Nicoeddf wrote:

Not disagreeing. But I am anyway not trying to advocate "better or worse". I am just saying that different sets of circumstance lead to different sources for error. And runway configuration and (lack of) visual approaches are part of the game.
Hence, room for improvement would be different for FRA vs. SFO, say. *shrug*

Sure I am with you on that - *every* Airport has room for improvement...

But a visual Approach should be briefed for and a non-Event really. I'd like to be a fly on the wall in those Cockpits. What briefing was being done? Why no cross check of the LLZ vs visual Approach path. When you're cleared onto a specific runway be it L/C/R then one should be using everything they have at their disposal to Monitor their Approach path especially into congested Airports with multiple runwys. All These glass Cockpits have a RX and it should be dead easy to spot you are not on the Approach to the correct runway...

There's always those too, that believe nothing can ever happen to them and complacency sets in. Both ATC and pilots. I mean, sometimes there is so much crap that is done as Standard and because nothing happens means it's OK. That is not OK. Just look at what it took to untangle the 25s Standard missed vs 25s departures. But there is never just 1 cause for These Things. There are always multiple causal or contributing factors... But one Needs to be objective in the Analysis.

neomax wrote:

If the frequency of these events is so high, does the FAA investigate all of them, even if they happen all the time?

FAA Order regarding occurrence reporting:

-Any go-around initiated by either a flight crew or ATC involving turbojet aircraft within a 1/2-mile of the arrival threshold not involving practice approaches.

-Any ground surveillance alert [Airport Surface Detection Equipment (ASDE) or Airport Movement Area Safety System (AMASS)] between two aircraft.

This is why the original Air Canada incident was investigated next day by facility management.

neomax wrote:

If the frequency of these events is so high, does the FAA investigate all of them, even if they happen all the time?

Like most things in life, the rules of no harm, no foul usually prevail. We're all human, pilots, controllers, rampers...we look out for each other. I've done my job at SFO for 5 years now, can write a book about the stupid stuff I've seen, but written maybe 4 or 5 reports about pilots. That's because most of the things that happen are just little brain farts that are easily corrected, even if they had potential to be serious had nobody stopped the incident from occurring. That being said, sometimes things that happen are serious enough to warrant a report. Ignore several go-around calls or almost crash into 5 jets, and you're on your own. Lol.

Neomax,

A word of advice—PARAGRAPHS.

If the NIMBYs in SFO would allow filling in the bay as necessary for standard runway spacng; these events would very likely be substantially reduced. Some piece of bait obviously carries more value in SFO.

Second, again due to NIMBYism and specifics terrain, SFO has lots of semi-squirrelly procedures for both pilots and ATC. I’ve flown in there half dozen times in a large business jet and we always briefed as a “threat”—close parallels, close traffic, lots of heavies at certain times, the required ground references as aids which I think can be more important on a visual than the radios. IT’S A VISUAL, so visual references should prevail. “We should be here on this end of the San Mateo bridge”. Flying a visual isn’t that tough.

GF

Mir wrote:

Nothing prevents you from tuning the ILS frequency on a visual approach so that you can see your deviation from the localizer. It's mandatory for most carriers, and if you do so I find it very difficult to see how someone could end up lined up for the wrong runway.

This ignores the realities when charted visual approaches are flown, as is common at SFO. In many modern aircraft, the localizer frequency is automatically tuned when loading an ILS approach from the FMS. That's fine when flying a generic visual approach backed up by an ILS. Just load the ILS approach from the FMS database and fly it on a visual approach clearance. But when flying a charted visual approach one would load the charted visual approach from the FMS. Since there is no ILS associated with a charted visual approach (as far as the FMS is concerned), the localizer is not automatically tuned when selected from the FMS. Nor should it be. It you look at the Quiet Bridge Visual 28L/R at SFO, the lateral course does not match up with the localizer until after crossing the San Mateo bridge.


Another anomaly. Looking at the TIPP TOE Visual Rwys 28L/R chart:


The notes state "When visual approaches to Runways 28L/R are in progress, arriving aircraft may be vectored into position for a straight-in visual approach to Runways 28L/R via the I-SFO localizer."

So if cleared for the TIPP TOE Visual 28R the text on this chart states to use the 28L localizer (I-SFO)?!?! When selecting the proper runway from the FMS in conjunction with the charted visual this should not be a problem, but still.... that wording is pretty bad. If a crew briefs the approach per that text, add in a language barrier... I can easily see how a crew is lined up on the wrong runway in this scenario. Its been several years since I've flown into SFO; maybe they only use the TIPP TOE for 28L arrivals. But I'm not surprised SFO is having these issues.

n471wn wrote:

The issue is simply that SFO has a badly outdated runway configuration and needs another long runway with adequate separation. Any other city would have done this long ago but not in the Bay Area where the environmental whacko’s have all the power and have no interest in bringing SFO up to standard.

