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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 Sep 27, 2018, 5:42 pm
  #946  
 
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Originally Posted by kjnangre
I think if AC had ANY interest whatsoever in taking a leadership position, they would have done it by now. Just a couple of days after the incident (15 months ago), it was widely known that pilot fatigue was a big part of this incident.
Perfect time for Porter or Westjet to meet or exceed current US regulations. They can use this to mock AC in print and video advertising by saying things like:

"19 hours after you wake up you're likely very tired and prone to errors or falling asleep. So are our competitor's pilots.'

The Airline industry has proven time and time again that all they will do is meet the minimum and spend huge sums of money lobbying to keep any requirements from increasing. Hence we have 30min CVRs. zero recent AC incident flights have retained this data because of.... "quick" overnight turns, pressing the pesky self test/erase button, etc.
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Old Sep 27, 2018, 9:21 pm
  #947  
 
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Originally Posted by KenHamer
From obsessively watching Mayday (which I am about to start using as a training tool) there seem to be a fair number of aviation incidents where one of more of the underlying causes happened hours, days, weeks or even years earlier, and certainly on a previous flight.
The reason we know about these causes is that they were logged. Perhaps not by voice, but in aircraft journey logs, maintenance entries or on company servers. My opinion is that specific conversations and 'who said/heard what and when' become less pertinent the further back from the incident one goes.

Originally Posted by KenHamer
Clearly you wouldn't reasonably be able to store, manage, and log years of CVR data. But perhaps 30 days might work.
Why not? Stored on a ground-based server after having been transmitted in real-time, it's entirely feasible.

Originally Posted by KenHamer
In any case, anything over the current 30 minutes would be a massive improvement.
Yes it would. As long as it's a meaningful and not incremental gain. We won't have advanced much if new legislation mandates 120 minute CVRs for example.

Originally Posted by KenHamer
On the other hand, even small commercial vessels like tugs now have systems on board that allow the entry of waypoints to create a route. Typically they immediately graphically show where that route will take you directly on the chart...even if you miss one of those oopies, typically after the route is entered you can scan it, and the processor will immediately spit out a report indicating where the depth is too shallow, you're too close to land, you're going under a bridge that's too low for you mast, you'll be in a prohibited or restricted area, and so on. More advanced systems might even inform or warn you of strong currents and maybe even recommend route alterations to take advantage of or mitigate currents. Others might interface with the weather system automatically any warn you of storms you might want to avoid. So even before you've left the dock you have a good idea of where you're going and more importantly that the route is safe...Equally independent of the programmed route, your chart system probably has an anti-grounding feature that can tell you if you continue on this course for "X" minutes / "Y" nautical miles you're going to run aground, or hit that bridge, or whatever...On top of this there will be some one monitoring the RADAR...Add to that the AIS system that will show you the position of all the commercial and many recreational targets near you. Moreover, both the RADAR and the AIS have the ability to warn you of potential collisions, and where they might happen in terms of both time and distance...All of these devices might be duplicated, triplicated or more, and are likely all interfaced together. Many items can do multiple related tasks; both a GPS and a doppler speed log can tell you your speed over the ground, but the log can also tell you your speed through the water, and in shallow waters (i.e. <100 m) also tell you your depth just like the depth sounder. AIS and RADAR can both be used for collision avoidance, while both GPS and RADAR can be used for position fixing...Note that all of these devices operate autonomously...Why don't they have a radio/RADAR altimeter, barometric altimeter and GPS altitude continually evaluating each other's performance and the plane's position and altitude, course, and speed, to determine that in "X" minutes / "Y" nautical miles things are going to get ugly...That mountain up ahead was there before humans walked the earth, and will likely be there long after humans have gone extinct. Why isn't there some independent, autonomous device that knows where the mountian is, knows where the plane is, and can figure out the difference?
All of this exists and is affordable on the individual level. Much is available in subscription-based software programs I use on my iPad when flying. Panel-mounted systems in biz jets, rich folks' turboprop toys and single-engine bush planes have been installed as described above for years, if not decades.
Originally Posted by KenHamer
As best I can tell all of this magic technology is available to the airline industry, but is only implemented far enough for the airlines to be able to say, for example, "yes we have GPS." They seem to be using it to the most minimal extent possible, instead of leveraging all the information for all of the devices and technologies to be able to understand exactly and precisely where they are at all times, and to warn them if something untoward is about to happen.
Note that much of this has been introduced into the cockpits of newer airline models from the major manufacturers. Refitting a fleet of 25yr old A320s is not a cost-effective option, given the exceedingly low rate of errors in western commercial aviation. All of this gadgetry certainly helps with situational awareness, but the old steam gauges and needles work to a satisfactory level (in aviation, the term "satisfactory" is measured in the millions of flight hours without incident).
Originally Posted by KenHamer
Perhaps it's the cost. But I'm guessing for the total costs accrued as a result of the Halifax hard landing crash, Air Canada could have made major upgrades to all of their systems on all of their planes.
The old industry nugget says: "you think safety is expensive, try having an accident". Airline safety records can be equated to the stock market (or pro athletes' stats or a hundred other things): past performance is not an indicator of future results. There is no failsafe option, and deciding how much to invest into the 'latest & greatest' remains a delicate balance for which there is no easy answer.
For me, investment in a safety culture rather than buying safety gadgets is a much better use of resources.
Originally Posted by KenHamer
If I had my druthers I'd eliminate all ILS and related ground/airport/waypoint based navigation aids tomorrow.
They are being systematically replaced by more modern navigation aids, but removing them without careful thought would be severely detrimental to the countless other users who rely upon them. The sky is filled with aircraft that don't operate under CAR 705 (airline) operations.

