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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 5, 2017, 11:58 am
  #631  
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Originally Posted by After Burner
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.
Let's say that the NTSB says "yes it was pilot error", what is the range of punishments that could be meted out? Will they take into account mitigating circumstances (if there are any)?

I recall that in the 777 BA38 incident at Heathrow that the pilots were grounded to assess and make sure that they were not suffering from any kind of PTSD (ok, this was a different incident entirely) - do you think this will have happened with the AC pilots? If they have been grounded what will the route back for them be do you know?

I know it is all speculation but you have a lot of insight here.
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Old Aug 5, 2017, 1:05 pm
  #632  
 
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Originally Posted by canopus27
From page 2 of the Forbes article:

The key part of the federal regulations state:

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.
Originally Posted by After Burner
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.

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).
Well, this then brings us to the question of what is reportable doesn't it?
I acknowledge the points raised and I can see why one would hold the views as written. However, that position is predicated on an acceptance of the Forbes article as written and assumes of course that the individual was not quoted out of context.

And this folks is where one must take into account the definitions that apply to the terms used. One must also take into account the normal practices and operating environment of the alleged wrongdoer.

The phrase that some are accepting exactly as written is;

(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.


The key then is what is meant by "land". If land was interpreted strictly as in the physical act of contact of the aircraft and the ground, then yes, one would certainly have to accept that there was no obligation to report. However, the term LAND has a much broader interpretation.

Annoyingly enough, in the US definitions specific to the requirement to report an incident, the term is not defined. Instead, one must look at other definitions to see how the term "land" is intended to be used. Those definitions include the immediate activities/events leading up to the actual physical contact with the ground. For example, let's use the most common landing experience regulation;
§ 135.122 Stowage of food, beverage, and passenger service equipment during aircraft movement on the surface, takeoff, and landing.
(a) No certificate holder may move an aircraft on the surface, take off, or land when any food, beverage, or tableware furnished by the certificate holder is located at any passenger seat.

(b) No certificate holder may move an aircraft on the surface, take off, or land unless each food and beverage tray and seat back tray table is secured in its stowed position.

(c) No certificate holder may permit an aircraft to move on the surface, take off, or land unless each passenger serving cart is secured in its stowed position.

(d) Each passenger shall comply with instructions given by a crew member with regard to compliance with this section.


It is obvious from the above definition the term "land" includes the actions immediate to the physical contact with the airport tarmac. It is reasonable to expect that land encompasses the actions directly related to the touchdown of the aircraft and it's reduction in speed to allow the taxiing and subsequent delivery of pax to the gate.

I anticipate, that some will insist that the regulations be taken exactly as they are written and that the poor folks at Air Canada were confused and did what was "normal". To that, I say, let's look at the Canadian regulations as set out under the Regulations Respecting Aviation and Activities Relating to Aeronautics P.C. 1996-1399 1996-09-10

Landing means

(a) in respect of an aircraft other than an airship, the act of coming into contact with a supporting surface, and includes the acts immediately preceding and following the coming into contact with that surface, and

(b) in respect of an airship, the act of bringing the airship under restraint, and includes the acts immediately preceding and following the bringing of the airship under restraint; (atterrissage)

I bolded the parts that explain that landing is more than physical contact as the reference in Forbes suggests. As expected, landing means the physical contact with the ground. However, it also includes the events leading up to the actual physical contact. This regulatory definition is consistent with common practice and common sense that holds one cannot just look at the end result, but one must also take into account the events leading up to the event.

The takeaway I have is that Air Canada operates in an environment (Canada) where it was to be expected that the events of the landing would be reported.
This suggests then, that the observations of others on this thread that there would need to be a willful disregard of the Canadian practice to not report, are reasonable. One can draw one's own conclusions. My opinion is that there was a requirement to report.
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Old Aug 5, 2017, 1:22 pm
  #633  
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Originally Posted by Transpacificflyer
Landing means

(a) in respect of an aircraft other than an airship, the act of coming into contact with a supporting surface, and includes the acts immediately preceding and following the coming into contact with that surface, and

(b) in respect of an airship, the act of bringing the airship under restraint, and includes the acts immediately preceding and following the bringing of the airship under restraint; (atterrissage)

I bolded the parts that explain that landing is more than physical contact as the reference in Forbes suggests. As expected, landing means the physical contact with the ground. However, it also includes the events leading up to the actual physical contact. This regulatory definition is consistent with common practice and common sense that holds one cannot just look at the end result, but one must also take into account the events leading up to the event.

