AC759 - 29ft from worst aviation crash in history

[zuluplus30]

Astro,

I'm struggling that you keep bringing up the Asiana crash. The NTSB final report say not one single thing about SFO ATC/NorCal approach operations. They were given a turn to final for 28L 14NM from the threshold and just slightly above glidepath, with instructions to maintain 180 to the marker, which they accepted without qualm. Seem's pretty simple to me. The Aisana crew mismanage the aircraft all the way to the seawall. How are you putting that on ATC? The first 6 categories of the NTSB recommendation are directly related to Asiana's training and SOPs. The rest relate to studies of impact forces and for SFO ARFF and emergency operations and communications.

Secondly, you and I both understand why the high & fast visuals. It's a direct result of your airline and every other airline trying to cram themselves into SFO when the weather allows. Visual approaches get you in quicker with reduced separation. If we move to RNAV/RNP/ILS approaches to get you on to more optimal glidepaths, the arrival rates plumet. The system ripples with nationwide ground delay programs & airborne enroute metering/mile-in-trail restrictions. Then it's ATC's fault again. If they clear you for a visual approach at 110/280K and you say "unable", what happens?

The part about ATC not observing that they were lined up on the taxiway? Can you from over 1 mile away tell that an object moving at 150mph is offset from it's correct path by 30 feet in the dark of night? The controller looks up, observes the aicraft on final is who he says he his, ensures the runway is clear, and goes back to other tasks. It's midnight in SFO. Reduced staffing means more tasks for the local and ground controllers.

Let me be clear. The controller is not off the hook here. Saftey of the NAS is a shared responsibility: period. But you came out in your very first post with an obvious bias against SFO tower and NorCal approach and I'm trying piece that together. For the record, I do not work at either one so I have no skin in this particular game.

 

[BozoDeClowne]

What options are available to the plane(s) on the taxiway? Could a pilot determine the inbound airliner was lined up with the taxiway with enough time to move his jet? What would the move be at that point? Squirting out onto the runway seems like it would be a very bad idea.

Get on the open frequency and scream for the approaching plane to wave off? Would a crew already busy with landing heed such a warning without confirmation from ATC?

Doesn't seem like there would be a lot of options for the sitting ducks on the taxiway.

 

[L_Sludger]

Originally Posted By: BozoDeClowne

Get on the open frequency and scream for the approaching plane to wave off?

I'm not entirely sure that call would carry weight outside of an aircraft carrier's flight operations envelope.

 

[Oro_O]

I have followed the thread on this incident at PPRUNE from the beginning (profesional pilots rumor network, it is up to about 20 pages there) and a factor mentioned there was that runway 28L was closed and the illumination off. The pilots presumably expected to see two operable runways and mistook 28R for 28L, and Taxiway C for 28R.

I am not a pilot and am not evaluating that as a credible reason alone for the incident. Just pointing out that important piece of information that has not been in this thread that I caught (I did go back and read from p. 1).

What combination of factors between ATC, runway configuration, landing aids in operation, and pilot error made this near-disaster possible, I don't know. But I'd let professional pilots who fly into and out of SFO, and ATC's who operate there do the speculating and keyboard forensics. I'd sit and listen and not interject. PPRUNE is excellent for that.

 

[edhackett]

Originally Posted By: Win
The way I read it, the aircrew making a mistake is a symptom of a bigger problem.

The way I read it, the problem is an arbitrary, perhaps dubious, objective of reducing noise in Palo Alto, San Carlos, etc., that is keeping aircraft too high to bleed energy and safely descend in the allowed distances, pushing air traffic off against a rapidly rising ridge instead of over flatter land, making them do complex visual approaches over open water at night, instead of using the installed expensive and highly reliable electronic navigation systems that make aviation safe, and would prevent the mistake in the first place.

And despite fatalities occuring, arguably flawed procedures are still in place, and more fatalities could occur until they are changed.

That's the way I read it, anyway.


I think you got it right on the money. I fly R/C with a retired controller who worked out of Minneapolis. We talked about this the other morning. Approachs' job is to maintain separation and get you in sight of the runway. Once you are placed on a visual approach or acknowledge visual of the runway on any other type of approach, they are done with you. It's all on the crew, as Astro says. He also said that the standard approach radar did not have the resolution to prevent such occurrences. Some airports only have 200 feet or so separating the taxiway from the runway.

