AC Lining Up with a Taxiway SFO...?

Topics related to accidents, incidents & over due aircraft should be placed in this forum.

Moderators: sky's the limit, sepia, Sulako, lilfssister, North Shore

Post Reply
Eric Janson
Rank (9)
Rank (9)
Posts: 1243
Joined: Thu Feb 08, 2007 10:44 am

Re: AC Lining Up with a Taxiway SFO...?

Post by Eric Janson »

altiplano wrote:Maybe in the 15 pages we get to read through every flight they somehow missed it? I don't know, but we get a lot of junk notams, that are essentially meaningless, to weed through. It would sure be nice if they would get rid of most of the notams published...
This is a very interesting point.


Just to add some more perspective.

My last flight:-

Remote dispatch
0145 departure

Documents:-

-117 pages of FIR NOTAM information
-45 pages of Airport weather and NOTAMS (departure/destination/alternate and en-route alternates)
-19 pages of weather charts (including 4 pages of volcanic ash information for 4 active volcanoes)
-7 page flightplan (with diversion and drift down scenarios).
-15+ pages of miscellaneous documentation (GenDec/ICAO flightplan/Diplomatic Clearances/Performance charts/Company paperwork)

We make our own loadsheet/balance chart. Also very easy to make mistakes - caught one 3 weeks ago.

Very easy to miss something important imho.

Only 15 pages? I'm obviously working at the wrong Airline :wink:
---------- ADS -----------
 
Always fly a stable approach - it's the only stability you'll find in this business
altiplano
Top Poster
Top Poster
Posts: 5377
Joined: Sat Jan 22, 2005 2:24 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by altiplano »

LOL... It is always more, you're right.... probably closer to 40 pages in the package for a flight like that... more if you're going further...

The result is skimming through the info and trying to pick out relevant ones... most of them will be gobbledygook unreadable or about weather balloons or something...

I'm not saying that is what happened here, but it surely isn't an ideal way to distribute the truly relevant information by mixing it in with a bunch of flotsam.
---------- ADS -----------
 
TheStig
Rank 8
Rank 8
Posts: 824
Joined: Thu Nov 10, 2011 12:34 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by TheStig »

http://flightservicebureau.org/the-prob ... it-notams/

It’s absolutely ridiculous.

We communicate the most critical flight information, using a system invented in 1920, with a format unchanged since 1924, burying essential information that will lose a pilot their job, an airline their aircraft, and passengers their lives, in a mountain of unreadable, irrelevant bullshit.

Yes CASA Australia, that’s you. Yes, Greek CAA, that’s you. And you’re not alone.

In an unintended twist of irony, the agencies seeking to cover their legal ass are party to creating the most criminal of systems – an unending flow of aeronautical sewage rendering the critical few pieces of information unfindable.

This is more than just hugely frustrating for each pilot, dispatcher, and controller that has to parse through it all; it’s downright dangerous.

If you’re a pilot, you’ll either have already experienced this, or you’re going to – you stuff something up, and then be told: “but there was a Notam out about that”. Sure enough, there it is in black and white (and in big capital letters). Do you think that “but there were 100 pages of them” is going to be a valid defence?



Well, it should be. The same agency conducting your post-incident interview is busy on the other end stuffing the system full of the garbage that prevented you from seeing it in the first place.

There are three parts to the problem: the system, the format, and the content. The system is actually quite amazing. The AFTN network connects every country in the world, and Notam information once added is immediately available to every user. Coupled with the internet, delivery is immediate.

The format is, at best, forgivable. It’s pretty awful. It’s a trip back in time to when Notams were introduced. You might think that was the 1960’s, or the 50’s. In fact, it’s 1924, when 5-bit ITA2 was introduced. The world shifted to ASCII in 1963, bringing the Upper and Lower case format that every QWERTY keyboard uses today, but we didn’t follow – nope, we’ll stick with our 1924 format, thank you.

