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SFO Incident


UpperDeck
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We also don't know if in fact the crew started a go-around prior to the tower instruction to do so. The call to ATC only happens when the go-around is established and as Vs has said, that doesn't happen instantaneously. There is more unknown about this incident than what is known. Personally, I'm waiting for the facts before passing any judgement at all.

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11 hours ago, Vsplat said:

30 metres is being cited, source still unknown, but let's assume for the moment it's correct.  For argument's sake, let's do the same for the quarter mile number that is floating around,  although I am unclear if that is the point the tower called go around or the point at which minimum altitude was reached.  The answer would make quite a difference.

One has to be very careful when numbers start getting passed around.  It's too easy to create a context that is not accurate and go from there.  I read this morning, someone saying 'these guys really intended to land on that taxiway' based on the number and the distance down the taxiway.  He started with two numbers, reference above assumption, and added an unfounded opinion about the crew's intent. That package starts to make the round, already skewed. Listeners will assign the same weight to the facts and the new opinion. 

So here's the thing about those numbers:   The minimum height during a go around is not the point at which the crew aborts the approach.  Once the decision to go around is made, the aircraft will fly a predictable "U" shaped profile, including a short phase of continued descent.

For engines of the type used by the Airbus, the lag between selecting TOGA thrust and engine response can be 8 seconds.  During that time, assuming the aircraft was on or close to their approach speed, there would be insufficient energy to commence a climb, so the aircraft continues to descend during spoolup, despite the pitch change, as they are still in a very high drag condition.  Once the engines are developing power and the aircraft gets a positive rate of climb , the process of gear retraction increases total drag for up to 18 seconds for this aircraft type, which can translate to a lot of track distance at approach speed.  The aircraft is not descending during this phase, but it can really flatten the profile.

All that to say, the aircraft may well have gotten as close as cited, but if it was already at go around thrust and in the go around attitude, the risk of a collision would be vastly lower.  I can easily believe a profile where go around was called at or before the 'threshold' of the taxiway but the aircraft did not actually start climibing away for another quarter mile.

With disclaimers that all of the above is just my opinion, trying not to distort or add to what is actually known about this flight.

Vs

vsplat....

Didn't really need the entire post to respond but.....

I intend no disrespect when I suggest that you are responding to detail rather than exercising a macro perspective.

I " understand" your observation about the curve between command and effect but you do not address the primary issue; by any reasonable assessment, the aircraft was not where it should have been.

On what do I base that assertion?

1. The statement by operating flight crew of the observation of lights on what they thought was the runway.

2. The remark by pilots on the ground that the aircraft was aligned to the taxiway. They were there! They knew what they were seeing!

3. The direction by ATC to reject the landing.

And so....if the aircraft was not where it was supposed to be....why?

The regrettable fact is that humans err and by all appearances, two pilots erred in this case with almost incredibly disastrous consequences.

I fully understand and sympathize with the desire to " avoid judgment" or to seek out and adopt explanations such as fatigue.

But...all of you pilots.....be honest. You are NOT saying; "there but for the grace of god...." and that is because you believe ( rightly or wrongly) that someone screwed up and YOU would never make such a  mistake.

 

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1 hour ago, UpperDeck said:

vsplat....

Didn't really need the entire post to respond but.....

...

But...all of you pilots.....be honest. You are NOT saying; "there but for the grace of god...." and that is because you believe ( rightly or wrongly) that someone screwed up and YOU would never make such a  mistake.

 

UD, two things:

1) Read the entire post before you start to infer from it.  Had you done so you would have perhaps realised I was not defending the pilots or even suggesting they were where they ought to be.   I was trying to stop the slide of innuendo about what would happen next based on a coordinate.  Ironic that you closed with exactly that, innuendo and extrapolation.

2) Your comment regarding 'all you pilots' is simply bizarre.  Do you really believe you know the minds of all pilots?  To infer that we are somehow dishonest because we don't subscribe to your theory about what we are thinking is out there.  Really out there.

Next time, do yourself and the others here a favour.  Before you rush to judgement, consider whether you've missed the point of the poster in your sights, as you have in this case.   And perhaps skip the mind reading part.

Vs

Edited by Vsplat
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22 hours ago, Vsplat said:

30 metres is being cited, source still unknown, but let's assume for the moment it's correct.  For argument's sake, let's do the same for the quarter mile number that is floating around,  although I am unclear if that is the point the tower called go around or the point at which minimum altitude was reached.  The answer would make quite a difference.

