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-   -   Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO! (https://www.pprune.org/rumours-news/596900-near-miss-5-airliners-waiting-t-o-taxiway-c-sfo.html)

787PIC 11th July 2017 01:16

Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
 
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!

nolimitholdem 11th July 2017 01:40

*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.

CHfour 11th July 2017 01:44

FAA investigating after incident at SFO where Air Canada flight nearly landed on taxiway | abc7news.com

Airbubba 11th July 2017 02:28


Originally Posted by nolimitholdem (Post 9826855)
*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.

Well, the Air Canada 759 folks asked why they saw lights on the runway. :eek:

The discussion starts at about 25:40 into this clip:

http://archive-server.liveatc.net/ks...2017-0630Z.mp3

An edited transcript from the news article linked in the previous post:


AC759: "Tower, just want to confirm. This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?"

SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."

"Where's this guy going? He's on the taxiway," the other pilot said.

SFO TOWER: "Air Canada, go around."

AC759: "Going around. Air Canada 759."

SFO TOWER: Air Canada looks like you were lined up for Charlie there. Fly heading 280. Climb maintain 3,000."

AC759: "Heading 2-8-0, 3,000 Air Canada 759."

UA001 PILOT: "United One, Air Canada just flew directly over us."

SFO TOWER: "Yeah, I saw that."
Nothing close to a disaster? Breathless nonsense? Well, a little close for me... :eek:

AC 759 was an A320 from YYZ. The other aircraft lined up on C behind UA 1 were PR 115, UA 863 and UA 1118. A lot of beacons.

There was a discussion on the thread about the Air Canada YHZ crash that implied that the AC A320's didn't have updated avionics. Was that a player here? Did they have a map shift that lined up perfectly with the taxiway? Obviously they knew there weren't supposed to be planes on the runway but they sure didn't seem to catch the error in time if they overflew United on the tower called go around.

Usual caveats, we mustn't speculate, a report will be out in a year or two, Harrison Ford will be called as an expert witness etc...

pattern_is_full 11th July 2017 02:33


What breathless nonsense.
Breathless - agreed. AC pilots did question their clearance and what they were aiming for.

But...


In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not.
It has happened before: https://en.wikipedia.org/wiki/USAir_Flight_1493

But at SFO, the runway has a honking big array of approach lights, and the taxiway does not. I'd find it hard to confuse one for the other, even more so at night.

Perhaps a database error? EDIT: I see that idea occured to airbubba, too.

hitchens97 11th July 2017 03:45

Was the ILS out?

jack11111 11th July 2017 03:57

Brings added meaning to the phrase, "see something, say something".

Airbubba 11th July 2017 04:42

1 Attachment(s)
From the SFO noise monitoring web page a comparison of the tracks of AC 759 on the go around and a few aircraft that landed in the preceding minutes:

Looks like they indeed nailed the taxiway for the line up. :eek:

Airbubba 11th July 2017 05:28

Hard to figure how this could happen on a visual approach at night...


Exclusive: SFO near miss might have triggered ‘greatest aviation disaster in history’

By Matthias Gafni | [email protected] | Bay Area News Group

PUBLISHED: July 10, 2017 at 3:18 pm | UPDATED: July 10, 2017 at 9:06 pm

SAN FRANCISCO — In what one aviation expert called a near-miss of what could have been the largest aviation disaster ever, an Air Canada pilot on Friday narrowly avoided a tragic mistake: landing on the San Francisco International Airport taxiway instead of the appropriate runway.

Sitting on Taxiway C shortly before midnight were four fully-loaded airplanes full of passengers and gas awaiting permission to take-off, according to the Federal Aviation Administration, which is investigating the “rare” incident. An air traffic controller sent the Air Canada Airbus 320 on a “go-around” — an unusual event where pilots must pull-up and circle around to try again — before landing safely, according to the federal agency.

FAA investigators are still trying to determine how close the Air Canada aircraft came to landing and potentially crashing into the four aircraft below, but the apparent pilot error already has the aviation industry buzzing.

“If it is true, what happened probably came close to the greatest aviation disaster in history,” said retired United Airlines Capt. Ross Aimer, CEO of Aero Consulting Experts. He said he’s been contacted by pilots from across the country about the incident.

