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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 9, 2017, 9:04 pm
  #691  
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Originally Posted by dhuey
(my emphasis)

Are you sure about that? Here's the report: https://www.ntsb.gov/news/press-rele...r20170802.aspx

I don't see anything to suggest that the pilot initiated a "go around" on his own.
From the more complete report referenced in your link
https://ntsb.gov/investigations/Pages/DCA17IA148.aspx

"At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point (see figure 4)."
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Old Aug 9, 2017, 9:07 pm
  #692  
 
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Originally Posted by The Lev
When interviewed, the pilots stated that they thought Taxiway C was 28R (presumably for whatever reason they did not see the big red lit X but did see two lit "runways" and knew they were supposed to land on the right hand side one. If 28L had been open and lit as was 28R, they almost certainly would have lined up correctly - hence the runway closure was a contributing factor to the pilots' (mis)perception.
I agree that this likely wouldn't have happened if 28L had been open. But the NTSB has also said that the SFO bulletin indicated the closed runway and the giant X was in place.

Therefore, I would rephrase your last sentence: The pilot's failure to observe/comprehend that a runway was closed is a contributing factor.
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Old Aug 9, 2017, 9:09 pm
  #693  
 
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Originally Posted by The Lev
That is pretty self-evident. Closure of 28L was one contributing factor, pilot error appears to be another and we'll see what else the investigation dredges up.
I'm hoping the investigation takes a look at what ought to be the best practice for lighting of closed runways. It seems like keeping 28L lit up would have prevented this, though I'm trying not to jump to conclusions that that's the right thing to do.

That said, I can only find one instance of an airplane landing on a closed runway, with a quick search through wikipedia's list of 1990-2019 and 1960-1989:
  • Western Airlines Flight 2605 -- landed on closed runway at MEX; 23L was closed, but 23R didn't have ILS. They were told to use 23L's ILS to approach, with an implied sidestep to 23R once visual was acquired. They never did the sidestep and landed (disastrously) on 23L. Not sure if runway lights were a contributing factor here.

Presumably there are other instances of closed runway landings or almost-landings that were less disastrous and thus less well recorded, but presumably there are also other instances similar to what happened in SFO, with not nearly as much of a close call.
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Old Aug 9, 2017, 10:56 pm
  #694  
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If 28L was properly marked as closed as per ICAO requirements and NOTAM was issued, then it really points to pilot error.
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Old Aug 9, 2017, 11:24 pm
  #695  
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Originally Posted by The Lev
From the more complete report referenced in your link
https://ntsb.gov/investigations/Pages/DCA17IA148.aspx

"At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point (see figure 4)."
Would the AC pilot have heard the UA1 pilot's two transmissions prior to the tower's "go around" order? Also, I read that the Phillipeans Air pilot turned on landing lights to get the AC's attention. Not clear at this point if AC would have self-corrected in time.
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Old Aug 9, 2017, 11:28 pm
  #696  
 
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Originally Posted by dhuey
Would the AC pilot have heard the UA1 pilot's two transmissions prior to the tower's "go around" order? Also, I read that the Phillipeans Air pilot turned on landing lights to get the AC's attention. Not clear at this point if AC would have self-corrected in time.
Yes, UA1's transmissions would have been heard in AC759's cockpit. I believe that's what caused AC pilots to initiate the go-around
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Old Aug 10, 2017, 1:20 pm
  #697  
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Originally Posted by kjnangre
Yes, UA1's transmissions would have been heard in AC759's cockpit. I believe that's what caused AC pilots to initiate the go-around
Believe, based on what?
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Old Aug 10, 2017, 4:06 pm
  #698  
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Originally Posted by canadiancow
Believe, based on what?
I don't claim to know either way. Seems like the pilots here would know: are the planes under tower control usually listening to other pilots' communications with the tower?

ETA: I should be more specific. Are planes approaching the runway (or taxiway, as the case may be) usually listening to other pilots' communications with the tower?

Last edited by dhuey; Aug 10, 2017 at 4:15 pm
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Old Aug 10, 2017, 4:38 pm
  #699  
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UA transmission would have been picked up by AC cockpit as both would have been on same frequency but it's a big jump to say that AC pilot hearing UA transmission caused them to initiate go-around.
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Old Aug 10, 2017, 4:59 pm
  #700  
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Originally Posted by seawolf
UA transmission would have been picked up by AC cockpit as both would have been on same frequency but it's a big jump to say that AC pilot hearing UA transmission caused them to initiate go-around.
I would imagine the AC cockpit voice recorder will shed some light on that. Still, if the AC pilot decided to go around a few seconds prior to the tower's order based on his or his co-pilot's observations (and not hearing UA1's transmissions or seeing the Philippians Air illumination of its landing lights), wouldn't you think he would have emphatically said that in the initial NTSB interview?
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Old Aug 10, 2017, 5:06 pm
  #701  
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Originally Posted by dhuey
I would imagine the AC cockpit voice recorder will shed some light on that.
CVR is lost as it was recorded over.
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Old Aug 10, 2017, 5:10 pm
  #702  
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Originally Posted by tcook052
CVR is lost as it was recorded over.
If that is true, then something is gravely wrong with the applicable regulations and procedures. It was immediately obvious that this was an incident worthy of serious investigation.
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Old Aug 10, 2017, 5:13 pm
  #703  
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Originally Posted by dhuey
If that is true, then something is gravely wrong with the applicable regulations and procedures. It was immediately obvious that this was an incident worthy of serious investigation.
True? You need to read more of this thread such as post #557 in which the NTSB commented on the near miss and noted the lack of CVR:

https://www.flyertalk.com/forum/air-...l#post28640178

The incident airplane’s cockpit voice recorder had been overwritten, so NTSB investigators did not have that data.
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Old Aug 10, 2017, 5:23 pm
  #704  
 
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Originally Posted by dhuey
I would imagine the AC cockpit voice recorder will shed some light on that. Still, if the AC pilot decided to go around a few seconds prior to the tower's order based on his or his co-pilot's observations (and not hearing UA1's transmissions or seeing the Philippians Air illumination of its landing lights), wouldn't you think he would have emphatically said that in the initial NTSB interview?
Do you have evidence that the pilots did not emphatically say that in the initial NTSB interview. The only thing I read was that they said they initiated the GA because something didn't feel right.
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Old Aug 10, 2017, 5:24 pm
  #705  
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Originally Posted by tcook052
True? You need to read more of this thread such as post #557 in which the NTSB commented on the near miss and noted the lack of CVR:

https://www.flyertalk.com/forum/air-...l#post28640178

The incident airplane’s cockpit voice recorder had been overwritten, so NTSB investigators did not have that data.
Does that not seem like a problem to you? Even if this is old equipment, designed to write over data and voice recordings from 30 minutes prior, wouldn't it make sense in a situation like this to essentially "unplug" both recorders right after the first approach? The tower and other pilots knew right there and then that something very serious happened. It's quite unlikely that data and recordings from the second approach will be of similar interest.
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