AC Near crash SFO - NOTAMS are a bunch of Garbage and pilot fatigue

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Nark1

[quote author=digits link=topic=9098.msg24924#msg24924 date=1538092859]
[quote author=Nark link=topic=9098.msg24909#msg24909 date=1538015229]
IAs a GD pilot, an airline (AIRBUS) pilot no less, why didn't they look at the PFD and wonder why the localizer was so fucked up.  [i]Why didn't the PNF look up and ask, gee those lights look funny for a runway. [/i]


[/quote]
If I recall correctly, they did exactly that. They looked outside, queried tower about traffic on what they thought was the runway, and went around because it didn't look good.
[/quote]


13 feet.  13 feet away from what could have  Been the most catastrophic disaster ever in aviation.


13 feet. 


Rookie Pilot
Posts: 404
Joined: Tue Sep 08, 2015 1:44 am

Read this:  It's ACA's submission to the NTSB:  They write their OWN complete report blaming everyone but themselves.  It's a giant fuck you to the NTSB -- saying "We will decide safety for ourselves".  WTF??????!!!!!!!!!!!!!!

THIS is Canada in a nutshell.  Nothing is our fault. 

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

ACA-determined Probable Cause:

"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-in-charge (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."

NTSB-determined 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."
Liquid Charlie
Posts: 524
Joined: Sun Aug 23, 2015 1:34 pm

Like most things in life the actual facts and truth lie somewhere in the middle - can't say the TSB would be completely unbiased in this situation and since there was no actual accident they will lean towards their own system. As always there is shared blame here but everyone goes into this day's metaphor -- "cover your ass" and "blow smoke" - clearly both sides are doing this.
Colonel
Posts: 3450
Joined: Wed Apr 29, 2015 10:31 am

There are two different sets of rules.

If an AC pilot makes a mistake, it's not really a mistake,
we are told.

Like when Ted Kennedy drowned his secretary.  Anyone
else had done that, they would have gone to jail.

If anyone else had come within 13 feet of the worst disaster
in aviation history, they would never fly again.

Two sets of rules for two sets of people.
digits

[quote author=Nark link=topic=9098.msg24931#msg24931 date=1538107344]
[quote author=digits link=topic=9098.msg24924#msg24924 date=1538092859]
[quote author=Nark link=topic=9098.msg24909#msg24909 date=1538015229]
IAs a GD pilot, an airline (AIRBUS) pilot no less, why didn't they look at the PFD and wonder why the localizer was so fucked up.  [i]Why didn't the PNF look up and ask, gee those lights look funny for a runway. [/i]


[/quote]
If I recall correctly, they did exactly that. They looked outside, queried tower about traffic on what they thought was the runway, and went around because it didn't look good.
[/quote]


13 feet.  13 feet away from what could have  Been the most catastrophic disaster ever in aviation.


13 feet.
[/quote]
Okay, so would you consider it less serious if it was "just" a 172 parked on the taxiway that turned on its landing lights? Either way the actions of the crew would have been the same.

People are using this as an example of how the system failed. I consider this an example of the system working: they noticed something was wrong, and they went around. Ideally they should have noticed it sooner, or not have made the mistake earlier. Absolutely. But you can't blame them for "the worst accident in aviation history" because there happened to be a bunch of airliners on the taxiway.

The whole "13ft away from disaster", while technically correct, is a bit misleading and more of a news headline title. Every time I drive on the highway I am 6 ft away from disaster. During every surface acro sequence, I'm sure CS is less than 13 ft away from disaster. During engine out procedures on a wet runway you are certified to be 15 ft away from disaster. Didn't it take the company and ATC 2 days to determine this was a reportable event? You'd think it would take them less than a minute to report it if it was such a dramatic-narrowly-escaped-humongous-crash-and-huge-collision event?

They screwed up, but let's cut down on the drama a bit.
Nark1

I’m captain of the exact same aircraft for a different company. 


13 feet is absolutely unacceptable. 
digits

[quote author=Nark link=topic=9098.msg24946#msg24946 date=1538152151]
I’m captain of the exact same aircraft for a different company. 


13 feet is absolutely unacceptable.
[/quote]
Okay, that means you should be able to explain to me why.

Why is it that 15ft clearance for an airplane with one engine out on a wet runway and reduced manoeuvrability is deemed acceptable and certified, but 13ft in a perfectly functioning airplane is not?
Nark1

The runway is cleared and terped  for obstacles. 


Taxiways are not.
Chuck Ellsworth

[quote][font=Verdana]People are using this as an example of how the system failed. I consider this an example of the system working: they noticed something was wrong, and they went around. Ideally they should have noticed it sooner, or not have made the mistake earlier. Absolutely. But you can't blame them for "the worst accident in aviation history" because there happened to be a bunch of airliners on the taxiway.[/font][/quote][font=Verdana]


If the system was working properly these two pilots would have been fired and charged with gross negligence.



[/font]
Rookie Pilot
Posts: 404
Joined: Tue Sep 08, 2015 1:44 am

[quote author=digits link=topic=9098.msg24948#msg24948 date=1538153012]
[quote author=Nark link=topic=9098.msg24946#msg24946 date=1538152151]
I’m captain of the exact same aircraft for a different company. 


13 feet is absolutely unacceptable.
[/quote]
Okay, that means you should be able to explain to me why.

Why is it that 15ft clearance for an airplane with one engine out on a wet runway and reduced manoeuvrability is deemed acceptable and certified, but 13ft in a perfectly functioning airplane is not?
[/quote]

If this was a normal event;  why did the crew willingly allowed the tapes to be overwritten? 

Don't even think of calling that an oversight. 

The company should be charged with destroying evidence to impede an investigation. 
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