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View Full Version : SFO Near Miss 28R


Mink
07-11-2017, 12:45 PM
Exclusive: Air Canada near-miss at SFO sparks FAA probe (http://www.mercurynews.com/2017/07/10/exclusive-sfo-near-miss-might-have-triggered-greatest-aviation-disaster-in-history/)

:eek:


C130driver
07-11-2017, 03:12 PM
This seems to happen more often than we would think. It could happen to any of us: add fatigue, lack of proficiency, maybe newly typed in the plane, etc. Just goes to show, never let your guard down. Even if flying a visual, always have a white/magenta/green (whatever you guys use) line to final. If there is an ILS, no reason not to use it as a backup. A localizer tuned up would have shown significant CDI deflection even a mile or two out from threshold as the pilot was lined up on the taxiway. I always brief the runway lighting if it is night or IMC so we both know what we are supposed to see when we break out of the goo.

Hawkerdriver1
07-11-2017, 03:41 PM
This seems to happen more often than we would think. It could happen to any of us: add fatigue, lack of proficiency, maybe newly typed in the plane, etc. Just goes to show, never let your guard down. Even if flying a visual, always have a white/magenta/green (whatever you guys use) line to final. If there is an ILS, no reason not to use it as a backup. A localizer tuned up would have shown significant CDI deflection even a mile or two out from threshold as the pilot was lined up on the taxiway. I always brief the runway lighting if it is night or IMC so we both know what we are supposed to see when we break out of the goo.

Great advice! With the frequency of serious errors that have already occurred, (wrong airports, etc), in just the last several years, I'm surprised that backup navigation has not already been "standardized" industrywide to mitigate these serious errors that just keep recurring. Does it require a catastrophe to effect industry change?


IDIOTPILOT
07-11-2017, 04:53 PM
The way that approach works and how the Airbus operates, you generally don't have back up nav.

FlyJSH
07-11-2017, 05:22 PM
This seems to happen more often than we would think. It could happen to any of us: add fatigue, lack of proficiency, maybe newly typed in the plane, etc. Just goes to show, never let your guard down. Even if flying a visual, always have a white/magenta/green (whatever you guys use) line to final. If there is an ILS, no reason not to use it as a backup. A localizer tuned up would have shown significant CDI deflection even a mile or two out from threshold as the pilot was lined up on the taxiway. I always brief the runway lighting if it is night or IMC so we both know what we are supposed to see when we break out of the goo.

All of that is great.

But I would add, if things look weird or the hairs on the back of your neck start to tingle, it is time to take a step back.

Listening to the radio calls, the Air Canada queries the tower about "lights on the runway" and asking to confirm landing clearance. It seems something isn't adding up to him.

At that point, it really doesn't matter who has erred. Maybe ground is crossing someone without regard to landing traffic, or a ground vehicle is lost, or we are lined up with the taxiway, it doesn't really matter because they all end in a bad way.

The point is when one gets that "this just don't feel right!" feeling, get to a safe place (in this case, go around) and do a reset. Don't continue when your gut says 'no'.

Adlerdriver
07-11-2017, 06:19 PM
The way that approach works and how the Airbus operates, you generally don't have back up nav.
:confused: You can't have the ILS in for the runway you are landing on?

IDIOTPILOT
07-11-2017, 06:33 PM
:confused: You can't have the ILS in for the runway you are landing on?

They were probably on the FMS Bridge Visual. You can't have the ILS and the RNAV data displayed on the PFD at the same time. There's no raw data RNAV lateral needle on the 320.

Mink
07-11-2017, 07:01 PM
They were probably on the FMS Bridge Visual. You can't have the ILS and the RNAV data displayed on the PFD at the same time. There's no raw data RNAV lateral needle on the 320.

So at the bridge, once the "Bridge Visual" part is done, have the PNF get out of RNAV and tune up / display the 28R localizer....?

threeighteen
07-12-2017, 05:29 AM
They were probably on the FMS Bridge Visual. You can't have the ILS and the RNAV data displayed on the PFD at the same time. There's no raw data RNAV lateral needle on the 320.

So the Airbus can't transition from an RNAV arrival/visual to an ILS?

IDIOTPILOT
07-12-2017, 02:45 PM
So at the bridge, once the "Bridge Visual" part is done, have the PNF get out of RNAV and tune up / display the 28R localizer....?

So the Airbus can't transition from an RNAV arrival/visual to an ILS?

