Air Canada approached taxiway at SFO

KCAccidental

Saw there in the report that Air Philippines pilot threw on his landing lights as a last ditch effort to signal the Air Canada plane. Must have been some soiled jocks in a couple of cockpits!

smurfjed

The Philippine Airlines crew demonstrated excellent situational awareness, but it was also reported that the AC crew didn't see these lights.

The ILS was off the air, but why didn't they "follow the magenta line". From my limited exposure of flying with American pilots (yes, I know AC is Canadian), they love visual approaches even when not required, and yet that is the country that appears to have the highest number of landings at wrong airports, is there a correlation?
It also appears that the CVR was overwritten due to the amount of time between the incident and engine shut down, so we may never learn what actually happened in the cockpit.

plodder

duskyjoe wrote: »

I am sure Norcal Tracon will get a mention in the NTSB final report. They are the controlling agency of all aircraft into SFO until 10nm from the threshold. SFO approaches are notorious for getting vectored onto final approach above the standard descent profiles to ensure separation on tight parallel approaches plus sequencing ......I wonder with all that in mind, at night and the ILS28R off the air that evening( I think) did all the holes line up on the Swiss cheese model with disorientation for the crew involved? Where they ended up circa 60ft above other aircraft on the taxiway below can only summarised as frightening.

As a passenger flying in there, I often wonder how they manage it, with three big airports around the bay, and numerous other small airfields.

cuterob

Those AC pilots are getting the sack I'm sure after this

Look in this article at the photo from it, how did they not realise sooner is beyond me

http://abc7news.com/ntsb-say-air-canada-flight-at-sfo-came-just-feet-from-taxiway-/2270588/

plodder

cuterob wrote: »

http://abc7news.com/ntsb-say-air-canada-flight-at-sfo-came-just-feet-from-taxiway-/2270588/

abc7news wrote:

It's a very rare occurrence for pilots to actually lock onto a taxiway at night versus the runway because taxiway lights are blue and runway lights are white," said ABC News Aviation Analyst John Nance.

I wonder if the blue taxi-way lights could have been obscured by the lights off the taxiing aircraft? Also, the parallel runways are very close, which must limit the kind of approach lighting they can use. Though looking at the video above, there is a very bright strip pointing to the centerline of the runway. How could they have missed that?

According to the report, the AirCanda flight was so off course that it hit a blind spot in the airport's radar system for 12 seconds. The radar system should have alerted air traffic controllers the aircraft was not where it was supposed to be.

Blind spot in the radar? That wouldn't fill me with confidence..

smurfjed

Those AC pilots are getting the sack I'm sure after this

Do you think that they should be sacked?

plodder

I wonder did they think that the approach lights for 28R were off and they were looking at the lights for 28L?

Van.Bosch

plodder wrote: »

I wonder did they think that the approach lights for 28R were off and they were looking at the lights for 28L?

I saw that theory elsewhere - seems plausible but I would hope there are better systems than "I usually land on the second set of lights from the left"

plodder

Van.Bosch wrote: »

I saw that theory elsewhere - seems plausible but I would hope there are better systems than "I usually land on the second set of lights from the left"

I think it's more like what would the standard procedure be if the approach lights for the runway you want to land on (at night) are off? I'm sure pilots can tell us, would that be allowed at all? If it's allowed then surely it could lead to this happening and if it's not allowed why were they trying to do it?

1123heavy

Baylee Melodic Windjammer wrote: »

Hopefully the investigators won't have such a narrow minded view and will look at ensuring it doesn't happen again.

You see, as much as you may find the statement in the article unsettling, he isn't really wrong.

SMS is a system whereby if even one of those holes in the cheese can be shut off - it is deemed to have worked. We didn't have an accident - the system worked. Did we come mighty close? Absolutely, however, SMS philosophy now is to look at what happened and to take steps to ensure those particular steps are mitigated to the best of everyone's ability in future. However this does not mean something like this will never happen again, nor can anything ever guarantee that we will never have a particular event again. There are an unlimited amount of holes that can develop in every slice of cheese and at every point on it.

The key thing that SMS aims to achieve is as deep a safety philosophy as possible, however, it will never, ever be 100% accident-free. So telling the public that a particular thing won't ever reoccur would be an unfounded promise. Telling the public that we have implemented a system that ensures that the risks of any particular tragic incident are vastly mitigated is actually the truth.

Looking at this incident, we came mighty close again as mentioned. However, it did not happen. That is a success for the system. Now the system dictates that we look at the events that lead to this close occurrence, and what each organisation can do in order to stop the holes that developed earlier on in the cheese layers.

