AC Lining Up with a Taxiway SFO...?

[rookiepilot]

We need foreign intervention to get our stuff together. Brutal. They must think Canada is bush league

This.

Should hear conversations I've had with friends about the trucking industry up here, too. Scary.

[Flitey]

It seems the United States wants some action on our fatigue rules as a result of their investigation:

https://www.cbc.ca/news/world/u-s-safet ... -1.4838586

[pelmet]

Maybe they should have taken a snooze in the cockpit which is allowed. I doubt they were any more fatigued than the guys departing at midnight from their home base for a 12 hour overseas flight to SFO or guys flying the midnight flights from west to east at AC, especially if you were on standby. Then again, we end up with stupid rules like insisting that the crew be awakened right in the middle of their sleep after about thirty minutes because some previous guy at the same airline woke up, thought a star was another aircraft and almost caused a midair collision. Stupid rules caused by stupid actions.

I realize everyone is different when it comes to sleep patterns but I just had another nice one hour snooze in the flight deck yesterday(after being initially bothered twice). The snooze ensured that I was wide awake for the landing.

[TheStig]

M.G should resign in disgrace. His inaction and ineptitude are inexcusable. At lease he'll be called out by a real agency. The FAA.

Since this incident AC has replaced its Director of Flight Operations, Director of Safety and Training and the Airbus 320 Chief Pilot. The flight ops directory, outside of crew manning, looks almost entirely different.

[groundpilot]

https://www.ctvnews.ca/mobile/business/ ... -1.4108110

[Hangry]

M.G should resign in disgrace. His inaction and ineptitude are inexcusable. At lease he'll be called out by a real agency. The FAA.

Since this incident AC has replaced its Director of Flight Operations, Director of Safety and Training and the Airbus 320 Chief Pilot. The flight ops directory, outside of crew manning, looks almost entirely different.

And?? Has AC instituted its own science based fatigue rules? You know. The rules that cost more money? Change the guard all you want. If you’re working within the same system big deal. I was talking about our illustrious transport minister.

[groundpilot]

https://youtu.be/LWLPDOXF7e4

NTSB:

"The NOTAMS are just a pile of garbage"

Describing reserve rules "NUTS"

[TheStig]

M.G should resign in disgrace. His inaction and ineptitude are inexcusable. At lease he'll be called out by a real agency. The FAA.

Since this incident AC has replaced its Director of Flight Operations, Director of Safety and Training and the Airbus 320 Chief Pilot. The flight ops directory, outside of crew manning, looks almost entirely different.

And?? Has AC instituted its own science based fatigue rules? You know. The rules that cost more money? Change the guard all you want. If you’re working within the same system big deal. I was talking about our illustrious transport minister.

My mistake, I thought you were referring to a different MG.

[Mr. North]

https://www.thestar.com/business/2018/0 ... -call.html

Board chair Robert Sumwalt said the majority of that information was just “garbage” and “written in a language only a computer programmer would really understand.

Finally some attention is being paid to the endless reams of information we're supposed to decipher. Enough with the ticker tape bullshit. NOTAMS should be CLEAR and EASY to read!!

[pelmet]

Since this incident AC has replaced its Director of Flight Operations, Director of Safety and Training and the Airbus 320 Chief Pilot. The flight ops directory, outside of crew manning, looks almost entirely different.

Interesting...what about line training guys? Anyways....An AC guy did tell me perhaps half a year ago that TC was all over them.

Although not confirmed, I have heard that they have also significantly extended the Airbus initial training curriculum. Apparently they were rushing people through with the inevitable results of a lot of incidents. I wonder who mandated the increased training?

I know an ex-AC guy that used to train Airbus guys at AC. He quit in frustration years ago back in the darker days when everyone thought they were going out of business and the pension could be under threat and took a job where no pension threat would ever exist. He said that during his day, AC kept on cutting back and cutting back on training so much so that he couldn't get all the required training in. I wonder if he has had any influence in convincing AC to extend their training.

