rankourabu

This isn't a serious question, is it?
That would cost money and drive down profits/bonuses. So I m going to go with no on that one, apart from what they were/will be mandated to do.

RangerNS

Well, yes.

Its a spectrum, of course. But either this pilot was uniquely tired, in which case Air Canada should have been able to recognize it, or that pilots are human is a rampant problem, and Air Canada should have a way to deal with it.

The amount of engineering that goes into a commercial passenger jets is untouched by any other field, and born of the findings of tragedy and accident reports. Telling pilots just to be even bigger macho ........s isn't really a productive path to deal with that part of the system.

longtimeflyin

It is not alleged anywhere that the pilot in question was not well rested because he or she decided to behave that way. Rather, the children of said pilot was the result of the pilot waking up at 0745. This is the reality of any parent and even if the pilot did try and sleep again, his body clock probably prevented him from this. This is a reality of the limitations of being only human beings. If the pilot did not fall asleep until 0200 or 0300 due to extensive partying on the pilot's part, then I would conceded that that is the responsibility of the pilot and his behavior and solely his actions put the lives of several individuals in jeopardy.

That said, the pilot's sleep schedule and account for his fatigue seemed, to me, like many who have ever raised children, and surely Air Canada recognizes that pilots have kids, right? The airline needs to address fatigue much better because I'm fairly confident that other pilots have routinely experienced this as well (with respect to children disturbing sleep in their residence).

jmastron

I think there's some shared responsibility. From my quick reading, I think the timeline was:
- Worked a flight the night before that didn't get in until ~midnight
- Fell asleep around 2-3am
- Woke at 7:45, didn't know at that point he'd be flying that night.
- Received reserve call around 11am-noon
- Arrived at airport for flight in the evening

Happy to be corrected, but the flaw in the rest requirements is that depending on time of day/family, N hours off doesn't guarantee e.g. N-2 hours of sleep. Especially here where he didn't know he was going to be called in. Ideally upon knowing that he would have gone back and slept for another 3-4 hours in the afternoon, but that's not realistic to do unplanned. On the other hand, I might expect a pilot to not bid for reserve duty or to decline a flight that doesn't fit with his potential sleep schedule (knowing that with a family he won't be able to sleep in, etc).

Having said that, the pilots' actions after the incident border on criminal in my opinion. Not reporting it because they were "tired" is BS. They were hoping to fly out unnoticed in the morning before the CVR could be reviewed...and they did. The recordings of what they said off radio, how they sounded, etc are critical to understanding how this could happen and between the pilots and AC they intentionally prevented that data from being saved. If it were up to me AC would be banned from SFO for a short time, and those pilots would be banned by the FAA from flying in US airspace again. Harsh, yes, but watching that video this was almost very very bad...

canadiancow

I'd like to point out that I don't think going to bed at 0300 is an issue when you're landing a plane at midnight 3 time zones west the next day. I'd actually say that's a prudent way to adjust your body clock.

However, the cause of his early wakeup isn't really relevant. He did not have enough sleep to be operating a flight that late. Did he inform AC of this? I think that's a key issue.

My questions:
1. Weren't there two pilots? We have an explanation for why one of them was too tired. What about the other?
2. They switched off the autopilot and flight director. Would either of these systems have indicated they were not lined up with the runway?
3. "surely Air Canada recognizes that pilots have kids, right" - If you live in an environment where it's hard to get a good night's sleep, should you really be working as a pilot, where your cognitive ability is critical? I live across the street from a 24/7 construction site. Even with eye shades and ear plugs, there are days where I know I'm not performing at my best because of the previous night's lack of sleep. But when I screw up, no one dies.

Mountain Explorer

I agree. I believe the coverup was intentional. And that's what makes my blood boil about this incident. Ultimately, we will never know the whole truth about what was going on during that first approach.

Jagboi

Apparently he was tired too. In the interview he said he felt like he needed 8 hours of sleep to feel rested and in the previous 2 nights he had had 5 and 6 hours, respectively. The two of them were both affected for fatigue and in the interview it was mentioned that they would look out for each other - i.e. keep each other awake.

Interesting, that they both missed the NOTAM about runway 28L being closed. Neither could recall seeing the X on it indicating it was closed, which is part of the reason they mistook the taxiway as 28R.

Bohemian1

Neither of them noticed the 'rabbits' (runway lead in lights) on 28R either. Had they lined up with those, they would have been on the correct runway even with them neglecting to put the localizer up (apparently required by AC SOP).