The takeaway I have is that Air Canada operates in an environment (Canada) where it was to be expected that the events of the landing would be reported.
This suggests then, that the observations of others on this thread that there would need to be a willful disregard of the Canadian practice to not report, are reasonable. One can draw one's own conclusions. My opinion is that there was a requirement to report.
"and includes the acts immediately preceding and following the coming into contact with that surface"

But it didn't come into contact with that surface. A go around was executed.
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Old Aug 5, 2017, 2:32 pm
  #634  
 
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Originally Posted by Silver Fox
Let's say that the NTSB says "yes it was pilot error", what is the range of punishments that could be meted out? Will they take into account mitigating circumstances (if there are any)?
Right now it would be a safe bet that this crew is no longer flying - suspended with reduced pay. Ultimately, I would put my money on this being a career ending event.
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Old Aug 5, 2017, 2:49 pm
  #635  
 
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Originally Posted by After Burner
Right now it would be a safe bet that this crew is no longer flying
I hope that's the case. But, given the fact that they did continue to fly after this incident, I am not nearly as confident as you.
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Old Aug 5, 2017, 4:16 pm
  #636  
 
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Originally Posted by canadiancow
"and includes the acts immediately preceding and following the coming into contact with that surface"

But it didn't come into contact with that surface. A go around was executed.
No cigar bro. The aborted landing is part of the overall landing event.
One can try and twist the language to argue against an obligation to report, but the intent is clear. The last guy who tried your line of reasoning to avoid responsibility was Martin Shkreli. It didn't work for him.
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Old Aug 5, 2017, 4:33 pm
  #637  
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Originally Posted by Transpacificflyer
No cigar bro. The aborted landing is part of the overall landing event.
One can try and twist the language to argue against an obligation to report, but the intent is clear. The last guy who tried your line of reasoning to avoid responsibility was Martin Shkreli. It didn't work for him.
I'm not trying to avoid responsibility.

I'm just giving you my interpretation of that paragraph.

It would only take a few more words to make it unambiguously mean what you claim.
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Old Aug 5, 2017, 5:14 pm
  #638  
 
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Originally Posted by After Burner
OF COURSE it's pilot error.
Can you please share with the class the detailed investigation that has led you to this conclusion - long before the government agencies have completed their investigations?

What is to say that changes will not be recommended that focus on AC's SOPs, government regulations, scheduling practices, ATC procedures, etc? If the pilots followed all the SOPs, flight manuals, etc and got the proper rest expected but these still contributed to the incident ... then pilot error would not be the primary cause. But you seem to know something that the rest of us don't ... so please share.
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Old Aug 5, 2017, 6:03 pm
  #639  
 
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Originally Posted by cedric
Can you please share with the class the detailed investigation that has led you to this conclusion - long before the government agencies have completed their investigations?
Aside from an abundance of evidence pointing to pilot error, the pilots were interviewed and acknowledged their error.


What is to say that changes will not be recommended that focus on AC's SOPs, government regulations, scheduling practices, ATC procedures, etc? If the pilots followed all the SOPs, flight manuals, etc and got the proper rest expected but these still contributed to the incident ... then pilot error would not be the primary cause. But you seem to know something that the rest of us don't ... so please share.
Yes, it's very likely that the NTSB will identify contributing factors and make recommendations accordingly, but that doesn't alter the fact that the pilot, with full control of the aircraft, steered it to a taxiway and descended to a dangerously low altitude.

What I know that maybe some others here don't know are visual approach rules. When a pilot accepts a visual approach clearance and subsequently accepts landing clearance, he has effectively accepted full responsibility for getting the aircraft safely to the runway.
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Old Aug 5, 2017, 6:14 pm
  #640  
 
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Originally Posted by Transpacificflyer
One can try and twist the language to argue against an obligation to report, but the intent is clear.
Right. There is a thing called "common sense". I can't imagine how any reasonable person could think this occurrence shouldn't be reported, regardless of what the regulations say.

But I can imagine how some parties might not want it to be reported or might have hoped it would go unnoticed and be dismissed as just another routine/precautionary go-around.
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Old Aug 5, 2017, 6:24 pm
  #641  
 
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Originally Posted by After Burner
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.
No idea. It's a baffling one. But not the result of the airline deciding against upgrading their avionics package beyond what they currently had installed in their A320s. The error seems much more fundamentally egregious than claiming a brand new whiz-bang moving map display would have prevented any ambiguity.
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Old Aug 5, 2017, 6:39 pm
  #642  
 
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Originally Posted by CZAMFlyer
No idea. It's a baffling one. But not the result of the airline deciding against upgrading their avionics package beyond what they currently had installed in their A320s. The error seems much more fundamentally egregious than claiming a brand new whiz-bang moving map display would have prevented any ambiguity.
Agreed.

But I suspect an automatic aural warning screaming "CAUTION TAXIWAY, CAUTION TAXIWAY" in conjunction with having been trained as to the meaning of that warning, might have got their attention.
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Old Aug 5, 2017, 7:01 pm
  #643  
 
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Originally Posted by After Burner
Agreed.

But I suspect an automatic aural warning screaming "CAUTION TAXIWAY, CAUTION TAXIWAY" in conjunction with having been trained as to the meaning of that warning, might have got their attention.
Assuming such a programmed warning exists. I've never heard of one.
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Old Aug 5, 2017, 7:05 pm
  #644  
 
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Originally Posted by CZAMFlyer
Assuming such a programmed warning exists. I've never heard of one.
RAAS (Runway Awareness and Advisory System). Made by Honeywell.
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Old Aug 5, 2017, 7:36 pm
  #645  
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Originally Posted by CZAMFlyer
Assuming such a programmed warning exists. I've never heard of one.
Assuming it doesn't exist, it should
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