ST165
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NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 12:28 am

Hi, this news has been making the rounds in Canadian media but hasn't popped up here yet.

https://www.cbc.ca/news/world/u-s-ntsb- ... -1.4838586
https://www.sfchronicle.com/bayarea/art ... 257531.php

The NTSB met to discuss the near miss of an AC A320 which almost crashed into several aircraft on landing after the pilots mistook a taxiway for a runway. A couple of key points:
  • First time that the NTSB considered a major investigation for an event w/o injuries or damaged planes
  • Probable cause was pilot error (didn't pay attention to NOTAM before flight and during briefing, failure to tune ILS properly, breakdown in CRM/expectation bias, etc.)
  • Recommendations include developing systems and presenting information that would prevent misidentification of taxiways as runways, and for Transport Canada to review pilot fatigue rules

https://www.ntsb.gov/news/events/Pages/ ... 8-BMG.aspx

In my opinion, it is hard to understate how close this came to the one of, if not the, largest air disaster in history, given it was three to six metres away from crashing into four aircraft!!
 
Bradin
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 1:59 am

 
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DA20RBV
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:12 am

I don't think the result of the investigation is a surprise.

I wonder if closure markings and lights will move from "may be usedx to "shall be used" to limit the possibility of confusion.

This will also be important for pilot association's in their argument regarding pilot duty hours and other pilot fatigue considerations.

RBV
 
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aemoreira1981
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:15 am

On this, it looks as though the plane would have missed the first B789 (UA1) and the PAL A343, but would have hit the third and fourth planes had he not corrected. One thing that should be done, if not already done, is mandatory ILS on all 28 approaches into SFO. (Has SFO ever used a runway series other than the 28s for landing?) If a plane cannot accept an ILS landing and the ceiling is below 1500 feet, it should be instructed to divert to an alternate aerodrome.

Also of note...the crew would have not been legal to fly under FAA regulations.
 
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SuperTwin
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:18 am

Scary stuff indeed.

One has to wonder if the actions of the PR pilot saved the day. That sudden burst of bright light would definitely grab their attention!

Come to think of it, the illumination would have created a pretty epic, in-your-face, silhouette of UA001.
SuperTwin
 
GalaxyFlyer
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:28 am

They couldn’t restrict all approaches to the 28s to ILS without creating unacceptable delays. What’s ridiculous is the refusal to fill in the bay as needed to create two real parallel runways.

First time that the NTSB considered a major investigation for an event w/o injuries or damaged planes


That’s to be congratulated. Chairwoman Hersman predicted doing just that years ago—investigate close calls rather than accidents.

GF
Last edited by GalaxyFlyer on Thu Sep 27, 2018 2:40 am, edited 1 time in total.
 
KICT
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:31 am

Are these pilots still employed with AC?
People are saying. Believe me.
 
GalaxyFlyer
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:41 am

I’m certain they are
 
Speedalive
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:51 am

From the abstract..