Originally Posted by RangerNS
Why after a 4 hour flight does someone not remind - and demand positive acknowledgement from - pilots of the NOTAM they didn't read before?
Workload
Trust
Empowerment
Professionalism

This is a very slippery-slope suggestion.

Originally Posted by expert7700
Perfect time for Porter or Westjet to meet or exceed current US regulations. They can use this to mock AC in print and video advertising by saying things like:

"19 hours after you wake up you're likely very tired and prone to errors or falling asleep. So are our competitor's pilots.'
Oof. Thankfully, the aviation community is unlikely to descend to such base and inflammatory tactics. It remains an industry in which advancements in the name of collective safety are shared by all; in which pilots remain simpatico regardless of the logo on the tail. Resorting to a US-style of 'demean your opponent' marketing would undermine generations of positive work and would likely backfire in the faces of any operator willing to stoop to that extent.
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Old Sep 28, 2018, 12:17 pm
  #948  
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Originally Posted by Bohemian1
Hopefully AC will take a leadership position without waiting for Transport Canada (or whatever governing body) and attempt to mitigate the incidence of tired pilots out there.
No doubt they will take leadership and do something that will cost them money.
No doubt.
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Old Sep 28, 2018, 11:10 pm
  #949  
 
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Originally Posted by kjnangre
I think if AC had ANY interest whatsoever in taking a leadership position, they would have done it by now. Just a couple of days after the incident (15 months ago), it was widely known that pilot fatigue was a big part of this incident.
Originally Posted by rankourabu
No doubt they will take leadership and do something that will cost them money.
No doubt.
AC's (mainline) current duty day regulations exceed the TC regulations. In addition, they actively track routes and fatigue reports (as well as controlled rest reports) to help determine where things need to change. This problem, however is a lot more difficult than just applying blanket regulations (either by TC or AC). Using the proposed regulations (or even the FAA based regulations) certain pairings would not be possible anymore (such as, depending on when the crew starts, YYZ-YVR-YYZ). That sort of pairing, which may not have been very fatiguing under the current regs, is all of a sudden deemed too fatiguing under the new regulations. Further, a lot of the resistance to this change isn't only from AC but from smaller 705 operators (705 operators include anyone operating a multi-engine aircraft with a max certified takeoff weight of 19,000 lbs and carrying 20 or more passengers - about 95% of all air travel is on a 705 operator).

