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Exclusive: SFO near miss might have triggered ‘greatest aviation disaster in history’

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Exclusive: SFO near miss might have triggered ‘greatest aviation disaster in history’

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Old Aug 3, 2017, 9:23 pm
  #616  
 
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Originally Posted by tennislover9
Aren't the people in the tower to blame as much or more than the pilots in the air?
This is 100% the responsibility of the pilots.
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Old Aug 3, 2017, 9:28 pm
  #617  
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Originally Posted by tennislover9
Aren't the people in the tower to blame as much or more than the pilots in the air?
The ATC not recognizing that the jet didn't show up where expected on his radar likely contributed to not recognizing the danger sooner and calling for the go-around sooner. It's an error that contributed, but of much less importance than the pilot error.
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Old Aug 3, 2017, 9:31 pm
  #618  
 
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Originally Posted by longtimeflyin
My understanding of the cockpit voice recorder limitation (based on this thread) is that it loops back over itself after 30 minutes and this was the result of privacy concerns brought up by the Air Canada Pilots Association. Also, as I understand it, this is not a hardware limitation of the CVR.

In this case, privacy shouldn't be a concern as cockpit conversations during critical phases of flight must be sterile, and after the aircraft had landed, one would guess that by the time the aircraft lands on the runway and it gets to the gate and parked, that the majority of the 30 minutes would already have disappeared.

If my understanding is correct, it seems incredibly silly to me that Air Canada management would allow for a 30 minute max in the first place. Is this an industry norm or is Air Canada outside the line of best fit?
The 30 minute limit is a US thing. I don't believe any such limit exists in Canada. The newer A320s have a 2h 30m capacity.

The trigger for the CVR recording to end is the shutdown of the last engine. It continues to record for a period after shutdown (an additional 5 or 10 minutes, IIRC).
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Old Aug 4, 2017, 8:18 am
  #619  
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https://www.forbes.com/sites/christi.../#2e0ef8c439e5

In its investigation into the Air Canada flight that came thisclose to triggering a multi airliner pile-up at San Francisco Airport last month, American safety authorities will try to determine why the Airbus A320 was over a crowded taxiway instead of an open runway awaiting the plane’s arrival.

But the National Transportation Safety Board should also examine why Air Canada didn’t notify authorities that Flight 759 flew within feet of creating a chain-reaction disaster of historic proportions.

This is not just a procedural question. Air Canada’s silence allowed the recording from the cockpit voice recorder to be taped over by subsequent flights. The CVR contained information critical to the investigation.

“It’s not clear whether there has been an attempt to cover up an incident,” said Jim Hall, the former chairman of the NTSB and now a safety consultant in private practice.
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Old Aug 4, 2017, 12:59 pm
  #620  
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I wonder if any of this had to do with the arrival time of around midnight in SFO an 3:00 AM Eastern. Likely not a lot of "people in authority" to consult at that hour.
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Old Aug 4, 2017, 1:03 pm
  #621  
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Originally Posted by The Lev
I wonder if any of this had to do with the arrival time of around midnight in SFO an 3:00 AM Eastern. Likely not a lot of "people in authority" to consult at that hour.
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Old Aug 4, 2017, 1:55 pm
  #622  
 
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Are we ignoring the comment from the NTSB, saying that this was not a reportable event?
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Old Aug 4, 2017, 10:57 pm
  #623  
 
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Originally Posted by YEG_SE4Life
Are we ignoring the comment from the NTSB, saying that this was not a reportable event?
Might as well the armchair experts are ignoring many other things too.
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Old Aug 4, 2017, 11:12 pm
  #624  
 
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Originally Posted by After Burner
But I'd be much less concerned about stupid CVR limitations than I would about airlines operating 1980s technology passenger airliners that allow a pilot to line up with and almost land on a taxiway.
Originally Posted by Admiral Ackbar
In this (and 90% of everything else about this incident ) we agree. As I stated earlier, I hope the $$$ saved were worth it.
Gentlemen, there is nothing about "1980s technology airliners" that "allow" a pilot to misalign a landing path. Precision approaches have been flown long before the earliest A320s were introduced, but I'd venture in this event that all reference was focused outside the front windows. Visual approaches are subject to the same human errors today as they were since Kitty Hawk days. Without having to dole out millions for the latest gee-whiz avionics suite, there are plenty of redundant navigation tools aboard every aircraft in AC's fleet to enable situationally aware pilots to land exactly where intended.
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Old Aug 5, 2017, 8:36 am
  #625  
 
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Originally Posted by After Burner
No argument from me on the 30 minute limit. It's utterly absurd.

Another question is: what is the effect of pulling the breaker? I talked to an A320 pilot this morning who told me there is, in fact, a CVR breaker in the cockpit. I asked what effect pulling it would have. The answer I got was "Hmm, I don't know." Possibly pulling the breaker will cause all data to be lost (??)

Apparently the manual doesn't provide much information about the CVR.
Didn't Air Asia flight 8501 (also an A320) crash because the pilot inadvertently turned off the wrong circuit breaker? I know that was a different situation ... but it highlights the risks of routinely asking pilots to turn off breakers.

Besides, what if the subsequent landing attempt is also ... ahem ... a "hard landing"?

