I'm sorry underfire, do you even understand what this diagram represents? The diagram shows a typical SOIA geometry, which has nothing to do with visual approaches like FMS Bridge! :ugh:

That DA on the top of the diagram is for the offset LDA PRM or equivalent, not for an RVFP. Just because FMS Bridge coincidentally has a similar left turn doesn't make SAMUL a DA!

And insisting that visual approaches have a DA just shreds your credibility on this topic.

SLUstu,

Except, in your industry, if you stuff it up, do you die along with the others?

No, it is the central tenet of almost all transportation safety boards around the world. It's also a major reason of why the NTSB was separated from the FAA (which does assign fault).

Besides, all US federal employees -- including NTSB investigators and board members -- already have "absolute immunity" against all torts when acting within the scope of their duties, except for violations of the Constitution or federal law (in which case they have qualified immunity, which may still protect them from litigation).

Nup.
Therefore in aviation incidents that should remove at least one hole from the swiss cheese - self-preservation. No?

No, but the point is the pilots don't go to work planning on dying. I was in military crash that killed to other pilot, neither went to work planning on a mid-air. The AC didn't either and proving criminal negligence should have a high standard of proof. We're human, just like you, and make mistakes, are subject to illusions, misinterpreted data or simple task and mental saturation. Those are not criminal offenses.

GF
Yegods, no one's raised the stakes to this extreme, yet. Though as I pointed out in an earlier post CA's top insurance lawmaker was none too pleased after learning why his AC579 flight did a sudden and weakly explained away GA.
My respect to you for suffering that horrifying event from your earlier flying.

Probably apocryphal, but there's the tale of the manager at IBM who screwed up and cost the company millions of dollars. He got called in to see the CEO and said "I guess you've called me in to fire me". The response was "Are you kidding? I just spent $30million teaching you a lesson."

What's the chance that either of those pilots, regardless of the reason they got it wrong this time, will make that mistake again?

liondel, how about taking it to the next level? Learning from others close calls & mistakes should be in our DNA
My hope is that there are many of us are now flying around with awareness of another potential "failure mode". I certainly am.

A punishment model is rarely the optimum method for imparting knowledge. Motivated professions learn much better when they seek to understand weaknesses in themselves and the system. A disciplinarian view of the world discourages this type of true evaluation in my experience.

Fix it. That's the aim that of most on this thread I imagine.
Firing the crew could be warranted I guess but what does it achieve? Almost nothing from a safety perspective. All the other crews remaining still have the same motivation not to crash as they did last week/ last month/ last decade.
Learning what factors lead to the mis-perception would greatly improve safety globally when the lessons were trained to tens of thousands of pilots through recurrent training programs.
It's easy to see reading this thread those who understand how Aviation achieved it's outstanding safety record and those who find comfort in the romantic notion that everyone up the pointy end is made of ' the right stuff'.

Far more importantly, and the reason that Old Carthusian is mistaken in his eagerness to can the crew, is that all other pilots can be taught the same lesson of why this incident occurred. A crew who believe that they may be summarily dismissed will do their best to gild the truth in a way that hides any mistakes they may have made and nobody identifies the hole in the cheese. Fine - now that leaves another crew to make the same mistake and this time they do land on a queue of widebodies - that major accident may not have happened if the first crew had not been under threat of dismissal for that same human misperception.

The only times when dismissal is merited is when it can be shown that an accident/incident was due to intentional mishandling or a gross lack of skill that had a level of history in training or in previous incidents.

SLFstu
 

The AC crew followed more or less standard practice that night.Until they got it wrong.
There is in my opinion something dramatically wrong with doing a visual at night without a ILS backup when available.
I do not expect you to understand this or the Old one, but at least he has a PPL.

The crew almost set a new record, then nicely pulled up for us to learn. And for AirCanada and FAA to get their stuff sorted.

I am disappointed with AC latest incidents and this crew was incompetent on this approach, but to fire them is not what we do.
Management in AC is not good and some should loose their job.

Finally SLF:
What profession do you represent that makes you think you can have a go at me.? On PPRUNE?
Seriously Dude.

IanW well said.

It is important for pilots to understand key failures learned in an event like this. In the real world of aviation, the follow up to such near hits is not always well thought out and applied by the powers that be. I too would very much like to know where our (multicrew) next signpost for error may be pointing.

