AC Lining Up with a Taxiway SFO...?

[crazyaviator]

Within 15 minutes of this incident, ATC, FAA, AC would know of the near "miss" and IF there was a procedure to follow to ESTABLISH whether this event constitutes an incident where-in CVR data must be retained, then there would not be any overwriting. Let me suggest the system is not there yet. The CVR should be easily downloaded onto a laptop etc. for preservation in less than actual accidents.

[Cliff Jumper]

1. No.
2. There already is.
3. No.

[Cat Driver]

Over on Pprune there is an interesting post about this incident.

It is post #790.

[GyvAir]

It is post #790.

Every time the moderators remove a post anywhere in the thread, all the subsequent posts get renumbered.. #790 will no doubt be reassigned before long.

[Alav]

It is post #790.

Is it this #790?

Too bad the CVR was conveniently overwritten. If it weren't, investigators would know if what should have occurred before this approach began actually occurred, including the crew using the primary, fundamental tools one does in order to plan/know what to expect; bookwork like we're paid to do, planning, and a proper briefing as dictated by Company SOPs. As it is, nobody knows if they followed any or conducted an approach briefing, or even if they used checklists appropriately or observed a sterile cockpit. We do know this, however;

The NOTAMS re the closure of 28L and 28Ls Approach Light System were both published. AC OPs Specs would dictate they were disseminated to the crew.

The ATIS received by the crew before the approach also notified them that 28L was closed and the Approach Light System for 28L was out of service. Company SOPs would dictate this be reviewed by the crew prior to the approach and ATC would expect acknowledgment it had been received.

The publications/Airport Diagram the crew had on hand showed the parallel runways with Approach Light Systems installed on each, and details or each installation plus runway lighting and PAPI. They also show Taxiway C running parallel to 28R.

The crew told the investigators that they thought 28L was 28R. That is admitting they didn't either read the NOTAMs or listen to the ATIS, or means they did but never talked about it/ignored what would could be an operational concern (runway closure).

It also means they were unaware of what they should be seeing for miles before they attempted to land on Taxiway C; an Approach Light System and a PAPI.

A proper approach briefing of any type identifies the primary guidance to be used, and most Company SOPs dictate their review and inclusion. This was a visual approach, at night, over water where any licensed pilot should be well-aware of possible black hole effect which makes the vertical guidance all the more critical to identify. Runway 28R has a diagramed and functioning Approach Light System (ALSF-II) stretching out into the water for lateral guidance. 28R has a PAPI located on the LH side of the runway for vertical guidance. These are ground-based, visual approach light systems that lead directly to the runway and Touchdown Zone of the correct runway. Those are the primary aids for the approach, not the FMS.

How hard is it to brief (and it makes no difference which FMS procedure got them to the point or what green taxiway lights look like from a distance) "the visual segment for 28R will be over water, we'll align with the ALSF-II and follow the PAPI located on the LH side"?

That's what a briefing is all about. To create a picture of what is known and printed right there in our faces about where we're going, and what to look for out the windscreen when the time for looking is at hand.

Briefings, SOPs, and checklists are there to backstop performance, especially when tired, etc. because they focus attention on where it needs to be focused. Even the well-rested pilot that does no bookwork, planning, or briefing will stuff things up a thousand times more often than a tired pilot that does all the above.

One can go around and around about FMS procedures, lack of EVS, "Tunneling" and circadian rhythms, but those aren't going to prevent stuff-ups of this nature if the crew didn't bother with fundamentals and basic adherence to procedures already in place.

Does anyone actually think a detailed, proper briefing that reviewed the primary guidance aids (ALSF-II and PAPI) to be followed for this visual approach was conducted in this case?

The statements by the crew and convenient overwriting of the CVR lead me to suppose this approach wasn't stuffed-up on short final, or 4 miles out due to an illusion, but long before when no attention to detail to what was published and/or briefed regarding the upcoming visual approach to the runway they were (supposed to be) landing on. If they had briefed the critical details of primary guidance aids just like everyone does for an ILS etc, this wouldn't have happened. The aids were right there, yet they never looked for them or (obviously) used them until the 2nd time around. Bear in mind that 2 crew with separate sets of eyeballs missed the same things.

I don't believe there's any big mystery or highly-unusual Human Factors, super-illusion boogeyman at work here. We deal with many all the time, usually by preventative measures. Until it can be shown that this crew followed those time-proven, fundamentals that prevent this sort of thing from happening I'm not going to assume it.

http://www.pprune.org/rumours-news/5969 ... fo-40.html

[Cat Driver]

Yes.

[confusedalot]

Inconsequential detail, but AC has ACARS (stating the obvious) and usually you would get the ATIS on the FMS CDU, and if desired, you would print it and clip it on the dashboard or wherever desired. So no need to ''listen'' on the ATIS frequency and copy it down. Saves alot of time.

