SFO Incident

[UpperDeck]

Just another aspect of this occurence that mandates further investigation. Many were aware of this incident within hours. Information was exchanged before the fin was scheduled for its next segment.

Why was the CVR not recovered and preserved? Why was that not a priority item?

[DEFCON]

The caca's going to fly now.

[Vsplat]

Quote

Everyone who would be expected to know was aware of this incident within hours. Numerous texts were exchanged in the hours before the fin was scheduled for its next segment.

Why was the CVR not recovered and preserved? Why was that not a priority item?

That's quite a post.  The question is actually one a criminal prosecutor would ask if the preceding statement is in fact found to be the case.

To be clear, failure to protect evidence of interest to federal investigators is an indictable offence.  Prison time for those convicted.

Take this for the honest advice that it is.  if  you have proof that individuals were notified but did nothing, and it sounds from your post that you know this to be the case, then you have knowledge of the commission of a crime and  this forum is not the place to share that information.  The RCMP is.

Vs

 

[Vsplat]

From the Transportation Safety Board Act

PART 1   Reports

Mandatory Reporting

Aviation Occurrences

Marginal note:Report to Board

2 (1) The owner, operator, pilot-in-command, any crew member of the aircraft and any person providing air traffic services that have direct knowledge of an occurrence must report the following aviation occurrences to the Board if they result directly from the operation of an aircraft:

 

(b) in the case of an incident involving an aircraft having a maximum certificated take-off weight greater than 2 250 kg, or of an aircraft being operated under an air operator certificate issued under Part VII of the Canadian Aviation Regulations

(i) an engine fails or is shut down as a precautionary measure,

(ii) a power train transmission gearbox malfunction occurs,

(iii) smoke is detected or a fire occurs on board,

(iv) difficulties in controlling the aircraft are encountered owing to any aircraft system malfunction, weather phenomena, wake turbulence, uncontrolled vibrations or operations outside the flight envelope,

(v) the aircraft fails to remain within the intended landing or take-off area, lands with all or part of the landing gear retracted or drags a wing tip, an engine pod or any other part of the aircraft,

(vi) a crew member whose duties are directly related to the safe operation of the aircraft is unable to perform their duties as a result of a physical incapacitation which poses a threat to the safety of persons, property or the environment,

(vii) depressurization of the aircraft occurs that requires an emergency descent,

(viii) a fuel shortage occurs that requires a diversion or requires approach and landing priority at the destination of the aircraft,

(ix) the aircraft is refuelled with the incorrect type of fuel or contaminated fuel,

(x) a collision, a risk of collision or a loss of separation occurs,

...

Time limit

(3) The person making the report must send to the Board

(a) as soon as possible and by the quickest means available, all the information required under subsection (2) that is available at the time of the occurrence; and

,,,

Keeping and Preservation of Evidence

Marginal note:Evidence

8 (1) Every person having possession of or control over evidence relating to a transportation occurrence must keep and preserve the evidence unless the Board provides otherwise.

Offences

Marginal note:Offences

35 (1) Every person who

is guilty of an indictable offence and liable on conviction to a term of imprisonment not exceeding two years, or is guilty of an offence punishable on summary conviction.

(a) contravenes subsection 19(8), (10) or (11),

(b) without lawful excuse, wilfully resists or otherwise obstructs a member or an investigator in the execution of powers or duties under this Act or the regulations,

(c) knowingly gives false or misleading information at any investigation or public inquiry under this Act, or

(d) makes a report pursuant to section 31 that the person knows to be false or misleading

[Guest]

Vsplat, what the the requirements in the US?

[Johnboy]

14 hours ago, blues deville said:

There is a slight difference in the depiction of this approach between your FAA version and Jeppesen. While the FAA clearly shows the location of the 28L/R localizers, it doesn't show the transistion (text only info) to it from the SFO 095R, which should occur at 6 DME or passing the San Mateo Bridge. If somehow you got busy looking out and forgot to make the transistion to the LOC, you would end up pointing at the Charlie taxiway and not the runway center lines. 

This my friend is exactly explains how the aircraft ended up where it did.  Is this an AC Procedure for this approach..I do not know.  Approach plates and approach briefings can be a real gotcha even in VMC conditions/transitional approaches.

[anonymous]

The QUIET BRIDGE approach is for non-FMS airplanes. Very unlikely that this was the flown approach, there is another version for FMS aircraft.

Some people in this thread really need to wind their necks in, especially the non-pilot(s) who seem to know all sorts of things...there is an on-going investigation and the facts and details will come out in time. 

 

[rudder]

9 hours ago, Malcolm said:

Vsplat, what the the requirements in the US?

 

Flight was operated on a CDN AOC in US airspace. Operator must comply with both CDN and US reporting requirements.

