Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]
ntsb.gov
ntsb.gov
The crew may have caught the closure of 28L and planned better with a review of NOTAMS before top of descent and including them in the approach briefing.
When I'm up there, and sleepy, I ask for a coffee and pull out the NOTAMS for one last look before we pull up the approach in the computer, manually set up the radios, and do the briefing.
On final approach, more precise ground based monitoring would be nice to have in case things are fubar in the plane.
I guess I'm surprised that it took so long for the pilots to see that there were other planes where they were landing.
Is it routine to keep binoculars in a cockpit? Could they have seen what was on the ground sooner if they'd looked through binoculars briefly (after noticing unexpected lights?)
The night of the accident, the left runway was closed and lights were turned off.. and they were expecting two runways and to land on the one on the right. There's still no excuse for this happening with two ATP-rated pilots that have done this type of landing thousands of times, but you can kinda see how it is possible at least.
This also isn't unheard-of. For example, Harrison Ford had a similar issue where he landed his private plane on a taxiway at an airport with parallel runways.
Small airports or bad weather at night are a different story - I would not fly into a new airport the first time in those conditions. Think 10x - 100x the risk.
Binoculars might be ok for the non-flying pilot to use, as long as he doesn't drop them on the floor and bind any rudder pedals.
At this point yes. There is a saying that "FAA regulations are written in blood" as a result.
It seems conservative on the surface but at this point the current system is incredibly safe and making changes without clear huge upsides isn't worth the risk of unintended consequences.
Pilot attention is at a premium during landing. The computer shouting "localizer" at you during an approach because you're misaligned might be the straw that breaks the cognitive burden's back while you're trying to deal with another crisis.
Making NOTAMs and the like more clear just seems like good design. They should certainly be able to prioritise information or only show what is relevant for a particular flight/aircraft/location/approach so you only have to read 3 things instead of 50.
!SFO 06/079 SFO OBST RIG (ASN 2017-AWP-3368-NRA) 373740N1222224W (0.5NM NE SFO) 41FT (34FT AGL) FLAGGED AND LGTD 1806201400-1811010100
This is a flagged and lighted obstruction half a mile way that is 34 feet above ground level.
Now put in a full route and takeoff airport and maybe if you have had some stops during the day. The NOTAM seems a bit long. Then if are overseas and have to deal with the BS political notams. Check out greece and turkey notams.
...THE REF (B) TURKISH NOTAM A3009/16 LTAAYNYX (111139 EUECYIYN JUL 2016) HAS NO GROUND, CANNOT PRODUCE ANY INTERNATIONALLY LEGAL EFFECT WITHIN ATHINAI FIR/ HELLAS UIR AND IS CONSIDERED NULL AND VOID.
I'm curious how many pilots fully read all NOTAMs, locate them geographically to understand where they are etc etc on every flight.
I was doing simulated flights over the continental US recently. Even small airports may have a lot of NOTAMs. Some are important (for instance, warning about objects close to some parts of the runway, or issues with a runway, or even animals or birds), but many others are completely useless.
Noise abatement restrictions ironically add a lot of NOTAM 'noise'. There should be a separate category for these, as these are not safety related.
THE REF (B) TURKISH NOTAM A3009/16 LTAAYNYX (111139 EUECYIYN JUL 2016) HAS NO GROUND, CANNOT PRODUCE ANY INTERNATIONALLY LEGAL EFFECT WITHIN ATHINAI FIR/ HELLAS UIR AND IS CONSIDERED NULL AND VOID.
vs
The ref (B) Turkish NOTAM A3009/16 LTAAYNYX (111139 Euecyiyn Jul 2016) has no ground, cannot produce any internationally legal effect within Athinai FIR/Hellas UIR and is considered null and void.
Have a one-hour watch to understand what kind of beast you are wrestling here: https://media.ccc.de/v/31c3_-_6308_-_en_-_saal_1_-_201412281...
good luck with changing hundreds of established,
life-or-death-systems, most of them actually
embedded in planes
Of course IMHO a mere change of case doesn't go far enough.
Turns out that people type what they want and the parser ended up needing to be almost a full AI. The exclusion zone around DC is a nightmare to parse for example.
That said there is some traction around this. And some interesting alternative takes (https://opsfox.net), which have their own problems.
