AC Lining Up with a Taxiway SFO...?

[pelmet]

*IF* the 18 meters is correct, some thoughts:

- The airplanes are designed to clear obstacles by 35 ft single eninge. 18 meters is 60 ft. An engine failure at take-off, while challenging, should be an abnormal event but definitely not a "disaster". They had about twice that space here.

- During every landing of an A380 in SFO, there can be planes as close as 92 ft to the landing airplane (distance holding point - wing tip). Assuming the plane stays on the centerline perfectly. 18 meters in an A320 is way closer than normal for that plane, and can/should be cause for concern, but the doomsday-inferno-disaster reports are a bit over the top IMO.

There is a big difference between aircraft intentionally operation parallel to each other and a aircraft heading straight for each other. I would think that you must be aware of the difference in risk. LAX seems to be particularly close with aircraft having a longest wingspans actually having their wingtips crossing over the hold short line for 25R.

What does a single engine climb performance of an aircraft have to do with this near disaster?

To put the 60ft separation into perspective. If 35 ft separation with a mountain is acceptable, then why is 60 ft separation with another airplane not?

Did it not occur to you that this is due to a system failure called an engine failure(which of course is the case in SFO as well). But if it is acceptable, then why is the NTSB do a FULL investigation of it?

[pelmet]

Not being an airline pilot and certainly not A320 qualified and only time in SFO I was a pax( with AC on a 320), I imagine this incident is getting the full attention of AC flight operations and the various safety sections within, with the intent to establish corrective action to ensure this doesn't happen again. To me, pontification aside, the question is why a very experienced crew lined up on a taxiway thinking it was the active landing runway. Perhaps an unforeseen trap of some sort, unknown or obvious let this happen. An unnerving situation with disastrous consequences, absolutely and no doubt about it. Thankfully it didn't happen due the actions of all who saw what was Unfolding (ATC, AC flight crew, other aircraft on taxiway). A miss by 20ft or 200ft whatever,doesn't matter as a major disaster was avoided.

Instead of arguing over the seriousness on not of this case, I think we could be a lot more productive in trying to making posts on how to prevent this sort of occurrence from happening again. The bottom line is that this is a case of runway misidentification on a visual approach. Hanging your head and saying the equivalent of "I am not an airline pilot or qualified on type so I have nothing to add"(or actually agreeing with those who say that) is foolish. Of course, you have nothing to add about the technical aspect of the operation of the particular aircraft involved but we have been told by pilots on type that there are aircraft out there that basically end up having to do a visual approach to places like this. A lot of us should have an opinion on what can be done from a non-specific to aircraft type point of view if in a similar situation.

the question is why a very experienced crew lined up on a taxiway thinking it was the active landing runway. Perhaps an unforeseen trap of some sort, unknown or obvious let this happen.

I have been in a very similar situation of runway misidentification many years ago that nearly led to landing beside the runway at a small VFR airport. This incident quickly reminded me of that day. I was lucky and learned the easy way about visual illusions and thought processes that can happen in an event like this. Each situation has differences but the initiating reason why this happened is that visual illusions happen. We need to just accept this as fact and do what we can to prevent it. Using SFO as an example and an aircraft where alignment with the runway is required visually, this is easily overcome by dual approach light systems. But if something changes, one needs to be suspicious of their eyes and their brains and use whatever else they can reasonably use. I have given my idea earlier.

Bottom line.....Don't trust your eyes. This morning I did an approach to a familiar airport with reasonably widely spaced parallel runways with decent weather and about 7km visibility. No problem as the automatics were used but I actually misidentified the runways initially. Two sets of bright white lights leading in were seen at about 8 miles back. It was only at about 4 miles back that the approach lights at low power setting came into sight(much more orangy in colour). The bright white lights were the much brighter ramp parking lights on either side of the terminal. A bit embarrassing to myself as I should know better but that is an example of what happens. It surprised me that I have never noticed how much brighter the white lights are compared to the approach lights but maybe there are different intensities to for the ramp lights and certainly there are different intensities to the approach lights. The eyes probably go for what they initially see at the expense of what you might be wanting them to see.