Findings

1. None of the following were factors in this incident: (1) flight crew qualifications, which were in accordance with Canadian and US regulations; (2) flight crew medical conditions;(3) airplane mechanical conditions; and (4) airport lighting, which met US regulations.
2. The first officer did not comply with Air Canada’s procedures to tune the instrument landing system (ILS) frequency for the visual approach, and the captain did not comply with company procedures to verify the ILS frequency and identifier for the approach, so the crewmembers could not take advantage of the ILS’ lateral guidance capability to help ensure proper surface alignment.
3. The flight crew’s failure to manually tune the instrument landing system (ILS) frequency for the approach occurred because (1) the Flight Management System Bridge visual approach was the only approach in Air Canada’s Airbus A320 database that required manual tuning of a navigation frequency, so the manual tuning of the ILS frequency was not a usual procedure for the crew, and (2) the instruction on the approach chart to manually tune the ILS frequency was not conspicuous during the crew’s review of the chart.
4. The first officer’s focus on tasks inside the cockpit after the airplane passed the final waypoint reduced his opportunity to effectively monitor the approach and recognize that the airplane was not aligned with the intended landing runway.
5. The flight crew-initiated, low-altitude go-around over the taxiway prevented a collision between the Air Canada airplane and one or more airplanes on the taxiway.
6. The controller responded appropriately once he became aware of the potential conflict.
7. Errors that the flight crewmembers made, including their false assumption that runway 28L was open, inadequate preparations for the approach, and delayed recognition that the airplane was not lined up with runway 28R, reflected breakdowns in crew resource management and led to minimal safety margins as the airplane overflew taxiway C.
8. The flight crewmembers’ lack of awareness about the runway 28L closure and the crewmembers’ previous experience seeing two parallel runways at San Francisco International Airport led to their expectation to identify two runway surfaces during the approach and resulted in their incorrect identification of taxiway C instead of runway 28R as the intended landing runway.
9. Although the notice to airmen about the runway 28L closure appeared in the flight release and the aircraft communication addressing and reporting system message that were provided to the flight crew, the presentation of the information did not effectively convey the importance of the runway closure information and promote flight crew review and retention.
10. The cues available to the flight crewmembers to indicate that the airplane was aligned with a taxiway were not sufficient to overcome their belief, as a result of expectation bias, that the taxiway was the intended landing runway.
11. Multiple salient cues of the surface misalignment were present as the airplane approached the airport seawall, and one or more of these cues likely triggered the captain’s initiation of a go-around, which reportedly occurred simultaneously with the first officer’s call for a go-around.
12. The captain and the first officer were fatigued during the incident flight due to the number of hours that they had been continuously awake and circadian disruption, which likely contributed to the crewmembers’ misidentification of the intended landing surface, their ongoing expectation bias, and their delayed decision to go around.
13. Current Canadian regulations do not, in some circumstances, allow for sufficient rest for reserve pilots, which can result in these pilots flying in a fatigued state during their window of circadian low.
14. Flight safety would be enhanced if airplanes landing at primary airports within class B and class C airspace were equipped with a cockpit system that provided flight crews with positional awareness information that is independent of, and dissimilar from, the current instrument landing system backup capability for navigating to a runway.
15. Although the investigation into this incident identified significant safety issues, cockpit voice recorder information, had it been available, could have provided direct evidence regarding the flight crew’s approach preparation, cockpit coordination, perception of the airport environment, and decision-making.
16. Once the flight crewmembers perceived lights on the runway, they decided to contact the controller to ask about the lights; however, their query was delayed because of congestion on the tower frequency, which reduced the time available for the crewmembers to reconcile their confusion about the lights with the controller’s confirmation that the runway was clear.
17. Although the use of line up and wait (LUAW) procedures during single-person air traffic control operations was not a factor in this incident, the tower controllers should have delayed consolidating local and non-local control positions until LUAW procedures were no longer needed.
18. If an airplane were to align with a taxiway, an automated airport surface detection equipment alert would assist controllers in identifying and preventing a potential taxiway landing as well as a potential collision with aircraft, vehicles, or objects that are positioned along taxiways.
19. Increased conspicuity of runway closure markers, especially those used in parallel runway configurations, could help prevent runway misidentification by flight crews while on approach to an airport.


Probable Cause

The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information.

--

I'm a huge fan of the little jab at TC about fatigue rules. They've been stalling on implementing the updated rules for a long time..

"To Transport Canada:
Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low."
 
spacecadet
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 5:41 am

Not a surprise - hard to see how almost crashing into three planes sitting on a taxiway instead of landing on a runway at a major airport using published approach plates and modern instruments is anything but pilot error.
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Caspian27
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 5:59 am

aemoreira1981 wrote:
On this, it looks as though the plane would have missed the first B789 (UA1) and the PAL A343, but would have hit the third and fourth planes had he not corrected. One thing that should be done, if not already done, is mandatory ILS on all 28 approaches into SFO. (Has SFO ever used a runway series other than the 28s for landing?) If a plane cannot accept an ILS landing and the ceiling is below 1500 feet, it should be instructed to divert to an alternate aerodrome.

Also of note...the crew would have not been legal to fly under FAA regulations.


Making additional procedures to account for people who didn’t follow proper procedures to begin with hardly make things safer...if someone didn’t follow the original procedures what makes you think that they would follow the additional “new” procedures?

SFO is only a viable airport because of charted visual approaches. Get rid of those and the only way to have enough capacity for the current arrival rate is to have another runway parallel to the 28s that’s 4,000 ft away. As a side note to the mega-environmentalists currently ruling the Bay Area: what is more damaging to the environment? Countless diversions when there’s one cloud in the sky that pollute the air and the diversion itself necessitates even more fuel and as we know the production of fuel pollutes the air, etc. not to mention the massive impact on passengers that get diverted that have to make alternate plans in fuel-burning machines. I can’t see how building another runway could possibly be more damaging than the cumulative effect of the massive flow delays currently experienced by the SFO airport in weather that wouldn’t even cause an operational blip at most airports.

ILSs aren’t the only approaches available. RNAVs, RNAV RNPs, heck even LOC and VOR approaches will get you within at least 500 ft of the ground in many cases.

As far as your question about runway configuration, landing on the 28s and departing the 1s is the most common configuration that SFO uses, however when a strong weather system moves in the wind generally shifts to the south which means landing on the 19s. I have landed on the 19s somewhat regularly, the 10s sporadically and in rare occasions the 1s. Further, the marine layer that moves in and causes most of the delays is almost always around 8 or 900 feet so I don’t see what point 1500 has in your example.

These particular pilots screwed it up that night, and we have to accept that we as humans are capable of this and know that every time something happens we don’t need to run out and rewrite the entire playbook.
Meanwhile, somewhere 35,000 ft above your head...
 
mxaxai
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 9:58 am

SuperTwin wrote:
Scary stuff indeed.

One has to wonder if the actions of the PR pilot saved the day. That sudden burst of bright light would definitely grab their attention!

Come to think of it, the illumination would have created a pretty epic, in-your-face, silhouette of UA001.

