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Air Canada Near-Miss at SFO

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This one is making quite the (understandable) buzz in the transportation and aviation world:

 

http://www.mercurynews.com/2017/07/10/exclusive-sfo-near-miss-might-have-triggered-greatest-aviation-disaster-in-history/

 

The FAA is absolutely investigating this one. So far it appears AC759 was on a manual visual approach, at night, to Runway 28R (which is just to the right of the runway that Asiana Airlines 214 crashed on, almost exactly four years ago to the day). I have to wonder if the Air Canada flight crew would have just augured in (as the media would have you believe) or have eventually initiated a go-around on their own once it became glaring they were in the wrong place, but its pretty amazing to think about this happening.

 

And AC759 happens to be the flight that me and Mrs. Blackwolf frequent when returning from the Great White North, so it struck me a little more intensely on a personal level!

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There were four flights lined up on Taxiway C. One of them was a flight I normally take back home from SFO.

 

The four flights were:

 

PAL 115 343 SFO-MNL

UAL 863 789 SFO-SYD

UAL 1118 739 SFO-MCO <-- the flight I normally take

UAL 1 789 SFO-SIN

 

The pilot of UAL 1 raised the alarm as heard in the ATC recording.

 

All in all close to a thousand people were potentially in harm's way.

 

Here is an Aviation Herald article.

 

Here is the Discussion thread on Airliners.net.

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Amazing....I've heard of commercial pilots sometimes mistaken the Left or Right parallel runways, but a parallel taxiway? Whew, that was just too close! Thank goodness no crash resulted....other than perhaps that pilot's career......

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It's shocking to think that a long list of irregular events and missteps that eventually resulted in the Tenerife disaster forty years ago could be outdone by a simple lack of situational awareness today.

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The more I read about this, the more chilling it gets. It was literally at almost the last possible moment that the go around was initiated after ATC instructed them following the question from what seems like someone in the cockpit of UA 1, who again comes on moments later saying "He flew right over us" and identifies as UA 1 this time! As it turns out just 100' over a 787-9 which has its tailplane about 55'-60' high!

 

Chilling! Really chilling!

 

No wonder NTSB is on it even though nothing really crashed into anything by just extreme good fortune and at least one pilot paying close attention to what was going on, it would seem.

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The more I read about this, the more chilling it gets. It was literally at almost the last possible moment that the go around was initiated after ATC instructed them following the question from what seems like someone in the cockpit of UA 1, who again comes on moments later saying "He flew right over us" and identifies as UA 1 this time! As it turns out just 100' over a 787-9 which has its tailplane about 55'-60' high!

 

If you listen carefully you can hear the 100ft readout for a nighttime approach to 28R...

 

 

...It's crazy to think they got this close to disaster.

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Indeed DA! After seeing the video I realized how close it was! According to some of the discussion in airliners.net, the Airbus was a quarter of a nautical mile down the runway er... taxiway before the go around was initiated!

Edited by jis

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I watched the animation last night, and it gave me chills. I can't even imagine being a pilot in one of those planes on the taxiway, watching another plane coming straight for my face.

 

As a passenger facing sideways out the window, I probably wouldn't have realized anything (thank goodness). I'm not sure I would have slept well after that.

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Amazing....I've heard of commercial pilots sometimes mistaken the Left or Right parallel runways, but a parallel taxiway? Whew, that was just too close! Thank goodness no crash resulted....other than perhaps that pilot's career......

Mistaking a parallel taxiway for a runway unfortunately is not as uncommon as one imagines, though usually it happens more often during daylight hours apparently. I can think of two right off the top of my head. One was at Atlanta, a Delta 767, and the other one in Newark, an United 737., that too on a taxiway parallel to the short 29 on a sidestep from 22L to 29.

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I suspect that at the conclusion of the NTSB investigation of this incident, it will result in some strong new rulemaking, that may eliminate manual visual approaches by commercial flights, perhaps....

I would like to hear some of our professional pilot members opinion's on this....

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This has happened a couple times during the day, into the sun, etc. But this was at night! You can see from DA's video the landing on 28R. Taxiway Charlie is to the right of that with green centerline lights and blue edge lights. Although you can see taxiways from the air, the dim blue and green is just meant to see the taxiway from the ground. The runway as you can see is bright white edge lights with white touchdown zone lights in the first 1500 feet either side of the centerline lights. You also see the approach lighting system that leads to the runway. Perhaps they were thinking those white lights were for 28L? I think fatigue has a huge factor in this. I called in "fatigued" a couple times in the last few months. Walking past the passengers that had been waiting for hours until 2 AM didn't seem happy, but little did they know, I was doing them a big favor!

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Thanks Chris! Its a tough job, glad you're one of the pros, hope you get some R&R!😉

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One thing to think about is that 28L wasn't being used. I heard maybe undergoing maintenance at night and the runway lights were off. Some of the discussion was that the pilots might have been fixating on the lights, thinking that they needed to see one set of lights to the right of another set of lights.