“If you could imagine an Airbus colliding with four passenger aircraft wide bodies, full of fuel and passengers, then you can imagine how horrific this could have been,” he said.
Exclusive: Air Canada near-miss at SFO sparks FAA probe

DaveReidUK 11th July 2017 07:00

Screenshot from SFO WebTrak. The parallel track is the same aircraft landing after the GA:

http://www.avgen.com/ACA759.jpg

Heights shown on WebTrak systems are usually AAL, corrected for QNH and to the nearest 100', though that may not be the case for SFO.

ironbutt57 11th July 2017 07:14

interesting to know if the approach lights and localizer were functioning

eckhard 11th July 2017 07:45

Maybe the ILS and approach lights for 28L were OTS. The AC crew saw the lights for 28R, mistook them for 28L and then approached the illuminated strip (TWY C) to the right of 28R, thinking that was 28R?

Similar thing happened at Gatwick in the late 80s(?). A BIA BAC1-11 actually landed on TWY J instead of RW08L. RW08R was closed but the crew saw the bright approach lights for 08L, assumed they were still on for the closed runway and mistook the dim taxiway lighting for RW08L. There was another aircraft taxiing out for departure at the far end but he/she made a rapid exit when they saw the 1-11 flaring for landing right ahead of them!

The tyre marks were visible on the taxiway for months afterwards.

ORAC 11th July 2017 09:16

From the transcript it is obvious the Air Canada crew could see the aircraft where they planned to land - that's why they asked ATC the question about them. From that point there was no danger of collision; even if ATC didn't order the go-round at some point the crew would have. Unless you think they would have thought, "what the hell, lets just land on top of them anyway.

ACMS 11th July 2017 10:11

Still, in 2017 this should not happen.

ironbutt57 11th July 2017 10:39

Unless you think they would have thought, "what the hell, lets just land on top of them anyway.

no, but they might have come a lot closer before they realized it...good thing the guys on the taxiway were watching and saw it...yah wonder how much further they would have gone without the comment from the crew on the taxiway

DaveReidUK 11th July 2017 10:41


Originally Posted by ORAC (Post 9827161)
From the transcript it is obvious the Air Canada crew could see the aircraft where they planned to land - that's why they asked ATC the question about them. From that point there was no danger of collision; even if ATC didn't order the go-round at some point the crew would have. Unless you think they would have thought, "what the hell, lets just land on top of them anyway".

Doubtless true.

But nevertheless satisfies a criterion for a "serious incident" per Annex 13:

"5. Landings or attempted landings on a closed or engaged runway, on a taxiway or unassigned runway"

FIRESYSOK 11th July 2017 10:47

'Twas night? Someone posted an altitude plot that read 200'. How tall are those 787 tails? How low do the undercarriage hang?

atakacs 11th July 2017 11:13

As others I'm pretty sure they would have not landed on top of the waiting aircrafts on the taxiway.

A more sinister scenario would have been for the taxiway to be empty up until the very last moment.

altiplano 11th July 2017 11:41

FMS bridge visual 28R is an offset approach which requires you to maneuver to the centerline.

It's very obvious which is the runway there, particularly on a clear night.

I can't imagine they were going to land on an aircraft. Again it's obvious where the runway is there. They were probably just not all the way over to the left yet and the go around was initiated with an abundance of caution.

wiedehopf 11th July 2017 12:10

i'd assume as someone already said lighting for 28L was off and they thought 28R was 28L and TWY C was 28R.

check this youtube video for reference: https://youtu.be/O3LTYeZrzH8?t=218

and here is a youtube video with approach lights for both runways on:
https://www.youtube.com/watch?v=MnzNvhQxu90


to be honest the taxiway lights are quite bright but still ...
can't imagine them landing on the strobes of the other airplanes.
on the other hand if you are sure that this is the runway and the tower says it's clear it's not far from disaster.

Ian W 11th July 2017 12:18


Originally Posted by eckhard (Post 9827063)
Maybe the ILS and approach lights for 28L were OTS. The AC crew saw the lights for 28R, mistook them for 28L and then approached the illuminated strip (TWY C) to the right of 28R, thinking that was 28R?