Read that again. 1924. Back then, upper case code-infested aeronautical messages would have seemed impressive and almost reassuring in their aloofness. But there weren’t in excess of 1 million Notams per year, a milestone we passed in 2013. The 1 million milestone is remarkable in itself, but here’s something else amazing: in 2006, there were only 500,000. So in seven years, Notams doubled. Why? Are there twice as many airports in the world? No. Twice as many changes and updates? Possibly. But far more likely: the operating agencies became twice as scared about leaving things out.

And so onto the culprit: the content. The core definition of a Notam is ESSENTIAL flight information. Essential, for anyone tasked with entering information into the Notam System, is defined as “absolutely necessary; extremely important”. Here’s a game you can play at home. Take your 100 page printout of Notams, and circle that ones that you think can be defined as essential. See how many fit that bill.

So why is all this garbage in the system? Because the questions that the creators of Notams ask are flawed. The conversation goes like this:

– “Should we stick this into a Notam?”
– “Yeah, we’d better, just in case”.

How many are actually asking, “Is this essential information that aircrew need to know about ?”. Almost none. Many ‘solutions’ to the Notam deluge involve better filtering, Q codes, and smart regex’s. This overlooks the core problem. It’s not what comes out that needs to be fixed, it’s what goes in.

Even in 1921, we had much the same problem. Obstacle, 18 feet high, several miles from the runway.

Nobody cares. Unless you’ve parked the Eiffel Tower on the threshold, leave this stuff for the AIP. And nobody cares about kites either. Nor about goat-grazing times. We don’t care if your bird scarer is U/S. We don’t care if there’s a cherry-picker fixing a bulb somewhere. We don’t care when you’re cutting your grass.

Nor do we care about closed taxiways. The only way I can get onto a taxiway is with an ATC clearance, and ATC will not clear me onto a closed taxiway.

We care if the airport is going to be closed when we get there. If we’re going to have to divert because the runway is shut. If someone might shoot at us. If there are new rules. We care about the critical items, but we won’t see them as things stand.

And so, about here is where a normal editorial piece might end with “we hope that the authorities improve the system”, and sign off.

But not here.

We’re in the business of doing things here at FSB, not just talking about them.

Last year we wrote a few pieces about the Greece vs Turkey Notam battle. This month we did a group look at Briefing Packages, and it was astonishing to see how many pages of this diplomatic drivel still appeared in all our members’ Briefings. All in all, on average 3 full pages of every briefing for a flight overflying Greece or Turkey contained this stuff.

So, we sent Greece a polite AFTN message on behalf of all of us.

That’s just one piece of a thousand-piece puzzle, and it would be nice to think that one piece at a time we could fix the sytem. Let’s get real. It’s a monster, and it’s out of control.

We don’t think that we can fix the Notam system.

But, we can think about a different solution. And that’s exactly what we’re doing right now in OpsGroup. With almost 2000 members, we can make a difference. Watch this space. Or, if you want to help take action, send your thoughts to goatams@ops.group.
---------- ADS -----------
 
Eric Janson
Rank (9)
Rank (9)
Posts: 1243
Joined: Thu Feb 08, 2007 10:44 am

Re: AC Lining Up with a Taxiway SFO...?

Post by Eric Janson »

The best way to display NOTAM info is in graphic format imho.

Example:- A taxiway at an airport highlighted in red is very easy to understand.

My understanding is that this is coming in a future update of Jeppesen FD Pro.

They've just integrated information from the manuals into the route which is a fantastic feature.
---------- ADS -----------
 
Always fly a stable approach - it's the only stability you'll find in this business
digits_
Top Poster
Top Poster
Posts: 5931
Joined: Mon Feb 14, 2011 2:26 am

Re: AC Lining Up with a Taxiway SFO...?

Post by digits_ »

TheStig wrote:http://flightservicebureau.org/the-prob ... it-notams/

It’s absolutely ridiculous.
In the spirit of the above text, it might not have helped them either.