I guess you could kinda do it this way but it wouldn't be SOP I think anywhere. I'm not sure what the FD would do if you only switched one side that low on the approach. You could put the raw data ILS into the MFD but you'd lose a lot of situational awareness. I think you're better off zooming in the MFD all the way and making sure it's over the line, especially with someone on the parallel.

I'm sure someone who's flown an Airbus more or tried something like this in the past could shed more light.

Std Deviation
07-12-2017, 02:59 PM
I'm sure someone who's flown an Airbus more or tried something like this in the past could shed more light.

We generally just look out the window at that point - in lieu of going heads down - and land on the concrete with the white lights like we did before the managed managed mode.:cool:

Saltlife85
07-12-2017, 05:21 PM
On the FMS bridge visual in the Airbus the FD will guide you all the way in on profile. No need to have the ILS up. IMO having the PM go heads down over the bridge and load up the ILS 28R is not all that safe, seeing as how they should be monitoring. But it could be done I guess. Not SOP at my airline.

threeighteen
07-13-2017, 01:31 AM
I guess you could kinda do it this way but it wouldn't be SOP I think anywhere. I'm not sure what the FD would do if you only switched one side that low on the approach. You could put the raw data ILS into the MFD but you'd lose a lot of situational awareness. I think you're better off zooming in the MFD all the way and making sure it's over the line, especially with someone on the parallel.

I'm sure someone who's flown an Airbus more or tried something like this in the past could shed more light.

How does one "lose situational awareness" by using a precision approach to back up a visual procedure?

On the FMS bridge visual in the Airbus the FD will guide you all the way in on profile. No need to have the ILS up. IMO having the PM go heads down over the bridge and load up the ILS 28R is not all that safe, seeing as how they should be monitoring. But it could be done I guess. Not SOP at my airline.

Why does the PM need to go heads down to load it up? Can't the ILS be preselected in a nav radio and then simply switch the nav source to it when crossing the bridge?

It's honestly blowing my mind that professional airline pilots are not using some sort of navigational backup to fly an approach into an airport that has super close parallel runways, especially at night.

Saltlife85
07-13-2017, 04:43 AM
Ok I see what your saying.. sorry. I guess you could "hard tune" the ILS in the RAD NAV page in the FMC. However, both pilots can't have both RNAV vertical guidance and the ILS displayed on the A319/320/321 series. You could have one on the RNAV and one on the hard tunes ILS. Its honestly something we just don't do on this approach because after all it is a visual approach. You usually have the runway in sight prior to the bridge. But if you were unfamiliar you would just keep following the FD's in until you know you had in sight. ( i.e. 500 ft on final)

Edit- it is a RNAV visual - so you can use the guidance from the FD's. No real need for a ILS backup as the RNAV lines you perfect for 28R after the bridge

vilcas
07-13-2017, 05:47 AM
I am surprised that you can visually confuse a Taxiway with a RUNWAY when the runway has ALSF-2 approach lighting system. Not only that the markings on a precision runway are extensive. I could see this error going into a smaller field with non precision runway and even then in visual conditions tough to comprehend. This is a good reminder to keep our basic skills sharp. I will wait too see what the official investigation has to say but doesn't look good.

abelenky
07-13-2017, 06:48 AM
All of that is great.

But I would add, if things look weird or the hairs on the back of your neck start to tingle, it is time to take a step back.

Listening to the radio calls, the Air Canada queries the tower about "lights on the runway" and asking to confirm landing clearance. It seems something isn't adding up to him.

At that point, it really doesn't matter who has erred. Maybe ground is crossing someone without regard to landing traffic, or a ground vehicle is lost, or we are lined up with the taxiway, it doesn't really matter because they all end in a bad way.

The point is when one gets that "this just don't feel right!" feeling, get to a safe place (in this case, go around) and do a reset. Don't continue when your gut says 'no'.


100% This. Absolutely.

The pilot clearly saw that something wasn't right, and asked for clarification.
The pilot should have gone around on his own accord until the situation was clearer.

The controller should have picked up on the pilot's uncertainty in the radio call, and double-checked everything.
The controller likely would've been able to recognize the bad lineup and put it together with the strange radio call, then called for a go-around sooner.

Basically, these guys knew something was wrong, but failed to actually process it and act on it.

Hawkerdriver1
07-17-2017, 02:28 PM
We have the option of including navigation overlays from different sources simultaneously with Proline 21. This allows us to have both active courses in Green from, say, GPS guidance & ground based course depictions as well; when we are in range of ground based facilities: ILS, LOC, LDA, SDF; depicted in blue....My own eyes have fooled me enough over the years to incorporate alternative positional awareness tools even on the clearest nights.

