is a lot higher on the fault tree than any confusing lighting.
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Originally Posted by DaveReidUK
(Post 10272343)
Let us know what you think once you have read it.
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. |
Originally Posted by JayMatlock
(Post 10272423)
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
The NTSB, doing what they do, have made some recommendations on how this all might have been avoided. Hopefully some will be adopted, but the record of NTSB recommendations being put into FAA regulations has not always been stellar. |
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/ |
Originally Posted by JayMatlock
(Post 10272423)
My opinion remains that a runway IS clearly distinguishable from a taxiway at night.
Your opinion is a bit moot actually because these competent pilots did not clearly distinguish the taxiway from the runway. The visual clues were not strong enough and the poor implementation and existing deficiencies of a number of safety barriers led to the incident. It's a very informative case of human factors and multiple root causes. |
Originally Posted by JayMatlock
(Post 10272423)
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. |
Originally Posted by jurassicjockey
(Post 10272527)
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/ |
Originally Posted by fdr
(Post 10272608)
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. You're going on and on about theoretical concepts but please.. Let me show you the illustration in the report https://i.gyazo.com/ef35b018638a0d55...1970a499ef.png 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. |
JayMatlock My opinion remains that a runway IS clearly distinguishable from a taxiway at night. 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. |
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. |
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. “My opinion remains that a runway SHOULD BE clearly distinguishable from a taxiway at night.”? |
Originally Posted by JayMatlock
(Post 10272886)
Plus there were other cues, visual or instrumental. The crew should have expected a taxiway to the right of the runways. |
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?) https://cimg1.ibsrv.net/gimg/pprune....1b3c3c0a39.jpg |
Originally Posted by underfire
(Post 10282702)
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?) 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. |
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
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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. |
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 |
Originally Posted by Underfire
Other drivers had no problem landing.
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 |
Originally Posted by underfire
(Post 10282954)
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
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. |
Originally Posted by underfire
(Post 10282954)
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
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? |
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! |
Originally Posted by underfire
(Post 10282954)
Other drivers had no problem landing.
Or do you expect hundreds to crash at the same time and place? |
Originally Posted by spoon84
(Post 10283428)
it was really obvious which was the RWY and which one was the TWY
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Runway identifiers
Originally Posted by 787PIC
(Post 9826847)
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! |
Originally Posted by msjh
(Post 10283460)
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"
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. |
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