[digits_]

There is a big difference between aircraft intentionally operation parallel to each other and a aircraft heading straight for each other. I would think that you must be aware of the difference in risk.

Yes. I would actually call a pilot intentionally flying 60 ft over the busy taxiway quite irresponsible, just like I would call a pilot who calculates a 2 engine climb clearing a mountain top by 35 ft an idiot.

However, in this situation and in an engine failure situation, those safety margins are there as a backup, as a safety. If, during non-normal ops (because you or the plane screws up), you stay within the safety margins, then that should be investigated, but that doesn't mean a major disaster was close to happening.

In my single engine example, the safety margin is meticulously calculated, in the SFO incident, the safety margin was less strict defined but eventually established by the crew's judgement.

All the holes in the swiss cheese were starting to line up, but they didn't. The crew, the other planes and ATC were all trying to -just in time- prevent the holes from lining up. They were still at least 2 holes away from a crash.

[Jet Jockey]

I was working with the 18 meter out of the report. If it is only 3 ft, then yes, it was much worse and close to a major incident.

The 18 metres/59 feet you refer to is the actual altitude AGL the aircraft descended to above taxiway C prior commencing its climb according to the NTSB and the aircraft's DFDR.

The crew initiated the "Go Around" around 85 feet AGL but the aircraft continued its descent for another 2.5 seconds to 59 feet AGL crossing/over flying PAL 115 at some point while still descending. The tail height of an Airbus 340 is 56 feet so this is where the possibility of only a 3 foot clearance comes in. It could have been 5 feet maybe 10 but I suspect only the NTSB could give you an exact number. Regardless, it was a very close call and again it is of my opinion that only the fact that the crew of PAL 115 turned on their landing lights (as per the NTSB) was the final grace that saved the day.

The NTSB would not be investigating this as a serious incident if it were not so.

[Cat Driver]

All the holes in the swiss cheese were starting to line up, but they didn't. The crew, the other planes and ATC were all trying to -just in time- prevent the holes from lining up. They were still at least 2 holes away from a crash.

And I am about two posts away from totally giving up hoping that people will get tired of making up excuses for airline crews that get that close to a major disaster flying a VFR approach at night.

[digits_]

Did it not occur to you that this is due to a system failure called an engine failure(which of course is the case in SFO as well). But if it is acceptable, then why is the NTSB do a FULL investigation of it?

Because the data available makes it uncertain wether or not it was a non-event or close to a major crash. If an engine fails it is very obvious what happened, here, not so much. Another reason is probably the media coverage this event got.

I'm not arguing against investigations, but I don't like the dramatised news about something that might have been a non-event initially. It starts to look like it might have been a bit more serious, but that doesn't mean dramatizing it is a good idea. Next you know every go-around will be a near-crash with terrified pax and bogus lawsuits. That's what I would like to prevent.

[pelmet]

Did it not occur to you that this is due to a system failure called an engine failure(which of course is the case in SFO as well). But if it is acceptable, then why is the NTSB do a FULL investigation of it?

Because the data available makes it uncertain wether or not it was a non-event or close to a major crash. If an engine fails it is very obvious what happened, here, not so much. Another reason is probably the media coverage this event got.

I'm not arguing against investigations, but I don't like the dramatised news about something that might have been a non-event initially. It starts to look like it might have been a bit more serious, but that doesn't mean dramatizing it is a good idea. Next you know every go-around will be a near-crash with terrified pax and bogus lawsuits. That's what I would like to prevent.

Ain't gonna happen. The media is out to over-dramatize in order to make money. Accept this as fact. One only need to look at the political hysteria in the media and that has been posted on this very forum(by professionals no less) to see why we have over-reaction.

Our company sent out a memo about the media trying to get stories of pilots illegally bringing stuff through customs. Instead, one can only do their best to avoid incidents as the media has chosen aviation as a subject that can draw viewers, get higher ratings, make more money. This is combined with a large percentage of our population having silly reactions to insignificant things. The best you can do is prevent incidents and think logically about things. But denial is not logical.

[pelmet]

As I said earlier....

"Instead of arguing over the seriousness or not of this case, I think we could be a lot more productive in trying to making posts on how to prevent this sort of occurrence from happening again."

