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Originally Posted by Airbubba
(Post 9830172)
Here is the TSB Canada incident report with the estimates quoted in the media that AC 759 overflew taxiway C for a quarter of a mile before the tower called the go around and they missed the first two aircraft by 100 feet :eek:.
2 observations from this. I'm not being flippant, I am interested to know the purpose of the "unknown" fields in the document. Can the number of unkown injuries ever exceed zero? What exactly is this field used for? The part (I paraphrase) "The closest lateral distance bectween AC and any aircraft was 29 feet"... Is that distance between the wingtips or distance from cockpit to cockpit, do we also know whether this distance was between C and 28R or on the other side of C from 28R? looking at the photos and video of a landing on 28R at KSFO, you can see four or five sitinct red lights to the right of the frame, given that the aircraft had already passed "over" taxiway C, was the aircraft to the right and heading to these lights? |
Originally Posted by JumpJumpJump
(Post 9830271)
do we also know whether this distance was between C and 28R or on the other side of C from 28R?
http://www.avgen.com/ACA759(3).jpg Note that aircraft symbols on WebTrak are generic ones and not specific to type or to scale. |
https://www.flysfo.com/community/noi...ent-procedures
The tab above noise abatement also touches on the Bridge/FMS Bridge visual. |
TSB report and ATC tape differ. Interim report by NTSB within 30 days will be interesting.
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From NavCan.
TSB Report#A17F0159: C-FKCK, an Airbus 320-200 aircraft operated by Air Canada, was conducting flight ACA759 from Toronto, ON (CYYZ) to San Francisco, CA (KSFO). As the aircraft was on a visual approach to Runway 28R at KSFO, ATC cleared ACA759 to land. Approximately 0.6 nautical mile from the runway threshold, the flight crew asked ATC to confirm the landing clearance for Runway 28R because they were seeing lights. ATC responded in the affirmative, and re-cleared ACA759 to land on Runway 28R. The controller was coordinating with another facility when a flight crew member from another airline taxiing on Taxiway C queried ATC as to where ACA759 was going, then stated that ACA759 appeared to be lined up with Taxiway C which parallels Runway 28R. ACA759 had overflown Taxiway C for approximately 0.25 miles when ATC instructed the aircraft to go around. Four aircraft were positioned on Taxiway C at the time of the event. It is estimated that ACA759 overflew the first two aircraft by 100 feet, the third one by 200 feet and the last one by 300 feet. The closest lateral proximity between ACA759 and one of the four aircraft on Taxiway C was 29 feet. The NTSB is investigating. UPDATE: FAA Report: The following information was reported by FAA Washington Operations Centre: On July 7 at 23:56 PST (July 8 2017 at 02:56 EDT) Air Canada flight 759, an Airbus A320 from Toronto (CYYZ) to San Francisco (KSFO) was cleared to land runway 28R and instead line up for Taxiway C which is parallel to the runway. The aircraft overflew United 1 and Philippine Airlines 115 by 100 feet, United 863 by 200 feet and United 1118 by 300 feet before being issued a go around by Air Traffic Control. |
jack11111
How can one mistake 28 left is closed or not...there's a big lighted "X" on the threshold.
Originally Posted by Rozy1
(Post 9830173)
It's odd that it took 4 pages to mention this. Maybe it's done otherwise in the eu, but unless it was just closed seconds prior, the huge, lighted, white X would have been there.