Similar thing happened at Gatwick in the late 80s(?). A BIA BAC1-11 actually landed on TWY J instead of RW08L. RW08R was closed but the crew saw the bright approach lights for 08L, assumed they were still on for the closed runway and mistook the dim taxiway lighting for RW08L. There was another aircraft taxiing out for departure at the far end but he/she made a rapid exit when they saw the 1-11 flaring for landing right ahead of them!

The tyre marks were visible on the taxiway for months afterwards.

Almost certainly this was the scenario. A visual approach cleared to land on 28R and ahead are two lit strips the left one must be 28L so the right hand one is 28R got manky lighting on it though... and are those lights work in progress on the runway? Ask tower to confirm cleared for 28R

See this incident at Gatwick :
"(i) Runway 26R was clearly visible throughout the approach but the pilots looked for and selected a pattern of lights to the right of it because they assumed erroneously that 26R was in fact 26L and they knew that the designated runway had to be to the right of this. "

https://aviation-safety.net/wikibase/wiki.php?id=147090

It seems that there is a recurrent human factors problem when a clearance is to parallel runways the crew will attempt to identify both (all) runways and therefore which one to land on. If the airport for whatever reason has lights off or dimmed on the other runway but visible brighter lighting on the parallel taxiway then crews who do not fly regularly to that airport may become confused.
Unfortunately, this has become more apparent with LED lighting where blue and green lights can appear white at a distance at high brilliance. (As in the case of a Delta 767 at ATL).

It is easy to dismiss these errors as inattention or stupidity but faced with what is effectively an optical illusion many crews have made mistakes. It is still happening so perhaps more needs to be done. From a report 10 years ago:

"As of August 23, 2007, 267 such events have occurred at 110 airports in the United States."
From: http://www.airtech.tc.faa.gov/safety...ds/TN07-54.pdf
DOT/FAA/AR-TN07/54
IDENTIFICATION TECHNIQUES TO REDUCE CONFUSION BETWEEN TAXIWAYS AND ADJACENT RUNWAYS

MATELO 11th July 2017 12:45


Originally Posted by altiplano (Post 9827313)

I can't imagine they were going to land on an aircraft. Again it's obvious where the runway is there. They were probably just not all the way over to the left yet and the go around was initiated with an abundance of caution.

Nope, they confirmed it..

AC759: "Tower, just want to confirm. This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?"

dave.rooney 11th July 2017 13:02


Nothing close to a disaster? Breathless nonsense? Well, a little close for me...
On my first solo there was a runway incursion while I was on short final. I saw it, queried my landing clearance with the tower (I was indeed cleared), and decided to go around. I'm betting that, even if the tower didn't issue a go-around order, the pilots who have a little more than my 12-14 dual hours at the time would have decided to do the same.

Granted an A320 moves a little faster than the Katana I was in. :)

JumpJumpJump 11th July 2017 14:33

Do we know what height the GA was initiated at?

DaveReidUK 11th July 2017 14:37

Wider view showing where the ACA intercepted the taxiway extended centreline:

http://www.avgen.com/ACA759(2).jpg

San Mateo bridge in bottom RH corner.

fleigle 11th July 2017 14:48

Seems obvious that they were flying the visual and got confused, but queried and all ended well.
Last flight of the day, how many legs had they done that day?
Phew !

Airbubba 11th July 2017 15:12

Here is an edited clip of the tower audio:

https://soundcloud.com/user-66001055...esy-liveatcnet

They were cleared for the dreaded FMS Bridge Visual approach to 28R.

Wind was given as 270/8 when AC 759 was cleared to land, nothing unusual.

momo95 11th July 2017 15:30


Originally Posted by nolimitholdem (Post 9826855)
*sigh*

In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not. ATC may have ordered a go-around but that doesn't mean the AC crew hadn't already noticed their error. If the aircraft on C were waiting to take off they would have been at the threshold end and clearly visible.

It certainly wasn't anything close to a disaster. An embarrassing, recoverable error if true, at most.

Ignoring the AC crew noticing their error, say the taxiway was empty ... at what stage would they have noticed their error?