It's interesting to listen to the radio chatter for this near-miss [1]. The air traffic controller misses a few chances to notice that something isn't right but when the pilot on the taxiway says in plain English, "Where's this guy going? He's on the taxiway" the problem immidately becomes obvious.
Keep in mind that these four planes were preparing for take-off, meaning that they were fully fuelled...
I work on an avionics product that's designed to prevent this exact scenario. We use the aircraft's position along with a database of runways and taxiways to determine if the aircraft is approaching the runway the pilot intends. If we determine the aircraft is landing, we issue a visual and aural alert to the pilot ("TAXIWAY LANDING" or "NOT A RUNWAY").
There's another runway (I don't remember where) where the direction in our database does not match what satellite imagery shows. I don't work in the database group but I was told that this can only be fixed by asking the airport manager to re-survey the runway. Short of that, we can't fix it even if we know it's wrong.
However, It's quite rare for them to be due to a database that's out of date -- most of the time it's due to an incorrect determination that the aircraft is taking off or landing.
We use inputs like GPS position, ground track, ground speed, altitude, and a phase-of-flight state machine that's determined for individual aircraft. This allows us to tailor the criteria for determining if the aircraft is landing for different aircraft. For some, we use throttle and landing gear position and others we use speed and altitude above the landing airport.
As for accuracy, we have minimum levels of GPS figure of merit where there's enough certainty to issue alerts. I don't remember the number off the top of my head, but in the US WAAS has made GPS quite accurate.
For this particular system, the alerting threshold is only met when we've determined that the aircraft is "landing". As I mentioned in another comment, I'm vague about this point because it depends on the way the aircraft manufacturer has configured this state machine. Sometimes we use throttle position, altitude, speed above Vref, gear position, height above threshold, etc. You're correct that conditions can slightly modify an approach, but we're confident that we can nail down "we're landing" closely enough to mostly eliminate nuisance alerts.
It's really unfortunate that the cockpit voice recorder was overwritten. I'm guessing they're using very old technology where storage space is at a premium.
They're still using the flashing X on closed runways - e.g. at SEATAC right now. The lights looked incandescent a couple nights ago while passing the X. So not very bright or visible.
This accident would probably have been one of the worst in history. Multiple passenger planes on the taxiway taken out by a passenger jet.
"Unable... to control... altitude" "Unable... to control... airspeed" "Unable... to control... heading" "Other than that, everything A-OK!"
Guy landed safely after ATC realized it was hypoxia and ordered the flight to descend.
EDIT: link https://fearoflanding.com/accidents/accident-reports/hypoxia...
And the recent case of Captain Maggie: https://youtu.be/B229-KLudTo
> Ladies and gentlemen, this is your captain speaking. We have a small problem. All four engines have stopped. We are doing our damnedest to get them going again. I trust you are not in too much distress.
The pilot sounds calmer than the ATC. Former fighter pilot.
The perspective of the control tower makes it difficult to catch issues like this, but a simple video camera aligned with the center-line of each runway would allow controllers to more easily verify that planes are lined up as well as other possible issues like gear down & locked, etc.
I'm surprised that forward-looking infrared cameras aren't more commonly used in civilian aircraft, especially given the availability of staring arrays with decent resolution/framerate that don't require cooling.
Even without the requisite certification for use as a for-realsies landing aid, it's nevertheless a useful tool to get situational awareness in inclement weather / at night.
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Anyways, in the last couple years the FAA has changed the regulations to allow EFVS for credit on Part 121 (passenger aircraft), you can read the rulemaking change proposal that was implemented [0].
The generation of camera that existed at the time of this rulemaking was generally a cryogenically cooled InSb sensor type. The main (certified for credit) cameras here were the CMA-2600/2700 from CMC Electronics (I worked on these) and the Kollsman EVS I and II. These were mostly on BizJets before the rules were changed , except for the FedEx fleet that had an exemption.
As the rules were changed, airport lighting started to change form incandescent to LED, which made those expensive and heavy InSb cameras useless at seeing the approach lights in bad weather.
Over the years microbilometer LWIR tech has improved, and while they won’t help you see any lighting at all, LWIR sensors will help you see the ground and have better weather penetration than other wavelengths.
All that leads to the next gen of cameras being fused multi sensor cameras, 2,3, or even 4 sensors. Rockwell Collins EVS-300 and Elbit’s Clearvision EVS are examples.
