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

Fri Sep 28, 2018 10:10 pm

Cubsrule wrote:
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.


Convenient? Mysteriously? I actually had a chuckle about that.

As stated above, when the flight crew handed the aircraft over to maintenance on arrival, in their minds there was no need to pull the C/Bs on the FDR and CVR. As far as they thought, it was just an unstabilized missed approach. Nothing was hidden as appropriate reports were filed the next morning. If they thought there was anything needing "exoneration" then procedures would have been followed.

Perhaps you are not aware of the Flight Data Analysis program. Again, a part of advanced Safety Management Systems, most aircraft in a participating airline are equipped with FDA chips that use data from the FDR. This data is compiled and trends are noted. Using this data, training areas are focused and addressed.

Normally, the data is not looked at on an individual basis. As you can imagine, the amount of data is huge. However ... if any preset limits are exceeded, the event is flagged. The gatekeeper then contacts the crew personally to discuss the issue. It is entirely voluntary on both sides. (BTW, he is called a "gatekeeper" as this data is kept depersonalized normally unless personal contact is needed. It can never be punitive as safety is the only goal).

When the data eventually came to the gatekeeper's computer, it was flagged, and he, when looking at the event, realized at what he was looking, contacted his superiors. It was actually a fluke that it was found!

It reminded me of the engine data received by Rolls Royce as a fluke that led to possible information about Malaysian 370.

No one denied responsibility for the event. But as I said above ... we are past that. At this point, the issue is the chain of events that led to the occurrence itself. If that chain can be studied, then recurrence of the event can be avoided.
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Cubsrule
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Sep 28, 2018 10:36 pm

longhauler wrote:
As stated above, when the flight crew handed the aircraft over to maintenance on arrival, in their minds there was no need to pull the C/Bs on the FDR and CVR. As far as they thought, it was just an unstabilized missed approach. Nothing was hidden as appropriate reports were filed the next morning. If they thought there was anything needing "exoneration" then procedures would have been followed.


I understand the personal nature of this incident for you and your desire to defend friends and colleagues. It’s admirable.

But, their subjective belief on this incident was wholly objectively unreasonable. UA told them they were “on the taxiway.” That’s a “normal” goaround?
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 12:49 am

Cubsrule wrote:
I understand the personal nature of this incident for you and your desire to defend friends and colleagues. It’s admirable.

I have never defended the actions of the pilots. That is not for me to judge. What I did do though, in this (and other message strings) is answer the common bleat "the pilots should be fired". I recounted the way that safety systems work. In other words ... firing the pilots only ensures that pilot never makes the mistake again. Investigating and fixing the problems that caused the mistake ensures no one makes the mistake again.

Cubsrule wrote:
But, their subjective belief on this incident was wholly objectively unreasonable. UA told them they were “on the taxiway.” That’s a “normal” go around?

I am not sure I understand your first comment here.

UA told SFO ground that AC was lined up with the taxiway. That information was not passed into SFO tower frequency, the frequency on which AC759 was working. It appears that while one controller was working both frequencies, neither could hear the other. So they didn't hear UA's comments, nor did UA hear AC ask twice if they were cleared to land, as it looked as though someone was on the runway.

I would have loved to hear the CVR, not for the events leading up to the go-around, but for the events following. I would be curious of their conversation after they finally landed.

Remember, the C/B on the CVR was not pulled. Also, the CVR was not erased. If they really felt they had done something wrong and were trying to hide something, as you suggested earlier, they could have just erased the CVR. It's just one button! They didn't.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 1:20 am

You don’t fire people for mistakes; only serves to drive mistakes with safety implications underground. Willful disobedience of regulations, repeated failure to attain or maintain proficiency, gross negligence, yes. I’ve been a Chief Pilot, a military commander, as such I’ve disciplined, even fired people, but not for mistakes.

This crew certainly didn’t come to work intending to be fatigued and intending to crash their plane. AC was cited for failings in presenting information; TC for crew duty and rest rules; there was only one controller on duty—all holes in the cheese. Get over the “possilities” and learn.