It's very easy to make blanket statements about this incident and how regulations need to change but Canada has a much more complex operating environment compared to the US making it harder to implement regulations. I'm not suggesting that the regulations around fatigue stay the same but just reminding everyone that the US and Canadian have very different operating environments making it a bit more challenging to find a solution that works for all parties in Canada.
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Old Sep 29, 2018, 12:17 am
  #950  
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Originally Posted by C-FMWQ
AC's (mainline) current duty day regulations exceed the TC regulations. In addition, they actively track routes and fatigue reports (as well as controlled rest reports) to help determine where things need to change. This problem, however is a lot more difficult than just applying blanket regulations (either by TC or AC). Using the proposed regulations (or even the FAA based regulations) certain pairings would not be possible anymore (such as, depending on when the crew starts, YYZ-YVR-YYZ). That sort of pairing, which may not have been very fatiguing under the current regs, is all of a sudden deemed too fatiguing under the new regulations. Further, a lot of the resistance to this change isn't only from AC but from smaller 705 operators (705 operators include anyone operating a multi-engine aircraft with a max certified takeoff weight of 19,000 lbs and carrying 20 or more passengers - about 95% of all air travel is on a 705 operator).

It's very easy to make blanket statements about this incident and how regulations need to change but Canada has a much more complex operating environment compared to the US making it harder to implement regulations. I'm not suggesting that the regulations around fatigue stay the same but just reminding everyone that the US and Canadian have very different operating environments making it a bit more challenging to find a solution that works for all parties in Canada.
Without disagreeing with you, how do you feel about a 6 hour flight departing at 9pm EDT for a crew living in EDT?

I don't particularly care about crews doing 10 hour days of 11am to 9pm, if they're alert. But AC 759 alone can be extremely taxing on the body. I've flown it as a passenger after being in that time zone for a few days, and I'm not very alert upon landing.
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Old Sep 29, 2018, 12:40 pm
  #951  
 
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Originally Posted by canadiancow
Without disagreeing with you, how do you feel about a 6 hour flight departing at 9pm EDT for a crew living in EDT?

I don't particularly care about crews doing 10 hour days of 11am to 9pm, if they're alert. But AC 759 alone can be extremely taxing on the body. I've flown it as a passenger after being in that time zone for a few days, and I'm not very alert upon landing.
Fatigue is an interesting beast. Its not uncommon to take a nap before flights like this but I agree with your point that staying up until 3am body clock time may put you in a circadian low -- how that affects you is really dependent on the individual. You bring up a good point though; blanket regs may not be the only thing needed here. Perhaps a YVR or YWG based crew is better off flying 759? A lot of different solutions but a silver bullet may be hard to come by.
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Old Sep 29, 2018, 5:15 pm
  #952  
 
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Originally Posted by C-FMWQ
Fatigue is an interesting beast. Its not uncommon to take a nap before flights like this but I agree with your point that staying up until 3am body clock time may put you in a circadian low -- how that affects you is really dependent on the individual. You bring up a good point though; blanket regs may not be the only thing needed here. Perhaps a YVR or YWG based crew is better off flying 759? A lot of different solutions but a silver bullet may be hard to come by.
This was a relief pilot. How would you work a YYZ SFO flight with a YVR based relief pilot?
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Old Sep 29, 2018, 9:40 pm
  #953  
 
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Originally Posted by YEG_SE4Life
This was a relief pilot. How would you work a YYZ SFO flight with a YVR based relief pilot?
What do you mean by relief pilot? This was flown by a narrowbody Airbus crew.

A YVR crew could fly YVR-YYZ, layover, then fly 759 then next day. On the A330 fleet, all flights from YYZ have the flight crew deadhead in from YUL. I suggested that as they are based on the west coast and may be able to better handle the timezone change. In reality, since not all pilots live where they are based, it might not be all that practical to do that.
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Old Sep 29, 2018, 10:01 pm
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Originally Posted by C-FMWQ
What do you mean by relief pilot? This was flown by a narrowbody Airbus crew.
He meant reserve pilot, if I may clarify on behalf of YEG_SE4Life.

If Canadian airline pilots get the fatigue rules changed to the extent they seek, it will undoubtedly mean significantly less flexibility for the airlines, a drastic rationalization of flights & frequencies, and exacerbate the impending crunch of qualified pilots, not just locally, but worldwide. It will make a negligible impact on safety, in my opinion. Look at the pilots' ask through a collective agreement lens rather than a public welfare or crew health & safety lens, and the picture focuses in a rather different way.
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Old Sep 29, 2018, 10:47 pm
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Originally Posted by CZAMFlyer
He meant reserve pilot, if I may clarify on behalf of YEG_SE4Life.

