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NTSB report on Air Canada at SFO


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My daughter had a volleyball coach from Taiwan who used to tell her team after a close game win “sometime lucky better than good”.

https://www.mercurynews.com/2018/05/02/video-new-shocking-sfo-footage-shows-just-how-close-air-canada-plane-came-to-landing-on-four-aircraft/

Edited by blues deville
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4 hours ago, Kip Powick said:

An uncomfortable read....

The FO’s airline record has now been released to the world news media, however, not too many details about the guy who was in charge and actually flying the plane? 

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Wow.  Is this the usual sort of information release for NTSB investigations?  I've never seen anything like it.  They've published everything; the entire flight release, the Captain's entire training record, sections from the ACPA contract, sections of the AOM, the route briefing notes, the threat briefing card, written statements (with names) from other pilots, the crew interviews, the controllers statements, FDR analysts, ATC statements, etc, etc.

Edited by seeker
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1 hour ago, seeker said:

Wow.  Is this the usual sort of information release for NTSB investigations?  I've never seen anything like it.  They've published everything; the entire flight release, the Captain's entire training record, sections from the ACPA contract, sections of the AOM, the route briefing notes, the threat briefing card, written statements (with names) from other pilots, the crew interviews, the controllers statements, FDR analysts, ATC statements, etc, etc.

Agreed I have never seen this much detail and personal information in an NTSB document.  Two items that standout for me was despite the FMS Bridge Visual for 28R why wouldn't the ILS/LOC be turned for "reference" and the fact that there was 1 tower controller on duty for TWR/GRD at SFO with this runway configuration is absolutely egregious.

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25 minutes ago, Johnboy said:

Agreed I have never seen this much detail and personal information in an NTSB document.  Two items that standout for me was despite the FMS Bridge Visual for 28R why wouldn't the ILS/LOC be turned for "reference" and the fact that there was 1 tower controller on duty for TWR/GRD at SFO with this runway configuration is absolutely egregious.

No shortage of information. It appears the NTSB have done a thorough review of the event and the pilots involved answered all questions to the best of their abilities. 

Regarding the one controller duty issue, SFO isn’t the only airport. I haven’t done any lately but I do recall many after midnight arrivals across Canada (and US) that were often handled by the same controller on tower and ground, YYZ being one of them. 

However, at SFO on the night in question with a main runway closed, non-standard taxi routes and lots of late night arrivals/departures, the controller on duty was extremely busy. From the NTSB report he may have been broadcasting on both tower and ground so lots of continuous chatter on the radio. If not for the comments from the UA flight waiting to depart, this event might have turned out differently.  

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I don't know what purpose the NTSB is trying to serve by putting the names out in public view. 

With that information in play, please try to keep in mind that speculation and comments here can now be picked up by a 'guest' with minimal understanding and any sort of agenda - the impacts will be felt by real people.  Another day, another airport, under a wide range of circumstances,  any number of us could end up in their shoes.

Keep a thought for these pilots and their families. 

Vs

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Double WOW !!!

I have never read a report, made available to the public, with so much personal and, I would think, confidential information. 

I would have thought a final report with much less "personal" information would have been sufficient. 

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21 minutes ago, Vsplat said:

I don't know what purpose the NTSB is trying to serve by putting the names out in public view. 

 

Yes, very odd.  Not only the names of the crew but the names and statements of pilots in other aircraft.  I can tell you that if I gave a statement, as an outside observer, regarding an incident I witnessed I would not expect it to be published in full with my name for public consumption.

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Quite frankly I'm disgusted by the NTSB's release of personal information. I've spent time with NTSB Chairman Robert Sumwalt on a few occasions and would never have imagined he'd allow such a thing under his watch. He always struck me as someone who believed in the principal of, "It's about what's right, not about who's wrong".

IMHO, unions like ACPA and ALPA should be calling them out on this.

Edited by J.O.
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 Ridiculous to release so much personal information, which with an eye to trying to mitigate future risk is truly irrelevant. 

 My question would be, would the personal data be released in a similar manner had it been United or Delta? 