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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 1:20 am

longhauler wrote:
UA told SFO ground that AC was lined up with the taxiway. That information was not passed into SFO tower frequency, the frequency on which AC759 was working. It appears that while one controller was working both frequencies, neither could hear the other. So they didn't hear UA's comments, nor did UA hear AC ask twice if they were cleared to land, as it looked as though someone was on the runway.


What evidence is there that UA was on Ground? Certainly, the NTSB ATC factual chapter contains no indication of that (indeed, the entire ATC factual chapter contains the word "ground" only once, and that is in a quotation of an FAA order concerning line-up-and-wait operations). The interview summary with Mr. Delucchi (which also belies your assertion that it was a "normal" goaround) does not either.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 2:07 am

Cubsrule wrote:
longhauler wrote:
UA told SFO ground that AC was lined up with the taxiway. That information was not passed into SFO tower frequency, the frequency on which AC759 was working. It appears that while one controller was working both frequencies, neither could hear the other. So they didn't hear UA's comments, nor did UA hear AC ask twice if they were cleared to land, as it looked as though someone was on the runway.


What evidence is there that UA was on Ground? Certainly, the NTSB ATC factual chapter contains no indication of that (indeed, the entire ATC factual chapter contains the word "ground" only once, and that is in a quotation of an FAA order concerning line-up-and-wait operations). The interview summary with Mr. Delucchi (which also belies your assertion that it was a "normal" goaround) does not either.


The original quote by longhauler is directly opposed by the statements made by both the captain and first officer of UA1 to the NTSB after the incident occurred. As per the statement from Captain Freeberg: "I transmitted on a quiet tower frequency, “Where’s that guy going, he’s on the taxiway.” The ATC controller then directed Air Canada to Go-Around."
And from Cliff Sheppard, the FO: The Captain quickly keyed the microphone and announced that he was lined up on the taxiway....SFO tower directed Air Canada to go around. Air Canada repeated back the clearance. At this point he was out of our view. Our Captain again keyed the microphone and announced that Air Canada had just flown directly over us. The tower answered back that he saw that United and we’ll get you going soon. Very shortly after that we were cleared for takeoff on runway 28R, winds were 250 at 8 knots as I recall. I heard the tower clear Air Canada to contact departure. We made an uneventful takeoffand continued our flight to Singapore." You can find more corroboration of this from the pilot statements from all of the airplanes in line that night. Here is that direct link:
https://dms.ntsb.gov/pubdms/search/docu ... mkey=95528
Unless these guys were given a Youtube link to watch before they made their statements, they were most certainly on the tower frequency. UA1 was number 1 for takeoff, I would think it would be a breach of procedure to still be on ground even with a single controller monitoring both frequencies.
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 4:00 am

m007j wrote:
Cubsrule wrote:
longhauler wrote:
UA told SFO ground that AC was lined up with the taxiway. That information was not passed into SFO tower frequency, the frequency on which AC759 was working. It appears that while one controller was working both frequencies, neither could hear the other. So they didn't hear UA's comments, nor did UA hear AC ask twice if they were cleared to land, as it looked as though someone was on the runway.


What evidence is there that UA was on Ground? Certainly, the NTSB ATC factual chapter contains no indication of that (indeed, the entire ATC factual chapter contains the word "ground" only once, and that is in a quotation of an FAA order concerning line-up-and-wait operations). The interview summary with Mr. Delucchi (which also belies your assertion that it was a "normal" goaround) does not either.


The original quote by longhauler is directly opposed by the statements made by both the captain and first officer of UA1 to the NTSB after the incident occurred. As per the statement from Captain Freeberg: "I transmitted on a quiet tower frequency, “Where’s that guy going, he’s on the taxiway.” The ATC controller then directed Air Canada to Go-Around."
And from Cliff Sheppard, the FO: The Captain quickly keyed the microphone and announced that he was lined up on the taxiway....SFO tower directed Air Canada to go around. Air Canada repeated back the clearance. At this point he was out of our view. Our Captain again keyed the microphone and announced that Air Canada had just flown directly over us. The tower answered back that he saw that United and we’ll get you going soon. Very shortly after that we were cleared for takeoff on runway 28R, winds were 250 at 8 knots as I recall. I heard the tower clear Air Canada to contact departure. We made an uneventful takeoffand continued our flight to Singapore." You can find more corroboration of this from the pilot statements from all of the airplanes in line that night. Here is that direct link:
https://dms.ntsb.gov/pubdms/search/docu ... mkey=95528
Unless these guys were given a Youtube link to watch before they made their statements, they were most certainly on the tower frequency. UA1 was number 1 for takeoff, I would think it would be a breach of procedure to still be on ground even with a single controller monitoring both frequencies.