Truthanator
07-18-2017, 07:58 AM
More details are out. These guys flew over the top of two airplanes and below 100 (83?) feet. The height of a 787...55' 10".

28' from striking the 787 tail.

They were about 1-2 seconds..literally... from one of the worst aviation disasters in history.

Unbelievable.

WhiskeyDelta
07-18-2017, 08:21 AM
More details are out. These guys flew over the top of two airplanes and below 100 (83?) feet. The height of a 787...55' 10".



28' from striking the 787 tail.



They were about 1-2 seconds..literally... from one of the worst aviation disasters in history.



Unbelievable.



Wow...I was just talking to my captain about this last night wondering how close they got. Knowing these details it's a lot more serious than we realized.


Sent from my iPhone using Tapatalk

Adlerdriver
07-18-2017, 08:48 AM
Why does the PM need to go heads down to load it up? Can't the ILS be preselected in a nav radio and then simply switch the nav source to it when crossing the bridge?

It's honestly blowing my mind that professional airline pilots are not using some sort of navigational backup to fly an approach into an airport that has super close parallel runways, especially at night.
I'm confused about this as well. Is the Bridge Visual line selectable in the FMS as an approach or STAR (or neither)? i.e. if you select and activate it in the FMS, have you done that in lieu of another approach like an ILS?

Or is it like a STAR that you could tie (or leave a discon after) to the standard ILS to the runway?

Either way, a few key strokes (less than 6, I'm guessing) to provide a solid back up to a visual, especially at night is just good head work, IMO. Is that really going to preclude the PM from continuing to "M" way out over the bridge? Yes, it is "after all a visual" but that doesn't mean you have to ignore available tools and rely on only eyeballs and PAPIs on principle.

2StgTurbine
07-18-2017, 09:08 AM
One factor could be the approach lights for the runways. 28L has MALSR and 28R has ALSF-2. The approach lights to 28R are brighter and stick out more than 28L. The crew could have seen the lights for 28R and mistaken them for 28L and therefore shift over to the right. The lights of the airplanes on the taxiway could have added to the confusion.

I had a similar thing happen to me in IAD. Normally the far west runway (19R) is not used late at night, but this night they actually had the east runway (19L) shutdown. I was cleared to land on 19C, so I started to line up with the runway to the right of what I thought was runway 19L. Thankfully I noticed that the localizer was not matching where my brain thought I was and the other crew member pointed out my mistake and I was still 15 miles away.

nfnsquared
07-18-2017, 10:04 AM
From this video, really hard to see how they mistook the taxiway for 28R....

https://www.youtube.com/watch?v=rNMtMYUGjnQ

BMEP100
07-18-2017, 11:00 AM
SFO is run pretty fast and loose. It is another accident waiting to happen. Approach issues ambiguous clearances, uses non standard phraseology, and has an "attitude".

I have had two close calls there over the last 5 years, where controllers made serious errors, and tried to cover them up.

One was my takeoff clearance on 1 R , with freighter on 3 mile final,to 28r with no landing lights on. (Rejected takeoff)
Another was emergency braking rolling off the 28l high speed with a an RJ under ground control cleared across our path on "B"at the intersection.

To be fair, it seems they are under a lot of pressure to move metal and it is a difficult geographic environment.

My favorite theses days is the "clearance" to fly the FMS bridge visual, "except maintain 8000", especially when the weather is less than 6 miles vis.

Ya'll be careful, out there.

blastoff
07-18-2017, 12:37 PM
I'm confused about this as well. Is the Bridge Visual line selectable in the FMS as an approach or STAR (or neither)? i.e. if you select and activate it in the FMS, have you done that in lieu of another approach like an ILS?



The "FMS Bridge visual" is a selectable RNAV approach, complete with glideslope and horizontal guidance. You usually get cleared for it way out on the feeder route from the STAR or with "traffic in sight" if there's traffic on 28L. On the Airbus, having it up precludes using the ILS and vice versa...you could have the ILS in the secondary flight plan and then activate it fairly quickly...totally unnecessary as the RNAV guidance is sufficient.

blastoff
07-18-2017, 12:40 PM
Other than some rumors the day it happened, has it been confirmed 28L was closed (as SFO has been doing several days a week for the last few months)? To me the simplest answer is they didn't review the NOTAM'd runway closure and saw 28R and assumed it was the left (which would have been dark except for the flashing "X")

shfo
07-18-2017, 07:11 PM
SFO is run pretty fast and loose. It is another accident waiting to happen. Approach issues ambiguous clearances, uses non standard phraseology, and has an "attitude".