Per the NTSB, the pilots did not consciously recognise anything that they might've considered an aircraft. But something probably caught their attention, and fortunately they stuck to the good rule to go around when in doubt whether the approach is safe:
"They did not recall seeing aircraft on taxiway C, however, something did not look right to them." "Multiple salient cues of the surface misalignment were present as the airplane approached the airport seawall, and one or more of these cues likely triggered the captain’s initiation of a go-around, which reportedly occurred simultaneously with the first officer’s call for a go-around."
 
steeler83
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 12:02 pm

Also glad to see the NTSB investigate this near-miss incident. This near-miss was seconds from being the biggest aviation catastrophe since Tenerife. Not at all surprised it was pilot error.
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Super80Fan
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 12:36 pm

Shame on Air Canada, they should be fined into oblivion. The pilots are just scapegoats for their poor training practices and I hope they do keep their jobs and are just retrained.
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Revelation
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 12:47 pm

steeler83 wrote:
Also glad to see the NTSB investigate this near-miss incident. This near-miss was seconds from being the biggest aviation catastrophe since Tenerife. Not at all surprised it was pilot error.

If it really was three to six meters separation I think it was less than seconds of difference, no?

What would be the sink rate at that phase of the approach?

https://www.youtube.com/watch?v=oF7FR7TjnME is pretty revealing.
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dopplerd
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 12:48 pm

I'm familiar with O'Hare which has a series of chasing lights (I'm sure there is an official name for them) that extend several hundred meter in front of an active runway. These make it utterly apparent where the runway is. Does SFO not have these lights because of the bay? Looking at Google maps there appears to be a structure that extends a long distance into the bay that could serve to support this type of lighting system.
 
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longhauler
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 12:55 pm

Super80Fan wrote:
Shame on Air Canada, they should be fined into oblivion. The pilots are just scapegoats for their poor training practices and I hope they do keep their jobs and are just retrained.

"poor training practices" ??? That's a laugh.

Air Canada A320 pilots, recognizing the unusual nature of the aircraft operation receive far more training ... not only than required by Transport Canada, but more than other aircraft types in the fleet. Two additional Simulator sessions a year are added to address "Airbus things" like flying with no automation, or into airports with unusual approaches.

The last two LOSA audits at Air Canada put standards in the top third of the pack. All anomalies have been addressed.

The elephant in the room here is fatigue ....

Two things that the NTSB stated are that the crew duty day flown would not have been legal in the United States but also they would have been legal for a further 8+ hours by Canadian Standards. This is something that Canada's pilots (not just Air Canada pilots) have been stating for years.

Canada's crew duty rules are among the worst on the earth. Canada's Transport Minister had the opportunity to address this and proposed new duty rules, but northern Canadian operators stated that they could not operate under the new rules!!! So nothing changed.

I am hoping that with this report, pilot groups from all of Canada's operators go to Ottawa (again) and have it fixed once and for all. In my opinion, the NTSB is among the most sophisticated investigative groups around. Their opinion can not be ignored.
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Revelation
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 1:31 pm

longhauler wrote:
The elephant in the room here is fatigue ....

Two things that the NTSB stated are that the crew duty day flown would not have been legal in the United States but also they would have been legal for a further 8+ hours by Canadian Standards. This is something that Canada's pilots (not just Air Canada pilots) have been stating for years.

Canada's crew duty rules are among the worst on the earth. Canada's Transport Minister had the opportunity to address this and proposed new duty rules, but northern Canadian operators stated that they could not operate under the new rules!!! So nothing changed.

I am hoping that with this report, pilot groups from all of Canada's operators go to Ottawa (again) and have it fixed once and for all. In my opinion, the NTSB is among the most sophisticated investigative groups around. Their opinion can not be ignored.

Yes. Above we read:

Speedalive wrote:
From the abstract..

Probable Cause

The NTSB determines that the probable cause of this incident was the flight crew’s misidentification of taxiway C as the intended landing runway, which resulted from the crewmembers’ lack of awareness of the parallel runway closure due to their ineffective review of NOTAM information before the flight and during the approach briefing. Contributing to the incident were (1) the flight crew’s failure to tune the ILS frequency for backup lateral guidance, expectation bias, fatigue due to circadian disruption and length of continued wakefulness, and breakdowns in CRM and (2) Air Canada’s ineffective presentation of approach procedure and NOTAM information.
----
I'm a huge fan of the little jab at TC about fatigue rules. They've been stalling on implementing the updated rules for a long time..

"To Transport Canada:
Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low."

--- and the first thing that struck me is that the fatigue issue should have been right up front instead of buried under a list of contributing factors.

I hope this is the opportunity to get the rules changed.

People flying the northern Canada routes into icy strips with dicey weather and little/no navaids have even more reason to be well rested.

If that marginalizes some business cases, so be it. The industry can and will adapt.
Last edited by Revelation on Thu Sep 27, 2018 1:35 pm, edited 1 time in total.
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Dominion301
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 1:34 pm

longhauler wrote:
Super80Fan wrote:
Shame on Air Canada, they should be fined into oblivion. The pilots are just scapegoats for their poor training practices and I hope they do keep their jobs and are just retrained.