At the threshold. Facing east. In these studies, observers engage in a continuous task that requires them to focus on one aspect of a dynamic scene while ignoring others. At some point during the task an unexpected event occurs, but the majority of observers do not report seeing it even though it is clearly visible to observers not engaged in the concurrent task The above paper includes the well known cognition experiment where a basket ball game is played back on video and observers asked to count the number of passes as the game goes on a person wearing a gorilla suit walks through the players across the screen - the gorilla is almost never noticed. I remember from a long time ago an incident where an aircraft taxiing taxied into a large red British post office truck lost on the taxiway - the pilot 'didn't see it' There are two effects here - something that is unexpected may be edited out by the cognition process in the brain that includes extra things happening or seeing things happen because they are expected to happen. So I expect to see 2 runways so I see 2 runways, I do not expect to see a large red cross - so I see no large red cross. Add to this the effect of workload on a challenging approach that tends to lead to 'cognitive tunneling' or fixation on particular tasks and it is unsurprising that what should be obvious is not. All of these effects are exacerbated by fatigue and circadian stress making them far more likely. It is really worth reading the two references and other similar references to understand what can _and_will_ happen to you. It is important that ANSPs also realize that reliance on 'large red flashing crosses' will not work. Indeed the more attention getting it is the more likely the brain is to edit it out like the gorilla in a basket ball game. Therefore, the ANSPs that insist that the tower verbally reinforce the warning that the runway configuration is different have got it right - all of a sudden the red-cross is expected and it will be seen. Don't fly into any gorillas :ok: |
The TSB and FAA reports are subtly different.
The TSB reports that the aircraft had overflown Twy C for around a quarter of a mile at the point when ATC instructed a GA. The FAA state that the A320 had passed over all four queuing aircraft before being told to GA. That may or may not amount to the same thing, although if FR24 is to be believed there was about 0.4 miles between the first and last queuing aircraft at the point where the ACA flew over (UAL1 was just about to turn the corner towards the threshold and UAL1118 was just past the November link). That aside, given that both reports confirm the A320 was already climbing by the time it overflew the third aircraft in the queue, it's clear that the GA was instigated by the pilot before the ATC instruction was given. That's consistent with the ATC recording: SFO Tower: "Air Canada, go around." ACA759: "In the go around. Air Canada 759." |
Ian W,
You speak great sense. Whether or not the illusions you describe are applicable in this incident, it behoves all pilots to study the types of visual illusions that can occur when flying. Take a look at this:- https://www.youtube.com/watch?v=IGQmdoK_ZfY |
Considering these three things:
1) From his remarks, the pilot was observing Charlie closely - seeing what he believed was traffic on that "runway". 2) Images were posted earlier in this thread of roughly what might be seen from the cockpit. Those images should have made the runway situation very clear to the pilot. 3) Before the go around was issued, the pilot had already overflown a quarter mile of runway. I don't see an easy explanation for this. But here is my best guess: On first siting of the runways, at long distance, the pilot mis-identified Charlie as 28R. He also saw traffic on that runway. From that point on, he was focused on the status of that traffic. In his mindset, it was more important to resolve the traffic issue that to further peruse the overall runway pattern. (Per a previous post, he wasn't looking for the guerrillas.) At a certain point on his approach, he decided that the traffic might not resolve in time for his landing - so he informed the tower of the traffic - and was recleared for the landing. He have had a rapidly improving view of the traffic of Charlie - so it is unlikely (or impossible) at that point that he would have resolved to land. Quite the contrary, he must have been very alarmed at the tower response. It probably indicated to him that they were completely unreliable. By the time the other craft alerted the tower of the Charlie approach, 759 had no intention of landing and the go around was already in progress. But at that point, he still had a problem: he didn't not know what clearance the other traffic on "28R" (ie, Charlie) had received or would soon receive. So his close approach to the runway was likely intentional - for the purpose of keeping his avoidance options open and to see and be seen. |
Originally Posted by .Scott
(Post 9830614)
So his close approach to the runway was likely intentional - for the purpose of keeping his avoidance options open and to see and be seen.
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By my guess: It was intentional in the sense that he had a plan for avoiding traffic - and was following it fairly accurately. And the plan was formulated well before he reached the runway threshold.
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Scott As a non pilot but former flight engineer your speaking gobbly gook. From what I've read his intention was to land plain and simple.
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roybert
I believe that human minds do not work "plain and simple" in order to fly safely. I support the issues mentioned by Ian W above. |
The crew were lined up with the wrong 'runway' crossing the threshold. Went around successfully. Corrected pilot error. Mitigating circumstances TBD.
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Originally Posted by .Scott
(Post 9830614)
But at that point, he still had a problem: he didn't not know what clearance the other traffic on "28R" (ie, Charlie) had received or would soon receive.