I have had two close calls there over the last 5 years, where controllers made serious errors, and tried to cover them up.

One was my takeoff clearance on 1 R , with freighter on 3 mile final,to 28r with no landing lights on. (Rejected takeoff)
Another was emergency braking rolling off the 28l high speed with a an RJ under ground control cleared across our path on "B"at the intersection.

To be fair, it seems they are under a lot of pressure to move metal and it is a difficult geographic environment.

My favorite theses days is the "clearance" to fly the FMS bridge visual, "except maintain 8000", especially when the weather is less than 6 miles vis.

Ya'll be careful, out there.

Tell them UBABLE, if need be. This past winter there were many days when the Metar was showing 14025G35KT but magically the ATIS was showing 20025KT so they could land 28s. This was also during heavy rains. If there is ever an accident due to incorrect info given there will be hell to pay.

C130driver
07-18-2017, 07:28 PM
More details are out. These guys flew over the top of two airplanes and below 100 (83?) feet. The height of a 787...55' 10".

28' from striking the 787 tail.

They were about 1-2 seconds..literally... from one of the worst aviation disasters in history.

Unbelievable.

Thank god the United 787 pilot (I believe) said something over the radio for everyone to hear leading to the tower to call the go around. Had the pilots realized their mistake even a second later and called their own go around, they may have very well collided in the reaction time of pushing the power up and arresting the descent.

Adlerdriver
07-18-2017, 08:04 PM
Tell them UBABLE, if need be.
I'm not sure that will have the desired effect. ;)

threeighteen
07-20-2017, 10:41 AM
More details are out. These guys flew over the top of two airplanes and below 100 (83?) feet. The height of a 787...55' 10".

28' from striking the 787 tail.

They were about 1-2 seconds..literally... from one of the worst aviation disasters in history.

Unbelievable.

wow, source?

Mink
07-22-2017, 08:19 PM
https://www.youtube.com/watch?v=ydUqfhNqUIc

Info from Flight Aware, according to the video.

mike734
07-26-2017, 10:31 AM
After watching the videos and listening to the ATC tapes, I fail to believe that the Air Canada crew would have continued to flare right into the line of aircraft waiting on the taxiway. There has to be something missing from this story.

rickair7777
07-26-2017, 01:44 PM
After watching the videos and listening to the ATC tapes, I fail to believe that the Air Canada crew would have continued to flare right into the line of aircraft waiting on the taxiway. There has to be something missing from this story.

They were certainly about out of time to execute a GA, whether on their own initiative or being told.

On a CAT-II you might bounce off the runway when doing a missed...they didn't have the luxury of getting anywhere near that low.

Something to think about...with another AC on the runway, you need his tail height + your alt lost while executing the GA + how far down your tail rotates when you pitch up. This one didn't seem that scary until you see how close they came.

Truthanator
07-26-2017, 02:03 PM
After watching the videos and listening to the ATC tapes, I fail to believe that the Air Canada crew would have continued to flare right into the line of aircraft waiting on the taxiway. There has to be something missing from this story.

It really does seem completely beyond belief, but multiple sources have reported they were directly over the first two aircraft on the taxiway.
The audio seems to verify that from one of the pilots.

Grumble
07-27-2017, 07:10 PM
After watching the videos and listening to the ATC tapes, I fail to believe that the Air Canada crew would have continued to flare right into the line of aircraft waiting on the taxiway. There has to be something missing from this story.

Believe it. They were only a few heartbeats away from being inside a wave off window that wouldn't result in contact. UA1 saved the day.

ptarmigan
08-02-2017, 12:38 PM
Here is an article on the topic in which I was quoted:

Did mental bias play a role in Air Canada's SFO near-miss? (http://www.mercurynews.com/2017/07/28/was-mental-bias-at-the-controls-of-air-canadas-near-miss-at-sfo/)

abelenky
08-03-2017, 08:34 AM
More details are out. These guys flew over the top of two airplanes and below 100 (83?) feet. The height of a 787...55' 10".

28' from striking the 787 tail.

They were about 1-2 seconds..literally... from one of the worst aviation disasters in history.

Unbelievable.

From NTSB Report (https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx)

... the minimum altitude recorded on the FDR was 59 ft agl.