Do you have anything to add Digits. Lets try preventing another incident.

[Jet Jockey]

Just as reminder...

The NTSB is conducting this matter as a "Serious Incident" so not small potatoes.

As per Annex 13, a Serious Incident: "An incident involving circumstances indicating that there was a high probability of an accident ..."

Annex 13 goes on to explain, rather chillingly, that "The difference between an accident and a serious incident lies only in the result".

Unfortunately we all know that the mass media likes to exploit any aviation incident and make it more dramatic than it really is however in this case it might be warranted.

[FICU]

If everyone is out to hang this crew in SFO why is no one talking about this "near disaster":

Incident: Sunwing B738 at Belfast on Jul 21st 2017, overran runway on takeoff

A Sunwing Airlines Boeing 737-800 on behalf of Thomson Airways, registration C-FWGH performing flight BY-1526 from Belfast Aldergrove,NI (UK) to Kerkyra (Greece) with 186 people on board, was accelerating for takeoff from Belfast's runway 07 when the crew detected problems with the acceleration of the aircraft and re-selected TOGA prior to beginning takeoff rotation. During the initial climb the crew selected max continuous thrust and power adjusted accordingly. ATC reported the aircraft had an unusually long takeoff run. The aircraft continued the flight and landed in Kerkyra without further incident.

The Canadian TSB reported that a runway inspection found an approach light for runway 25 bent over.

Mistakes were made in both incidents that could have turned out much worse than they did.

[Old fella]

Did it not occur to you that this is due to a system failure called an engine failure(which of course is the case in SFO as well). But if it is acceptable, then why is the NTSB do a FULL investigation of it?

Because the data available makes it uncertain wether or not it was a non-event or close to a major crash. If an engine fails it is very obvious what happened, here, not so much. Another reason is probably the media coverage this event got.

I'm not arguing against investigations, but I don't like the dramatised news about something that might have been a non-event initially. It starts to look like it might have been a bit more serious, but that doesn't mean dramatizing it is a good idea. Next you know every go-around will be a near-crash with terrified pax and bogus lawsuits. That's what I would like to prevent.

The facts as I see it:
1. An AirCanada A320 lined up on the taxiway at SFO thinking they had actually on final for the active runway.
2. The error was detected by various combinations of the actual flight crew, ATC and other aircraft on the taxiway.
3. A go around was initiated and subsequently the aircraft in question landed uneventfully on the correct runway.
4. There was no damage to any aircraft, no injuries to any passengers or ground personnel.

NTSB is investigating in conjunction with other parties to determine the reason why this happened. The investigation is ongoing and cause/contributing factors hasn't been released.

[mbav8r]

I was working with the 18 meter out of the report. If it is only 3 ft, then yes, it was much worse and close to a major incident.

The 18 metres/59 feet you refer to is the actual altitude AGL the aircraft descended to above taxiway C prior commencing its climb according to the NTSB and the aircraft's DFDR.

The crew initiated the "Go Around" around 85 feet AGL but the aircraft continued its descent for another 2.5 seconds to 59 feet AGL crossing/over flying PAL 115 at some point while still descending. The tail height of an Airbus 340 is 56 feet so this is where the possibility of only a 3 foot clearance comes in. It could have been 5 feet maybe 10 but I suspect only the NTSB could give you an exact number. Regardless, it was a very close call and again it is of my opinion that only the fact that the crew of PAL 115 turned on their landing lights (as per the NTSB) was the final grace that saved the day.

The NTSB would not be investigating this as a serious incident if it were not so.

Jetjockey, for what it's worth, I'm over it and was simply pointing it out because there have been posters in the past who YELL everything, so being it was not intentional, no need to get your nickers in a bunch.
As for your possibly 3 foot clearance how is that not sensational BS? I have looked at the same photos as everyone else and clearly there was lateral separation as well, if you show me a photo of them crossing the tail 3' above it, then yes it was close. There is no question the go around was initiated at a point worth investigating and it is, so outside of this, it's all speculation.
As for the CVR, at what point was the crew aware they were the subject of an incident investigation?
For all anyone knows at this point, they were planning on self reporting the go around via an SMS report and not aware of the need to save it by disabling it for the next flight, implying a cover up is fairly high up on the speculation chart without anything to back it up.