I'm more interested in your statement i put in bold. In light of the articles posted above, where this has happened at night before, at a large international airport no different to SFO ... what evidence are you using to back your claim that this can never happen? I'm genuinely interested

RAT 5 11th July 2017 15:53

A visual approach cleared to land on 28R and ahead are two lit strips the left one must be 28L so the right hand one is 28R

Just thinking about approach/landing briefs & TEM. Is 28C a landing runway? If that's the case, and it's included in the brief, then identifying 28L means the next one over is 28R doesn't fit the briefing. Surely 28C would have been mentioned.
Also, from a crew behaviour point of view I'm assuming they would not have briefed a visual approach from TOD and not set up an FMC approach. I'm assuming SFO has a preferential takeoff & landing combination; therefore if 28L is preferential takeoff rwy, it follows on that 28R is preferred landing rwy, and the FMC would have been programmed and briefed before TOD. Being short cut to a visual still leaves the MAP programmed for 28R.
I'm not familiar with SFO or A320, so please correct my assumptions as necessary. Someone also asked about the status of ILS on 28R. If it was on, and I assumed tuned, it would have showed some deflection. Were both heads outside all the time? PM duties etc?
Regarding the lights of a/c at night: in EU strobes are normally only used on the runway not holding. Thus perhaps only taxi lights & ACB's were showing. Amidst all the runway & taxiway lights a/c become hidden, especially from above. Remember the accident at LAX when a B737 landed on top of a Metroliner. When NTSB flew the approach they could not see the Metroliner hidden within the runway lighting. It's not that easy, seeing a/c, and you can believe your eyes are playing tricks. The brain has been programmed by ATC that is clear and you believe you're where you are supposed to be. I'm sure a GA would have been made by the crew eventually, but probably at a low height when it all suddenly became abundantly clear with a huge "WTF Go Around" call.

DaveReidUK 11th July 2017 16:05


Originally Posted by momo95 (Post 9827554)
In light of the articles posted above, where this has happened at night before, at a large international airport no different to SFO

Apropos the above: from the report on the 1988 incident referred to in post #13, showing the final positions of the two aircraft involved:

http://www.avgen.com/aar%202-1989.jpg

The One-Eleven (on the left) having come to a stop at the end of its ~950m landing roll on the taxiway and the 737, which had been taxying for takeoff, with both mains bogged down in the grass in an attempt to get out of the path of the oncoming aircraft.

Airbubba 11th July 2017 16:48


Originally Posted by RAT 5 (Post 9827572)
A visual approach cleared to land on 28R and ahead are two lit strips the left one must be 28L so the right hand one is 28R

Just thinking about approach/landing briefs & TEM. Is 28C a landing runway? If that's the case, and it's included in the brief, then identifying 28L means the next one over is 28R doesn't fit the briefing. Surely 28C would have been mentioned.

Somehow, I don't think they mentioned 28C in the brief. At least I hope they didn't...

PeetD 11th July 2017 16:49

Dumb SLF here so apologies. If my car can know if it is wandering out of the lane I'm driving on, there must be a technical solution to an aircraft being say, 50m left or right of the track it should be on for the runway rather than the taxiway? Why does aviation seem so slow in adopting better technical solutions to the problems in front of it? Coloured lights (imperfect, as pointed out further up this chain) do seem a bit yesterday?

Feathered 11th July 2017 16:50

Not true, nolimitholdem
 

Originally Posted by nolimitholdem (Post 9826855)
*sigh*

What breathless nonsense. In visual conditions there's no way anyone's landing on an occupied strip of pavement, night or not.

A similar attitude led to 35 people dead, 29 seriously injured on February 1, 1991 at LAX. In this case, the "occupied strip of pavement" was runway 24L. The "occupant" was a Skywest Fairchild Metroliner, and the aircraft landing on the "occupied strip of pavement" was a US Air Boeing 737.