[rookiepilot]

https://www.ctvnews.ca/mobile/business/ ... -1.4108110

"We could not have gotten literally or figuratively any closer to having a major disaster," said the safety board's vice chairman, Bruce Landsberg, during a hearing Tuesday in Washington."

According to the home gamers it was a "non event, nothing to see here -- why even investigate".

Check the comments at the beginning of this thread.

Difference between US and Canada. One wants to simply cover their eyes.

[Zaibatsu]

Oh f*ck off with this Canada vs America crap.

https://www.pprune.org/rumours-news/596 ... c-sfo.html

Less information was available before, more information is available now.

[pelmet]

Finally some attention is being paid to the endless reams of information we're supposed to decipher. Enough with the ticker tape bullshit. NOTAMS should be CLEAR and EASY to read!!

They should be, but as of right now, we have to deal with what we've got. Which is....taking the time to read through them. At minimum, that can be done during the nice long cruise time to SFO.

The Ukraine notams leading up to the shootdown of MAS were the worst example of notams not written loud and clear although plenty of airlines seemed to be quite happy to save gas by "safely flying" 1000 feet above a war zone. I know some people that were very close to that aircraft on that exact day. Funny how the route to Europe change the very next day.

[rookiepilot]

Oh f*ck off with this Canada vs America crap.

https://www.pprune.org/rumours-news/596 ... c-sfo.html

Less information was available before, more information is available now.

I'll get you a "feelings" blanket.

Blame the notams. Blame the fatigue regs. Blame the visual approach (which the pilots accepted) Blame the fact it actually gets dark at night. In YHZ, blame (and sue) the airport. Blame the NTSB for "overreacting" and embarrassing Canada with an investigation. Blame Trump.

Enough. Stop blaming everyone else. Sick of it.

[Old fella]

Can’t speak for airline nor A320 SFO operations because I done neither but certainly can speaking for my industry time being assigned to Air Ambulance ops and the many 15-20 hr duty times and fighting sleep on the final approaches last leg. I was extremely lucky in those long ago far away days that nothing seriously happened. Flying tired and fatigue creeping up on you isn’t fun at all, I considered it the most serious issue in my ho- hum career in this business of aviation.

[Rockie]

I have to defend Trump here, he had nothing to do with it.

[Eric Janson]

Hopefully the Canadian CVR/FDR policy gets upgraded to match the standards of just about everywhere else.

Shocking that after a serious incident CVR/FDR data was overwritten because the circuit breakers weren't pulled and the data downloaded.

This has happened more than once at multiple Canadian Airlines.

[Hockaloogie]

This has happened more than once at multiple Canadian Airlines.

Nobody minding the store? Some people think so.

[rookiepilot]

https://dms.ntsb.gov/public/61000-61499 ... 618785.pdf

This is ACA's submission to the NTSB. Picked this up on the other site.

Pretty interesting the summary of cause, between the NTSB, and ACA.

[pelmet]

A few weeks ago I was once again able to feel proud as a Canadian in SFO as we did the slow taxi toward 1L/1R and saw two RCAF C130J aircraft lined up in echelon formation on 1L and subsequently cleared for takeoff. Have no idea why they were in town. But.....looks like we are in the bad books again with SFO ATC.

"C-FSDB, a Boeing 737 Max 8 aircraft operated by Air Canada, was conducting flight ACA780 from San Francisco Intl, CA (KSFO) to Montréal/Pierre Elliott Trudeau Intl, QC (CYUL) with 6 crew members and 137 passengers on board. Prior to taxiing for departure off Runway 28L at KSFO, ATC instructed the flight crew to taxi via Foxtrot, across Runway 1L and hold short of Runway 1R. The flight crew heard and read back "Taxi Alpha, Foxtrot", and ATC did not correct the flight crew on the incorrect read back. As the aircraft was taxied across Runway 1R, ATC instructed ACA780 to stop, and issued an alternate taxi instruction. The aircraft taxied for departure on Runway 28L with no further issues. Neither Runways 1L and 1R were active at the time of the occurrence."