However they were all too close for comfort... So his close approach to the runway was likely intentional - for the purpose of keeping his avoidance options open and to see and be seen. |
Originally Posted by portmanteau
(Post 9830410)
TSB report and ATC tape differ. Interim report by NTSB within 30 days will be interesting.
Does the NTSB issue an interim report within 30 days? |
Before the go around was issued, the pilot had already overflown a quarter mile of runway.
Whether the GA was pilot induced or ATC induced is a debate. The above statement/report causes me a question. (Thanks to those who posted the diagrams. Early in the post there were people talking about 28L, 28C & 28R, I thought. My mistake, as we now see C is to the outside of 28R and not between.) The threshold 28R and the beginning of taxi C are side by side; or is there a heavily displaced rwy threshold. I've asked what was the PF using for glide path guidance. If it was the ILS 28R then the LLZ deviation should have alerted PF & PM: if it was the PAPI then they are on the left edge of 28R. If AC overflew the taxiway for 400m BEFORE the GA, and at a low height, and if they were on the correct glide path to land the correct distance in, it suggests they flew level for 3-400m. That in itself is an odd manoeuvre. I've missed something earlier. how far down the taxiway were the holding a/c? Were they taking full length or an intersection? If the AC initiated the GA at 100', but after 400m down the taxiway, where was the touchdown aiming point? And at that point the holding a/c must have been very visible. What happens in USA after an incident like this? Is there an immediate debrief of the crew on site by an FAA or airport official? I'm assuming they night-stopped; is that correct? |
Originally Posted by Airbubba
(Post 9830745)
How do the TSB report and ATC tape differ?
Does the NTSB issue an interim report within 30 days? Do we know whether the NTSB is even looking at this SFO incident? |
Originally Posted by RAT 5
(Post 9830793)
Whether the GA was pilot induced or ATC induced is a debate.
The threshold 28R and the beginning of taxi C are side by side; or is there a heavily displaced rwy threshold. If AC overflew the taxiway for 400m BEFORE the GA, and at a low height, and if they were on the correct glide path to land the correct distance in, it suggests they flew level for 3-400m. Were they taking full length or an intersection? |
Clearly a serious incident but clearly not the first crew to have done it. Quite a few US airports have multiple parallel runways and wide taxiways that can be confused (Las Vegas springs to mind). Confirmation bias of seeing only 1 lit runway to the left. Not all runways have approach lights and centreline lights so a taxiway can look a bit like a runway. The ILS probably wouldn't be tuned as think it's an RNAV type approach.
In some ways I find it harder in daylight into a setting sun to distinguish runways and taxiways, especially as the lights are hard to see then. San Diego has a centre stripe down the middle of the runway which is a different texture which makes it look like a taxiway until you see it has another section either side. The newest Boeings have RAAS which tells you what you're lined up with on final approach and would warn you if lined up with a taxiway, so technology is catching up. |
Originally Posted by Propellerhead
(Post 9830831)
" . . .so technology is catching up."
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I wonder if it would be feasible to change the taxiway lighting plan to have the letter T formed by sets of lights along taxiways? That would require adding lights to the existing lights so that the letter T was clearly visible to landing pilots (don't head for tea might be the motto).
Different rates of flashing might also assist with the colour code clearly not doing the job with 100% effectiveness. I intend these suggestions for all airports not just SFO. Final suggestion, some change to the take-off-ready light signals from waiting aircraft. Pilots would soon get used to the different look of taxiways and this might prevent an accident like this near miss. What if the lighting appeared like this? L L ]] T T L L :: T T L L :: T T L L :: T T or even flat ground-level electronic signs embedded in ground at runway and taxiway end points saying RUNWAY and TAXIWAY in large enough script to be readable from half a mile ... only pilots flying could see these, no visual distraction to aircraft taking off. Should give enough warning to go around even if nobody else is aware. (or make a lane change) :hmm: |
Instead of thinking of new runway lighting layouts, which would induce a huge financial layout. Is there any merit in simply not turning the lights out on a closed runway? There seems to be a lot of speculation with regards to the possible illusions this Crew may have seen..... If both runways were lit, these illusions would most likely have been mitigated.