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Chris can give us the best opinion based on first hand knowledge since he is the only one among us who has actually landed a plane on 28R as PIC.

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One thing to think about is that 28L wasn't being used. I heard maybe undergoing maintenance at night and the runway lights were off. Some of the discussion was that the pilots might have been fixating on the lights, thinking that they needed to see one set of lights to the right of another set of lights.

 

Which is why it's important for large commercial airports to use runway outage lights (big flashing "X" at each end in FAA territory) during major maintenance periods and for pilots to fully familiarize themselves with any active NOTAM's.

Edited by Devil's Advocate

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One thing to think about is that 28L wasn't being used. I heard maybe undergoing maintenance at night and the runway lights were off. Some of the discussion was that the pilots might have been fixating on the lights, thinking that they needed to see one set of lights to the right of another set of lights.

 

Which is why it's important for large commercial airports to use runway outage lights (big flashing "X" at each end in FAA territory) during major maintenance periods and for pilots to fully familiarize themselves with any active NOTAM's.

 

Wouldn't the automated ATIS announcement from the airport also mention the runway closure? Usually, when a pilot contacts a tower for permission to land, he or she confirms that they have listened to the latest recording identifed by a phonetic letter...

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One thing to think about is that 28L wasn't being used. I heard maybe undergoing maintenance at night and the runway lights were off. Some of the discussion was that the pilots might have been fixating on the lights, thinking that they needed to see one set of lights to the right of another set of lights.

 

Which is why it's important for large commercial airports to use runway outage lights (big flashing "X" at each end in FAA territory) during major maintenance periods and for pilots to fully familiarize themselves with any active NOTAM's.

 

Wouldn't the automated ATIS announcement from the airport also mention the runway closure? Usually, when a pilot contacts a tower for permission to land, he or she confirms that they have listened to the latest recording identifed by a phonetic letter...

 

 

Yes. In addition to weather, ATIS identifies any abnormal operational issues such as runway closures.

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Why does a tricky airport like San Francisco not have all the safety system working?

 

Sorry not a pilot, but after the last crash one think we would learn a important lesson.

If it's not all working, for whatever the reason, are they supposed to shut the entire airport down until it's all working again?

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Why does a tricky airport like San Francisco not have all the safety system working?

 

Sorry not a pilot, but after the last crash one think we would learn a important lesson.

What exactly was not working? I have no clue what you are talking about.

 

SFO does visual whenever possible to increase throughput. This is similar in spirit to what is done at Penn Station approach from the east where routinely trains proceed on restricting speed visually crawling upto the tail of the train ahead.

 

Are you suggesting that they should stop doing so? That will reduce the throughput capacity of SFO by more than 50%, and is not going to happen.

 

They still have PAPI to guide them to the landing spot. When someone loses situational awareness, all bets are off, unfortunately.

 

It is possible that if they had the Rabbit on it would have reduced the possibility of this particular mistake, and that might indeed be a recommendation that comes out of this. Saxman and I had an interesting discussion about this at the AU Gathering.

 

BTW, in a preliminary NTSB review, a representative of the SFO ATC said that the big red "X" was lighted at the end of the out of service runway 28L at the time of the incident.

 

Incidentally also, because of the displaced threshold of 28R, most fortuitously, the landing craft overflew the first two planes awaiting takeoff on Taxiway Charlie, instead of crashing into the first one in line. That gave ATC the time to react and command the go around just in time- some say within five seconds of disaster involving the landing plane and the third and fourth plane in queue on Charlie.

Edited by jis

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Why does a tricky airport like San Francisco not have all the safety system working? Sorry not a pilot, but after the last crash one think we would learn a important lesson.

 

What do you feel makes San Francisco airport especially tricky? What lesson do you feel should have been learned by the last crash?

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Saxman= One of our Airline Pilot Members!

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Saxman= One of our Airline Pilot Members!

Not only that. He has actually landed a plane on Runway 28R at SFO!

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It seem to maximize the airport capacity we are making trades. Safety vs Profit. By using the visual approach we can land more planes. The lost of one or two out of the hundreds of thousands is worth it.

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What do you feel makes San Francisco airport especially tricky? What lesson do you feel should have been learned by the last crash?

 

 

My understand is the airport approach is over water which of course has a lack of landmarks. One of the factors in the crash of 214. The water approach is why it's tricky.

 

Asiana Airlines 214 that crash. One of the factors was the aircraft was on visual. Several other issues also helped in that crash.

 

 

 

The recurring issues is the aircraft is on visual. 😉If we invented a radio beacon, a radar, or a guy on the ground providing a signal that could tell the pilot that there approached is good. Well then this mess would not of happened.

 

 

Oh wait we have said systems we just don't use them.😜

 

 

Profits above safety. A winning combination.

 

 

 

.

Edited by Just-Thinking-51

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