Mr. Sheppard’s statement specifically references UAL001 switching from Ground to Tower before the incident.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 9:58 am

Thanks for the references, I could not find them.

But, yes, it was a normal go-around. Namely, as soon as it was confirmed that they were "unstablized" (lateral track violated) a go-around was performed.
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ElPistolero
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 12:31 pm

Dominion301 wrote:

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?


I'm willing to bet good money that the FAA's response to that question is: "regulatory capture".

TC can revise those minima, within exemptions, whenever they want. They've decided, under pressure from airlines, to give airlines full leeway.

AC could have implemented FAA rules seven years ago - when a snoozing pilot put passengers in hospitals after fatigue-related disorientation over the North Atlantic. It chose not to. TC could have done the same thing. It chose not to.

Instead we were fed some story about Canadian airlines using "scientific" methods to find solutions, rather than, you know, using the work NASA and the FAA have already done. Now we're in an odd situation in which the FAA has publicly told TC to get its act together. It's embarrassing.

The real problem is that too many folk in Ottawa buy into the notion that Canada has high safety standards because...Canada. The actual track record is decidedly more mixed.
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 12:54 pm

longhauler wrote:
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.


This is all very confusing. On the one hand, the "NTSB is one of the most sophisticated investigative groups around". On the other hand, it's ignored data provided by AC that has resulted in it misrepresenting how dangerous an AC incident was. Which is it?

There's nothing stopping AC from releasing this non-public domain data into the public domain. What has it got to lose?
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 1:13 pm

longhauler wrote:
Thanks for the references, I could not find them.

But, yes, it was a normal go-around. Namely, as soon as it was confirmed that they were "unstablized" (lateral track violated) a go-around was performed.


If it’s normal at AC to call the tower shaken up after a goaround, their safety culture problem is worse than anyone has suggested.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sat Sep 29, 2018 1:29 pm

Both runways have these huge sets of approach lights. They were not even lined up with them and as they go closure did not figure that out. Asleep at the wheel.
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Sep 30, 2018 12:48 pm

Cubsrule wrote:
longhauler wrote:
Thanks for the references, I could not find them.

But, yes, it was a normal go-around. Namely, as soon as it was confirmed that they were "unstablized" (lateral track violated) a go-around was performed.


If it’s normal at AC to call the tower shaken up after a goaround, their safety culture problem is worse than anyone has suggested.

As I have said before, I will not discuss this incident other than to talk about how safety systems work.

In generalities ... a go-around can be done for many reasons. Traffic on the runway, poor weather conditions, reduced aircraft capability, unstabilized conditions being among the more common. Airlines have noticed that they must make go-arounds seem "normal", that way if any of the above conditions arise, it is second nature. So ... in simulator training and extra training, many many many go-arounds are practised.

You are never committed to land until reverse thrust is selected. So in my last training session (for example) I did a go-around anywhere from 1000' AAL to after touchdown.

So, if a crew encountered unstabilized conditions, they go-around and perform the landing again. All very controlled and normal.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Sep 30, 2018 12:56 pm

ElPistolero wrote:
There's nothing stopping AC from releasing this non-public domain data into the public domain. What has it got to lose?

That is a very good point.

Yesterday, I flew down to the Caribbean and back and the First Officer mentioned that, in fact, Air Canada has published it's own internal report about this incident. I was not aware it was in the public domain. He said it was on another aviation website. I didn't recognize the name. Maybe someone has seen it and can post a link here.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Sep 30, 2018 2:03 pm

longhauler wrote:
ElPistolero wrote:
There's nothing stopping AC from releasing this non-public domain data into the public domain. What has it got to lose?