The non-certified for credit systems have mostly used microbolometers over the years although some have used SWIR sensors as well.
As others have said the ITAR comes into play with anything approaching usable frame rates and resolution, although these are being slightly relaxed. Also, don’t buy American and you don’t have this problem.
After camera-based systems they are database driven Synthetic Vision Systems (SVS) that would have helped greatly in this particular near disaster. Then you can get even fancier and fuse synthetic with infrared to get a Combined Vision System (EVS + SVS = CVS), while Elbit and Rockwell offer. Sometimes I miss working on these vision systems.
[0] https://www.federalregister.gov/documents/2013/06/11/2013-13...
There are software and hardware/network setups designed to do this now, in fact London City Airport is about to move to a fully virtual control tower, with a bunch of super high res pan/tilt/zoom cameras on a mast instead of an on-site tower.
https://www.google.com/search?client=ubuntu&channel=fs&q=lon...
What? Is that really a thing? Toilet seat covers on a roll? How would that even work?
However, I'm still not clear from this reporting how the crew mistook blue taxiway lighting for white runway lighting. This isn't supposed to be subtle, and I haven't ever experienced it to be subtle.
Edit: OK there is a partial explanation here that appears as though at the time they committed to taxiway C as runway 28R, the visual cue they relied on was airplane lighting looking like it was runway lighting. Airplane taxi and takeoff/landing lights are white, navigational lights are green or red. Strobes usually aren't on while on the ground or at least probably shouldn't be.
It's an interesting dilemma. And fatigue is a significant contributing factor as well.
Here in Seattle, SeaTac airport has a parallel taxiway (Taxiway Tango) with a long history of being mistaken for a runway. The list of things tried so far to resolve the issue is interesting:
https://www.bizjournals.com/seattle/news/2015/12/31/tango-ta...
It's probably a situation like Chesterton's fence. There are probably good reasons for not having the Xes. At least I hope so, I hope it's not just "that costs money and then we have to maintain it". The money can't be an issue. How much would 500 or 1000 deaths cost? How expensive are all the other proposals which have been mentioned? Those aren't cheap either.
My SOP is beacon (red, top and bottom) on with aircraft battery bus on, strobes on only when on an open runway, landing lights on when cleared for takeoff (or lined-up and waiting in position for takeoff). That seems to be a fairly common SOP for aircraft with separate control of beacon vs strobe.
It communicates a small amount of additional information, but more relevantly, it doesn't leave you sitting next to another airplane with blinding strobes on, killing your night vision adaptation. (Cirrus drives me crazy with their single switch anti-collision lights which light the strobes and beacon together.)
Here's the FAA (recommended, but not regulatory) guidance on the topic: (See "Use of Aircraft Lights") http://www.faraim.org/aim/aim-4-03-14-209.html
Wonder if we couldn't have "ground strobes" visible only to viewers looking downward at a significant angle.
If there were another approach that required manual tuning and it was not a visual approach, the crew would detect they didn't have a localizer/equivalent to follow and would identify the missed step, because that's the only way they could navigate to the airport/runway.
It's a specific combination of visual approach and the only approach that required manual tuning (and not having another aircraft to follow visually) that setup this possible outcome. Then, the crew visually acquires the wrong bit of pavement and there's no safety mechanism inside the airplane remaining unless/until the pilots see that they're lined up wrong or get a go-around call from ATC/another aircrew.
[0] - Quote from the NTSB report: The FMS Bridge visual approach to runway 28R was the only approach in Air Canada’s Airbus A320 database that required manual tuning for a navigational aid, so the manual tuning of the ILS frequency was not a usual procedure for the flight crew.
Sokoloff's post just before mine is more articulate on this. I learned the same: strobes on when cleared for takeoff.
https://www.youtube.com/watch?v=ENe89j89tBA
What's up with that?
I would love to be an airline captain.
http://pilotseye.tv/en/flightroutes/
If you really want to see something captivating, watch this clip of a Swiss A340 crew handling an overheating engine in-flight. It's incredibly well done.
What happened here is that the pilots were locked into a wrong model: In an environment with very little light there is no visual source to compare taxiway lighting against. If we know from experience that a light is white, our brain will use this to calibrate. Without this ever becoming a conscious thought. Color correction happens automatically for us and we don't feel it. This process can easily lead to nominally weird things like blue lights being percieved as white.