Old Carthusian, your post is well timed but maybe not well informed. Perhaps you dont know what you dont know, yet. In a world where some believe our spheroid is still flat, it is important, however, to be reminded of our responsibilities. They do not diminish in actual fact, but do erode in our daily psyche. There are many posters here au fait with the aftermath of their own and others error's, perhaps they have experience that better qualifies their view where it differs from yours wrt the outcome for the AC crew?

It has been pointed out that you aviate. It would be reassuring to know that you, like other good aviators, are always trying to improve. Perhaps your short term path would benefit immensely from a wee study of aviation human factors, the behaviour of humans in complex systems. You never know, there may just be something gleaned that you can apply whether your shooting your next approach to a green lit taxiway or a grass runway.

Or, just look up 'wrong way Corrigan'. The truth may never come to light.

Remind us again which objects ran into other ones and how many lives were lost in this incident?

It's fine to try and make a point, but it usually works better if it has an ounce of relevance.

Certainly learning from the incident - why it happened is important. I would not deny that. However, what Ian W and Darkbarly miss I think is that any organisation needs to set limits. Things which cannot be accepted no matter what the excuse. Now I would submit that trying to land on a taxiway which is clearly marked with different coloured lights is one of those things. It is basic to being a professional isn't it?
I also note that the point I make about the possible consequences of the accident has been ignored. How many people might have died? How many died at Tenerife because the pilot didn't exhibit the required level of professionalism. In management one relies on both the carrot and the stick - the latter is used as sparingly as possible but it needs to be there because sometimes the motivational soft approach is not going to work.
This time they were lucky but it is unwise to tolerate this kind of incident. I would also remind you all of the 'Clipper Skipper' syndrome.

Organisations do set limits. The limit, in a modern airline with a Just Culture, is along the lines of wilful violations, gross negligence, and destructive acts. If an incident occurs due to a genuine mistake then dismissal is generally counter productive because all it does is foster a "cover it up" culture among the work force.

Trying to land on a taxiway is what happened. In order to determine whether the crew should be punished in some way, you need to find out why it happened.

If it turns out the crew said to each other, "hey look, there are four jets on C, lets give them a dust up!" Then absolutely, you fire them. If, on the other hand, they thought they were on 28R until it all clicked and they did the go-around, then no, you don't fire them. You try and find out what set of circumstances led them down the garden path, then you pass that information on to all the other pilots and airlines around the world in the hope we can learn something from it. If there is a procedure that can be changed to help prevent it happening again, then you consider changing it (I'm not a fan of changing procedures in response to a single incident unless there is evidence that similar incidents are likely to occur.)

I can't speak to the other transportation safety boards, but the NTSB's immunity from having to even testify was enacted by Congress. On your other point, the NTSB was never part of the FAA. The NTSB's function was previously handled by the Civil Aeronautics Board, which was also the parent agency over the FAA's predecessor agency, the Civil Aeronautics Administration (CAA). But, the NTSB wasn't within the CAA.

In 1958 both the FAA and the NTSB were created as independent agencies. A few years later the Federal Aviation Agency was folded into the Department of Transportation and became the Federal Aviation Administration.

Correct, but only NTSB employees are immune from being called to testify in civil litigation, which may result from a transportation accident.

as a pure S.L.F.
 

938 posts on this thread.

I wonder how many times the pilots and ATC have replayed the incident in their minds?

I should have originally written, "... a major reason of why the NTSB was separated from the DOT".

The NTSB wasn't created in 1958, but later in 1967 when the FAA was renamed and folded into the DOT. But back then, the NTSB was also (administratively) part of the DOT, which created some conflicts of interests.

So in 1974, the NTSB was separated from the DOT and became fully independent. The role of investigators to find probable causes of accidents and incidents -- instead of determining faults or to place blame -- is very central to NTSB's mandate as an independent safety board.

(As an aside, it seems that the Civil Aeronautics Board was never the parent agency of the Civil Aeronautics Administration either. Both were spun off from the Civil Aeronautics Authority.)

On possible administrative sanctions, if warranted, even the FAA may have limited recourse in seeking enforcement actions against the AC759 pilots since presumably the pilots only hold Transport Canada licenses and not FAA certificates. The FAA may refer possible violations to Transport Canada via the State Department and the Canadian Embassy; However, it would be up to Transport Canada to take matters further (or not).

Happens in Daylight as Well
 

At a certain Southern Ontario small airport, visiting aircraft often line up on the taxiway the first time in because it has more contrast to the terrain than the actual runway.

Illusions happen. At night much more often.

If it turns out the AC chaps failed to do a thorough briefing and missed the NOTAM, potentially increasing their chances for 28L/R confusion....is that grounds for dismissal?