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4 hours ago, seeker said:

Wow.  Is this the usual sort of information release for NTSB investigations?  I've never seen anything like it.  They've published everything; the entire flight release, the Captain's entire training record, sections from the ACPA contract, sections of the AOM, the route briefing notes, the threat briefing card, written statements (with names) from other pilots, the crew interviews, the controllers statements, FDR analysts, ATC statements, etc, etc.

Forewarned is forearmed. Do not live under some illusion that Canada’s privacy laws are portable to foreign jurisdictions.

And on another note - why would anybody believe that their technical records are private? And any ACP or training Pilot that has had their assessment or comments challenged knows that they are accountable for everything they record.

This should be an eye opener for those operating internationally about transparency.

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34 minutes ago, SMP said:

 Ridiculous to release so much personal information, which with an eye to trying to mitigate future risk is truly irrelevant. 

 My question would be, would the personal data be released in a similar manner had it been United or Delta? 

I would say 'yes' and the same level of detail is available for the 2013 Asiana flight at SFO.

A much more serious event and it is certainly evident from investigation and information provided by the NTSB's report.

 https://dms.ntsb.gov/pubdmss/search/hitlist.cfm?docketID=55433&CurrentPage=1&EndRow=15&StartRow=1&order=1&sort=0&TXTSEARCHT

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Interesting that the Captain commented that moving map display on approach was not particularly assistive as aircraft was non-GPS equipped and therefore position accuracy was not assured.

This would be the second AC incident where non-GPS status may have been a contributing factor. YHZ aircraft had no EGPWS capability.

I understand that AC has reversed its decision on HGS for the MAX fleet and it will now be installed. Perhaps a deliberate shift to enhanced optional equipment configuration where available.

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30 minutes ago, Vsplat said:

Thanks blues.  I was just looking that up myself. 

Does anyone know if a similar level of disclosure is inflicted on US crews, or is this special treatment for foreign operators?

Vs

Here is a link to the UPS crash in Birmingham////////

Looks like they do the same thing, (publish personal data ) about the crew in USA as well..

https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1402.pdf

 

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I've never believed names were relevant to the public interest.

Anyone remember Dryden? Almost anyone that had anything to do with the crash had their names published and in many cases, especially crew, all sorts of very personal information was revealed.

I remember too when the contents of voice recorders was supposed to be confidential, but a lot of those often final conversations are somehow leaked / released.

 

 

 

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What???

Why would you suggest that lawyers should bear blame? For what?

I never cease to be amazed at the willingness to point the finger at lawyers without regard to the fact that the lawyer is retained by a client--- a member of the public--- to represent an interest. And how many of those who wield that accusatory finger themselves rush to obtain representation or seek advice at the first sound of alarm?

Hmmmm. Does the above sound defensive?

 

Now read all of the posts above decrying the dissemination of information about involved individuals. Does the public not have an over-riding interest in complete disclosure? " But they won't understand!!" Well...if those who DO have the requisite knowledge and experience to understand are the final arbiters on what information is disclosed to the public---- the public won't know much, will they?

I suppose the words of Vsplat are telling---- be cautious what you say lest a " guest" use that gleaned information.

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UD

"Does the public not have an over-riding interest in complete disclosure? "

Yes, I feel full disclosure is absolutely necessary, but only because the names etc. must be included in the official record.

On the other hand, I can't imagine how the disclosure of personal information serves the public good?

I might feel better about the release of personal information if the media wasn't so prone to abusing it.

Maybe you could explain why it's illegal for the media to publish, or pass on the names of young offenders when the victims and locals know who the little puke is and are free to forward all relative information as they see fit?

If the same sort of rules applied to aviation, I think insiders would feel better overall.

 

 

 

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Ask yourself why the NTSB releases pilot personal data when the TSB does not. Both agencies claim that their mandate is advancing safety without apportioning blame, why does one protect the personal information of the crew when the other does not? It’s not unreasonable to infer that the American propensity to sue is at least partially responsible. The very idea of non-punitive investigations is foreign to the legal industry, especially south of the border. Gotta have someone to sue, even when a human error was made in a challenging environment.

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