One has to be very careful when numbers start getting passed around.  It's too easy to create a context that is not accurate and go from there.  I read this morning, someone saying 'these guys really intended to land on that taxiway' based on the number and the distance down the taxiway.  He started with two numbers, reference above assumption, and added an unfounded opinion about the crew's intent. That package starts to make the round, already skewed. Listeners will assign the same weight to the facts and the new opinion. 

So here's the thing about those numbers:   The minimum height during a go around is not the point at which the crew aborts the approach.  Once the decision to go around is made, the aircraft will fly a predictable "U" shaped profile, including a short phase of continued descent.

 

Vs

I believe your response to my last post to be " overly aggressive" and intentionally insulting which is unfortunate.

I believe the above portion of your post to which I was responding conveyed the substance of your message; 30 metres should not to be taken as the distance at which there was a response. However, that is tied in to your assertion that one should also not use that measurement in support of a conclusion that " these guys really intended to land on that taxiway".

My response which generated " read the entire post " etc was to note additional factors to the minimum height above the departing aircraft. That was all.

My "way out there" remark was to invite pilots to question themselves. I do not think that was beyond the pale. Whether one is a pilot, doctor, police officer or indian chief, there is a natural tendency to " close ranks" and seek out justification for actions that appear " at first blush" to be questionable.I do not believe that it will take much effort to establish that studies indicate that individuals reveal a different perspective when questioned at a personal level; " Would you do this?". One study was of police officers and the discharge of firearms. A remarkably high percentage of officers stated that in the hypothetical, the use of force was justified. However, the inverse was true when asked whether they would have used that degree of force.

I suggest that my remark was not " bizarre" but rather a legitimate invitation.

You don't agree. I respect that. I don't have any need of validation by concurrence and certainly don't feel that insult is necessary to emphasize a contrary opinion.

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On 2017-07-11 at 3:01 PM, the hammer said:

Quote:

" ACA759 had overflown Taxiway C for approximately 0.25 miles when ATC instructed the
aircraft to go around. Four aircraft were positioned on Taxiway C at the time of the event. It is
estimated that ACA759 overflew the first two aircraft by 100 feet, the third one by 200 feet and the
last one by 300 feet. The closest lateral proximity between ACA759 and one of the four aircraft on
Taxiway C was 29 feet. The NTSB is investigating."

I'm not sure that the NTSB will have much to go as the incident was 3-4 days earlier. I assuming that the aircraft was departing early the next morning and if it flys 10-12 hours a day the FDR would be overwriting the go-around time so there would be no info to capture.

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11 hours ago, Vsplat said:

UD, two things:

1) Read the entire post before you start to infer from it.  Had you done so you would have perhaps realised I was not defending the pilots or even suggesting they were where they ought to be.   I was trying to stop the slide of innuendo about what would happen next based on a coordinate.  Ironic that you closed with exactly that, innuendo and extrapolation.

2) Your comment regarding 'all you pilots' is simply bizarre.  Do you really believe you know the minds of all pilots?  To infer that we are somehow dishonest because we don't subscribe to your theory about what we are thinking is out there.  Really out there.

Next time, do yourself and the others here a favour.  Before you rush to judgement, consider whether you've missed the point of the poster in your sights, as you have in this case.   And perhaps skip the mind reading part.

Vs

http://www.newyorker.com/magazine/2017/02/27/why-facts-dont-change-our-minds

"Confirmation bias" and shared beliefs within social groups.

By the way....1) no rush to judgment because no judgment. Unqualified to make judgment and certainly, not enough facts; 2) no one " in my sights". Don't have any desire to aim at anyone or anything; 3) not a mind reader .....see linked article.

An open mind might give rise to horrific fears but offers limitless possibilities.

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Well...well, a few at it again.....another cat-fight :P

What I find amazing is that there is a great reluctance to call a spade, a spade and it is certainly not that pilots are bizarre, but rather that pilots are human. 

This entire incident appears to be purely "pilot-error" ...there I said it....... based  purely on all that I have read in this thread, the drivers of that aircraft made a mistake.....an "error".................no one hurt,(except pride), no damage and that should be the end of it.

The incident is merely a learning tool for others and a lesson learned about doing "visual" approaches.....at night...at a high density airport.

Those that can not see that this incident was a pilot error, albeit minor, have failed to consider all the other hundreds of aircraft that have done the same approach to that specific runway and not made that "error".

