Close One!

[Guest 06L06R]

Cadors #2013O0564

Don't know how to copy the page, but this was close!

Here is the link to the Cadors search page.

http://wwwapps.tc.gc.ca/Saf-Sec-Sur/2/cadors-screaq/qs.aspx?lang=eng

[IFG]

This link worked for me (saves sorting out the zero's from the "O"'s in the CADOR#)

http://wwwapps.tc.gc.ca/Saf-Sec-Sur/2/cadors-screaq/rpt.aspx?lang=eng&rptcads=2013O0564&cads=&cadorsno=2013O0564®cd=0&occdtefrom=&occdteto=2013-03-13&occtypecd=0&fatop=%3E=&fatal=0&aeroidtxt=&aeroidcd=&loc=&provcd=0&accatcd=0&acoptxt=&acopcd=&acmaketxt=&acmakecd=&acmodeltxt=&acmodelcd=&evnts=&evtype=0&narr=

Cheers, IFG

[Seeker]

Listen from the 6 minute mark...

yyz_tower_12March.mp3

[mo32a]

Well neither of the links worked and the audio seemed unremarkable, what happened?

[Airband]

Well neither of the links worked and the audio seemed unremarkable, what happened?

Might give this a shot...

ACA178.pdf

[Ex 9A Guy]

Listening to the audio the controller uses only the flight number twice without the company identifier. Obviously a surprise for him also but a properly worded "Air Canada 178 pull up and go around" would probably have gotten the crew's attention at a pretty critical phase of flight.

[Moon The Loon]

I'd like to find out more about the runaway Sunwing vehicle. Ex9AGuy's point is very valid, especially if it was busy. I haven't been through CYYZ for awhile. How is their RT talk generally these days?

[Seeker]

Well neither of the links worked and the audio seemed unremarkable, what happened?

Both options lead to the report for me.

[Seeker]

Don't know how to copy the page, but this was close!

I'm not sure I understand what you mean by "close". Do you mean close in the sense that the crew didn't hear or understand what was communicated to them and it could have lead to something catastrophic or close in physical proximity? The crew is much closer to the landing area than the controllers (several miles closer) and has a better view too. I know it's night and the controller is looking at his ground radar but the crew still gets a better look at the landing zone than the controller. I guess most controllers aren't aware of all the noise, verbal calls and auto call-outs that happen in the last 1/2 mile before landing. Here's all the stuff we say/hear on the Embraer just before landing:

Aircraft aural annunciation: "APPROACHING MINIMUMS"

PNF: "STABLE"

PF: "ROGER"

Aircraft aural annunciation: "MINIMUMS"

PNF:"RUNWAY IN SIGHT"

PF: "LANDING"

Aircraft aural annunciation: "AUTOPILOT, AUTOPILOT" (cancelled by crew)

Aircraft aural annunciation: "AUTOPILOT, AUTOPILOT" (again cancelled by crew)

then RAD ALT call-outs: "50, 40, 30, 20, 10"

The "go-around" instruction from the tower controller was weak and indistinct and, I'm guessing, was lost in the rest of the mandatory SOP and aircraft call-outs. The pilots may have heard something about a go-around but the fact that the controller was working 24R and 23 on the same frequency and seeing no other aircraft on the runway probably didn't match his mental picture.

I once heard a go-around issued in BOS, co-incidentally to an Air Canada flight, that went like this:

Controller: "AIR CANADA 123 GO-AROUND! AIR CANADA 123 GO-AROUND!, AIR CANADA, AIR CANADA GO-AROUND, AIR CANADA 123 GO-AROUND! GO-AROUND AIR CANADA 123". The controller must have said it about 8 times in a loud clear voice. I got a go-around in ORD once and the controller said it at least 4 times - the wheels were already in the wells and he was still telling me to go-around - "178 go-around" just doesn't cut it.

[Guest 06L06R]

Close as in the targets merged on the runway and the aircraft flew over the van.

I have not heard the tapes yet, but would it not be prudent to ask tower for clarification in this case? You are short final and you hear go around instructions, I think you should do some quick checking.

[Seeker]

Did you listen to the audio file? The pilots probably should have asked for clarification but the controller used non-standard phraseology and was somewhat low-key in tone. A last minute instruction like this needs to needs to be clearly understood and to stand out from the rest of the radio clutter - if the transmission was clear to begin with there's no need to ask for clarification.

[J.O.]

It's easy to say that standard phraseology must be used at all times, but I've watched enough simulator sessions over the years to know that it sometimes gets forgotten in a moment of stress, like a high-speed reject in 600 RVR when the FO forgets to broadcast a Mayday / Pan-Pan when they call ATC. Seeing a vehicle about to enter the runway that you just issued a landing clearance for is bound to raise the stress level of the controller.

[inchman]

Did you listen to the audio file? The pilots probably should have asked for clarification but the controller used non-standard phraseology and was somewhat low-key in tone. A last minute instruction like this needs to needs to be clearly understood and to stand out from the rest of the radio clutter - if the transmission was clear to begin with there's no need to ask for clarification.

Absolutely.

A one or two second transmission could easily have been stepped on as well. If the go-around was that important, the controller should have been very clear and very long in his transmission and added some intensity to it... maybe even a "Truck on the runway" comment.

This is some of the worst diction and sloppy transmission (not just the go around instruction) I have ever heard on the radio from YYZ tower. They are usually much better than this.

[J.O.]

I listened to the audio file and I am pretty sure that the transmissions are clipped at the start. If the audio is from the LiveATC website then this makes sense. My understanding is that this site uses a media scanner to capture the audio files. The problem with scanners is that they often miss the initial stages of a transmission because they are constantly tuning from one frequency to another, only stopping at a particular frequency when there is a consistent signal present above the background spectrum.