"what do I care if one of 2 parallel runways is closed, they are not going to clear me to land on a closed runway, are they?"
---------- ADS -----------
 
As an AvCanada discussion grows longer:
-the probability of 'entitlement' being mentioned, approaches 1
-one will be accused of using bad airmanship
crazyaviator
Rank 7
Rank 7
Posts: 671
Joined: Sun Oct 21, 2007 7:52 pm
Location: Ontario

Re: AC Lining Up with a Taxiway SFO...?

Post by crazyaviator »

IF lack of a proper TOD briefing happened and IF fatigue was a real issue THEN WHAT would prevent the pilots from making a third mistake and botch the go around? The A/C may have been under 10 feet from touching another plane and with a botched GA WHO knows what could have happened,,,,,,,,, All in all, much to learn here!
---------- ADS -----------
 
pelmet
Top Poster
Top Poster
Posts: 7138
Joined: Tue Jun 14, 2005 2:48 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

altiplano wrote:The pprune post referenced is a lot of guessing and supposing...

I also think the casual way the poster dismisses what role something like fatigue could have played in this event is disturbing and telling that they lack credibility and experience in an airline environment and the types of rosters guys can be up against.
Aside from that poster probably being very aware of airline schedules......The fatigue thing has already been discussed as seen and properly responded to here.

viewtopic.php?f=118&t=117542&p=1007155#p1007155
---------- ADS -----------
 
pelmet
Top Poster
Top Poster
Posts: 7138
Joined: Tue Jun 14, 2005 2:48 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

I have to admit...I didn't realize that runway 28L was actually closed. I thought it was just the approach light not being serviceable with the assumption that the crew could have possibly missed a notam about lights. The ATIS normally mentions about runway closures.

What a strange idea from the FAA that you can't do a night visual approach if the parallel runway is closed. It seems that something has to be changed to being more difficult, less flexible, added regulations as an excuse to show that something was actually changed after there has been an incident and we are all worse off. Eventually, all visuals will be cancelled to parallel runways, then runways with parallel taxiways as the inevitable occasional screw-ups happen.

FAA changes San Francisco landing procedures after A320 near miss

The Federal Aviation Administration has modified nighttime landing procedures and control tower staffing requirements at San Francisco International airport following a close call last month involving an Air Canada Airbus A320.

Controllers at the airport will no longer permit pilots to perform visual approaches at night "when an adjacent parallel runway is closed", the agency tells FlightGlobal.

"When these conditions prevail, our controllers issue pilots instrument landing system approaches or satellite-based approaches, which help pilots line up for the correct runway," says the FAA in a statement.

The agency adds that San Francisco's tower management now requires two controllers be working in the tower "until the late-night arrival rush is over".

The changes took effect "right after" a 7 July incident during which an Air Canada A320 operating flight 759 from Toronto nearly landed on a busy taxiway at San Francisco, the FAA says.

Controllers had cleared the pilots to land on runway 28R, but they lined up on the parallel taxiway C, which four aircraft occupied at the time, including a United Airlines Boeing 787, according to the NTSB and to air traffic control recordings.

The A320 pilots overflew the taxiway by about 0.25nm before controllers ordered it to go around. They descended to minimum altitude above the taxiway of 59ft and passed within 29ft laterally of one aircraft and 100ft above two others, according to US and Canadian investigators.

At the time of the incident, San Francisco's runway 28L was closed and unlit.

Pilots of the Air Canada A320 told US investigators they thought the lighted runway was 28L and that taxiway C was runway 28R, the NTSB said.


https://www.flightglobal.com/news/artic ... -a-440380/
---------- ADS -----------
 
User avatar
complexintentions
Rank 10
Rank 10
Posts: 2183
Joined: Thu Aug 19, 2004 3:49 pm
Location: of my pants is unknown.

Re: AC Lining Up with a Taxiway SFO...?

Post by complexintentions »

Eric Janson wrote:The best way to display NOTAM info is in graphic format imho.

Example:- A taxiway at an airport highlighted in red is very easy to understand.

My understanding is that this is coming in a future update of Jeppesen FD Pro.