That would be ideal but one thing they could do that is more practical in San Francisco is shift 10L28R to the north just a little bit (where taxiway "C" sits) and put the parallel taxiway between the runways. It would make the layout more standard as far as dependent parallel runways/taxiways go and I think it would help alleviate some of these issues, especially the Air Canada incident. They made this safety improvement at CLE and LAX (southside).

KSFO Air Traffic Control (NORCAL 28R/L Approach and Tower) critical communications to and from AMX668, as best as can be heard from the ATC audio:
- 1940: 32Z ATC Approach- “Report on the localizer 28R”
- 1942:20Z AMX668- “With you on the localizer”
- 1942:30Z ATC Approach- “4 miles from DUYET, correction AXMUL, CLEARED ILS 28R APPROACH”…AMX668 Confirmation, “CLEARED 28R APPROACH”
- 1943:29 ATC Approach- “Contact San Francisco Tower 120.50”
- 1943:51 AMX668 to ATC Tower- “AMX668 at DUYET” (Note: DUYET is the FAF for RWY28L, Not 28R that they were cleared on and accepted)
- 1943:52 ATC Tower- “28R cleared to land”
- 1943:53 AMX668 confirmation - “28R cleared to land”
- 1945:53 From ATC Tower with urgency in voice – “AMX668 go around” (note: this occurred at FlightRadar24 indicated altitude of 525’ MSL (std. press/temp basis) and 0.9 NM from Rwy28L threshold).

At the time that AMX668 was instructed to go around by ATC Tower (AMX668 didn’t initiate their own GA), VX1041 an A320 was in takeoff position on Rwy28L, the runway that AMX668 could have landed on if KSFO ATC Tower had not given them the emergency instruction to go around. The ATC conversation is crystal clear that AMX668 was cleared for (and accepted) an ILS approach to runway 28R, and AMX’s readbacks/confirmations indicated same, even though they were actually landing on runway 28L.

There’s a lot of discussion herein of just overlooking this error. It was not a night landing. It was daytime. The weather was not a factor despite the 1400’ broken/ceiling. The flight picture for landing on 28R would have been clear in the cockpit, including the 28R ILS course, and I.D. on the PFD, 28R runway would have been displayed on the ND including the path from the IAF at CEPIN and the FAF at AXMUL and to the threshold. A clear visual picture looking out the windscreen just after AXMUL (given the METAR) of only two runways, one on the left side and one on the right side and the appropriate lead in approach lighting indicating runways and not taxiways would be apparent. And the A320 aircraft in position to takeoff at the threshold area of runway 28L would have been glaringly obvious.

As such, this was IMO likely a serious lack of situational awareness by the aircraft crew, and thank God that KSFO ATC intervened in time to avoid a potential very serious incident. BTW, the flight track of AMX668 from FlightRadar24 data shows they passed directly over the 28L IAF/CEPIN, 28L FAF/DUYET, and straight in to runway 28L, despite receiving and accepting a clearance to land on 28R.

I doubt moving 28R to the right would work as there is enough side line room with the GA ramp, USCG, the fire station on that side. Runway clearance surfaces are bigger than taxiway ones.

I fly a biz jet based at KSFO and have many years experience operating from there. KSF0 is nearly always a busy work load for arriving pilots...with visual approaches in particular. We always brief the visual approach procedure even after many years of operating to/from SFO.

I still don’t understand how both pilots could mistake 28R from taxiway C. (Air Canada incident)

If the transcript above is correct I can start to see how this happened and both ATC and the Pilot are a bit at fault, but more the Pilot.

I think they probably had 28L loaded before clearance and when ATC said DUYET correction AXMUL the pilots still heard DUYET which reinforced their (wrong) belief they were to be on 28L.

When they switched and reported to Tower and said they were at DUYET that probably was a good indication to the Tower they weren’t on the right approach and more than likely had the wrong Plate and Frequency plugged in.

This is a less serious incident in my book than the Air Canada taxiway incident.

cat3appr50 wrote:

At the time that AMX668 was instructed to go around by ATC Tower (AMX668 didn’t initiate their own GA), VX1041 an A320 was in takeoff position on Rwy28L, the runway that AMX668 could have landed on if KSFO ATC Tower had not given them...