[Vsplat]

Malcom, rudder is correct. 

In short, if Air Canada personnel were aware of the need to report and did not, as alleged, they would be in violation of the TSB act regardless of the location of the event, both because it was a Canadian carrier and because it is a Canadian registered aircraft.  (so a wet lease for a foreign operator would have some obligations as well)

As a Part 129 operator in the US, failure to respect ICAO obligations from the home state would be enforced by the FAA, as well as any additional US requirements.

Vs

[blues deville]

1 hour ago, anonymous said:

The QUIET BRIDGE approach is for non-FMS airplanes. Very unlikely that this was the flown approach, there is another version for FMS aircraft.

Some people in this thread really need to wind their necks in, especially the non-pilot(s) who seem to know all sorts of things...there is an on-going investigation and the facts and details will come out in time. 

 

I was in SFO last week. Daytime arrival. Approaches in use were ILS & RNAV 28L/R, and Quiet Bridge visual 28R.

[anonymous]

The ATIS will advertise the QUIET BRIDGE but the FMS equipped aircraft will be cleared for the FMS BRIDGE VISUAL....

[blues deville]

4 hours ago, anonymous said:

The ATIS will advertise the QUIET BRIDGE but the FMS equipped aircraft will be cleared for the FMS BRIDGE VISUAL....

So what approach does your SOP suggest you use from your data base? There are several offset approaches including this one.

 

[UpperDeck]

On 8/3/2017 at 11:02 PM, Vsplat said:

That's quite a post.  The question is actually one a criminal prosecutor would ask if the preceding statement is in fact found to be the case.

To be clear, failure to protect evidence of interest to federal investigators is an indictable offence.  Prison time for those convicted.

Take this for the honest advice that it is.  if  you have proof that individuals were notified but did nothing, and it sounds from your post that you know this to be the case, then you have knowledge of the commission of a crime and  this forum is not the place to share that information.  The RCMP is.

Vs

 

Vsplat.....You may be "over-stating" your position as was I when I presented assumption as " known fact".

That said, do you honestly believe that the flight crew went to the hotel in those early morning hours and promptly fell asleep with nary a thought to what had just occurred?

These were both experienced pilots. I ASSUME they each had more than one " go round" in their careers which were routine and not worthy of particular note. I of course exclude any which were necessitated by mechanical defect.

This missed approach was not routine. I do not know what finally triggered the go round....the UA pilot's call or the activation of the landing lights of the next aircraft or....but there must have been significant "pucker" in the AC cockpit.

There is a lot of discussion here about approaches, alignment and instrumentation but you will NEVER know what was said in that cockpit. How and why the event unfolded would at the very least be useful to other pilots. The CVR would have been a learning aid.

Returning to my "premise".....the pilots KNEW they overflew aircraft on the ground because they were over a taxiway and not the runway. Do you not think that at least one of them would appreciate the significance of that event? Would it not occur to ANYONE that the CVR MIGHT be relevant?

Personally, I think that as I laid there in that hotel room  re-playing the mental video over and over, I might consider immediately notifying the chain of command....and if I did so, I would anticipate that the person I contacted would do the same.

In that event, the pool of people who MIGHT appreciate the potential relevance of the CVR would be increased.

I understand that the recording cycle of the CVR is 120 minutes. Perhaps that is incorrect but if true, the CVR was not over-written until the next flight which I read was around noon that day.....ten hours later.

[Vsplat]

UD, every Canadian licence holder is trained and examined on their obligations in the event of a reportable offence.  Air Canada crews, like most air carriers I presume, have specific directions to follow in the event they believe they were involved in a reportable incident.   Failure to follow those directions exposes a crew to prosecution. 

Nothing about the regulations I posted is an over statement.  They are what they are, as posted.  Crew and company officials have been prosecuted for the very things you alleged in your initial post, to which I responded. 

That said, I have seen no public comment on the crew's follow up actions.  Perhaps they followed the prescribed follow up and some of the actions you feel should have been taken, were.  That will likely come out later.  As for the CVR, we don't know what maintenance the aircraft underwent during its time at the station or whether the CVR was recording for any of its time on the ground.  Some maintenance checks select it, others do not. 

As for the crew's perception of the event, as expected,  the crew did not continue the approach beyond the point they believed it was going bad.  IMO, understanding this event will hinge on what they perceived and when.  Perhaps it was the radio call, the landing lights, or something else.  Unknown at present.

What is important is that we now have public comment from the NTSB that the crew did, in fact, initiate the go around on their own and that the aircraft did, in fact, descend after GA was initiated, as was suggested early in this thread.   A low radalt reached while developing GA thrust and at the GA attitude is a very different risk scenario than an approach idle descent through the same place.