Oh well. Maybe they might want to review what sort of clearance you need to cross a runway and proper readbacks. Best to not cross a runway unless you have actually read back that you are cleared to cross that runway. I personally write stuff like that down as the taxi clearance is being issued but have noticed that a lot of people don't.

[pelmet]

https://dms.ntsb.gov/public/61000-61499 ... 618785.pdf

This is ACA's submission to the NTSB. Picked this up on the other site.

Pretty interesting the summary of cause, between the NTSB, and ACA.

Interesting. I am just getting started and I realize that it is only the Introduction statement on page 1 but it appears that AC in the report on their version of the event, feels that the controller lost situational awareness in this incident(based on his delay in responding to AC's query about lights on the runway) but loss of situational awareness is not mentioned for the pilots. Could it be that the delay was due to the LONE controller taking a look at the runway prior to transmitting back to the pilots. it will be interesting to see what the rest of the report says.

"ACA759 was on an approximate 0.6 mile final when the PM asked the lone, combined local control/controller-in-charge (LC/CIC) in the KSFO tower to verify that they were still cleared to land on Runway 28R as the crew were seeing lights. Several seconds later, the LC/CIC controller responded in the affirmative and re-cleared ACA759 to land on Runway 28R. Based on the LC/CIC controller’s delay in responding to the flight crew, it appears he had lost situational awareness of ACA759’s position; and he did not offer any additional guidance about the runway 28L closure or construction lighting. In addition, the airport had not conducted any analysis of the adequacy of lighting to be used during the runway 28L construction.

At this point, ACA759 was inadvertently and unknowingly lined-up on parallel Taxiway C, which had four airplanes on it awaiting takeoff clearance (a B787 first in line followed by an A340, B787, and B737). The flight descended below 100 feet Above Ground Level (AGL) before the crew sensed something was wrong and initiated a goaround. As is normal during a go-around, the flight path continued to descend for several seconds while the engines accelerated to go-around thrust. Consequently, ACA759 overflew the first aircraft (B787) after the go-around was initiated but before a positive climb was underway, and the second aircraft (A340) on the taxiway was also overflown. The go-around was properly executed and the remainder of the flight was uneventful. The aircraft landed on July 8, 2017, at 0017 Pacific Daylight Time (PDT) (0317 Eastern Daylight Time (EDT))."

[pelmet]

Discussing in this post only the ATC portion of the incident.....the report created and submitted by AC appears to be an attempt to place most of the blame on the controller. He should have seen what was happening. It is significantly his fault, even though he might be particularly busy at this time with various other aircraft. Something that happens even in the daytime when there can be several controllers on duty at the same time. A controller can't be expected to baby every flight.

"Based on the LC/CIC controller’s delay in responding to the flight crew, it appears he had lost situational awareness of ACA759’s position; and he did not offer any additional guidance about the runway 28L closure or construction lighting."

Perhaps in AC's haste to blame the controller for this incident, they forgot about their delay in response argument as proof of a lack of situational awareness for the controller when later on in the report Air canada admits that..."As the crew of ACA759 was soliciting information regarding the status of the runway, the LC/CIC controller took time to scan the runway, check his radar monitor and verify the Airport Surface Surveillance Capability (ASSC) display." Of course that is only because they are trying to blame him for not interpreting his radar properly when he sees them right of course even though the FMS arrival intentionally places the aircraft right of course for the arrival for noise abatement.

It appears that the pilots had to take the initiative to go around as the controller took too long to tell them to do so....
" Finally, in looking for the aircraft, he began to recognize something was not right. After a critical period of an additional three seconds from the time the flight crew of ACA759 had already determined on their own that a go-around was needed and executed this maneuver, the LC/CIC controller advised the crew to goaround."