Have nice weekend  (at anchor, in the sun and enjoying life):D

 

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2 hours ago, Kip Powick said:

Those that can not see that this incident was a pilot error, albeit minor...

Minor? What frightens me about this is that the pilots only aborted the landing after being told to go around by ATC...and ended up 100 feet from crashing into the aircraft on the taxiway. How much longer were they going to proceed had ATC not ordered them to go around? It would seem like only a few more seconds into their approach and they wouldn't have had the time to do so successfully. They saw the lights, reported them, were told there was nobody on the runway, and yet they continued the approach right into/onto the lights that they saw in front of them until the last possible second when ATC told them to go around.

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2 hours ago, moeman said:

Minor? What frightens me about this is that the pilots only aborted the landing after being told to go around by ATC...and ended up 100 feet from crashing into the aircraft on the taxiway. How much longer were they going to proceed had ATC not ordered them to go around? It would seem like only a few more seconds into their approach and they wouldn't have had the time to do so successfully. They saw the lights, reported them, were told there was nobody on the runway, and yet they continued the approach right into/onto the lights that they saw in front of them until the last possible second when ATC told them to go around.

Moeman....

One of the points made above is that without further analysis, we don't know whether or not the "go around" was initiated before or only upon the directive of the ATC. In other words, the pilots may have heard the ATC reply to the inquiry about runway lights AND the observation by the pilot on the ground and have initiated the procedure before the ATC directive. My " friend" VSPLAT has noted that the aircraft would have continued its descent as the engines spooled up in response to the thrust command.

Regardless, most agree the aircraft was not where it was supposed to be.

And thank God that the potential was never realized!

 

 

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I'm not sure which Airbus he's referring to but the A330 in landing configuration (as they would have been) goes around with no perceptable delay. An 8 second response would only be from engines at very low power. That sort of delay would mean every Cat2 go-around would bounce - they don't.

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23 minutes ago, UpperDeck said:

Moeman....

One of the points made above is that without further analysis, we don't know whether or not the "go around" was initiated before or only upon the directive of the ATC. In other words, the pilots may have heard the ATC reply to the inquiry about runway lights AND the observation by the pilot on the ground and have initiated the procedure before the ATC directive. My " friend" VSPLAT has noted that the aircraft would have continued its descent as the engines spooled up in response to the thrust command.

Regardless, most agree the aircraft was not where it was supposed to be.

And thank God that the potential was never realized!

 

 

This was in one of the articles written about the incident, which is what I was basing that on. But whatever the case, it's disturbing that the pilot waited until the last possible moment to abort. Had he waited any longer...

Quote

Below is a transcript of the conversation between the tower and pilots in the air and on the ground.

AC759: "Tower, just want to confirm. This is Air Canada 759. We see lights on the runway there. Across the runway. Can you confirm are we cleared to land?"

SFO TOWER: "Confirmed cleared to land. Runway 28 Right. There's no one on 2-8 Right but you."


The sfo runway has a series of very bright lights which help identify the runway, never to be mistaken with a taxiway which has dim lights.

As the pilot of the Air Canada plane appears to be moving toward the taxiway, another pilot alerts the tower.

"Where's this guy going? He's on the taxiway," the other pilot said.

That's when the SFO tower ordered Air Canada to abort the landing and go-around.

SFO TOWER: "Air Canada, go around."

AC759: "Going around. Air Canada 759."

SFO TOWER: Air Canada looks like you were lined up for Charlie there. Fly heading 280. Climb maintain 3,000."

AC759: "Heading 2-8-0, 3,000 Air Canada 759."

 

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UD first raised the point and KP seconded; the visual to 28R has been flown by thousands of other crew without similar incident.

Blues questioned the apparent lack of back up electronic flight guidance ... a very big question in need of an answer!

thor raised the possibility the CVR & FDR data may have been lost, which would be sad, but the same camera that captured the Korean 777 crash may have useable footage that'll assist to some degree? 

mo32a questioned fatigue; "if they were too tired to perform their duties they shouldn't have been flying". I didn't rush fatigue out as an 'excuse' for poor a result, but do you really think the crew would have truly known they were TOO fatigued to safely complete the flight 6 hours earlier? This incident may end up providing the kind of impetus the new fatigue rules need to finally come into force?

