AC Lining Up with a Taxiway SFO...?

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

Post by Rockie »

Cat Driver wrote:CRM is an extension of good decision making skills as it adds a second person in the process.
Backwards. Adding a second person to the process and good decision making is the result of CRM.

But I know what you mean and agree.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Rockie »

confusedalot wrote:No I was actually thinking about you (Rockie) for slamming pelmet. He,s a poster like the rest of us. Experienced, not experienced, whatever.

What did I do to you cat? Christ, I didn't write it. But I think it is a good idea to play nice with the other children.

Brother............the phone rings requiring my attention for 2 minutes and all of a sudden another thunderboomer develops.

Anyways, out with the fencing swords. :lol:
Well...no. Determining what happened in an event like this requires a non-biased investigation. The NTSB will without a doubt find out if the lights were turned on, but what we're discussing is if the crew should have asked if the lights were on. What Complex and myself are saying is that it is not a question a crew would reasonably ask in this situation. First of all because of where this occurred. People unaccustomed to flying there professionally may disagree, but let's just say they're wrong.

Secondly, the crew thought they had the runway identified. Do you ask if the lights are on when you see the runway?
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Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

Rockie wrote:The NTSB will without a doubt find out if the lights were turned on, but what we're discussing is if the crew should have asked if the lights were on. What Complex and myself are saying is that it is not a question a crew would reasonably ask in this situation. First of all because of where this occurred. People unaccustomed to flying there professionally may disagree, but let's just say they're wrong.
Hmmm, guess what? I fly there and professionally too.
Rockie wrote:Secondly, the crew thought they had the runway identified. Do you ask if the lights are on when you see the runway?


Let me expand on this as well. Regardless of whether you think or don't think you have the runway is in sight, this is something that I would suggest as soon as handed over to tower in the same situation of close parallel runways combined with being unable to back up with an ILS or RNAV approach accurately and only one set of approach lights illuminated....and especially once something subsequently seems unusual.

As I said many pages earlier.....there is usually a hint that you are making a big mistake, but some sort of excuse is made in your mind(sometimes a silly one) as an explanation. This is based on personal experience.

As for the "they thought they had the runway" theory....so did evey airline pilot in recent memory who landed at the wrong airport or the wrong runway and didn't back it up with something. Perhaps in some cases, there was minimal time or minimal back-up available but usually there is something easily available.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Cat Driver »

The NTSB has released an updated report on the taxiway go around.

It is to say the least interesting.

Especially the picture showing AC just about to fly over the first airplane holding at the end of the taxiway.

The CVR had been over written and the crew claimed they did not see any airplanes on the taxiway.

Looking at the picture maybe they couldn't see because next two airplanes had their landing lights on and that blinded them?
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Re: AC Lining Up with a Taxiway SFO...?

Post by ZaSz »

Cat Driver wrote:The NTSB has released an updated report on the taxiway go around.
https://www.ntsb.gov/investigations/Pag ... IA148.aspx
The captain had over 20,000 total flight hours, of which about 4,797 hours were as captain in Airbus A320‑series airplanes. The first officer had about 10,000 total flight hours, of which over 2,300 hours were in Airbus A320-series airplanes.
About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Cat Driver »

About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.
It would be interesting to know just how close they really came to hitting one of those airplanes.
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Re: AC Lining Up with a Taxiway SFO...?

Post by digits_ »

At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point (see figure 4).
That puts one discussion point to rest. They did figure out something was wrong themselves before ATC told them to go-around. That makes this quite a bit less of a big deal IMO.
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Re: AC Lining Up with a Taxiway SFO...?

Post by hamstandard »

digits_ wrote: That puts one discussion point to rest. They did figure out something was wrong themselves before ATC told them to go-around. That makes this quite a bit less of a big deal IMO.
Sometimes I just shake my head when I see some statements made here like the one above.

AC went down to 59 feet. A 747-8 is 63 feet tall. If one had been at the wrong place at the wrong time, this would have been a disaster. I went back through the thread to see who else make me shake my head and found a few more amazing quotes:

complexintentions wrote:What brutally sensationalist reporting. If it's even true, a non-event.

complexintentions wrote: Hence, an event that did not occur, or as I call it...a non-event. Of course for those who enjoy breathless telenovelas it certainly sounds exciting "HE FLEW RIGHT OVER ME", wow!

complexintentions wrote: Yes, they lost situational awareness, and no, it wasn't SECONDS AWAY FROM DISASTER.

complexintentions wrote: But I categorically reject that it was anywhere as close to an accident as some seem determined to believe it was.

Rockie wrote:If you're referring to SFO, then yes, they are alive because of the expertise and skills and training of the crew that was flying that airplane.


And finally,

Rockie wrote:The part of your suggestion about asking if the runway lights are on is what doesn't make sense in this situation Pelmet, first of all because of where it was. In a place like SFO they're always on, and since it was the active runway being used non-stop for departures and arrivals why would anyone think they were off?


From the report: 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.
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Re: AC Lining Up with a Taxiway SFO...?