They've just integrated information from the manuals into the route which is a fantastic feature.
Agreed. I use the built-in highlighter in FD Pro to draw any closures right on the airport chart in the iPad. And the mental process of transposing text into visual right on the chart helps to build a good picture.

I somehow doubt AC is using the same system though, given the reluctance to spend money on technology.

I agree there's too much irrelevant ass-covering lawyer-speak in the package. But it's not really THAT difficult to quickly eliminate the nonsense and get to the important stuff. You do need some kind of a system.
---------- ADS -----------
 
I’m still waiting for my white male privilege membership card. Must have gotten lost in the mail.
mbav8r
Rank 10
Rank 10
Posts: 2325
Joined: Sun Jul 02, 2006 8:11 am
Location: Manitoba

Re: AC Lining Up with a Taxiway SFO...?

Post by mbav8r »

complexintentions wrote:
Eric Janson wrote:The best way to display NOTAM info is in graphic format imho.

Example:- A taxiway at an airport highlighted in red is very easy to understand.

My understanding is that this is coming in a future update of Jeppesen FD Pro.

They've just integrated information from the manuals into the route which is a fantastic feature.
Agreed. I use the built-in highlighter in FD Pro to draw any closures right on the airport chart in the iPad. And the mental process of transposing text into visual right on the chart helps to build a good picture.

I somehow doubt AC is using the same system though, given the reluctance to spend money on technology.

I agree there's too much irrelevant ass-covering lawyer-speak in the package. But it's not really THAT difficult to quickly eliminate the nonsense and get to the important stuff. You do need some kind of a system.
AC does have EFBs, iPads and I'm assuming FD pro since that is what we have at Jazz.
---------- ADS -----------
 
pelmet
Top Poster
Top Poster
Posts: 7138
Joined: Tue Jun 14, 2005 2:48 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

Eric Janson wrote:The best way to display NOTAM info is in graphic format imho.

Example:- A taxiway at an airport highlighted in red is very easy to understand.

My understanding is that this is coming in a future update of Jeppesen FD Pro.

They've just integrated information from the manuals into the route which is a fantastic feature.
Already have this technology on AMM(Airport Moving Map) although I am not sure if it is entered by the company or somehow automatically done by Jeppesen.

Manually highlighting in green the closed taxiways in Jepp FD Pro is useful as well for ground operations. Something likely not applicable to this incident though.
---------- ADS -----------
 
User avatar
complexintentions
Rank 10
Rank 10
Posts: 2183
Joined: Thu Aug 19, 2004 3:49 pm
Location: of my pants is unknown.

Re: AC Lining Up with a Taxiway SFO...?

Post by complexintentions »

mbav8r wrote:AC does have EFBs, iPads and I'm assuming FD pro since that is what we have at Jazz.
Cool.
pelmet wrote: Already have this technology on AMM(Airport Moving Map) although I am not sure if it is entered by the company or somehow automatically done by Jeppesen.
Done by Jepp on the AMM. But it's not always accurate to the written NOTAMS.
---------- ADS -----------
 
I’m still waiting for my white male privilege membership card. Must have gotten lost in the mail.
Rockie
Top Poster
Top Poster
Posts: 8433
Joined: Sat Oct 08, 2005 7:10 am

Re: AC Lining Up with a Taxiway SFO...?

Post by Rockie »

AC has JeppFDPro. While we don't (currently) have the system that automatically displays closures on the airport diagram, highlighting closures ourselves is an effective technique most people use. AC is embracing technologies available using the P-EFB though so the automated system may be in the offing. Not foolproof as mentioned, but certainly a step forward.
---------- ADS -----------
 
teacher
Rank 10
Rank 10
Posts: 2450
Joined: Thu Feb 19, 2004 3:25 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by teacher »

Exclusive: SFO makes changes for pilots, air traffic controllers after Air Canada close call

SAN FRANCISCO — In the wake of last month’s near-collision at San Francisco International Airport, federal officials have made significant changes to how pilots land at the airport and how many air traffic controllers must be working in the tower during nighttime hours, the Bay Area News Group has learned.
The Federal Aviation Administration also plans to begin testing modified radar systems in a few months at its Aeronautical Center in Oklahoma City — and possibly also at the San Francisco airport — to allow the facility’s ground surveillance systems to alert air traffic controllers when an aircraft is attempting to land on a taxiway rather than a runway, as happened in the SFO incident. Those systems were originally designed, according to the FAA, to prevent runway incursions and runway collisions, not taxiway mishaps.