As Astro reported, and as you read it, it sounds like SFO has a culture of fobbing flights off onto visual and moving on to the next plane instead of staying with the pilots through difficult approaches.

Ed

 

[sleddriver]

Originally Posted By: Astro14
...I've been at 11,000 feet, heading 100, 280 KIAS assigned, and abeam the airport - "cleared the visual 28R - start your turn now"

H O L Y...C O W.........

 

[Vikas]

Quote:
It's all on the crew, as Astro says.
No he did NOT. He made a nasty comment about ATC being on "phone". What was ATC supposed to say "Sorry Captain, let me remove those planes from the taxiway so you can land on it".

That is why I will never be ATC; too sarcastic to be of any use

 

[Vikas]

A time stamp at 11:56:07 p.m. on July 7 shows the exact moment an air traffic controller ordered an Air Canada pilot to abort his landing. The Airbus 320 had already flown over one jet and was just above another. The dots show a second-by-second account of the Air Canada’s flight path with its altitude at the time. (Courtesy of FlightAware)

 

[turtlevette]

Theres a new article on this. http://www.mercurynews.com/2017/07/21/sf...ts-source-says/

Surely they are not saying they only had one controller for the whole airport?

 

[fdcg27]

Let me see if I understand you correctly.
The intended runway had a perfectly functional ILS which would have enabled the crew to avoid the error they made but approach procedures commonly used at this airport preclude the use of the ILS and instead require that the crew make an unnecessary and unstablized visual approach?
Even when he weather is wonderful, an A320 isn't a C172 and at least tracking and monitoring the ILS would force a stabilized approach from a much great distance from the runway threshold and would also lead the crew to the runway threshold every time.

 

[turtlevette]

If Astro and other pilots say they need more help landing, then we need to get them some help period. Everything in this country is being run by MBA beancounting types. I have such utter contempt for people in charge of stuff they don't understand. Wouldn't it make sense to have an ex pilot running the airport? They probably have some stuffed shirt.

What would it cost to get a half dozen controllers in there to help with landings? Nothing. They could take it out of petty cash.

I like how people can take to social media to change seating policy, but do nothing after an incident like this. People should be outraged. The internet should be lit up over this. You can't trust burecrats and penny pinching airport managers to fix this. They're too dumb.

 

[fdcg27]

What I'm getting from all of this is that neither Astro nor any other ATP needs more help in landing and having more controllers would do nothing to alleviate the difficult position that pilots can face arriving at SFO.
The management of the airport also has nothing to do with it since they aren't involved in issuing clearances or establishing approach procedures.
Rather, it appears that pilots are often given clearances that involve non-standard visual approaches requiring rapid descents both to maintain the operations rate and to limit the noise footprint over surrounding areas.
That SFO is a busy airport at peak periods is not likely to change anytime soon. However, those who bought houses long after the airport came into use should have no expectation of being protected from a little turbine noise at the expense of less than ideal approach clearances given to pilots flying planes full of people.

 

[Astro14]

An update from the NTSB: Flight safety

I will post more later, but this point is critical: the runway lights for 28L were OFF.

So, a crew on a visual approach, that wasn't aligned to a runway, and expecting to see two runways lined up on the "right hand" set of lights...which was the taxiway...

Always read the NOTAMS!

 

[turtlevette]

There is an article out with a picture from the tower of the plane overflying the others. Really bone chilling. I don't want to fly anymore. Its more fun driving anyway.

 

[Astro14]

Originally Posted By: turtlevette
There is an article out with a picture from the tower of the plane overflying the others. Really bone chilling. I don't want to fly anymore. Its more fun driving anyway.



So, that trip to Hawaii, then...what are you planning on driving?

 

[Win]

Quote:
.... Always read the NOTAMS!


" ... during the final 3 nm (6 km) of the approach, the airplane’s flightpath was lined up with the taxiway and maintained the runway heading."

What is the approach speed of an A320? Looking at the VFR plate you posted, it looks like you're over the threshold at about 1.25 - 1.5 minutes after that last course change?