Post by digits_ »

hamstandard wrote:
digits_ wrote: That puts one discussion point to rest. They did figure out something was wrong themselves before ATC told them to go-around. That makes this quite a bit less of a big deal IMO.
Sometimes I just shake my head when I see some statements made here like the one above.

AC went down to 59 feet. A 747-8 is 63 feet tall. If one had been at the wrong place at the wrong time, this would have been a disaster. I went back through the thread to see who else make me shake my head and found a few more amazing quotes:
[/quote]

But they didn't , didn't they? They initiated a go-around because they saw the obstacle. Close, yes. Too close for comfort, yes. A near crash? Not really. Crew knew someting was wrong and went around.
hamstandard wrote: From the report: 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.
Well obviously. They would have had to be pretty insane to line up with the taxiway if they knew they were wrong, wouldn't they?

The planes on the taxiway probably saved them from a landing on the taxiway. Or not, who knows if they would have caught that.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Cat Driver »

Well as to the lights according to the NTSB runway 28L was notamed closed and there was a lit up X at the threshold.

R28R was lit at a normal setting with approach lights and PAPI working.

Taxiway C was lit with green centre line and blue edge lighting.

The weather was VFR so why did they not figure out they were landing on the taxiway until they were almost on it ???

I sure am puzzled by this whole episode because it should not matter if you are flying a Cessna 150 or the space shuttle the picture is the same.
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Re: AC Lining Up with a Taxiway SFO...?

Post by wallypilot »

Wow...good image in the lower frame of how low they were.
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Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

digits_ wrote:
hamstandard wrote: AC went down to 59 feet. A 747-8 is 63 feet tall. If one had been at the wrong place at the wrong time, this would have been a disaster.
But they didn't , didn't they? They initiated a go-around because they saw the obstacle. Close, yes. Too close for comfort, yes. A near crash? Not really. Crew knew someting was wrong and went around.
From reading the report, I suspect that the only reason the crew knew something was wrong was that the aircraft on the runway started making statements over the radio. If crew on the taxiway had been head down, which is quite possible, I suspect that AC would have been even lower. Two seconds later for a go-around initiation could have been totally different depending on positioning of the aircraft on the taxiway.

We keep on getting evidence of the aircraft being lower and lower in this incident, now backed up bypictures. Yet it appears that this makes others here more and more adament that there was no near-accident. What exactly is a near accident then? Is the picture in the post above not close enough to be considered one? How much closer does he have to be to the aircraft on the taxiway before it becomes a near accident?
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Re: AC Lining Up with a Taxiway SFO...?

Post by Cat Driver »

There is a saying pelmet that goes like this.

"" It depends on who's Ox is being gored ""

Or in the case of aviation.

"" It depends on who's airline is getting bad publicity. ""
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Re: AC Lining Up with a Taxiway SFO...?

Post by Jet Jockey »

@ digits_

"But they didn't , didn't they? They initiated a go-around because they saw the obstacle. Close, yes. Too close for comfort, yes. A near crash? Not really. Crew knew someting was wrong and went around."


I'm sorry but I have a hard time with you (and a few others) that are pretending that this is a non incident... IMHO AC 759 was going to land on taxiway C but if it were not for UAL 1's call to the tower advising them that AC 759 was lined up on taxiway C (first wake up call to AC's pilots) and then most importantly and probably the one thing that saved the whole day was the fact that PAL 115 an Airbus 340 and the second aircraft on taxiway C then turned on their landing lights as a warning to the approaching AC 759.

Some facts and comments...

- According to their testimony, both AC pilots claim they never saw the aircrafts on taxiway C, very hard to believe IMHO.

- Both pilots apparently mistook taxiway C for 28R and 28R for 28L despite NOTAMS saying that 28L was closed and had an X light up on it. 28r was fully operational with all its lights working including the approach lights. Taxiway C had its blue edge lights and its green centerline lights working.

- the CVR was overridden, so no data from that piece of equipment which I believe goes against the CARS.

- AC 759 was far enough of course (north of centerline) that the airport's radar could not see it for 12 seconds.

- UAL 1 was probably not in danger of getting hit by AC 759 because it had already turned the corner. However if you look carefully at the picture available you can see that the half end section of the fuselage of UAL 1 is light up by the landing lights of AC 759.

- Abeam the threshold and over the end of taxiway C, AC 759 is 131 feet above ground.

- AC 759 while over flying taxiway C applies go around trust at 85 feet AGL (probably after seeing PAL 115's lights) but continues descending for 2.5 seconds until it is 59 feet AGL and this near taxiway W where PAL 115, the Airbus 340 is located... The tail of an A340 is 56 feet tall, so AC 759 most likely cleared PAL 115's tail by 3 feet maybe more. Also worth noting in the pictures is that the tail section of PAL 115 is brightly light up by AC 759's landing lights.

You and others may think this is a non event and the "guys" did a great job but I beg to differ! You cannot put your aircraft into such a position and risk the lives of many onboard your aircraft and other aircrafts and get away with it. The union and AC management may want to spin this anyway they want but this was way more than "just too close for comfort".
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Re: AC Lining Up with a Taxiway SFO...?