[pelmet]

As I said earlier....

"Instead of arguing over the seriousness or not of this case, I think we could be a lot more productive in trying to making posts on how to prevent this sort of occurrence from happening again."

Does anyone have anything to add? Lets try preventing another incident.

[JeppsOnFire]

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.

Why do you keep expressing the event this way? Why don't you state. as a fact, "The highly trained Air Canada crew lined up, approached, descended and came close to landing on the taxiway at SFO International airport on top of fueled and populated aircraft waiting to depart."

What point are you trying to make? That they didn't crash? I said that too AND it gets the gravity of the situation across at the same time, unlike your statement. Ah, maybe that's the point!

I say nobody got hurt and nothing was bent to inject some much needed non-hysteria to the dialogue. If it is your belief I'm dismissing this as a non-event unworthy of investigation then I suggest you go back and read all of my posts again.

Super funny that Rockie is is in favour of injecting 'some non hysteria' into this topic. If this was a topic during the election of a particular American President, rampant hysteria is ok.

If that photo is accurate, this is worth the attention its been getting. Why some people think that every mistake is indicative of a greater systemic problem is curious. We've all made mistakes - in this SMS world, we are always looking for CAPs (corrective action plans) which makes perfect safety sense, unless a crew just simply screwed up. Sometimes humans just make mistakes. I'll say it again, sometimes humans just make mistakes. This situation appears without any ill intent, procedures followed and a skilled crew. It appears they just effed up. Why are we not allowed to say they just effed up?
Like Rockie, I believe there is no need for anyone to be hanged but like I said before: 'The occurrence pilots are absolutely responsible; they had no less information available to them than all the other planes that approached/landed safely that night. They will receive their consequences and we all should all be thankful it wasn't us and move forward motivated to not make the same mistake.'

[Cliff Jumper]

I still don't know what people want this crew to do now, or want the company or FAA/TC to do.

A group of you are stating "they must be held responsible", and other similar statements. But, what does this mean? They should be fired? fined? jailed? publicly humiliated? .... for a mistake? Or, do you really belief this was in some way intentional?

Or do you just mean that they should take 'personal responsibility' ie, in one's own mind? If so, don't you think the crew has? Have they said something that would suggest they haven't done this?

[Cliff Jumper]

Why are we not allowed to say they just effed up?

Because that does absolutely nothing to prevent another person from effing up in the same manner.

While, trying to determine why they did what they did, does.

[pelmet]

Why are we not allowed to say they just effed up?

Because that does absolutely nothing to prevent another person from effing up in the same manner.

While, trying to determine why they did what they did, does.

Then how about joining me and.....

"Instead of arguing over the seriousness or not of this case, I think we could be a lot more productive in trying to making posts on how to prevent this sort of occurrence from happening again."

Do you have anything to add? Lets try preventing another incident.

[Cliff Jumper]

Why are we not allowed to say they just effed up?

Because that does absolutely nothing to prevent another person from effing up in the same manner.

While, trying to determine why they did what they did, does.

Then how about joining me and.....

"Instead of arguing over the seriousness or not of this case, I think we could be a lot more productive in trying to making posts on how to prevent this sort of occurrence from happening again."

Do you have anything to add? Lets try preventing another incident.

I'm all for that, but at this point, we have almost no idea why they did what they did, so it's going to be nearly impossible to guess how to prevent it.

[pelmet]

Then how about joining me and.....

"Instead of arguing over the seriousness or not of this case, I think we could be a lot more productive in trying to making posts on how to prevent this sort of occurrence from happening again."

Do you have anything to add? Lets try preventing another incident.

I'm all for that, but at this point, we have almost no idea why they did what they did, so it's going to be nearly impossible to guess how to prevent it.

I disagree that is impossible to prevent but I check your remarks...so if you magically get a flight there tomorrow under the same circumstances as they had with no reliable electronics to align you with the runway, what is your plan to prevent a repeat captain?

[Rockie]

Funny comment Jepps, except this incident was over before anybody heard about it and now all that's left is to dissect it to hopefully prevent a recurrence.