If Canadian airline pilots get the fatigue rules changed to the extent they seek, it will undoubtedly mean significantly less flexibility for the airlines, a drastic rationalization of flights & frequencies, and exacerbate the impending crunch of qualified pilots, not just locally, but worldwide. It will make a negligible impact on safety, in my opinion. Look at the pilots' ask through a collective agreement lens rather than a public welfare or crew health & safety lens, and the picture focuses in a rather different way.
Summed up well.
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Old Sep 29, 2018, 11:28 pm
  #956  
 
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This CA was not scheduled to work this flight. The scheduled pilot was unable. Instead of putting a pilot based where the flight is scheduled to leave, would you have the airline just cancel flights, when a pilot cannot work his schedule? Or, should the plane sit in YYZ until they fly a YVR based pilot to fly from YYZ to SFO? And if they do, how fatigued will that pilot be by the time s/he deadheads YVR YYZ and then flies YYZ SFO? Is it not possible that the YVR pilot also would have kids making a fuss that interrupted his/her sleep, prior to being called out for the deadhead? That appears to be the real cause of the fatigue in this particular incident.
I am merely suggesting that things aren't that simple.
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Old Sep 29, 2018, 11:57 pm
  #957  
 
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Originally Posted by YEG_SE4Life
This CA was not scheduled to work this flight. The scheduled pilot was unable. Instead of putting a pilot based where the flight is scheduled to leave, would you have the airline just cancel flights, when a pilot cannot work his schedule?
Or you do like other airlines do at their main hubs and have crews on standby just for that eventuality, so a flight can leave with a rested crew even if the originally scheduled crew is unable to fly.
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Old Sep 30, 2018, 1:33 am
  #958  
 
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Originally Posted by C-FMWQ
Using the proposed regulations (or even the FAA based regulations) certain pairings would not be possible anymore (such as, depending on when the crew starts, YYZ-YVR-YYZ).
Boo hoo. If a crew cannot fly a late night YYZ-YVR and do a redeye turn YVR-YYZ, then so be it!

I'd LOVE to see this affect some of the separate (for book keeping purposes only) low cost contract carriers who run monopoly routes for AC to the smaller cities. During EYW, at stations like St Johns NL, Thunder Bay ON, and Charlottetown PEI, we had late 1am-2am arrivals, where the flight crew "rested" in the crew lounge at the airport until they flew the 5/6am departure. How does this not interfere with sleep cycles?
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Old Sep 30, 2018, 2:51 am
  #959  
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Yet, with all this hair pulling the system worked and as @CZAMFlyer correctly points out, the solution is advancing a safety culture, not more tech, lines of code or worse the dead-hand of regulation.

What is a near miss btw?

in this case, An error in the system was detected and the Reason model of providing unaligned defenses worked just fine...

Can industry learn from this NON-EVENT, of course, but what was ATC in SFO main purpose in life - catch system errors which will always exist even if we fully automate flying as the error will just appear buried in code somewhere.

ps...would you buy a car that had as many bugs as typical software and needed ongoing updates - liveware / humanware interfaces are NOT infallible but pretty useful to have them both checking the other

Last edited by skybluesea; Sep 30, 2018 at 2:53 am Reason: sp
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Old Sep 30, 2018, 6:30 am
  #960  
 
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Originally Posted by Jagboi
Or you do like other airlines do at their main hubs and have crews on standby just for that eventuality, so a flight can leave with a rested crew even if the originally scheduled crew is unable to fly.
I am not going to pretend to know what other airlines do. This particular pilot had put himself on stand by. That is why he was called to work. Do other airlines do it differently?
And, FYI, I was responding to the notion that a YYZ SFO night flight should be flown by a YVR crew. If we continue with that notion, should each hub have stand by crews from various bases, just to keep sleep cycles in sync?

Last edited by YEG_SE4Life; Sep 30, 2018 at 9:05 am
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