“Just about every safety improvement in aviation was written in blood or the aftermath of an egregious mistake or a screw-up,” retired United Airlines Capt. Ross Aimer, an aviation safety consultant, wrote in an email. “I think all three improvements (by the FAA) are a welcome sight and long time to come. Too bad it took a near disaster for them to finally happen!”
On July 7, Air Canada Flight 759 flew as low as 59 feet off the ground before the pilot aborted his landing, flying dangerously close to four other aircraft awaiting takeoff with an estimated 1,000 passengers on board all the planes, according to an ongoing National Transportation Safety Board investigation. Federal investigators determined that the Air Canada plane dropped off the air traffic controller’s ground surveillance system radar during its final 12 seconds on approach.

Aviation experts have said the near-miss could have triggered one of the worst aviation disasters ever and have criticized the delayed notice of the incident, which allowed the cockpit voice recorder to be overwritten.
Since the close call, the FAA no longer allows visual approaches for aircraft approaching SFO at night with an adjacent parallel runway closed, according to spokesman Ian Gregor. On July 7, Runway 28-Left was closed and darkened, and the Air Canada flight crew told investigators that they shifted their sight-line to the right, causing them to believe Taxiway C was their approved runway Runway 28-Right. Taxiway C runs parallel to 28-right.
“When these conditions prevail, our controllers (will) issue pilots Instrument Landing System approaches or satellite-based approaches, which help pilots line up for the correct runway,” Gregor said.
Sources have said the Air Canada pilot did not use his computer guidance instruments on the July 7 errant approach, which is not uncommon.

Shem Malmquist, a Boeing 777 pilot who has landed many times at SFO, said the new requirements are a positive step as instrument approach would provide precise guidance and clear indications if a pilot veers off course.
“Our human visual systems evolved for land-based creatures that moved only as fast as their legs could carry them,” Malmquist wrote in an email. “We adapt pretty well, but flight with its combination of height, weather and speed, can fool them. The use of an instrument approach keeps the pilots closely aligned with the runway threshold.”
Malmquist said challenges at SFO under such conditions are largely the result of noise-abatement requirements that keep planes at higher altitudes than normal and farther east over the bay. Pilots must take an angled approach, settling into the normal straight-on landing path when they are closer to landing.
In the tower, the FAA will now require two controllers to remain in position during busy late-night hours, Gregor said. Two controllers were working at the time of the SFO incident, he said, but only one was in the tower, and that individual was busy talking to another facility in the final seconds of Air Canada’s botched approach.
“Following the event, SFO tower management adopted a policy requiring two controllers to be on position working traffic until the late-night arrival rush is over,” Gregor said.
Malmquist said that change is good but, as other sources have said, it’s difficult for an air traffic controller at the SFO tower to determine whether an incoming plane is lined up with the runway or adjacent taxiway.
“So reliance on the (air traffic controller) radar becomes more critical — which means it has to work!” Malmquist said. “That said, more eyes are always better as they would offset bias, distraction and other factors.”
Taxiway confusion is not unheard of. In a Dec. 8 FAA memo, the agency reminded pilots that aircraft landing or departing on the wrong runway, taxiway or airport are “among the highest-profile and most dangerous events in aviation.” Those events average about 24 per year, according to the report, but increased to more than 60 in 2016.
“The common denominator for most wrong surface landings/departures was the lack of situational awareness, with closely spaced parallel runways, off set parallel runways, or taxiways which run parallel with runway,” according to the FAA.
The agency provided an example of when a Boeing 737 landed on a parallel taxiway that ran between two parallel runways at Seattle-Tacoma International airport. The FAA also said controller workload or radar limitations that preclude timely intervention by air traffic controllers could contribute to such incidents — both played roles in the SFO incident.
---------- ADS -----------
 