The key difference in that case was ATC cleared the 737 to land on 24L while the Fairchild was also cleared to position and hold on 24L. But yes, a professionally piloted aircraft landed on an "occupied strip of pavement" with tragic results. Thank goodness for the go around instruction by ATC this week at SFO.

fleigle 11th July 2017 17:04

There is no runway 28C at SFO, there isn't enough room for 28L and R on IFR approaches, which is why SFO gets to be really slow in the summer when the fog is in.

costalpilot 11th July 2017 17:22


Originally Posted by FIRESYSOK (Post 9827249)
'Twas night? Someone posted an altitude plot that read 200'. How tall are those 787 tails? How low do the undercarriage hang?

scary rather than a ho hum go around, i would say.

a story went around back in the day that a certain Captain in our regional airline landed on one end of a taxiway in Atl one night, picked up the mike and asked the tower why another aircraft was on the other end of the active runway. then the other pilot said: "I wasnt going to say anything Southern, but you just landed on the taxiway." the story sounded like something the Sou pilot would have said,(in character). if it happened. dont think it made hard copy. not sure.

otoh, I will never forget seeing two stretch 8's in exactly the same attitude on the same runway in the midst of a moderate rain shower, one landing, one taking off, both otg with the same pitch up.

it was eerie. no one said a word.


also I was on a runway holding for TO at a SFla. airport one VFR day and a C-150 flew fight over me and landed down the runway.

gasbag1 11th July 2017 17:40

I might suggest inexperience with SFO is a major factor. There are many AC pilots who read a route Brief on the airport but it doesn't give you all the answers or information. Also the Airbus managed descent for the arrival usually leaves the aircraft high and many pilots are distracted in getting down and slowing down usually getting stabilized between 1000 and 500 ft.

After the Asiana incident I thought the ops in SFO would have the landing runway ILS operating. Hard to ignore the localizer, or may be not.

clareprop 11th July 2017 18:06

Whatever is written or said, what really matters is was whether this was a normal end to a flight. Yes...Fugetaboutit.
No...press and media are going to town.

EGLD 11th July 2017 18:10


Originally Posted by altiplano (Post 9827313)
FMS bridge visual 28R is an offset approach which requires you to maneuver to the centerline.

It's very obvious which is the runway there, particularly on a clear night.

I can't imagine they were going to land on an aircraft. Again it's obvious where the runway is there. They were probably just not all the way over to the left yet and the go around was initiated with an abundance of caution.

I dunno what scares me more these days, the utter incompetence of pilots entrusted with the lives of their passengers, or their colleagues tendency to attempt to gloss over incidents like this as minor trivialities

They weren't merely not quite lined up, they'd been lined up for a while

And they didn't initiate a go around with an abundance of caution, they were instructed to go around to save from landing on several large fully fuelled aircraft

WHBM 11th July 2017 18:28

The Gatwick landing on the taxyway (actually the relief taxyway alongside the regular one) actually happened twice, the BIA One-Eleven described above, and then later I believe it was an Air Malta 737.

In all these cases there are multiple closely parallel runway/taxyway combinations (three at Gatwick, four it seems at SFO), it happens at night, and heading for the runway on one side, they head for a taxyway further over on that side. Had the SFO runway lights over on 28L been switched off for any reason ? This was what had happened at Gatwick. If you know there are two parallel runways, you are landing on the right hand one, you see from several miles out just two parallel lines of lights, actually the right hand runway and its associated taxiway, you can start to see it.

If I recall SFO correctly, the two closely parallel runways are commonly both used together for simultaneous landings, and also takeoffs, in the "use everything together" style common in the USA but not so much elsewhere. So you might expect two lit runways.

I'm sure that an airport like SFO has superb lighting. In fact the general taxyway illumination is quite likely more brilliant than the runway lighting at some other points the crew encounter on the network, approach lights apart, where the runway is just passable and the taxyway pretty thin viewed from the air.

ZOOKER 11th July 2017 18:52

Looking at the various videos, (both day and night), of the 28R approach available on line, if the full approach lighting system was serviceable and switched on, it's astonishing that this could have happened.
This incident will obviously act as a 'heads-up' for this potential confusion. If both of the 28 approach light systems are routinely displayed simultaneously, a line of eastward-facing HI reds, across the seawall, adjacent to where the building is, while not a high-tech solution, might prevent a similar occurrence.


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