That is a very good point.

Yesterday, I flew down to the Caribbean and back and the First Officer mentioned that, in fact, Air Canada has published it's own internal report about this incident. I was not aware it was in the public domain. He said it was on another aviation website. I didn't recognize the name. Maybe someone has seen it and can post a link here.


This is the official submission from Air Canada to the NTSB: https://dms.ntsb.gov/public/61000-61499 ... 618785.pdf

Despite their conclusions being nakedly CYA nonsense, the flight path depicted on page 8 roughly agrees with the NTSB's diagram https://www.ntsb.gov/investigations/Pub ... 8-fig3.jpg . Nowhere do I see that Air Canada agrees with your assertion that "when the aircraft was at it's lowest point, it was over the runway, not the taxiway". The pilots would have had to have made some drastic and dangerous maneuvers to to get over the runway, this was not a normal go-around due to unstabilized approach.

(I agree with your first post that fatigue is the elephant in the room.)
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Sep 30, 2018 2:09 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?


It's true, the pilots made a huge mistake that almost killed loads of people. The fact that no one was harmed or died is remarkable. I'm not a pilot myself, but I have heard that pilots like these, with this distinct knowledge and experience (albeit negative), are basically gold for internal education and re-training. They could be a great tool to ensure this, and other potential accidents like this, don't happen. This whole experience, although sickly, is an ideal training example for AC. Of course it would be great if it never happened, but now that it did, squeeze the juice out of this crew for the benefit of all.

Anyone second this or am I off my rocker?

V/r
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Cubsrule
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Sep 30, 2018 2:58 pm

longhauler wrote:
Cubsrule wrote:
longhauler wrote:
Thanks for the references, I could not find them.

But, yes, it was a normal go-around. Namely, as soon as it was confirmed that they were "unstablized" (lateral track violated) a go-around was performed.


If it’s normal at AC to call the tower shaken up after a goaround, their safety culture problem is worse than anyone has suggested.

As I have said before, I will not discuss this incident other than to talk about how safety systems work.

In generalities ... a go-around can be done for many reasons. Traffic on the runway, poor weather conditions, reduced aircraft capability, unstabilized conditions being among the more common. Airlines have noticed that they must make go-arounds seem "normal", that way if any of the above conditions arise, it is second nature. So ... in simulator training and extra training, many many many go-arounds are practised.

You are never committed to land until reverse thrust is selected. So in my last training session (for example) I did a go-around anywhere from 1000' AAL to after touchdown.

So, if a crew encountered unstabilized conditions, they go-around and perform the landing again. All very controlled and normal.


Fair enough. Go-arounds aren’t abnormal. Calling the tower shaken up afterwards is.
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Oct 05, 2018 12:57 am

Here’s what Bob Sumwalt has to say about the NOTAM process,

“Notams are a bunch of garbage,” NTSB chairman Robert Sumwalt said last week, at the board’s probable-cause meeting about last year’s close call in San Francisco. “The Notam system is really messed up,” he continued. “There are 10 pages of Notams [for the Air Canada flight] … and [the runway closure] is on page 8 of the dispatch release … and they are written in some kind of language that only a computer programmer would really understand.” This week, Chairman Sumwalt told AVweb, “There is a definite need to improve our Notam system and I am optimistic that, given the Board’s recommendations on this issue, some ingenious software developer will come up with a very low-cost solution.”

Sumwalt added, “Today we have iPads and other tablets that have tremendous capability that can help us. That said, our recommendation to FAA is for them to establish a group of human-factors experts to study the issue and develop solutions. That will take time.” In its final report, the NTSB asks the FAA to “create and publish guidance on best practices to organize, prioritize, and present this information in a manner that optimizes pilot review and retention of relevant information; and work with air carriers and service providers to implement solutions that are aligned with the guidance.”


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

Fri Oct 05, 2018 1:50 am

longhauler wrote:
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.