I found the 787 tail height is 55' 6" (source (http://www.modernairliners.com/boeing-787-dreamliner/boeing-787-dreamliner-specs/)), meaning vertical distance may have been 3.5 feet.

And that does not even account for the landing gear!

Its likely the landing gear actually passed below the top of the tail of the United flight.

GogglesPisano
08-03-2017, 08:37 AM
One controller in the tower cab.

tennesseeflyboy
08-03-2017, 06:43 PM
The last time I flew into SFO using 28R on the bridge visual , we ended up in a TA/RA with a go around .......... that airport is a mess waiting to happen .........

rickair7777
08-04-2017, 08:27 AM
The last time I flew into SFO using 28R on the bridge visual , we ended up in a TA/RA with a go around .......... that airport is a mess waiting to happen .........

Yes! They used to assign a leader and a follower, which was way more comfortable than how they do it now, with airplanes passing you from behind, setting off RA's, etc. It's not really a great idea to fly airliners in close formation, we're not trained for that.

Flightcap
08-07-2017, 08:51 PM
From NTSB Report (https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx)



I found the 787 tail height is 55' 6" (source (http://www.modernairliners.com/boeing-787-dreamliner/boeing-787-dreamliner-specs/)), meaning vertical distance may have been 3.5 feet.

And that does not even account for the landing gear!

Its likely the landing gear actually passed below the top of the tail of the United flight.

...............

wat

:eek:

RI830
08-08-2017, 10:50 AM
...............

wat

:eek:

Imagine if we find out he straddled the 787 tail with his landing gear.

HuggyU2
08-08-2017, 10:53 PM
Did I miss it, or were they cleared the FMS Bridge Visual to 28R? Or the ILS?

EasternATC
08-09-2017, 02:30 AM
Did I miss it, or were they cleared the FMS Bridge Visual to 28R? Or the ILS?

The FMS visual.

rickair7777
08-09-2017, 07:10 AM
Did I miss it, or were they cleared the FMS Bridge Visual to 28R? Or the ILS?

The FMS visual.

The ILS is published on that chart. You can and should use it as a backup reference on final.

A306pilot
08-17-2017, 03:40 PM
The ILS is published on that chart. You can and should use it as a backup reference on final.

The Airbus doesn't let you do that.

rickair7777
08-17-2017, 03:51 PM
The Airbus doesn't let you do that.

Darn.
......

WhiskeyDelta
08-17-2017, 05:07 PM
https://www.flightglobal.com/news/articles/faa-changes-san-francisco-landing-procedures-after-a-440380/

ptarmigan
08-19-2017, 12:18 PM
The Airbus doesn't let you do that.

I am assuming this is a joke?

A306pilot
08-19-2017, 12:39 PM
The Airbus FMGS decides what the kit will tune depending on the approach selected. If you select an Rnav approach, that doesn't have an associated navaid then it will not tune the ILS. You can manually tune it but it will produce a warning to check approach guidance. It uses one button on the FCU to arm the approach guidance for the flight director.Airbus assume that when you go visual you will be looking out the window at the runway, not looking inside to check the guidance.

ptarmigan
08-19-2017, 04:32 PM
The Airbus FMGS decides what the kit will tune depending on the approach selected. If you select an Rnav approach, that doesn't have an associated navaid then it will not tune the ILS. You can manually tune it but it will produce a warning to check approach guidance. It uses one button on the FCU to arm the approach guidance for the flight director.Airbus assume that when you go visual you will be looking out the window at the runway, not looking inside to check the guidance.

That makes sense. Is the quiet bridge visual in the FMS database? I have not checked ours to see, but it would be the same on the Boeing, overall.

A306pilot
08-20-2017, 07:06 AM
I am European bus driver and we do not have KSFO in the database.

tomgoodman
08-20-2017, 08:08 AM
I am European bus driver and we do not have KSFO in the database.

Then that airplane will refuse to land at KSFO, even from a visual approach.
It will automatically go around and call you a nasty name. :D

UAL T38 Phlyer
08-20-2017, 10:39 AM
Then that airplane will refuse to land at KSFO, even from a visual approach.
It will automatically go around and call you a nasty name. :D


A8yjNbcKkNY

galaxy flyer
08-20-2017, 07:28 PM
I believe the Airbus all-purpose nasty name is "Retard, Retard". :D

GF

worstpilotever
08-23-2017, 11:20 PM
I believe the Airbus all-purpose nasty name is "Retard, Retard". :D

GF

Only on the short bus.