"poor training practices" ??? That's a laugh.

Air Canada A320 pilots, recognizing the unusual nature of the aircraft operation receive far more training ... not only than required by Transport Canada, but more than other aircraft types in the fleet. Two additional Simulator sessions a year are added to address "Airbus things" like flying with no automation, or into airports with unusual approaches.

The last two LOSA audits at Air Canada put standards in the top third of the pack. All anomalies have been addressed.

The elephant in the room here is fatigue ....

Two things that the NTSB stated are that the crew duty day flown would not have been legal in the United States but also they would have been legal for a further 8+ hours by Canadian Standards. This is something that Canada's pilots (not just Air Canada pilots) have been stating for years.

Canada's crew duty rules are among the worst on the earth. Canada's Transport Minister had the opportunity to address this and proposed new duty rules, but northern Canadian operators stated that they could not operate under the new rules!!! So nothing changed.

I am hoping that with this report, pilot groups from all of Canada's operators go to Ottawa (again) and have it fixed once and for all. In my opinion, the NTSB is among the most sophisticated investigative groups around. Their opinion can not be ignored.


I know this might sound rather ridiculous, but is there any way the FAA could essentially force TC to follow the US’ lead on pilot fatigue by forcing foreign airlines to adhere to US duty hour regulations when flying to a US airport? Another option is, could TC have a “North of 60” exemption and adopt US-style regs for everything else = 98% of ops anyways?

I guess a separate question is, when it comes to crew duty hours, why does AC’s crew scheduling only adhere to TC minimums, when there’s nothing stopping the airline from vastly exceeding those?
 
DarthLobster
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 1:42 pm

Dominion301 wrote:
I know this might sound rather ridiculous, but is there any way the FAA could essentially force TC to follow the US’ lead on pilot fatigue by forcing foreign airlines to adhere to US duty hour regulations when flying to a US airport? Another option is, could TC have a “North of 60” exemption and adopt US-style regs for everything else = 98% of ops anyways?


Given how far behind the US regs are regarding fatigue compared to international counterparts - controlled rest being a prime example - I highly doubt any international body or carrier would agree to that. FAR 117 is a knee-jerk theater reg that's made things worse and exacerbated the pilot shortage rather than actually address the root causes of fatigue.
 
Bimboslice
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 1:51 pm

Scary incident indeed, but my question is this, It is reported that the cockpit voice recorder was not available because it had been taped over (could not retrieve because of 2 days passing since the incident) will this be changed/improved? This was critical information not available for the investigation! When the plane reaches the gate upon any arrival could this not be securely downloaded and preserved for such instances?
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BobbyPSP
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 2:48 pm

aemoreira1981 wrote:
On this, it looks as though the plane would have missed the first B789 (UA1) and the PAL A343, but would have hit the third and fourth planes had he not corrected. One thing that should be done, if not already done, is mandatory ILS on all 28 approaches into SFO. (Has SFO ever used a runway series other than the 28s for landing?) If a plane cannot accept an ILS landing and the ceiling is below 1500 feet, it should be instructed to divert to an alternate aerodrome.

Also of note...the crew would have not been legal to fly under FAA regulations.



Yes, SFO uses other approaches, the fascinating one is landing on the 1’s.

You seem to post a lot requiring extensive procedure changes whenever an incident occurs.

I’d like to point out that there wasn’t really anything abnormal going on at the airport at the time of the incident.

The FAA has placed the blame squarely on the pilots. You don’t reinvent the wheel everytime. The place for greater influence is within the airline (AC) at this point to correct the issues that came up.
 
golfradio
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 3:57 pm

SuperTwin wrote:
Scary stuff indeed.

One has to wonder if the actions of the PR pilot saved the day. That sudden burst of bright light would definitely grab their attention!

Come to think of it, the illumination would have created a pretty epic, in-your-face, silhouette of UA001.


I don't know if this is just a popular myth. The go-around was initiated after crossing the runway threshold. The video https://youtu.be/bdDp0Rj9RVM shows the PR landing lights to be on right from the start of the video even when AC759 was still out over the bay.
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Web500sjc
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 4:02 pm

dopplerd wrote:
I'm familiar with O'Hare which has a series of chasing lights (I'm sure there is an official name for them) that extend several hundred meter in front of an active runway. These make it utterly apparent where the runway is. Does SFO not have these lights because of the bay? Looking at Google maps there appears to be a structure that extends a long distance into the bay that could serve to support this type of lighting system.



The approach light system are a competent of the ILS system that is only turned on when the airport or Approach requires it.

As an example, in ORD, with out any of the lights on- but using an ILS radio array- an aircraft can land with no less than 4000 feet of visibility. With the approach light system operational- but no in pavement lights on the runway (not the runway edge lights) an aircraft can land with no less that 2400 feet of visibility. With every light in the runway working, an aircraft can land with no less than 1800 feet of visibility.