Buffman

thomasj wrote: »

Surely ATC would have had radar etc

o At 2355:46 PDT, when ACA759 was about 0.7 mile from the landing threshold and about 300 ft above ground level (agl), the flight crew contacted the ATC tower, mentioned seeing lights on the runway, and requested confirmation that the flight was cleared to land.

o As ACA759 approached SFO, at 2355:52 PDT, the airplane flew too far right of course to be observed by the local controller’s ASDE-X/ASSC and was not visible on the ASDE-X/ASSC display for about 12 seconds.

o At 2355:56 PDT, when ACA759 was about 0.3 mile from the landing threshold, the local controller confirmed and recleared ACA759 to land on runway 28R.

Without wanting to be a 'Captain Hindsight', a possible missed opportunity for ATC to call for an earlier go-around here.

plodder wrote: »

I wonder did they think that the approach lights for 28R were off and they were looking at the lights for 28L?

Van.Bosch wrote: »

I saw that theory elsewhere - seems plausible but I would hope there are better systems than "I usually land on the second set of lights from the left"

In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.

That seems to be their explanation.

smurfjed wrote: »

The Philippine Airlines crew demonstrated excellent situational awareness,

Ye, they did well, from looking at the photos the third plane further down the taxiway (a UAL 787) also switched on its lights.

smurfjed wrote: »

The ILS was off the air, but why didn't they "follow the magenta line". From my limited exposure of flying with American pilots (yes, I know AC is Canadian), they love visual approaches even when not required, and yet that is the country that appears to have the highest number of landings at wrong airports, is there a correlation?

Yep, there seems to be a number of avoidable incidents occuring with visual approaches, taxiway landings, wrong runways, wrong airports. Asiana Airlines Flight 214 was on a visual to 28L when it crashed.

1123heavy wrote: »

SMS is a system whereby if even one of those holes in the cheese can be shut off - it is deemed to have worked. We didn't have an accident - the system worked. Did we come mighty close? Absolutely,.......................

Looking at this incident, we came mighty close again as mentioned. However, it did not happen. That is a success for the system. Now the system dictates that we look at the events that lead to this close occurrence, and what each organisation can do in order to stop the holes that developed earlier on in the cheese layers.

I do get where you're coming from and agree that lessons have to learnt from this, however I think saying the system 'worked' in this case is lessening the seriousness of it. IMO this was beyond close, the system got very lucky.

The A320 went around from 85 ft agl, and reached 59 ft agl before climbing. If one of the aircraft it overflew was an A380 (79 ft high) instead of the lower 787s and A340, I don't think the system would have worked.

plodder

Buffman wrote: »

That seems to be their explanation.

Interesting. There's a simulation of the approach at the link below. Looks like some of the details aren't correct, but it gives a good sense of how they didn't start the go around until they were over the first a/c on the taxiway. So, they descended quite a bit further and the lowest point appears to be between the second and third in line. Scary stuff.

https://www.youtube.com/watch?v=ydUqfhNqUIc

smurfjed

I cant see how this can be an indication that the SMS worked, in fact i would see this as exactly the opposite that the system didn't work and only by fluke the crew elected to to a baulked landing due to a "feeling".

Buffman

plodder wrote: »

Interesting. There's a simulation of the approach at the link below. Looks like some of the details aren't correct, but it gives a good sense of how they didn't start the go around until they were over the first a/c on the taxiway. So, they descended quite a bit further and the lowest point appears to be between the second and third in line. Scary stuff.

https://www.youtube.com/watch?v=ydUqfhNqUIc

Ye, I saw that simulation before and yes, I think it's timings are slightly out in comparison to the NTSB data.

nsa0bupkd3948x

1123heavy wrote: »

You see, as much as you may find the statement in the article unsettling, he isn't really wrong.

SMS is a system whereby if even one of those holes in the cheese can be shut off - it is deemed to have worked. We didn't have an accident - the system worked.

Just because there wasn't an accident doesn't mean the system worked.

To me, a near miss being avoided as a result of a TCAS warning is evidence the system works.

An accident being avoided by non standard actions such as turning on landing lights to try and get the attention of a landing aircraft, or a pilot asking on ATC "Where's this guy going? He's on the taxiway" is not proof the system works.

Van.Bosch

plodder wrote: »

Interesting. There's a simulation of the approach at the link below. Looks like some of the details aren't correct, but it gives a good sense of how they didn't start the go around until they were over the first a/c on the taxiway. So, they descended quite a bit further and the lowest point appears to be between the second and third in line. Scary stuff.

https://www.youtube.com/watch?v=ydUqfhNqUIc

If the lowest point was between 2nd and 3rd, imagine being in the cockpit of the 3rd plane.

1123heavy

smurfjed wrote: »

I cant see how this can be an indication that the SMS worked, in fact i would see this as exactly the opposite that the system didn't work and only by fluke the crew elected to to a baulked landing due to a "feeling".

That's not quite what happened, far from. A balked landing is when the aircraft touches down and then lifts off again. This aircraft, whilst coming close, did not touch the ground and he wouldn't have even been in the flare stage at 60ft AGL.

Just because there wasn't an accident doesn't mean the system worked.

To me, a near miss being avoided as a result of a TCAS warning is evidence the system works.