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@trw
if anything i'd rather have flashing leadin lights for every runway. way easier to implement ... |
@trw
There is already a huge difference in runway lighting vs. taxiway lighting. This is even more obvious at night. Not sure how you can confuse them but it's obviously possible. |
It's been done literally hundreds of times in the US alone.
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Well if the regulators deem it a big enough threat then it could be mandated that all air transport aircraft be fitted with RAAS or equivalent. Of course that costs the airlines money.....
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I assume the CVR will be the biggest clue here, even if NTSB are the only people to listen to it. That ought to capture the decision-making process in the cockpit, when the crew had the first WTF? moment and when they decided it was going pear-shaped and hit the TOGA button.
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I don't understand how you can line up on a taxiway with blue lights, narrower, and no approach lights, instead of a RUNWAY with white lights, center-line lighting, wider, and approach lighting which the crew would have reviewed before landing...?
And after they were told there's no other aircraft on the runway, is there no lightbulb moment flashing? There doesn't seem to be anything in the thread about how long they had been flying/on duty, fatigued, or at the end of a stressful day. Anyone have info on that? |
..... the old saying... there are two types of pilot..... those that have never [insert] those that will [insert] ...........
...... there will be another gear up landing in the next 6 months |
What I don't understand is that both of the FC must have had a unhappy feeling to say the least. Why not GA at that time? Same for ATC!
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It is surprising how easy it is to misperceive what is right in front of you. Sometimes, even the obvious is not obvious. When under a high workload, or under stress, you perceive what you want to see regardless of the visual evidence.
I think that many aviators have experienced this, usually without a bad result. There are many tricks that can be used to help you but, in the hurly-burly of the real world it is not always easy to apply them. I think we should wait until the aviation psychologists have had something to say about this one. |
Originally Posted by aterpster
(Post 9830807)
Do we know whether the NTSB is even looking at this SFO incident?
Originally Posted by Airbubba
(Post 9828922)
Don't know about the TSB but the NTSB is certainly going to take a look:
@NTSB_Newsroom NTSB investigating last Friday’s incident involving an Air Canada Airbus A320 at San Francisco Airport. 5:58 AM - 12 Jul 2017
Originally Posted by RAT 5
(Post 9830793)
What happens in USA after an incident like this? Is there an immediate debrief of the crew on site by an FAA or airport official? I'm assuming they night-stopped; is that correct?
My guess is that after midnight Friday evening you're not going to have a lot of feds in the SFO office even if a report was immediately filed. The tower probably filled out an incident report but it may not have been seen until Monday morning when the media started calling about reports of the incident based on radio transmissions monitored by 'ham radio operators'. United 1 may have typed up a report on the way to SIN and filed it with the company but I would be surprised if it got much attention outside the airline over the weekend. The Air Canada 759 pilots may have called ops, grounded themselves, fessed up to a near horrific mishap and waited to be deadheaded back to base on another carrier. Or, they may have filled out a couple of CYA safety reports and operated back to YYZ over the weekend before anyone noticed.
Originally Posted by llondel
(Post 9830934)
I assume the CVR will be the biggest clue here, even if NTSB are the only people to listen to it. That ought to capture the decision-making process in the cockpit, when the crew had the first WTF? moment and when they decided it was going pear-shaped and hit the TOGA button.
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You guys who drive are missing the point that only you can clarify - as OldLurker pointed out, these guys were fixated on an unreal situation and it has happened before. It most likely has to do with fatigue or just being up at the wrong bio-cycle. How is it possible to fixate on a situation and not take in the evidence? How did Comair Lexington happen? How did Air France remained stalled for 38,000 feet? I can't believe that among 3 experienced pilots, no one understood how to recover from a stall. Has anything similar ever happened to one of you?
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Originally Posted by wingview
(Post 9830958)
What I don't understand is that both of the FC must have had a unhappy feeling to say the least. Why not GA at that time? Same for ATC!
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CVR
There is no excuse whatsoever for what these two chaps did and they better have preserved the CVR.