For one reason or another, airports don’t operate the full approach light system all the time. In some cases, the airport will only turn them on when required (the approach requires them with the current weather) some of them may be turned on only partially at night, and some of them may use the lights all the time. But in no case, are the lights required to be operated at any time unless they are required by aircraft for the current weather conditions if the airport wants to remain operational.

In the case of SFO, both 28s have approach light systems that extend into the bay.
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YYCguy
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 4:57 pm

KICT wrote:
Are these pilots still employed with AC?

Currently "are being held out of service."
Source: https://www.ctvnews.ca/business/ntsb-fa ... -1.4108110
 
m007j
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 5:03 pm

golfradio wrote:
SuperTwin wrote:
Scary stuff indeed.

One has to wonder if the actions of the PR pilot saved the day. That sudden burst of bright light would definitely grab their attention!

Come to think of it, the illumination would have created a pretty epic, in-your-face, silhouette of UA001.


I don't know if this is just a popular myth. The go-around was initiated after crossing the runway threshold. The video https://youtu.be/bdDp0Rj9RVM shows the PR landing lights to be on right from the start of the video even when AC759 was still out over the bay.


No, those are just his taxi lights at the beginning. You can see a change in intensity right at 0:34 of the video you linked, takes about half a second for all those lamps to warm up and light up. You can bet the pilots and the passengers of UA1 would be mightily pissed off if the landing lights were on the whole time because they would have been blinded every time they looked out the right side of the airplane. Pilots tend to keep the lights off as much as possible in a busy night environment, not only to help their night vision as well (to see taxiway edge lights and signs, which are not as important while on a takeoff roll assuming you're on the right runway) but also to keep other pilots from getting a blast of light in their eyes. I've talked to crews who even keep the strobes off until the very last minute as they release brakes on the roll to minimize the effects on the departure line behind them.
 
DiamondFlyer
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 5:50 pm

DarthLobster wrote:
Dominion301 wrote:
I know this might sound rather ridiculous, but is there any way the FAA could essentially force TC to follow the US’ lead on pilot fatigue by forcing foreign airlines to adhere to US duty hour regulations when flying to a US airport? Another option is, could TC have a “North of 60” exemption and adopt US-style regs for everything else = 98% of ops anyways?


Given how far behind the US regs are regarding fatigue compared to international counterparts - controlled rest being a prime example - I highly doubt any international body or carrier would agree to that. FAR 117 is a knee-jerk theater reg that's made things worse and exacerbated the pilot shortage rather than actually address the root causes of fatigue.

FAR117 is vastly different than the prior rest rules. To imply that FAR117 has created the pilot shortage is insane. If you were to blame the ATP law, that’s one thing, but FAR117 has not done so
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twincessna340a
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 5:56 pm

Web500sjc wrote:
dopplerd wrote:

At SFO 28L has MALSR and 28R has ALSF-2. However, ALSF can be only partially lit up as MALSR in favorable conditions.

According to the abstract, the pilots recognized that the approach lights were on (they thought they were for 28L, maybe because 28R was lit as MALSF?). However even if 28R was lit as ALSF, IMHO a fatigued mind that can mistake a taxiway with 4 aircraft on it as a runway isn't going to appreciate and reconcile the difference between what should be the proper approach light pattern.

BTW, I believe the sequenced strobes at the beginning are functionally referred to as 'lead in lights', of which MALSR and ALSF both have.
 
Armadillo1
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 6:09 pm

Please describe canadian standarts for crew working hours
 
BoeingGuy
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 6:20 pm

Revelation wrote:
steeler83 wrote:
Also glad to see the NTSB investigate this near-miss incident. This near-miss was seconds from being the biggest aviation catastrophe since Tenerife. Not at all surprised it was pilot error.

If it really was three to six meters separation I think it was less than seconds of difference, no?

What would be the sink rate at that phase of the approach?

https://www.youtube.com/watch?v=oF7FR7TjnME is pretty revealing.


The normal sink rate of a jet transport on a ~3 degree approach prior to flare is in the ballpark of 700-800 feet per minute.
 
Kno
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 7:46 pm

Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?
 
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Super80Fan
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 7:56 pm

Kno wrote:
Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?


Usually with "pilot error" crashes involving fatalities, the pilots are usually fired/let go from the airline, then sue the airline and settle. I know the co-pilot from Comair 5191 is hated from the passenger's families.
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Revelation
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 7:56 pm

BoeingGuy wrote:
Revelation wrote:
steeler83 wrote:
Also glad to see the NTSB investigate this near-miss incident. This near-miss was seconds from being the biggest aviation catastrophe since Tenerife. Not at all surprised it was pilot error.

If it really was three to six meters separation I think it was less than seconds of difference, no?

What would be the sink rate at that phase of the approach?

https://www.youtube.com/watch?v=oF7FR7TjnME is pretty revealing.


The normal sink rate of a jet transport on a ~3 degree approach prior to flare is in the ballpark of 700-800 feet per minute.