An accident being avoided by non standard actions such as turning on landing lights to try and get the attention of a landing aircraft, or a pilot asking on ATC "Where's this guy going? He's on the taxiway" is not proof the system works.

You do not have access to what was happening on the flight deck and what systems were in place that prevented this.

I assume you are aware that an aspect of SMS may consist of something as simple as instructing crew that if they feel anything is off whatsoever they either query it or just go around. If you listen to the recording, the AC pilots themselves were the first ones to pick up something may have been wrong and so they queried it and took the necessary action to GA before being told to do so, and they copped something was wrong and prepared for a GA even before the United pilots said anything.

If that procedure was what saved the day, then the system worked. You may not like how close it came (no one does), but this is aviation. We have to learn from it and see how we can do our best to not get that close again.

The truth is that nobody here has any access to what was said, what procedures were in place by the airline that may have prevented this, even the crew themselves (they're receiving a fair beating but people are forgetting they were the first ones to cop their mistake).

Whilst it is sort of de rigeur for most forums to speculate and be judge and jury as well as the prosecuters when things like this happen, the fact of the matter is that we know nothing. So to be saying with such conviction the system did not work, when in reality we have no access as to exactly what it was that may have blocked that final slice of cheese is a bit baseless.

Wait until the report and then point fingers.

nsa0bupkd3948x

1123heavy wrote: »

Wait until the report and then point fingers.

I have not pointed any fingers and I haven't said categorically the system didn't work. My point was that just because an accident didn't happen, doesn't mean we can conclude the system worked.

I think we both agree there are obviously lessons to be learnt from this event.

I believe you cannot state the system is safe as Zwingle did just because there wasn't an accident. That comes across as very unprofessional. I don't think the AC pilots necessarily should never fly again after all pilots are humans and are fallible but we need to learn from their experience and not just say there was no accident, nothing to see here.

Buffman

Van.Bosch wrote: »

If the lowest point was between 2nd and 3rd, imagine being in the cockpit of the 3rd plane.

From the NTSB data, it appears that it may have been number 2 in line (PAL115) which got the 'worst' view.

Baylee Melodic Windjammer wrote: »

I don't think the AC pilots necessarily should never fly again after all pilots are humans and are fallible

Agreed, 'human factors' will likely be a major part of the investigation.

circular flexing

Some other interesting points

- Control tower was understaffed, one controller was on duty, standard is two.
- Aircraft was lined up for taxiway C for approx. 3nm, would this have been caught if there were two controllers?

smurfjed

That's not quite what happened, far from. A balked landing is when the aircraft touches down and then lifts off again. This aircraft, whilst coming close, did not touch the ground and he wouldn't have even been in the flare stage at 60ft AGL.

The following is taken from Skybrary...
In most cases, a missed approach is begun at or before the applicable DA or MDA for the approach being flown. Because any later decision to go around must have followed an earlier positive decision by PF to continue to a landing, it is often described as a rejected landing or a baulked landing, although neither term has any formal definition. It may or may not involve at least part of the landing gear contacting the runway and in extreme cases, touchdown may have occurred on all main landing gear units.
So the aircraft doesn't have to touch the ground.

plodder

circular flexing wrote: »

Some other interesting points
- Aircraft was lined up for taxiway C for approx. 3nm, would this have been caught if there were two controllers?

It's not clear if the controllers' ASDE-X/ASSC system is able to detect that. I don't really understand this business with the aircraft disappearing off it altogether for 12 seconds either

nsa0bupkd3948x

The Federal Aviation Administration will now require pilots landing at night to do an instrument landing, using the runway’s advanced guidance systems, when a parallel runway is closed. In addition, two air traffic controllers must be on duty through the late-night arrival rush, said Ian Gregor, an FAA spokesman.

Looks like they're implementing some changes in LAX as a result.

Comhrá

It's great to see new safety implementation as a result of an event where no-one had to die or suffer injury. Even the aircraft was unharmed.

AlekSmart

Comhra wrote: »

It's great to see new safety implementation as a result of an event where no-one had to die or suffer injury. Even the aircraft was unharmed.

The one BIG thing that the Avation sector has managed to cling to,is it's willingness to study,evaluate and act upon the results of investigations into incidents.

If only the motoring sector could be ncouraged to do the same it would be a huge step forward.

Take,for example,recent major road traffic incidents,all of which were subject to road closures to facilitate forensic investigation.

Not a single element of these Investigations will ever find it's way into the Public Domain,whereas great benefits could be gained by not alone making the results public,but also highlighting any measures taken to address whatever causitive factors are identified.

The avation sector remains far head of the rest of the world in this important issue.

circular flexing

AlekSmart wrote: »

The one BIG thing that the Avation sector has managed to cling to,is it's willingness to study,evaluate and act upon the results of investigations into incidents.

There are many, many examples where this wasn't the case - the Concorde accident in 2000 springs to mind as being a good example of where inaction led to a serious incident.