Fatigue and stress would contribute to ward off looming decoherence such as "why are the lights on 28L redder than on 28R?" When under pressure, we go with the strongest signal. And that signal may very well come from our knowledge, not our perception.
I'd expect at SFO, like any other major airport I have flown into, does have both runway and taxiway lighting enabled as pilots are on final approach. So they do have a reference: the white runway lights versus blue taxiway lights, which on final approach are in the same field of view. And even on the lowest intensity setting, runway lights are brighter than taxiway lights.
Something about this particular situation definitely is off. I don't know if there's something operationally different about SFO's lighting. Or if the pilots really were that fatigued, and this is a seriously underestimated factor.
Obviously it's a rare occurrence otherwise airport lighting would have been adjusted to avoid the mistake.
Damn. It didn't matter that the whole world was telling him it was a taxiway because he was so sure it was a runway.
Other point is that the NTSB isn't generally particularly shy about calling out the need for expensive changes (one example being their recommendation for fuel tank inerting systems after TWA 800). They have no power to mandate their recommendations be implemented after all: that's the job of the FAA.
https://www.gpo.gov/fdsys/pkg/CFR-2011-title14-vol3/xml/CFR-...
EDIT - removed erroneous reference to 14 CFR 121.480-> which applies to cargo ops.
> The flight crew’s work schedule for the incident flight complied with the applicable Canadian flight time limitations and rest requirements; however, the flight and duty time and rest requirements for the captain (a company reserve pilot) would not have complied with US flight time limitations and rest requirements (14 CFR Part 117).
How long are recordings normally kept? I would assume at least a few days for mundane flights (storage is cheap, isn't it?) but any sort of incident similar to this I would assume they keep recordings for much longer, if only for internal purposes.
>(storage is cheap, isn't it?)
Not on ancient planes where everything needs a billion certifications from all sorts of regulatory bodies.
1. https://www.wired.com/2014/07/malaysia-370-cockpit-camera/
Going to guess this is one of those things where, yes, we have all the requisite technology, but practical implementation is the hard part.
Beyond that it gets really hard because visual and circling approaches can be in any heading, as well as large cross-winds.
In this deviation, the pilots literally got lost. Kind of tough to do much about that.
With a GPS and onboard databases of runways and taxiways, we can determine if a pilot is attempting to take off or land on a taxiway. The key is preventing nuisance alerts when the pilot is just flying around and happens to be aligned with a runway. The "11 secret herbs and spices" depend on the aircraft but are usually speed and configuration (ie landing gear) based. Approaches are fairly predictable and we can use that to sequence through a state machine that tells us the pilot intends to land.
Here's a video of the system on a G1000 (meant for smaller planes) skip to 0:45ish https://www.youtube.com/watch?v=V2bswm0w4cY
>The full report will be available on the NTSB website in several weeks.
[1] https://en.wikipedia.org/wiki/Airport_Surface_Surveillance_C...
Some airports do have a system [0] designed to track taxing aircraft and allow collision risks to be detected.
There are many aircraft on the ground at airports. Given the high approach speeds, this is probably a non-trivial problem.
Perhaps the full report will have more detail on this, as it stands I have to believe somebody made the decision to overwrite this because they thought it'd be better if it didn't exist. Whether that's the crew, their bosses or other staff, somebody managed to go from "serious incident, preserve evidence" to "maximum ass covering" and that person or persons are an obstacle to effective investigation and thus to safe air travel.
By the time the aircraft goes around, is resequenced, completes the second approach, lands, taxis in, and shuts down, much of the initial approach setup conversation may have already been overwritten anyway. I wouldn't jump to the assumption that there was malicious intent in the fact that the CVR was overwritten. (I also wouldn't want the crew to stop the CVR recording only to have a second, more serious incident on the same flight that would then go unrecorded.)
There's also plenty of communication with Air Traffic Control in the tower, and not a whole lot of gaps to introduce significant mystery, so it's pretty unlikely that there would be anything earth shattering on the cockpit voice recorder.
Without even trying to mislead investigators a human will report a sanitised version of events when not cued by facts. "Then I scratched my arse and sniffed my finger" is not going to appear in this sanitised version of events even if true. Neither is "I glanced at the panel, I know I'm supposed to scan it, but usually anything important flashes red". The tower log helps, CVR is better, and CCTV better again.