Post by confusedalot »

Hence my handle.............Sometimes, I just don't get it. How could this happen, I dunno.

Flying experience does not matter, good equipment does not matter. Superb airports do not matter. Good ATC does not matter, and pilots with the wherewithal to state a problem and turn all of their lights on do not matter.

I remain confused. Alot.

Mysteries of the human mind I suppose. :(
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Re: AC Lining Up with a Taxiway SFO...?

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Cat Driver wrote: I sure am puzzled by this whole episode because it should not matter if you are flying a Cessna 150 or the space shuttle the picture is the same.
Human factors certainly are different between an A320, C172 and Space shuttle. Since this incident is probably all about human factors, the "picture" is not the same. But with your years of experience in aviation, you certainly understand this. Or not.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Cat Driver »

Hence my handle.............Sometimes, I just don't get it. How could this happen, I dunno.

Flying experience does not matter, good equipment does not matter. Superb airports do not matter. Good ATC does not matter, and pilots with the wherewithal to state a problem and turn all of their lights on do not matter.

I remain confused. Alot.

Mysteries of the human mind I suppose. :(
Yes it is very disturbing to know that despite all the advancement in aircraft and airports these things still happen.

The weak link of course is the human factor.

Maybe we need three pilots so at least one of them will have enough situational awareness to correct something like what happened in San Fran soon enough that it would not have turned into a public news nightmare.

Sure it would cost more for three pilots but what cost would the loss of hundreds of people be.

Eventually the human factor will be taken out of the equation by advanced automation, both in the airplane and on the ground.
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Re: AC Lining Up with a Taxiway SFO...?

Post by photofly »

"About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl"

The altitude of which bit of the aircraft is recorded by the FDR?
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Re: AC Lining Up with a Taxiway SFO...?

Post by Black_Tusk »

I wonder how long they were working? When was their check in? Could fatigue have been a factor?
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Re: AC Lining Up with a Taxiway SFO...?

Post by leftoftrack »

705 pilots won't be affected by sleep science for another 10 months, 703/704 won't be affected by sleep science for another 4 years. Thanks Mr Astronaut
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Re: AC Lining Up with a Taxiway SFO...?

Post by wallypilot »

I have only landed on the 28's maybe 15-20times...and none in the past 3 years, but was the LOC out? As per the quiet bridge visual, they should have been tracking the LOC. If they were, I dont understand how this could have happened. Also, add to that big bright lights on end of runway, no lights on end of taxiway. I honestly don't know why there is so much debate. This, most likely, was a major f-up.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Nark »

Wallypilot,


Air Canada pilots don't @#$! up... ever. Not in Halifax, not in Montgomery Bay, not if San Fran....

I can't remember where the radar altimeter antenna is, but I imagine with the deck angle during go around, the tires were lower than 59'.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Rockie »

The NTSB is only stating facts in this preliminary report, not jumping to any conclusions like the people here. But some facts are worth recapping:

The crew went around as they are trained to do. Nobody was hurt and nothing was bent. Not a non-event because we need to understand why they misidentified the runway so we can prevent all pilots (even the ones ready to hang this crew who are convinced it could never happen to them) from making that mistake again - the whole point of an investigation.

The CVR was over-written, not erased. That is not a violation of the CAR's nor a deliberate act of deception by the crew.

The lights were on. If asked ATC would have said the lights were on. The crew didn't think the lights were off. I don't see here why the crew would ask about them or what confusion would be cleared up if they did. They thought they were lined up on the correct runway. Again - why?
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Re: AC Lining Up with a Taxiway SFO...?

Post by pelmet »

Rockie wrote:The NTSB is only stating facts in this preliminary report, not jumping to any conclusions like the people here. But some facts are worth recapping:

The crew went around as they are trained to do. Nobody was hurt and nothing was bent. Not a non-event because we need to understand why they misidentified the runway so we can prevent all pilots (even the ones ready to hang this crew who are convinced it could never happen to them) from making that mistake again - the whole point of an investigation.

The CVR was over-written, not erased. That is not a violation of the CAR's nor a deliberate act of deception by the crew.

The lights were on. If asked ATC would have said the lights were on. The crew didn't think the lights were off. I don't see here why the crew would ask about them or what confusion would be cleared up if they did. They thought they were lined up on the correct runway. Again - why?
Are you talking about approach lights? I have been specifically talking about approach lights as that is what the notam was about and that is typically what is used for runway alignment on a night visual approach. The term "The lights" that you are using can refer to many things. Clarity in communications is important.

As for the CVR, I don't know what AC's policy is. Let us know that the ops manual says.
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Re: AC Lining Up with a Taxiway SFO...?

Post by Rockie »

Yes, I'm talking about the approach lights, and the runway lights. Although I'm sure they can be adjusted separately I would be surprised if they weren't controlled as a single unit as a matter of policy - perhaps a tower controller here can shed some light on that? When a controller says "lights on strength 5" do you ask them specifically what light's he's talking about in the interest of clear communications?

As for AC's CVR policy, you can assume it complies with the regulation and is consistent with industry practice.
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