Wouldn't they still be looking at the localizer, even if it was not part of the approach, just as a cross check on their final position?

Do we know what the NOTAM said, i. e. the lights were off? I wonder if the flashing X was horizontal, vertical, or even working ....

" ... The incident airplane’s cockpit voice recorder had been overwritten ...."

Not sure what inference to draw from this. That gives the aircrew some maneuvering room ...

edit: do they always run the rabbit at night? Or is that turned on / off at request ? Does that runway even have one ?

 

[turtlevette]

Its alarming to me that there's no movement to do something. No concern. No outrage.

I'm not sure what the solution is, but I know doing nothing isn't it.

A thousand people almost burned but they're more worried about hurting someone's feelings? Is that it?

 

[KD0AXS]

Originally Posted By: Win


" ... The incident airplane’s cockpit voice recorder had been overwritten ...."

Not sure what inference to draw from this.



The CVR only holds a certain amount of audio. I believe it used to be 30 minutes, not sure if that has changed. After it reaches the limit, the previously recorded audio is overwritten.

The aircraft probably made several more flights before there was any official investigation into this incident, so the CVR audio from this flight would have been overwritten with audio from later flights.

 

[Astro14]

Originally Posted By: turtlevette
Its alarming to me that there's no movement to do something. No concern. No outrage.

I'm not sure what the solution is, but I know doing nothing isn't it.

A thousand people almost burned but they're more worried about hurting someone's feelings? Is that it?




What do you mean "no movement"??

It's being investigated. The report I linked is preliminary data from the NTSB. So, it's being treated like a crash investigation. What more do you want?

No one died. No one was hurt.

And yet, the authorities are treating it as if it were a crash. The profession is taking this very seriously. We identify mistakes and trends all the time, butt taking action is premature when the investigation is still on-going. We need to know what happened in order to do anything.

What worries me, and should worry you, is this: will there be any self-examination of the ATC procedures and practices that led to this incident?

You see, the partnership for safety includes both pilots and ATC. I recognize that the pilots are going to be scrutinized. They should be. At first blush, it appears to be a case of confirmation bias: seeing what you expect instead of what is there. They expected to see two runways, but only one was actually lit, so they lined up on what appeared to be the right hand runway.

Except that it wasn't.

Now the reasons for that mistake are complex. They're being investigated. The ILS would have them lined up properly, but SFO chose to clear them for an FMS visual approach procedure that deliberately keeps you off centerline. Great for spacing traffic into runways that are too close together, but not good for runway identification on a dark night, with a fatigued crew that may not be familiar with the airport.

Was that the best choice for the circumstances?

The tower was minimally staffed. Traffic load was relatively low. So, why the FMS visual?

A NOTAM is a "Notice to Airmen" - notes on the operating conditions and temporary procedure changes for an airport or enroute facility. Clearly, the crew missed the NOTAM that said that 28L was closed. What was the lighting that night? Was the big X visible?

Before you criticize the crew, take a look at SFO:



This picture was taken on a clear day, and on centerline, but it looks a lot like three runways. I'm familiar with how runway lighting is supposed to appear, but make it dark, late, add in fatigue, turn off the lights to the left runway (when the crew expected them to be illuminated) and put the airplane to the right of taxiway C on the FMS bridge visual...and I can see how confusion/mistakes happen.

The crew should have known that 28L was out of service. I get that. That's a mistake. The should have gone around sooner when the visual picture didn't make sense - also a mistake and I get that, too. Pilots, like all highly-trained people, want to complete the task at hand, so there exists a strong bias towards landing, even if you're a bit out of parameters.

I've talked about SFO quite a bit. It's not an easy airport. It's made harder by ATC procedures designed, not for safety, but to increase traffic flow while minimizing the noise footprint.

Imagine a partnership, a marriage, say, in which one partner says, "All the mistakes are your fault, I'm perfect". While this might sound a bit like your ex...and it sure sounds like mine...this isn't a healthy partnership that will lead to improvements in safety. It's a blame culture. And just pointing fingers at the other party without self-examination will not lead to improvements in safety.

That's what worries me.