And if only the controller turned on the SFL instead just the 3000 feet of approach lights that were illuminated, this would not have happened..."The LC/CIC controller never considered the airport lighting. The airfield lights were automatically set, and unless the Controller took specific actions to adjust the lights, the standard settings would be offered. This, despite construction and a complete lack of knowledge about the intensity of these lights or their impact on landing crews, suggests a more engaged, proactive LC/CIC controller might have asked crews about the lighting given the construction. Sequenced strobes to Runway 28R were available but not employed–this simple tool would have all but eliminated the possibility of misalignment. To the LC/CIC controller, the normal, automated set-up of lights had always been adequate, and he did not question why anything would be different on this night."

So in the end, AC has come up with their probable cause being pilot 'misperception' with all the contributing factors being by the controller...

"The Probable Cause of the ACA759 overflight incident was the flight crew’s misperception of SFO Taxiway C as Runway 28R during the approach. Contributing to the incident were: (1) San Francisco International Airport’s inadequate lighting of the runway environment, including lighting of the ongoing construction, to distinguish the normally-configured parallel runways from runway 28R and Taxiway C given the closure of runway 28L; (2) failure of the sole, combined local controller/controller-incharge (LC/CIC controller) in the KSFO tower to provide any direction or information to the flight crew, following the flight crew’s request, until after the flight crew had already initiated the go-around; and (3) insufficient training and knowledge by the combined LC/CIC controller on use of available lighting resources and ADSE-X/ASSC capabilities."

Seeing as AC feels that the controller did not provide any information to the flights request, let's see what the request was....“Just want to confirm this is Air Canada seven five nine we see some lights on the runway there across the runway. Can you confirm we’re cleared to land?”

The controllers response to their request to confirm that they were cleared to land was....“Air Canada seven five nine confirmed cleared to land runway two eight right. There’s no one on runway two eight right but you.”

While the report concentrates on their belief that the controller had lost situational awareness, aside from being aligned with the taxiway, it does state...."initiation of the go-around occurred as the flight was crossing the Taxiway C seawall and at 85 feet AGL" "The crew of ACA759 believed that they were between 300-400 feet Mean Sea Level (MSL) when they initiated the go-around."

Even post-flight, the controller got it all wrong which is perhaps why the CVR was not saved...We are not told what 'pertinent data' that was not offered to the crew.
"The actions of the LC/CIC controller after the incident were also important. In his discussion with the Pilot, the Controller stated he was trying not to raise concern with the crew and missed offering pertinent data that could have identified the seriousness of the event. In fact, the LC/CIC controller did not recognize the serious nature himself and did not even file a Mandatory Occurrence Report. Instead, the LC/CIC controller told Investigators he saw the event as a pilot deviation and not an ATC error, and as such, took little action to raise awareness about the actual event."

All of a sudden, I am interested in reading AC's submission to the TSB regarding the Halifax crash. Anybody have a copy.

[rookiepilot]

If as the AC folks repeatedly state on this thread, this was not an incident but simply a routine go around, why did AC feel the need to write its own -- what is it, a 30 something page report on it?

[pelmet]

If as the AC folks repeatedly state on this thread, this was not an incident but simply a routine go around, why did AC feel the need to write its own -- what is it, a 30 something page report on it?

This may be standard practice to get input from the interested parties in a major investigation. I suppose it is their opportunity to present their point of view but it should in my opinion be honest about the causes.

I have heard of this before and apparently a company that I worked for did similar, possibly in coordination with the union or not. I heard that there were significant things they wanted changed in the draft report which may have been done but that is just heresay. Unfortunately, our TSB keeps many of these things either secret or not nearly as easy to access as the NTSB which seems to believe(or be mandated) that it can be useful for pilots to learn from giving out more information which may do the most important thing that investigation boards exist for....preventing future accidents. I challenge the TSB start an on-line docket system just like the NTSB if it has not been done.

[Shady McSly]