We need it to understand how it was possible and prevent other incompetent crew doing the same. And for now : No more night visuals. It is rather simple. They could not do the basic task of identify the rwy. Give me a break. They were about to possible triple the standing world record of aviation fu..ups. Sorry for not being all cudely and understanding about this. There has to be limits. |
Originally Posted by Ian W
(Post 9830561)
jack11111
It would really do everyone a lot of good to read about visual perception and visual cognition. Our brains invent a huge amount of what we think we are 'seeing' much of the time our eyes are scanning around but the brain uses the informaiton from the balance system to edit out the movements of the eyes (see http://thebrain.mcgill.ca/flash/caps...e_movement.pdf ) (See http://www.drjoebio.com/uploads/1/8/..._our_midst.pdf ) The above paper includes the well known cognition experiment where a basket ball game is played back on video and observers asked to count the number of passes as the game goes on a person wearing a gorilla suit walks through the players across the screen - the gorilla is almost never noticed. I remember from a long time ago an incident where an aircraft taxiing taxied into a large red British post office truck lost on the taxiway - the pilot 'didn't see it' There are two effects here - something that is unexpected may be edited out by the cognition process in the brain that includes extra things happening or seeing things happen because they are expected to happen. So I expect to see 2 runways so I see 2 runways, I do not expect to see a large red cross - so I see no large red cross. Add to this the effect of workload on a challenging approach that tends to lead to 'cognitive tunneling' or fixation on particular tasks and it is unsurprising that what should be obvious is not. All of these effects are exacerbated by fatigue and circadian stress making them far more likely. It is really worth reading the two references and other similar references to understand what can _and_will_ happen to you. It is important that ANSPs also realize that reliance on 'large red flashing crosses' will not work. Indeed the more attention getting it is the more likely the brain is to edit it out like the gorilla in a basket ball game. Therefore, the ANSPs that insist that the tower verbally reinforce the warning that the runway configuration is different have got it right - all of a sudden the red-cross is expected and it will be seen. Don't fly into any gorillas :ok: Had this incident happened to a non western carrier, the amount of scorn and racial insinuations would have been thunderously deafening! ' nuff said. |
CVR, Safety Management, & Facts
1. Precise and verified (as verified as possible) facts are not yet in hand - hopefully NTSB as well as TSB will produce. Sorry to be repeating a forum cliche in this sense. Yet this seems to need to be said, not so much because of various differing emphasis by knowledgeable posters about technical details - rather more due to a basic divergence, with some tending to take a view that "the system worked" (my paraphrasing) even despite evidence that the point of collision-no-return was looming imminent - or so it seems. Report, or Reports, we need these.
2. If. If the CVR could have been ditched - and I deplore, hate and loath having to imply fault or blame on the aviators - but IF they made things so that the CVR evidence no longer is available....wow. Big problem. If I were Civil Aviation Czar for a week, I'd get an immediate amendment to anything and everything to prevent this from taking place again (the CVR tamper, I mean). |
JumpJumpJump
Here is the TSB Canada incident report ... Thanks for the document AirBubba. I'm not being flippant, I am interested to know the purpose of the "unknown" fields in the document. Can the number of unkown injuries ever exceed zero? What exactly is this field used for? Currently, in the UK, there are investigations of a terrible fire in a London block of flats that destroyed the building - the number of deaths will only ever be "At least nn" because no one knows who was there and some bodies will be far beyond recognition. |
airbubba, by now you will have seen the posts between mine and yours. The impression given by ATC is that they instructed 759 to go around while still on the approach (thus averting a calamity). Not so according to TSB who say 759 was already overshooting and had passed over 0.25 miles of Twy C before ATC issued their go around call. Thus 759 was at least in control of his recovery actions. No criticism of ATC, theres not much else (useful) that you can say to an aircraft climbing out over a crowded taxiway.
Re expected report. We have been here before, Emirates, Lamia etc. Dont tell me the US does not comply with ICAO annex 13? Overshooting runway is an investigatable event and a Preliminary report ( not Interim) is mandated within 30 days. It won't apportion blame as per usual, just the facts , man. This is no ordinary overshoot of course and we would all really like to know how it came about. |
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