So if they were sinking at 800 ft/min and they missed by 3 meters they were around 0.7 seconds from collision, and for 6 meters it'd be 1.4 seconds.

That's pretty damn close.
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MaksFly
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 7:57 pm

Kno wrote:
Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?


Spot on!

On one hand pilots get fired for having a drink before flying (not saying it is okay)... BUT screwing UP WHILE SOBER! so poorly, should be fired.
In any case, you can potentially say that if it was fatigue, that is as bad as drinking as the effect is exactly the same.

Pilot fatigue has always been an issue and in many cases has led to people losing their lives.

Yes, there are mandatory rest requirements, but airlines cannot force you to "relax" and it is ultimately up to the pilots themselves to make sure they are rested.
 
kalvado
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 8:15 pm

MaksFly wrote:
Kno wrote:
Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?


Spot on!

On one hand pilots get fired for having a drink before flying (not saying it is okay)... BUT screwing UP WHILE SOBER! so poorly, should be fired.
In any case, you can potentially say that if it was fatigue, that is as bad as drinking as the effect is exactly the same.

Pilot fatigue has always been an issue and in many cases has led to people losing their lives.

Yes, there are mandatory rest requirements, but airlines cannot force you to "relax" and it is ultimately up to the pilots themselves to make sure they are rested.

Question is always the same - what are you trying to achieve with a punitive action?
Do you think these particular pilots are not fit for the job and shouldn't be allowed to control an aircraft? I doubt that is a good conclusion, pilots are most likely about average. System is designed to weed out those well below average. Captain, who was the pilot flying, apparently spent that many years in FO seat and had a bit of training for CA seat (this is without looking at NTSB data. NTSB says CA has almost 5000 hours as A320 captain - that is 5 years of flying)

Do you think their termination would be a deterrent to other pilots? Fact that pilots will be the first to die in such a situation - and that other pilots know that happened and what the outcome would be is a pretty good deterrent factor as well. Deterrent is a good thing against intentional action, not against a mistake.

On a same token: I don't quite understand how legal system deals with certain types of crimes. Imprisonment for an honest mistake, however bad it is, seems to do little good for anyone. But US public in general often seems to be blood thirsty, good reason or not.

Now I am not sure if I personally would go back into cockpit after all this (I am not a pilot, and I didn't control any vehicle larger than small truck). I didn't have serious car accidents, but getting back to steering wheel after a no-injury fender bender required some effort on my side. But this is highly personal after all.
 
BoeingGuy
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 8:25 pm

MaksFly wrote:
Kno wrote:
Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?


Spot on!

On one hand pilots get fired for having a drink before flying (not saying it is okay)... BUT screwing UP WHILE SOBER! so poorly, should be fired.
In any case, you can potentially say that if it was fatigue, that is as bad as drinking as the effect is exactly the same.

Pilot fatigue has always been an issue and in many cases has led to people losing their lives.

Yes, there are mandatory rest requirements, but airlines cannot force you to "relax" and it is ultimately up to the pilots themselves to make sure they are rested.


I strongly disagree with this. So you are suggesting that pilots should be fired for being fatigued, just like they are for being drunk? Where is the logic in that? Do you think it was their choice to be fatigued? Somehow they intentionally didn't sleep so were negligent in their rest?

When was the last time you chose to be fatigued?

They were following the work hours that their company assigned them to do.

I'm not saying the pilots are without blame, because they were responsible. But holding someone responsible for being fatigued is pretty ridiculous.
 
ST165
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Thu Sep 27, 2018 11:21 pm

BoeingGuy wrote:
MaksFly wrote:
Kno wrote:
Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?


Spot on!

On one hand pilots get fired for having a drink before flying (not saying it is okay)... BUT screwing UP WHILE SOBER! so poorly, should be fired.
In any case, you can potentially say that if it was fatigue, that is as bad as drinking as the effect is exactly the same.

Pilot fatigue has always been an issue and in many cases has led to people losing their lives.

Yes, there are mandatory rest requirements, but airlines cannot force you to "relax" and it is ultimately up to the pilots themselves to make sure they are rested.


I strongly disagree with this. So you are suggesting that pilots should be fired for being fatigued, just like they are for being drunk? Where is the logic in that? Do you think it was their choice to be fatigued? Somehow they intentionally didn't sleep so were negligent in their rest?

When was the last time you chose to be fatigued?

They were following the work hours that their company assigned them to do.

I'm not saying the pilots are without blame, because they were responsible. But holding someone responsible for being fatigued is pretty ridiculous.


One thing I would also add though is that this incident was not reported for over two days, thus rendering the cockpit recorders useless as they were recorded over. In my opinion, the pilots should have understood the severity of what happened and they should have reported it to AC/FAA immediately, either one of which should have notified NTSB as soon as possible. The fact that this didn't happen is shocking and makes it hard not to infer that somebody didn't want this to blow up. Or in other words, maybe the pilots were scared of losing their jobs, or, if they did report it to AC, that AC didn't want a big incident so tried to delay telling FAA until the cockpit recorders were recorded over or somebody else reported it.
 