'pucker factor'?  not likely, simply due to workload.  The crew assessed, decided and executed within the span of a couple of seconds, then they were into the go around and preparing for another approach.  They might have reflected on the event at the hotel, but we cannot know their thoughts.

From the moment of selecting GA, the crew's focus would not be on ground traffic, but on executing the go around maneuver, a fairly high demand task with AP off, at night, with a significant pitch change initiated before the flight directors were fully restored.  Given the conditions and aircraft pitch attitude, I doubt they would have had any idea how close they did or did not get to the ground traffic. Most crews do not read the minimum radio altitude during that event and procedures do not place any focus on doing so.

BTW, knowledge of the commission of the violation of a federal statute without reporting it to an official is also an offence.  With the tendency for anyone to say whatever they feel like on forums, one can forget that freedom of speech is not unlimited.  My advisory was made in good faith as I said.  While I don't agree with everything that gets said here, neither would I like to see someone get hung up over it. 

FWIW

Vs 

 

 

[DEFCON]

Isn't an 'Incident Report' mandatory in these circumstances?

I'm not certain, but isn't the crew supposed to notify Ops immediately following a reportable incident?

 

 

 

 

 

[JL]

ICAO proposing 25 hour CVRs by 2021 and EASA has an NPA for 15hr minimum CVRs by 2019. L3 has 25 hour combined recorders on the A350 and 320neo  http://www.airbus.com/newsroom/press-releases/en/2017/06/airbus-launches-new-fixed-and-deployable-flight-recorders-for-it.html 

[Vsplat]

DEFCON, there are indeed mandatory reporting requirements.  I have not read anything saying the crew did or did not report as required. 

Keep in mind that crew perception of the hazard is central to this event.  It is possible the crew eventually considered themselves to be badly positioned as a result of the approach and so conducted a go around per SOP.   

As discussed a few pages ago, overflying the taxiway on a go around is not that unusual if the crew elects to side step.  The vertical separation from ground traffic would not likely be perceived by the operating crew during the go around, and may not have been gauged to be as close as the press depicts at present.   The changes in the NTSB updates reflect how spartan the data is, and that is in hind sight, with access to security cameras and airport surveillance radar.  Generally the crew in the moment has even less to work with.

So, presuming for the moment that the crew simply considered themselves to be badly positioned during the approach phase and initiated a go around per SOP, what would they have been obliged to report?  A go around is not a TSB reportable incident and the CVR is not quarantined in that circumstance.

All this to say, it is possible that everything was done correctly, based on what was understood at the time.  We won't likely know for some time.

Vs

 

[DEFCON]

Thanks Vsplat

"presuming for the moment that the crew simply considered themselves to be badly positioned during the approach phase and initiated a go around per SOP, what would they have been obliged to report?  A go around is not a TSB reportable incident and the CVR is not quarantined in that circumstance."

Understood, but if the incident became so alarming to aircraft on the taxiway that a query, or two was made to ATC regarding the perceived flight path of the 320 and one waiting crew even turned the landing lights on to alert the 320 crew, it's probably safe to assume the event was anything but a normal miss.

For the sake of safety I'm hoping there's a finding of fatigue, which should support / assist Canada's bid to finally update its 'flight / duty Regs .

I'm also hopeful the NTSB will let us know why and how long the FAA has known there's a 12 mile hole in the tower's radar coverage.

 

  

 

[blues deville]

Its clear now what happened during the first attempt at this approach. I'm curious what this crew did differently the second time around. I wonder if the NTSB asked that question?

 

[Vsplat]

I believe I read they were vectored to ILS 28R....

Vs

[mo32a]

2 hours ago, DEFCON said:

Thanks Vsplat

"presuming for the moment that the crew simply considered themselves to be badly positioned during the approach phase and initiated a go around per SOP, what would they have been obliged to report?  A go around is not a TSB reportable incident and the CVR is not quarantined in that circumstance."

Understood, but if the incident became so alarming to aircraft on the taxiway that a query, or two was made to ATC regarding the perceived flight path of the 320 and one waiting crew even turned the landing lights on to alert the 320 crew, it's probably safe to assume the event was anything but a normal miss.

For the sake of safety I'm hoping there's a finding of fatigue, which should support / assist Canada's bid to finally update its 'flight / duty Regs .

I'm also hopeful the NTSB will let us know why and how long the FAA has known there's a 12 mile hole in the tower's radar coverage.

 

  

 

How many times has this route been flown successfully with no go around? Is it a known "fatigue" flight? How many other carriers successfully fly this approach?

What duty time do other carriers have that make them less "fatigued"? 

[blues deville]

What is AC's procedure for flight crew and first time destinations?