If we want to secure the CVR data better (and I agree we do), then the way to achieve that is not by turning it off mid-flight.
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Old Aug 5, 2017, 9:01 am
  #626  
 
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Originally Posted by YEG_SE4Life
Are we ignoring the comment from the NTSB, saying that this was not a reportable event?
Originally Posted by upgradesecret
Might as well the armchair experts are ignoring many other things too.
What? Where? When did the NTSB say this was "not a reportable event?"
Please direct me to the part of the NTSB statement where this was stated.
I am looking at the statement from updated August 2 and do not see mention of this description. https://ntsb.gov/investigations/Pages/DCA17IA148.aspx
Was this a supplemental statement? I don't understand how this could not be a reportable event, as the aircraft nearly crashed into several other aircraft. I certainly am open to education in this regard if I am misunderstanding something here.

What I do see is the news release of August 2 which suggests the pilot(s) had a significant role in this event https://www.ntsb.gov/news/press-rele...r20170802.aspx

Both pilots said, in post-incident interviews, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.

If I go into armchair expert mode, if it looks and sounds like pilot error, then chances are it most likely is pilot error. However, I am waiting for the results of the full investigation, before going into flatbed expert mode.
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Old Aug 5, 2017, 9:21 am
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https://www.forbes.com/sites/christi.../#4dc994d23845

From this Forbes article, it says that Keith Holloway, NTSB spokesman, said that the airlines was not required to report this incident, purely based on the NTSB regulations.
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Old Aug 5, 2017, 9:35 am
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Originally Posted by Transpacificflyer
What? Where? When did the NTSB say this was "not a reportable event?"
Please direct me to the part of the NTSB statement where this was stated.
I am looking at the statement from updated August 2 and do not see mention of this description. https://ntsb.gov/investigations/Pages/DCA17IA148.aspx
Was this a supplemental statement? I don't understand how this could not be a reportable event, as the aircraft nearly crashed into several other aircraft. I certainly am open to education in this regard if I am misunderstanding something here.
From page 2 of the Forbes article:

Keith Holloway, a spokesman for the NTSB referenced the federal regulations in explaining, “the operator was not required to make a report to the NTSB.”
The key part of the federal regulations state:

830.5 Immediate notification.
The operator of any civil aircraft ... shall immediately, and by the most expeditious means available, notify the nearest National Transportation Safety Board (NTSB) office, when:

(a) An aircraft accident or any of the following listed serious incidents occur:

(12) Any event in which an operator, when operating an airplane as an air carrier at a public-use airport on land:

(i) Lands or departs on a taxiway, incorrect runway, or other area not designed as a runway; or

(ii) Experiences a runway incursion that requires the operator or the crew of another aircraft or vehicle to take immediate corrective action to avoid a collision.
As observed in the Forbes article, subsection 12 as written applies "when operating an airplane as an air carrier at a public-use airport on land" ... but in this case, the plane was not on land ... instead it executed a "go around".

Let me go & grab a bowl of popcorn before everyone starts to debate this interpretation.
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Old Aug 5, 2017, 10:03 am
  #629  
 
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Originally Posted by Transpacificflyer
What? Where? When did the NTSB say this was "not a reportable event?"
Please direct me to the part of the NTSB statement where this was stated.
I am looking at the statement from updated August 2 and do not see mention of this description. https://ntsb.gov/investigations/Pages/DCA17IA148.aspx
Was this a supplemental statement? I don't understand how this could not be a reportable event, as the aircraft nearly crashed into several other aircraft. I certainly am open to education in this regard if I am misunderstanding something here.

What I do see is the news release of August 2 which suggests the pilot(s) had a significant role in this event https://www.ntsb.gov/news/press-rele...r20170802.aspx

Both pilots said, in post-incident interviews, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.

If I go into armchair expert mode, if it looks and sounds like pilot error, then chances are it most likely is pilot error. However, I am waiting for the results of the full investigation, before going into flatbed expert mode.
OF COURSE it's pilot error.

I hunted through the regs myself, shortly after this occurred, and couldn't find anything specifying that this type of occurrence must be reported. So believe it or not it does appear that there is no regulatory reporting requirement.

From this Forbes article, it says that Keith Holloway, NTSB spokesman, said that the airlines was not required to report this incident, purely based on the NTSB regulations.
The NTSB is not a regulatory body, so I don't believe there are NTSB regulations. The FARs (Federal Aviation Regulations) make up the regulatory framework which is part of CFR (Code of Federal Regulations).
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Old Aug 5, 2017, 10:27 am
  #630  
 
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Originally Posted by CZAMFlyer
Gentlemen, there is nothing about "1980s technology airliners" that "allow" a pilot to misalign a landing path. Precision approaches have been flown long before the earliest A320s were introduced, but I'd venture in this event that all reference was focused outside the front windows. Visual approaches are subject to the same human errors today as they were since Kitty Hawk days. Without having to dole out millions for the latest gee-whiz avionics suite, there are plenty of redundant navigation tools aboard every aircraft in AC's fleet to enable situationally aware pilots to land exactly where intended.
Yes, if the pilots had set up for ILS guidance, and had paid attention to it, the 1980s technology in their A320 would have given them an unambiguous indication that they were off course. But apparently (for unknown reasons) they didn't do this.

More up-to-date technology would clearly show the aircraft not being aligned with the runway even if the ILS had not been set up. But as you suggested, 100% of their attention may well have been out the window rather than on the instruments. The problem I have with that notion is that the final fix in the FMS 28R approach (F101D) places them exactly on the localizer, exactly lined up with a tunnel of unmistakable approach lights. That's what they would've seen out the window. They actually would have had to have banked the aircraft substantially to the right to line up with the taxiway.

Did they think those approach lights in front of them were for 28L? If so, that would mean they didn't brief/understand the FMS28R approach and missed the NOTAM, the ATIS, and NORCAL transmissions that reported 28L as closed.
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