YYZatcboy
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 12:41 am

The other big thing that we need to finally address here is the fact that NOTAMS are not useful to ANYONE in the industry. There are 20-40 pages of useless notams per flight, with actual useful information buried. Airport contractors are paid by notam in some situations and thus are incentivized to put trivial information into NOTAMs and Airport Operators can use them to cover their butts. Further, some FIRs even have 'NOTAM Battles'. Great example there is Greece vs Turkey for their SAR regions. We are training ourselves to ignore NOTAMS and IMO it is past time for them to get thrown out and replaced with something better.
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airportugal310
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 12:44 am

YYZatcboy wrote:
Airport contractors are paid by notam in some situations ...


Do tell more!
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YYZatcboy
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 1:06 am

airportugal310 wrote:
YYZatcboy wrote:
Airport contractors are paid by notam in some situations ...


Do tell more!


I heard it from a US Dispatcher, particularly at regional airports with a small airport authority. They pay per service, so the contractor gets paid if they have to clean the runway, put out a notam, replace a light. etc. I don't have a specific airport in mind.
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longhauler
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 1:06 pm

ST165 wrote:
One thing I would also add though is that this incident was not reported for over two days, thus rendering the cockpit recorders useless as they were recorded over. In my opinion, the pilots should have understood the severity of what happened and they should have reported it to AC/FAA immediately, either one of which should have notified NTSB as soon as possible. The fact that this didn't happen is shocking and makes it hard not to infer that somebody didn't want this to blow up. Or in other words, maybe the pilots were scared of losing their jobs, or, if they did report it to AC, that AC didn't want a big incident so tried to delay telling FAA until the cockpit recorders were recorded over or somebody else reported it.

This is not even remotely accurate.

A Voyage Report (internal Air Canada) and an Air Safety Report (as required by the Safety Management System) were filed the morning after the incident. This was for the missed approach due to the unstabilized condition below 1000'.

The CVR and FDR C/Bs were not pulled when the crew handed the aircraft over to maintenance because to them, it was just a missed approach. Remember, when the aircraft was at it's lowest point, it was over the runway, not the taxiway. (But that doesn't sell news nor generate facebook hits). They were no more "seconds from distaster" than if they had taken off from 28R.

No one was trying to "hide" anything. Air Canada was quite open with this incident and still is. It is ludicrous to suggest that they tried to "delay telling the FAA". Large airlines just don't work that way.

What was used though, was the FDA chip, as this aircraft was so equipped. 2200 parameters lasting the previous 20 hours. It was plugged into a simulator and played back. What it showed was that things were not even close to as "horrific" as CNN hoped.
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longhauler
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 1:20 pm

Kno wrote:
Usually I agree when posters say pilots shouldn’t be fired for small mistakes - but if you don’t fire pilots for this what do you fire them for?

Can’t think of many jobs where you almost kill hundreds and keep your job...: or did they get fired?

Safety Management Systems of developed countries don't work that way. To fire a pilot only ensures that the pilot never makes the mistake again. Instead, the incident is investigated and causes for the mistake are determined and fixed. That way no one makes the mistake again. It is far safer to fix the slices of Swiss Cheese so the holes don't align again.

The best example would be an accident of which we are all familiar ... the Pan American / KLM collision at Tenerife. The cause of the accident was the Captain of the KLM aircraft took of without a takeoff clearance. The investigation could have ended right there. Pilot Error, had he survived, fire the Captain ... case closed. But no, a very long investigation ensued asking the one basic question ... "Why would such an experienced Captain, working for a very respected company, make such a basic mistake?" As we know, it was the culmination of a very long series of events and conditions.

So you fix the cause(s) of the mistake and likely the mistake wont recur.

I should add though. If during the investigation the crew is found to be negligent or reckless. Namely willfully not complying with SOPs or Air Regulations then yes, he is usually fired.
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B747forever
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 2:20 pm

longhauler wrote:
Remember, when the aircraft was at it's lowest point, it was over the runway, not the taxiway. (But that doesn't sell news nor generate facebook hits). They were no more "seconds from distaster" than if they had taken off from 28R.
What it showed was that things were not even close to as "horrific" as CNN hoped.


Can you point me to a report that shows the lowest point of the airplane was over 28R?

This is from the NTSB report


"The flight crew-initiated, low-altitude go-around over the taxiway prevented a collision between the Air Canada airplane and one or more airplanes on the taxiway."

"The incident airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The incident flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft and overflew the second airplane on the taxiway before starting to climb."


As per the NTSB report, the crew were over the taxiway at an altitude of 60ft (lowest point) before starting the go around. The NTSB is pretty clear over the fact that the lowest point reached was when they were over the taxiway and that the go around was initiated at that point. That is not something CNN or someone else has made up to make the incident more sensational. I dont know why you try to minimize this serious incident.
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longhauler
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 4:27 pm

B747forever wrote:
Can you point me to a report that shows the lowest point of the airplane was over 28R?