I think it's pretty obvious at this point that the crew erred in one, or more ways, but that is not where the story ends. Investigations are supposed to answer the 'how did it happen' question. If we assume (never a sound policy) the crew was technically competent and weather, equipment & infrastructure were obvious non - factors, impairment by fatigue stands out as the logical first place to look for answers imo.

 

 

 

Edited by DEFCON
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I had not heard the comment from SFO tower about "Looks like you were liked up for Charlie". Some news reports have left that line out. To me it confirms they were not seeing a clear picture of their landing runway.

Not quite sure how this should be classified (non, minor, major) but it could have been a serious event. A further delayed attempt at a G/A might have made some contact between wings and tails. However, the tower controller didn't seem too phased when he added "we will talk to you again". 

Blues deluxe is booked into SFO for next week and I feel confident there won't be any issues at this airport again. 

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Even though things worked out favourably this time, the potential consequences were so horrific it's near impossible to imagine the incident being classified as 'minor' ... just mho.

 

 

 

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I can't help but wonder if one or both of these pilots had landed at SFO many times before and, given that they were supposed to land on 28R, they lined up with the "runway" on the right like they would normally do but missed/forgot that 28L was closed.

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Re... 100 feet... when they landed on the return, they were probably much closer to the traffic on the taxiway than 100 ft... wingtip to wingtip, and at the same altitude. It was unfortunate that a retired pilot possibly trying to make a name for himself as a consultant made such a big deal about the potential. Clearly anyone looking out the window would not continue to descend into aircraft illuminated by the landing lights.

AvHerald reports that they went around from about 400 ft. So why did they continue to descend to as low as 100 ft? The A320 just about jumps through the roof when thrust is advanced to GA. But, the acceleration from the power increase would give the seat-of-the-pants impression of climbing very steeply and might actually result in the pilot pushing forward. This phenomenon happened in a go around at CDG or ORY a couple of years ago and the Rostov B-737 crash last year. 

There is some apparent loss of situational awareness, maybe lack of CRM, maybe fatigue and maybe a couple of other threats that happened to come together to make this happen. Ultimately, general airmanship saved the day. 

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"A further delayed attempt at a G/A might have made some contact between wings and tails."

If the 320 went directly over and as close to the ac holding on taxiway C as the story line suggests, even as little, or as much as one further second of delay in GA initiation would have produced a very poor outcome.

"the acceleration from the power increase would give the seat-of-the-pants impression of climbing very steeply and might actually result in the pilot pushing forward"

That's an interesting consideration.

"Ultimately, general airmanship saved the day."

If you're referring to the call from the AC crew to ATC querying their visual interpretation of the runway / landing environment and the American crew that questioned the position of the 320, I would agree; I think it was the observations of both crew that alerted ATC to an accident in the making, which resulted in the intervention that may have saved the day?

"Re... 100 feet... when they landed on the return, they were probably much closer to the traffic on the taxiway than 100 ft... wingtip to wingtip, and at the same altitude"

Not likely at all; I think someone would have to be on the grass to get that close to another ac.

 

 

 

 

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On 2017-07-14 at 9:29 PM, UpperDeck said:

But...all of you pilots.....be honest. You are NOT saying; "there but for the grace of god...." and that is because you believe ( rightly or wrongly) that someone screwed up and YOU would never make such a  mistake.

 

As a former aircraft accident investigator, I firmly believe that pilots (all or almost all or most - I'm not sure which) routinely judge other pilots' accidents or near-accidents as screw-ups.  They tend to be quite unmerciful.  They do this for their own peace of mind.  Once they've judged others' errors or omissions, they can reassure themselves that they're safe.  There's no way that they will fall into that trap.  The up side is that they actually do mentally file away the error or omission and do what they can to avoid repeating it.

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1 hour ago, canadairguy said:

As a former aircraft accident investigator, I firmly believe that pilots (all or almost all or most - I'm not sure which) routinely judge other pilots' accidents or near-accidents as screw-ups.  They tend to be quite unmerciful.  They do this for their own peace of mind.  Once they've judged others' errors or omissions, they can reassure themselves that they're safe.  There's no way that they will fall into that trap.  The up side is that they actually do mentally file away the error or omission and do what they can to avoid repeating it.

Forgive me, Canadair if I am being obtuse but I take from the above post that you agree with "me"; that is, the portion of the post quoted. Am I mis-understanding?

I put "me" in quotes because as indicated in subsequent posts, this was not an "original thought" but my attempt to summarize my understanding of some literature on how we individually react to the misfortune of others.

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