My airline is quite strict with a monitored review of all monthly scheduled destinations. More complex ones require completing a quiz to ensure important details are reviewed. SFO falls into this category due to ATC, airport procedures and local terrain. 

 

[UpperDeck]

9 hours ago, Vsplat said:

UD, every Canadian licence holder is trained and examined on their obligations in the event of a reportable offence.  Air Canada crews, like most air carriers I presume, have specific directions to follow in the event they believe they were involved in a reportable incident.   Failure to follow those directions exposes a crew to prosecution. 

Nothing about the regulations I posted is an over statement.  They are what they are, as posted.  Crew and company officials have been prosecuted for the very things you alleged in your initial post, to which I responded. 

That said, I have seen no public comment on the crew's follow up actions.  Perhaps they followed the prescribed follow up and some of the actions you feel should have been taken, were.  That will likely come out later.  As for the CVR, we don't know what maintenance the aircraft underwent during its time at the station or whether the CVR was recording for any of its time on the ground.  Some maintenance checks select it, others do not. 

As for the crew's perception of the event, as expected,  the crew did not continue the approach beyond the point they believed it was going bad.  IMO, understanding this event will hinge on what they perceived and when.  Perhaps it was the radio call, the landing lights, or something else.  Unknown at present.

What is important is that we now have public comment from the NTSB that the crew did, in fact, initiate the go around on their own and that the aircraft did, in fact, descend after GA was initiated, as was suggested early in this thread.   A low radalt reached while developing GA thrust and at the GA attitude is a very different risk scenario than an approach idle descent through the same place.

'pucker factor'?  not likely, simply due to workload.  The crew assessed, decided and executed within the span of a couple of seconds, then they were into the go around and preparing for another approach.  They might have reflected on the event at the hotel, but we cannot know their thoughts.

From the moment of selecting GA, the crew's focus would not be on ground traffic, but on executing the go around maneuver, a fairly high demand task with AP off, at night, with a significant pitch change initiated before the flight directors were fully restored.  Given the conditions and aircraft pitch attitude, I doubt they would have had any idea how close they did or did not get to the ground traffic. Most crews do not read the minimum radio altitude during that event and procedures do not place any focus on doing so.

BTW, knowledge of the commission of the violation of a federal statute without reporting it to an official is also an offence.  With the tendency for anyone to say whatever they feel like on forums, one can forget that freedom of speech is not unlimited.  My advisory was made in good faith as I said.  While I don't agree with everything that gets said here, neither would I like to see someone get hung up over it. 

FWIW

Vs 

 

 

Vsplat....I'll take my chances with any consequences of the free exchange of opinions on this forum which I believe to be a valuable process.

I sense that you are somewhat constricted in your willingness to express an opinion. That could be for various and sundry reasons.

I have spoken with;  otherwise communicated with; and read the opinions of a number of commercial pilots regarding this incident. One particular aquaintance delayed his response to a question I posed until he had the opportunity to do a visual into SFO.

Will it surprise you to learn that you are one of the very few who have strived so hard to avoid ANY suggestion ( or even the realization!l) of fault on the part of the flight crew.

You state that the crew did not continue the landing once they realized it was "going bad" and initiated the go round "on their own".

In my opinion, that characterization is simply wrong. It strongly suggests a desire to exculpate. The crew specifically asked whether they were clear to land because there appeared to be traffic on the runway. AT THAT POINT....they were clearly not visualizing the active runway......and SA would suggest they initiate a go around.

They heard the UA radio reporting they were lined up to the taxiway or they saw the landing lights....or both...but look at the timing. It was then and only then that they initiated the go round and applied thrust. It is very improbable ( incredibly coincidental) that they did it " on their own".

You deny or dismiss the alleged " pucker factor". Really? You stand alone, sir. Everyone I have spoken to has said that in the same situation, there would have been a moment at least of significant clenching.

You have stated that you know of cases where crew and company were prosecuted where they knew of or were involved in a misapproach resulting from confusion between a taxiway and runway and yet failed to preserve the CVR. Could you please give me a reference? I confess that despite best efforts, I have been unable to come up with even ONE precedent.

[Vsplat]

UD,  I offered my comments in good faith.  Your response is, well, unfortunate. 

You clearly have no idea what I think, and your comments reflect zero insight into the function of the crew of 759. 

You seem to have a strong need to attack, filter and reframe comments into an invalid context. 

Finally, you seem to want the freedom to slander Air Canada employees and spread innuendo at will, up to and including your implication of violation of federal statues and destruction of evidence.  Your reply when reminded of the law, shown it in fact is that you'll take your chances and want to see who else has been convicted. 

 

Quote

'll take my chances with any consequences of the free exchange of opinions on this forum which I believe to be a valuable process.

If you want to act like a troll you will be disregarded as one.

Vs

 

[Guest]

Review complete.