Does takeoff position necessarily mean that vx1041 was Cleared for takeoff? Just thinking about possibility of whether vx1041 could have been on roll as amx was on threshold....

flyPIT wrote:

Another anomaly. Looking at the TIPP TOE Visual Rwys 28L/R chart should not be a problem, but still.... that wording is pretty bad
.

Or introducing another human factors concern: Should there be different charted visual approach names for different runways? "Quiet Bridge" and "Tipp Toe" apply to both runways.

BoeingGuy wrote:

hOMSaR wrote:

neomax wrote:

“Fool me once, shame on you. Fool me twice, shame on me. Fool me three times, shame on both of us.”

At this point, SFO is just as guilty of not doing anything to prevent this problem, even if the pilots are the ones who messed up. This is third time we've had a runway related miss at SFO in less than 6 months with the same runway. Normally, the third time is the strike (Yikes!) and I don't think most people realize how insanely lucky SFO has had it lately.

There was Air Canada and this one. What was the third one?

There was a second Air Canada event.

https://www.mercurynews.com/2017/10/23/ ... up-at-sfo/

Second event is not related. Simply a frequency issue. So it’s two events.

This really seems like more of a pilot training issue. Is there an option to have these less familiar pilots/airlines do instrument landings even in visual landing conditions? Or can you not mix and match approach types with other airlines that are landing?

cat3appr50 wrote:

As such, this was IMO likely a serious lack of situational awareness by the aircraft crew, and thank God that KSFO ATC intervened in time to avoid a potential very serious incident. BTW, the flight track of AMX668 from FlightRadar24 data shows they passed directly over the 28L IAF/CEPIN, 28L FAF/DUYET, and straight in to runway 28L, despite receiving and accepting a clearance to land on 28R.

So, what happens in this situation if two planes are given simultaneous approach and landing clearances, one to 28L and one to 28R, but this same issue happens again and they both fly the 28L approach?

phatfarmlines wrote:

Or introducing another human factors concern: Should there be different charted visual approach names for different runways? "Quiet Bridge" and "Tipp Toe" apply to both runways.

Yep. I still can't get over the fact that one chart states to track the 28L localizer even if conducting a visual to 28R...

GalaxyFlyer wrote:

I doubt moving 28R to the right would work as there is enough side line room with the GA ramp, USCG, the fire station on that side. Runway clearance surfaces are bigger than taxiway ones.

I'm only talking about moving the runway 150' or so to the north, enough to put the parallel taxiway between the runways. Probably wouldn't even need to touch where taxiway C currently sits, although C would need to be removed. USCC is not even close and the GA area easily modified or relocated; same with the storage tanks near the Super Bay. The only issue I could see is a corner of the closest United maintenance building. But in the grand scheme of things regarding runway construction the relocation of these few structures are minor issues.

barney captain wrote:

fly4ever78 wrote:

One reason for these incidents is the fact that the FAA has allowed visual approaches to 28L/R below their own minimum standards for parallel runways separation limits. This does not negate the responsibility for the pilots to make sure they are lined up for the correct runway, but it obviously allows for higher odds of these types of incidents to occur. I don't know the specifics of this particular incident, but throw in some inoperative equipment (which is commonplace) and it is very easy to line up for the wrong runway.

Actually no, it's not.

Why this happens, I can't easily explain.

Left. Right. It's simple rule...........

Congratulations, you've got it all figured out.

71Zulu wrote:

Set the runway localizer in your NAV radio and you have mostly eliminated the chance of this happening, why isn't this a required procedure?

Sent from my SM-N920T using Tapatalk

If the localizer is NOTAM'd out of service that would do you no good.

I still can't get over the fact that one chart states to track the 28L localizer even if conducting a visual to 28R...

It’s a VISUAL APPROACH, not an ILS. The reason for the reference to the the LOC or SFO R-095 is for alignment over the water. It’s noise related, not landing navigation.

Yes, the could mix up approaches, ILS for those non-familiar (furriners) and visuals at a cost of acceptance rates, holding, etc.

GF

FlyPIT,

stacle free surface for a precision runway is 1000’ wide centered on the runway centerline with and OIS plane, free of obstacles on the sidelines of 7:1; off the ends there is a 50:1 plane for 10.000’. Also, there is a 500’ clearance requirement between the runway and the taxiway. Look at Google Earth and place the runway where taxiway Charlie is now and most everything on the north side goes; UA Tech Ops would mostly be in the way. It’s very complicated, very expensive for a marginal improvement. This was the motivation for the land fill project years ago that was turned down on environmental grounds.

GF