[Eric Janson]

Inconsequential detail, but AC has ACARS (stating the obvious) and usually you would get the ATIS on the FMS CDU, and if desired, you would print it and clip it on the dashboard or wherever desired. So no need to ''listen'' on the ATIS frequency and copy it down. Saves alot of time.

Disclaimer:- This is information only. I do not work for Air Canada.

Some of our aircraft have this capability but most don't as they are close to 20 years old. The airport also needs to have this capability - not all do. It's called D-ATIS.

ACARS has multiple options - we have different ACARS screens across our fleet.

[Jet Jockey]

It is post #790.

Every time the moderators remove a post anywhere in the thread, all the subsequent posts get renumbered.. #790 will no doubt be reassigned before long.

Why would they remove that post?

I think it is right to the point.

[GyvAir]

I guess my phrasing was a little ambiguous. I didn't mean to say that I thought post 790 would be deleted. I meant that if any posts made prior to it were deleted, that the post currently numbered 790 would be assigned a lower post number. Looks like that hasn't happened, though.

[Cat Driver]

http://www.mercurynews.com/2017/08/15/e ... near-miss/

[confusedalot]

ah yes, the bridgegate conspiracy.

maybe the russians had something to do with it?

[Old fella]

"As a result, key evidence from the cockpit voice recorder was erased and the pilots were never tested for drugs or alcohol. It’s a bureaucratic cover-up that conveniently protects the federal agency and the airline involved."

Oliver Stone is putting together a script for the conspiracy of the year.

[altiplano]

The pprune post referenced is a lot of guessing and supposing...

He/she seems to want to paint these guys as intentionally reckless, unprepared or incompetent. I also think the casual way the poster dismisses what role something like fatigue could have played in this event is disturbing and telling that they lack credibility and experience in an airline environment and the types of rosters guys can be up against.

Fact is though, the culture at the company isn't to just skip the briefing...

Maybe it's different on the bus... but I doubt it... I fly with lots of guys that have been on the bus... never seen anyone brush it off.

Also, I could be mistaken but, I thought I heard the rwy closure/lights out wasn't on the ATIS. Just in the NOTAM. Maybe in the 15 pages we get to read through every flight they somehow missed it? I don't know, but we get a lot of junk notams, that are essentially meaningless, to weed through. It would sure be nice if they would get rid of most of the notams published...

Anyway.

Glad they recognized it and I hope we learn from it. I'll wait for the full report.

[Rockie]

In the US they put out a NOTAM if a taxi light burns out or a painted line get scuffed. Not saying that's wrong, but it does make it more difficult to pick out the important stuff. Perhaps there's a way to highlight the really important relevant stuff in the pages of coded information.

[Eric Janson]

Maybe in the 15 pages we get to read through every flight they somehow missed it? I don't know, but we get a lot of junk notams, that are essentially meaningless, to weed through. It would sure be nice if they would get rid of most of the notams published...

This is a very interesting point.


Just to add some more perspective.

My last flight:-

Remote dispatch
0145 departure

Documents:-

-117 pages of FIR NOTAM information
-45 pages of Airport weather and NOTAMS (departure/destination/alternate and en-route alternates)
-19 pages of weather charts (including 4 pages of volcanic ash information for 4 active volcanoes)
-7 page flightplan (with diversion and drift down scenarios).
-15+ pages of miscellaneous documentation (GenDec/ICAO flightplan/Diplomatic Clearances/Performance charts/Company paperwork)

We make our own loadsheet/balance chart. Also very easy to make mistakes - caught one 3 weeks ago.

Very easy to miss something important imho.

Only 15 pages? I'm obviously working at the wrong Airline

[altiplano]

LOL... It is always more, you're right.... probably closer to 40 pages in the package for a flight like that... more if you're going further...

The result is skimming through the info and trying to pick out relevant ones... most of them will be gobbledygook unreadable or about weather balloons or something...

I'm not saying that is what happened here, but it surely isn't an ideal way to distribute the truly relevant information by mixing it in with a bunch of flotsam.

[TheStig]

http://flightservicebureau.org/the-prob ... it-notams/

It’s absolutely ridiculous.

We communicate the most critical flight information, using a system invented in 1920, with a format unchanged since 1924, burying essential information that will lose a pilot their job, an airline their aircraft, and passengers their lives, in a mountain of unreadable, irrelevant bullshit.

Yes CASA Australia, that’s you. Yes, Greek CAA, that’s you. And you’re not alone.

In an unintended twist of irony, the agencies seeking to cover their legal ass are party to creating the most criminal of systems – an unending flow of aeronautical sewage rendering the critical few pieces of information unfindable.