The situation down south is an ongoing accelerating disaster that everyday exceeds even the most pessimistic fears. Not the same thing at all..

[Jet Jockey]

As for your possibly 3 foot clearance how is that not sensational BS? I have looked at the same photos as everyone else and clearly there was lateral separation as well, if you show me a photo of them crossing the tail 3' above it, then yes it was close. There is no question the go around was initiated at a point worth investigating and it is, so outside of this, it's all speculation.
As for the CVR, at what point was the crew aware they were the subject of an incident investigation?

Sensational BS? Not really, just going by the facts.

I don't know what info you are looking at but this is from the official NTSB site and it cannot get any clearer than that.

Look at the following diagram and see for yourself the track of AC 759. This is figure #1 where AC 759 is abeam the threshold of RWY 28R and dead centre of taxiway C at an altitude of 131 feet MSL or 118 feet AGL. To its immediate left is UAL 1 and down the taxiway and approaching taxiway W is PAL 115, one of 3 other aircrafts taxiing down C for a takeoff on RWY 28R. Also notice the caption between the diagram and the picture with UAL 1 saying "he's on the taxiway"



The next diagram (figure #2), shows AC 759 already in the "Go Around" still dead centre of taxiway C at an altitude of 119 feet MSL or 106 feet AGL. By this time it already over flew directly above PAL 115 and overflew the nent two aircrafts both UAL aircrafts.. According to the NTSB the Go Around was initiated at 85 feet AGL prior to crossing PAL 115 and descended to 59 feet AGL at some point before climbing again. So it is very possible that AC 759 overflew the tail of PAL 115 by as little as 3 feet.

[Cliff Jumper]

I disagree that is impossible to prevent but I check your remarks...so if you magically get a flight there tomorrow under the same circumstances as they had with no reliable electronics to align you with the runway, what is your plan to prevent a repeat captain?

No, I didn't say it was impossible to prevent, just that with the proven info we have right now, and not knowing why it happened, it is impossible to guess how to prevent it.

Take your quoted example... the ILS. You are going on the premise that they didn't have it tuned, and that's likely true, but it isn't proven to be true. So, deciding now that AC should come up with new policies to always tune the ILS or replace the aircraft with newer ones, is a solution for a problem that only hypothetically exists.

What do we really know for sure? Distances, times, heights, couple of screen caps, atc tapes, notams, and weather. That's about it.

Based on those alone, I have no idea why what happened happened. Couple of wild theories perhaps, but it this moment, that's all they are.

[complexintentions]

I stand by my comment. It was a non-event.

Tenerife. That was an event.

Was this one closer than it should have been? Yeah duh. Of course it needs to be investigated as to why. But this one has been reported as if it WAS a disaster. When it was actually a disaster that was prevented. Obviously the press and some of the more excitable types here have picked which side of that equation they'd like to focus on, with the AC-bashers gleefully leading the charge. It's fine to argue all day long about how narrowly it was prevented, or by whom, whatever, but it gets old reading the hyperventilating rhetoric, that almost at times seems ghoulishly disappointed it was prevented, because hey then we could say those AC guys REALLY "effed up", right? This is the age we live in, when actual disasters are rare enough that "close calls" have to fill in for sensationalism.

As Rockie said, hysteria.

I feel somewhat vindicated by the fact they were already in a climb when ATC instructed the go-around.

[digits_]

I think it's time for this to lighthen the mood:

https://www.youtube.com/watch?v=Ccq30minme8

[JeppsOnFire]

Funny comment Jepps, except this incident was over before anybody heard about it and now all that's left is to dissect it to hopefully prevent a recurrence.

The situation down south is an ongoing accelerating disaster that everyday exceeds even the most pessimistic fears. Not the same thing at all..

OK. Of course this incident was over before anyone heard about it. I am not clairvoyant enough to discuss it before it happened and I if you expect Avcanada to be already abuzz while this Airbus was spooling up on the Go, you're optimistic at best.

Of course an Airbus Go-Around is dissimilar to a Presidential election. The common ground between the two is that Rockie from the internet, by decree, will announce what is worthy of hysteria and what is not. Unbiased of course.

If anyone looks at those photos and thinks 'meh', that's disturbing.