Nope, as it is not in the public domain.

B747forever wrote:
The NTSB is pretty clear over the fact that the lowest point reached was when they were over the taxiway and that the go around was initiated at that point. That is not something CNN or someone else has made up to make the incident more sensational. I dont know why you try to minimize this serious incident.

As the FDR information was not saved, the NTSB used surveillance camera video data which was found several days later to estimate the actual position and altitude of the aircraft. In fact, looking at the data, one can see that the sides of the taxying aircraft were illuminated by the wing lights of the A320 as it passed by indicating it was beside the aircraft and not over.

It was about a week later, and only as a fluke that the FDA (Flight Data Analisys) chip was removed as normally scheduled from the aircraft that the gatekeepers saw with amazement the data they held. That data was presented to the NTSB. Why it was not used, I am not aware. Perhaps as it was not "official" like the FDR, but somehow less "official" than video surviellance camera pictures.

Trust me ... no one is minimizing this event. Just that I find on this site, the rumour is far more entertaining than fact, thus the rumour lives on.
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chrisair
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 6:43 pm

longhauler wrote:
It was about a week later, and only as a fluke that the FDA (Flight Data Analisys) chip was removed as normally scheduled from the aircraft that the gatekeepers saw with amazement the data they held.


Are these FDA chips downloaded and analyzed on a regular schedule? This is the first time I've heard of it, probably because I live under a rock.

longhauler wrote:
Just that I find on this site, the rumour is far more entertaining than fact, thus the rumour lives on.


This surprises you? :lol:
 
Bradin
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 6:43 pm

Just as a courtesy reminder, there was at least one Boeing 787 and one Airbus A340-300 on taxiway C.

Both aircraft are approximately 17 meters/56 feet in height.

https://www.boeing.com/commercial/787/
https://www.airbus.com/aircraft/previou ... 0-300.html
 
GalaxyFlyer
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 7:17 pm

Chris,

Flight Operations Quality Assurance (FOQA) data from a Quick Access Recorder (QAR) is pretty much standard at air carriers and large corporate jets. Downloaded and analyzed by a ASAP “gatekeeper” for deviations from normal ops.

GF
 
B747forever
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 8:20 pm

Longhauler, thank you for the reply. I am sorry if I came across as hostile, but the only information regarding this incident that I have relied on is from the NTSB report. Reading their report, they make it seem that the aircraft was right overhead the airplanes/ taxiway C when they initiated the go around. You bring in another perspective, and I will take your word for what the FDA provides. I am just surprised that the NTSB was provided the FDA, yet they do not mention those findings in their report.
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kalvado
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 8:33 pm

Well, NTSB has a plot which seems to be more detailed than what can be extracted from the camera footage.
I am talking about https://www.ntsb.gov/news/events/Docume ... tation.pdf page 5.
It indeed shows deviation from taxiway centerline towards runway at the lowest point, and that indeed looks like obstacle avoidance move. But this deviation, per NTSB, is approximately the width of a taxiway, 100-200 feet; not a distance to runway. Deviation all the way to runway would require, based on the same diagram, a 45 degree turn at "what is he doing?!" moment.

The way I read NTSB plot, AC did deviate just enough to hopefully avoid wing into horizontal stab collision with A340 if they did sink another 10 feet - minimum radio altitude per NTSB is 60 feet. For me the word "radio" means it is not camera data, but aircraft data.
Last edited by kalvado on Fri Sep 28, 2018 8:43 pm, edited 1 time in total.
 
Cubsrule
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 8:35 pm

longhauler wrote:
B747forever wrote:
The NTSB is pretty clear over the fact that the lowest point reached was when they were over the taxiway and that the go around was initiated at that point. That is not something CNN or someone else has made up to make the incident more sensational. I dont know why you try to minimize this serious incident.

As the FDR information was not saved, the NTSB used surveillance camera video data which was found several days later to estimate the actual position and altitude of the aircraft. In fact, looking at the data, one can see that the sides of the taxying aircraft were illuminated by the wing lights of the A320 as it passed by indicating it was beside the aircraft and not over.

It was about a week later, and only as a fluke that the FDA (Flight Data Analisys) chip was removed as normally scheduled from the aircraft that the gatekeepers saw with amazement the data they held. That data was presented to the NTSB. Why it was not used, I am not aware. Perhaps as it was not "official" like the FDR, but somehow less "official" than video surviellance camera pictures.

Trust me ... no one is minimizing this event. Just that I find on this site, the rumour is far more entertaining than fact, thus the rumour lives on.


This is a hair disingenuous, no? Isn't it one hundred percent AC's fault and/or the pilots' fault that the FDR data were not saved? It's convenient that they would lose the official data and then mysteriously find other data that benefit them days later.

In trial, when a party loses relevant evidence we often instruct jurors to presume that the evidence would have hurt the losing party. Perhaps that sort of presumption is appropriate here. Surely if the pilots believed that the FDR and/or CVR would exonerate them they would have taken steps to ensure preservation.
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