I think other replies in this thread have responded to this far better than I could. I would also add that I'd much rather trust a public report provided by NTSB, a well respected agency that specialises in investigating air incidents than a internal report published by Air Canada, a party to the incident.
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Oct 05, 2018 3:04 am

GalaxyFlyer wrote:
Here’s what Bob Sumwalt has to say about the NOTAM process,
This week, Chairman Sumwalt told AVweb, “There is a definite need to improve our Notam system and I am optimistic that, given the Board’s recommendations on this issue, some ingenious software developer will come up with a very low-cost solution.”


Wait -- the NTSB chairman really said this?

If so, he's a moron!

As a friend of mine says, "Hope is not a plan".

A corollary of that is waiting for a software developer to emerge out of the void who can/will solve a problem like the international NOTAM system at a very low cost isn't a plan, it's a fantasy!
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Oct 05, 2018 3:28 am

I doubt you know Bob, he’s anything but a moron. True, hope is not a strategy, but it’s not in the Board’s remit or technical portfolio to detail solutions to a mess—that’s the FAA’s job. The NTSB investigates and submits recommendations on safety risks to the regulators and industry to fix.

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

Fri Oct 05, 2018 4:04 am

ST165 wrote:
longhauler wrote:
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.


I think other replies in this thread have responded to this far better than I could. I would also add that I'd much rather trust a public report provided by NTSB, a well respected agency that specialises in investigating air incidents than a internal report published by Air Canada, a party to the incident.


Couldn't help but "chuckle" at the random potshot at CNN. All very political theatre-y. Not to mention the teapot in space...err... apparently relevant AC report on random unnamed website. If this had involved TS or WS, some folk here would be singing a very different tune.

At the end of the day, AC made a business decision that left room for fatigue-related safety risks. This is not unique. Many companies do it. That's why we have regulators. Ultimately, its a TC issue. They haven't covered themselves in glory - what with their desire to reinvent a wheel that many other governments have already invented. We can only surmise that Canadian pilots are exempt from the rules of human biology. Or that there is an absurd amount of regulatory capture in play.

Did anyone ever figure out what that late night hull loss in YHZ was all about?
 
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Re: NTSB: Pilot error responsible for AC759 @ SFO

Fri Oct 05, 2018 11:29 am

GalaxyFlyer wrote:
I doubt you know Bob, he’s anything but a moron. True, hope is not a strategy, but it’s not in the Board’s remit or technical portfolio to detail solutions to a mess—that’s the FAA’s job. The NTSB investigates and submits recommendations on safety risks to the regulators and industry to fix.

It's his job to point out that the NOTAM mess contributed to this accident, and in hindsight the should have stopped there.

Suggesting that something that is a legal/political/institutional/bureaucratic/inertial/human factors issue can be solved by a software developer at very low cost makes one sound moronic especially to anyone who understands software development.
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AirlineCritic
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Joined: Sat Mar 14, 2009 1:07 pm

Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Oct 07, 2018 8:19 am

I'm surprised by the NOTAM problem. But after thinking about it for a bit, it seems the incentives are right there to make it such a mess. Everything, even irrelevant stuff, needs to go into the NOTAMs due to just-in-case and CYA; and humans are not very good at scanning tens of pages of garbage. They will miss salient points when they rarely appear somewhere in the garbage. As happened here...

It is great that the chairman has called out the problem.

I do agree 110% with Revelation that it is not a "just need a smart programmer" problem. As usual, the issues are MUCH deeper than software. Meaning of the information, its relationship to the crew's task, incentives to provide critical information and incentives to not overload the crew, etc.
 
YYZatcboy
Posts: 1159
Joined: Fri Apr 22, 2005 2:15 am

Re: NTSB: Pilot error responsible for AC759 @ SFO

Sun Oct 07, 2018 10:06 am

I think Bob was misquoted. I watched that whole presentation, and the only time I heard them discuss software engineers was in regards to developing a solution (IMO that already exists with runway awareness software) cheaply for GA pilots. I'd have to watch it again to be sure, but I don't recall it in relation to notams.
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