[Say Again, Over!]

J.O., I agree. Add to that the fact that it's easy, when a little stressed to start talking as you're pushing the button thereby cutting out another microsecond.

I agree with inchman as well that trafic info would have driven the point across better to the crew. But it's easy to second guess both the controller and aircrew from the perspective a couple of days give.

Flix

[Seeker]

I listened to the audio file and I am pretty sure that the transmissions are clipped at the start. If the audio is from the LiveATC website then this makes sense. My understanding is that this site uses a media scanner to capture the audio files. The problem with scanners is that they often miss the initial stages of a transmission because they are constantly tuning from one frequency to another, only stopping at a particular frequency when there is a consistent signal present above the background spectrum.

LiveATC can have several issues but I think this particular recording is pretty good. The main issue is when two different frequencies are recorded together such as a couple of terminal freqs or when both tower freqs are being used at the same time. As you say, the scanner will sometimes miss a half a second or part of a transmission when both happen to be active at exactly the same instant. In this case the scanner is locked on a single frequency and there does not appear to be any loss for the previous reasons. The controller just seems to be loose with his radio calls. The pilots should have heard the first call and should have heard the second so I'm not putting all the blame on the controller though.

I certainly agree that disecting the event from the comfort of an office with the benefit of a recording doesn't necessarily give those involved a fair shake.

[Moon The Loon]

Seeker highlights a point I've tried (sometimes successfully) to get across to various flight ops management over the years. We have a sterile cockpit but it can easily be contaminated by verbosity i.e. saying way too much way too many times. I worked for one operator that insisted on completing their 17 item landing checklist inside the FAF, make their mandatory pilot-to-pilot calls, communicate to ATC to the point it was nearly non-stop noise from the FAF to landing.

A polluted environment like that invites missed calls, ESPECIALLY if the calls are non-standard verbage from ATC. Add to that a 2 pilot flight deck, Cat II or III weather, auto-callouts, pilot & controller fatigue, multiple runway changes from Top of Descent to final approach...all leading up to how they said it in Mama Mia: dot, dot, dot, meaning someone just got ...well, you know.

Anyway, in this particular case, thankfully those involved all went home safely after the fact.

Just a few musings...

[Guest 06L06R]

Would love to hear the overhead recorder for the crew. What did they hear? Did they discuss?

The pilot stated that "we thought it was for someone else" You don't confirm that?

Every clip off of the internet is cut off at the start of a transmission, and the transcripts are not out yet,

The controller used a "low key tone" as someone said. Does that mean he should be disregarded? Staying calm and saying pull up should not be the problem, Ignoring an instruction, now that is an issue. I have yelled at a pilot to not do something, and they did it any way so volume and tone is not always the issue.

The controller could not see what was there. They did not know what is was until there was an inspection.

[Seeker]

Maybe they heard it, maybe they didn't. Maybe they discussed it, maybe they didn't. The point I get from the recording is that the instruction was quiet, and relatively monotone - "178 pull up, go around" rather than "AIR CANADA 178 GO-AROUND". I can't guarantee it would have made a difference but I think it would have. The question I have (I already know the answer) is why is there only one guy working both 24R and 23? He's obviously splitting his attention to two widely separated runways. At what point did he first realize there was a potential conflict and would he have alerted the crew if he wasn't busy with the departures on RWY 23? A simple comment like this, "be ready for a possible go-around as we may have a vehicle across the hold line" would have the crew prepped long before he needed to make the call. Yeah, I know it's staffing, costs etc etc.

[Specs]

If I'm on final and I hear Go Around from anybody anywhere then there's only one response that's reasonable. Call him into the office for a debrief and assessment.

And If I have an employee who lets an errant vehicle run halfway across an airport and an active runway, there's only one response that's reasonable. Call him into the office for a somewhat vigorous debrief and assessment.

(Hey crap happens even to the best of them so everybody get's an occasional let)

[Guest 06L06R]

The vehicle did not have any lights on and rolled off the ramp at DV and onto the threshold and across in the dark. I would challenge any one to see dark move across dark 2 miles away. The controller found out the problem as soon as the alarm went off and start calling the pilot right away. While the controller might not be excitedly issuing the instruction it was certainly not mono-tone.

Again I must stress that you don't go on the audio that is on the internet. It is incomplete, and cuts out the start of every transmission.

[J.O.]

This one is being investigated both by NavCan and the TSB so I am sure that the real audio recordings will reveal what was really said. I still think it's clipped on the LiveATC file because there's a partial word before "178", not only during the calls to go around, but also 3 minutes earlier when the landing clearance was issued.

[Guest 06L06R]

It is confirmed that the FULL ident was used by the controller.

[Seeker]

It is confirmed that the FULL ident was used by the controller.

OK, glad that's clarified. You know this from listening to the actual tape yourself?

[Southshore]

"Hey crap happens even to the best of them so everybody get's an occasional let"

Bingo. Paraphrasing Colin Powell, good leaders don't punish every mistake.

But about this event.

This event awoke a memory from a few years ago. I was waiting for takeoff on the left side in YYZ when a Czech A300 was cleared for take off after a lander. The lander missed his exit. I'm watching this and going "WTF??" A couple seconds later the controller said very casually "Czech *** stop your takeoff", once. Then nothing. The Czech kept going. I'm going "What's happening?". The lander finally clears. The the Czech says "Toronto, say again?". Toronto says "Disregard". All during the takeoff roll.

It was surreal - like remembering a bad dream. I thought I was watching an accident and nobody cared.

Funny. I'd forgotten about this.