As usual, lots of little errors that could have lead to a very serious accident. I'm no expert, but of lot of the bigger 'incidents' blamed on pilot error seem to follow a similar pattern of small mistakes / failures leading to a loss of situational awareness with potentially very bad outcomes.

CZAMFlyer

Neither of those systems would have given them that indication on this flight. They are only as good as the (heading, altitude, speed, climb/descent rate) data that's been programmed into them, and will unfailingly follow any command or approach procedure as input from a pilot. As we know, they were cleared for a visual approach to 28R.
It is customary - unless flying a very-low visibility Cat III approach - for airline pilots to disengage the autopilot and hand-fly an airplane the final minute or so of flight. I'm not sure if there are implications to arriving traffic spacing if all aircraft were mandated to fly by autopilot all the way to the landing surface.

I've said upthread: if we could take away just one thing from this incident, it's the need for regulations to catch up and mandate CVR/FDR recordings to include at least 12 hours of data before being overwritten. I'd endorse longer, given that many flights exceed 12 hours length.

I believe the two AC SFO incidents of last year, as well as the AC YLW incident of 2003 were all lost as a result of the next leg being flown prior to retrieval of the recordings. How many of these close-call incidents are acceptable?

jazzsax

It's nto AC's fault the pilot has kids, nor that he doesn't make adjustments for it. I have kids. If i need to sleep, my wife deals with them.

He chooses to bid reserve out of convenience. He knows what can happen. His obligation is to be in ready shape to perform his job. The obligation to say he's too tired solely rests on him, unless he's giving visual indicators that others on crew can pick up on.

My adoptive father used to be an SD/FA with AC for 20 years and at certain times of year (ie summer) bid reserve. It's a part of the scheduling and has it's pro's and cons, but one thing you had to be prepared for was to be called out on short notice, and sleep was a requriement. Not AC's fault his home life isn't setup to accomodate. He picked the job.

There were other errors at play here unfortunately as well but ultimately these come down (in my opinion) to pilot fatigue. Cascaded from there.

longtimeflyin

It is also worth noting that disconnecting the autopilot and flight director is common on Air Canada flights as most approaches are hand flown. In the case of SFO perhaps a more prevalent use of CAT III landings is in order.

eigenvector

In any safety-critical workplace, failure to report a serious incident is grounds for dismissal. Whatever agency licenses commercial pilots in Canada should also be opening an investigation into these two.

tracon

I'll accept your conclusion as written in the report.
I'm not entirely convinced the pilots would have split AC from CP time. Nor would the NTSB have cared as the merger was almost 20 years ago.
YYZ-YVR, can be flown in the same duty day. A long day but it can be done. SFO may be just on the edge of a same day return.

ChrisA330

Transpacificflyer

You answered the question but misplaced the responsibilities. The unions do not set the rules, nor do they discipline the pilots who are non compliant. The airlines have a duty to supervise and to manage the employees. It is an established and uncontested principle of management and of legal liability that the duty of care is related to the responsibilities assumed. That is why pilots are subject to strict alcohol use rules and regulations, while the guy who collects the baggage carts at the airport is subject to less stringent rules and regulations. There is also a system of checks and balances for flight crews alcohol use, much of which relies on peer interaction and supervision.

You are ignoring the Canadian airline sector's policy position to downplay the risk of pilot fatigue. Remember last June when the government was finally about to tweak the minimum rest regulations and the airlines were protesting? We were treated to the cold cost accounting explanation of John McKenna, president of the Air Transport Association of Canada, who said that the requirement for more rest would exacerbate the shortage of pilots problem, because the airlines would need more pilots. At the time he stated that the proposed regulations could increase the demand for pilots by up to 30 per cent. His comment that fatigue needed to be managed that ended with a "what's the rush?" , summed it up succinctly.

The placing of an estimate of 30% on the pilot requirement brings to mind the Ford calculation that it was less costly to pay the cost of litigation arising from the Ford Pinto fuel tank fiasco, than it was to redesign the tanks, recall and replace the defective vehicles. The airline sector is weighing the costs of hiring more pilots vs. the cost of a potential catastrophe, much of which would be covered by their aviation operations insurance.

My take way was that the airlines promote an indifference amongst the pilots such that they can sometimes misjudge their exposure. The airlines' position is not one that emphasizes the need for fatigue caution. It is no different than a workplace which enforces strict safety codes and injury prevention and a workplace that does the bare minimum.