https://eresonatemedia.com/
https://bambaits.ca/
https://youtube.com/channel/UCWit8N8YCJSvSaiSw5EWWeQ
pelmet
Top Poster
Top Poster
Posts: 7138
Joined: Tue Jun 14, 2005 2:48 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

Bottom line....NIMBY's cause increased chances of death and destruction with noise abatement procedures. Just ask those on the 146 that crashed in Switzerland a few years ago.

https://aviation-safety.net/database/re ... 20011124-0
---------- ADS -----------
 
GyvAir
Rank (9)
Rank (9)
Posts: 1804
Joined: Mon Mar 12, 2012 7:09 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by GyvAir »

pelmet wrote:Bottom line....NIMBY's cause increased chances of death and destruction with noise abatement procedures. Just ask those on the 146 that crashed in Switzerland a few years ago.

https://aviation-safety.net/database/re ... 20011124-0
Wrong thread?
---------- ADS -----------
 
Black_Tusk
Rank 7
Rank 7
Posts: 693
Joined: Sun Oct 09, 2016 8:57 am

Re: AC Lining Up with a Taxiway SFO...?

Post by Black_Tusk »

GyvAir wrote:
pelmet wrote:Bottom line....NIMBY's cause increased chances of death and destruction with noise abatement procedures. Just ask those on the 146 that crashed in Switzerland a few years ago.

https://aviation-safety.net/database/re ... 20011124-0
Wrong thread?
Probably not. The visual approach they were flying is a noise abatement approach is it not?
---------- ADS -----------
 
User avatar
confusedalot
Rank 8
Rank 8
Posts: 959
Joined: Fri Jul 03, 2009 9:08 pm
Location: location, location, is what matters

Re: AC Lining Up with a Taxiway SFO...?

Post by confusedalot »

pelmet wrote:Bottom line....NIMBY's cause increased chances of death and destruction with noise abatement procedures. Just ask those on the 146 that crashed in Switzerland a few years ago.

https://aviation-safety.net/database/re ... 20011124-0
Nope. Two situations that have zero to do with each other. Sorry.
---------- ADS -----------
 
Attempting to understand the world. I have not succeeded.

veni, vidi,...... vici non fecit.

:?
pelmet
Top Poster
Top Poster
Posts: 7138
Joined: Tue Jun 14, 2005 2:48 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

confusedalot wrote:
pelmet wrote:Bottom line....NIMBY's cause increased chances of death and destruction with noise abatement procedures. Just ask those on the 146 that crashed in Switzerland a few years ago.

https://aviation-safety.net/database/re ... 20011124-0
Nope. Two situations that have zero to do with each other. Sorry.
Yup...they do.
---------- ADS -----------
 
altiplano
Top Poster
Top Poster
Posts: 5377
Joined: Sat Jan 22, 2005 2:24 pm

Re: AC Lining Up with a Taxiway SFO...?

Post by altiplano »

pelmet wrote:
altiplano wrote:The pprune post referenced is a lot of guessing and supposing...

I also think the casual way the poster dismisses what role something like fatigue could have played in this event is disturbing and telling that they lack credibility and experience in an airline environment and the types of rosters guys can be up against.
Aside from that poster probably being very aware of airline schedules......The fatigue thing has already been discussed as seen and properly responded to here.

viewtopic.php?f=118&t=117542&p=1007155#p1007155
Your response is your reference? Lol... more guessing and supposing.

Fact is you can't say why 2 experienced pilots got mixed up... neither can I, but you certainly can't go dismissing things.

I'll wait for the report.
---------- ADS -----------
 
Post Reply

Return to “Accidents, Incidents & Overdue Aircraft”