It also really helps to get into the routine of analysing this stuff. If your aircrew routinely skip steps 4, 18 and 23 from the checklist, only finding that out when 200 passengers die in a crash is stupid. Let's find out now. That needs lots of heavy lifting, pilots have to trust the airlines not to fire them for ordinary human frailties, and airlines have to accept that their pilots are human and "But the manual says not to do that" doesn't make it stop happening magically.
You're right that fatigue is an obvious element here, and there are several technical countermeasures mentioned. I definitely don't want to come across as believing in a conspiracy to hide the facts, but on the other hand I struggle to believe that it took over 30 minutes to get this thing back down after the incident and so the overwrite was not a decision. And if we agree it was a decision, it was a seriously bad one that should not be repeated.
I struggle to believe that it took
over 30 minutes to get this thing
back down after the incident
A concerted effort to dump the recorder buffer would require the participation of more than just the flight crew, since it manipulates the standing traffic pattern. Not an impossibility, and we know that in-group "walls of silence" definitely accumulate in high-intensity industries, but the air traffic control audio suggests a really minor transgression of situational awareness, even if the circumstances are assuredly unforgiving ones.
In the radio audio, the pilot clearly states that he's noticing lights on what he imagines to be his runway, and asks for confirmation as to what they might be. The tower reaffirms that he's all clear. Only then does a pilot from one of the planes on the ground speak up, and complain.
At that moment, both ATC and the plane realize the error. It's arguable that the pilot anticipated a likely go-around, based on intuition that the lights he was observing were definitely other planes, and that what appears to be an extremely close call proves it's own margin of error as reasonable, given that the participants recovered from the error.
The text from the linked abstract says: "Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident"
One of the nice things about working in the Web PKI is that this crap doesn't get you anywhere since keeping records is one of the requirements, and any time the options are "This issuer might be crooked or they might be incompetent" both are disqualifiying anyway, no need to figure out which it is to make a determination.
It lets me sleep easier, were people at Symantec reckless, or were they so greedy that they actively tolerated fraud? Don't care, not my problem now, let their shareholders worry about it.
It just sounds like a fishing expedition for some kind of cover up that exploits an incredibly narrow gap, covered by a myriad of alternative information sources that are more than capable of sealing up an air tight sequence of events by other means.
Open, consumer information sources like flightaware.com alone had the answer to the questions you're asking, long ago.
The radar history for this event was paywalled here for days after the event:
https://flightaware.com/live/flight/ACA759/history
The open, freebie log only gives like two weeks of charts, but the data you mention was lying around, available for like 8 months, to anyone with premium access to that particular service. And anyway, I'm sure it's just a convenience wrapper to public data that's still floating around to anyone willing to dig.
Here's another service, if you've got $500 bucks, and really would like to know right now:
https://www.flightradar24.com/data/flights/ac759/
And to reiterate, this is only costing money today on account of being late to the party.
Multiple systems surfaced this data to the world in real time, and openly back-logged for months after. I'd bet good money a wide audience fact checked exactly what you've suggested a long time ago (even here: https://news.ycombinator.com/item?id=14741605). But my opinion isn't very important when the information is available in a general sense, to anyone who really wants it, even now, more than a year later. Feel free to be suspicious about these resources being far downstream and non-official consumer products, but if that doesn't suffice, then other (much, much bigger) doubts occlude any potentially satisfactory assessment which won't get solved in a random thread by amateur internet detectives like us.
Nobody was operating for that length of time. The captain had been awake for 19 hours, the first officer had been awake for 12 hours.
Granted, most people can't function anywhere near their peak performance after being awake for 19 hours. Also there's not enough information in the summary to know the captain's recent history; how much rest time did he have before that flight?
Nonetheless, I'll put forward, that even if a direct flight from Toronto to San Francisco only takes about 5 or 6 hours, 19 hours, and rounding out the time of day to midnight as a circadian cue, definitely puts the pilot 3 hours past the usual 16 hour limit for bedtime (right, 12 hours for the co-pilot, okay). Both the pilot and co-pilot probably had at minimum another entire hour before they'd even have a chance to wind down and turn in for the night, so pile up the anticipatory nature of having to deplane and get to a hotel room onto their psychological state.