This is more than just hugely frustrating for each pilot, dispatcher, and controller that has to parse through it all; it’s downright dangerous.

If you’re a pilot, you’ll either have already experienced this, or you’re going to – you stuff something up, and then be told: “but there was a Notam out about that”. Sure enough, there it is in black and white (and in big capital letters). Do you think that “but there were 100 pages of them” is going to be a valid defence?



Well, it should be. The same agency conducting your post-incident interview is busy on the other end stuffing the system full of the garbage that prevented you from seeing it in the first place.

There are three parts to the problem: the system, the format, and the content. The system is actually quite amazing. The AFTN network connects every country in the world, and Notam information once added is immediately available to every user. Coupled with the internet, delivery is immediate.

The format is, at best, forgivable. It’s pretty awful. It’s a trip back in time to when Notams were introduced. You might think that was the 1960’s, or the 50’s. In fact, it’s 1924, when 5-bit ITA2 was introduced. The world shifted to ASCII in 1963, bringing the Upper and Lower case format that every QWERTY keyboard uses today, but we didn’t follow – nope, we’ll stick with our 1924 format, thank you.

Read that again. 1924. Back then, upper case code-infested aeronautical messages would have seemed impressive and almost reassuring in their aloofness. But there weren’t in excess of 1 million Notams per year, a milestone we passed in 2013. The 1 million milestone is remarkable in itself, but here’s something else amazing: in 2006, there were only 500,000. So in seven years, Notams doubled. Why? Are there twice as many airports in the world? No. Twice as many changes and updates? Possibly. But far more likely: the operating agencies became twice as scared about leaving things out.

And so onto the culprit: the content. The core definition of a Notam is ESSENTIAL flight information. Essential, for anyone tasked with entering information into the Notam System, is defined as “absolutely necessary; extremely important”. Here’s a game you can play at home. Take your 100 page printout of Notams, and circle that ones that you think can be defined as essential. See how many fit that bill.

So why is all this garbage in the system? Because the questions that the creators of Notams ask are flawed. The conversation goes like this:

– “Should we stick this into a Notam?”
– “Yeah, we’d better, just in case”.

How many are actually asking, “Is this essential information that aircrew need to know about ?”. Almost none. Many ‘solutions’ to the Notam deluge involve better filtering, Q codes, and smart regex’s. This overlooks the core problem. It’s not what comes out that needs to be fixed, it’s what goes in.

Even in 1921, we had much the same problem. Obstacle, 18 feet high, several miles from the runway.

Nobody cares. Unless you’ve parked the Eiffel Tower on the threshold, leave this stuff for the AIP. And nobody cares about kites either. Nor about goat-grazing times. We don’t care if your bird scarer is U/S. We don’t care if there’s a cherry-picker fixing a bulb somewhere. We don’t care when you’re cutting your grass.

Nor do we care about closed taxiways. The only way I can get onto a taxiway is with an ATC clearance, and ATC will not clear me onto a closed taxiway.

We care if the airport is going to be closed when we get there. If we’re going to have to divert because the runway is shut. If someone might shoot at us. If there are new rules. We care about the critical items, but we won’t see them as things stand.

And so, about here is where a normal editorial piece might end with “we hope that the authorities improve the system”, and sign off.

But not here.

We’re in the business of doing things here at FSB, not just talking about them.

Last year we wrote a few pieces about the Greece vs Turkey Notam battle. This month we did a group look at Briefing Packages, and it was astonishing to see how many pages of this diplomatic drivel still appeared in all our members’ Briefings. All in all, on average 3 full pages of every briefing for a flight overflying Greece or Turkey contained this stuff.

So, we sent Greece a polite AFTN message on behalf of all of us.

That’s just one piece of a thousand-piece puzzle, and it would be nice to think that one piece at a time we could fix the sytem. Let’s get real. It’s a monster, and it’s out of control.

We don’t think that we can fix the Notam system.

But, we can think about a different solution. And that’s exactly what we’re doing right now in OpsGroup. With almost 2000 members, we can make a difference. Watch this space. Or, if you want to help take action, send your thoughts to goatams@ops.group.

[Eric Janson]

The best way to display NOTAM info is in graphic format imho.

Example:- A taxiway at an airport highlighted in red is very easy to understand.

My understanding is that this is coming in a future update of Jeppesen FD Pro.

They've just integrated information from the manuals into the route which is a fantastic feature.

[digits_]

http://flightservicebureau.org/the-prob ... it-notams/

It’s absolutely ridiculous.

In the spirit of the above text, it might not have helped them either.

"what do I care if one of 2 parallel runways is closed, they are not going to clear me to land on a closed runway, are they?"