My comments about ATC have been called "nasty". Oh, please. I repeated what ATC themselves reported. Hardly nasty. The tower was minimally staffed and not watching. The TRACON assigned the visual. There are things that they could've done differently.

The crew screwed this up. No doubt. But if ATC continues to put crews in a position that makes mistakes more likely, then shouldn't ATC re-evaluate the balance between noise abatement and safety? Examine when a visual is appropriate and when it is higher-risk? We, as pilots, laugh about the "SFO Slam Dunk" because it happens all the time...but should it happen all the time? It's fine when the weather is clear, and the crew is experienced, and no one makes a mistake...but add in weather, fatigue, unusual operating conditions like a runway closure and the risk goes up.

If we want to improve air safety, there must be an ATC/pilot partnership and an examination of all the factors that led to this near-miss.

 

[Astro14]

Originally Posted By: Win
Quote:
.... Always read the NOTAMS!


" ... during the final 3 nm (6 km) of the approach, the airplane’s flightpath was lined up with the taxiway and maintained the runway heading."

What is the approach speed of an A320? Looking at the VFR plate you posted, it looks like you're over the threshold at about 1.25 - 1.5 minutes after that last course change?

Wouldn't they still be looking at the localizer, even if it was not part of the approach, just as a cross check on their final position?

Do we know what the NOTAM said, i. e. the lights were off? I wonder if the flashing X was horizontal, vertical, or even working ....

" ... The incident airplane’s cockpit voice recorder had been overwritten ...."

Not sure what inference to draw from this. That gives the aircrew some maneuvering room ...

edit: do they always run the rabbit at night? Or is that turned on / off at request ? Does that runway even have one ?



Win - to your specific questions:

The FMS Bridge Visual to 28R keeps you off centerline until 4.4 DME (NM from the runway threshold). If you're cleared for the ILS, you then tune the ILS. In some airplanes, you'll tune the ILS as a back-up to the visual, as a matter of SOP and IF the circumstances allow. The ILS may be out of service, that's WHY the FMS approach is in use.

In the A-320, when the FMS approach is selected from the FMS (Flight Management System) the airplane uses the FMS procedure as its navigation reference and doesn't tune the ILS. It tunes the ILS when the ILS approach is selected. It's got GPS, so the FMS is highly accurate.

But that FMS Bridge visual to 28R lines you up to the right of the airport until the transition at SAMUL (see the approach plate I referenced earlier). From that perspective, at night, lined up to the right of the taxiway, the visual picture they saw probably didn't make sense.

It's not clear to me if they were coupled (i.e. Autopilot on) or hand-flying. We, as a profession, criticize crews for not using the autopilot and then are amazed to find that they can't hand-fly the airplane...so we tell then to hand fly more....and automation use will, no doubt, be examined in this case.

Typical A-320 approach speed (which depends on gross weight, flap setting, and wind) is about 135 KIAS. I don't know this particular airplane's weight, or flap setting, or the winds that night, so I could be off by up to 15 KIAS.

What was published in the NOTAMS will be examined. I have no idea what they were that night, but currently, SFO has about 40 published NOTAMS. Got to read every single one of those...and buried in today's NOTAMS are runway closures, inoperative ILS approaches, runway lighting out of service. All of those bits of inoperative equipment were a factor in both this incident as well as the Asiana crash.

The ILS sure helps.

If it's turned on...

As was mentioned, the CVR in the A-320 has a finite recording capability. Yeah, I know that memory has gotten cheaper, but memory that's certified for aircraft and built into a survivable black box (that is actually orange) hasn't gotten cheaper.

On UAL airplanes, it records the past 2 hours, and data that is older is continually over-written.

No idea what the capacity is on an Air Canada airplane, but if it's 30, or even 45, minutes, it's pretty easy to get overwritten. Do the go-around, take 20 minutes for vectors and approach, a bit of ground delay getting to a gate (and even in low traffic, I've waited 30 minutes on the ground for a gate in SFO) and yep, the incident is overwritten.

The crew has NO ability to overwrite or erase the CVR, so, no there is nothing to read into that.

The rabbit should be running at night. But then the ILS should be working, and the runway should be open, and the centerline lights should be working, and the taxiways should be open and lit...but looking at today's NOTAMS, there are a lot of things out of service at SFO...