Disaster Averted! Or Not?

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When I first saw the story yesterday in the Mercury News, that a jet had to execute a go-around at SFO after lining up on the taxiway instead of the runway, my first reaction was that the “disaster averted!” angle was overwrought. Really? I thought. Just like every day, when I tap the brakes to stop at a red light, I guess that’s a disaster averted, too. After all, if I didn’t stop, carnage would likely ensue. Sure, a mistake was made by the A320 crew, but mistakes are always made, and that’s why there are checks in place, to be sure those mistakes don’t turn into smoking holes. Those checks worked, at SFO, just as they should have, and all went on as usual. No story here.

But then I listened to the audio (you can listen to it here, courtesy of atclive.net) and my heart skipped a beat. An A320 crew member called ATC to ask about the “lights on the runway.” The controller calls back that he’s “confirmed, clear to land,” and says “There’s no one on 28 Right but you.” OK, says the pilot, then a new voice chimes in. “Where’s this guy goin’? He’s on the taxiway.” As far as I know, that voice hasn’t been identified, except as maybe another pilot on the frequency. But in this case he might be labeled as the voice of reason, the clear light of reality, the last chance of averting disaster. “Go around,” ATC pipes in, and the crew goes around, all is well, nothing bad happened.

So how close a call was it? Would the crew have figured it out in time to react? It was almost midnight — pitch dark. It’s not clear exactly how high the A320 was when they made the call to ATC, but they were on final approach. It’s also not clear exactly what they were doing in the cockpit or how they got lined up wrong in the first place. If that voice hadn’t piped in … would ATC have figured it out in time to warn the A320 crew? It seems inevitable the crew would have figured it out shortly — but would they have figured it out in time to pull up and go around safely? An A320 scrolling down final has an awful lot of momentum. We’re lucky that we can sit around today and ask these questions, and not have to be thinking about all that wreckage at SFO.

Comments (34)

"It was almost midnight - pitch dark."
How many runways at SFO have blue edge-lights?

Posted by: Tom Yarsley | July 12, 2017 3:51 AM    Report this comment

News reports (if you want to believe them) suggest the Airbus got down as low as 175' AGL before the engines finished spooling up and it climbed out. I don't know about the horizontal separation or how far it was from the threshold.

Another complication was the construction on Runway 28L; its lights were turned off. From a long way out, you now have two rows of lights - Runway 28R (the *left* row), and the taxiway (the *right* [but wrong] row). Yes, the wrong color, but it's late, target fixation, get-home-itis, etc., (i.e. - the human factor).

Unanswered is whether or not Air Canada routinely uses the ILS and/or LOC on a night VFR approach.

Thank goodness everyone is around to talk about it. Hopefully the explanations (and solutions, if needed) will be equally positive.

Posted by: Kirk Wennerstrom | July 12, 2017 5:45 AM    Report this comment

Maybe the A320 crew needs to talk to Harrison Ford...

Posted by: A Richie | July 12, 2017 7:20 AM    Report this comment

The story says, "Okay, says the pilot, then a new voice chimes in. "Where's this guy goin'? He's on the taxiway." As far as I know, that voice hasn't been identified, except as maybe another pilot on the frequency. But in this case he might be labeled as the voice of reason, the clear light of reality, the last chance of averting disaster."

Who owned that new voice?

Luck is not a robust barrier?

Posted by: Bill Corcoran | July 12, 2017 7:49 AM    Report this comment

The story says, "Okay, says the pilot, then a new voice chimes in. "Where's this guy goin'? He's on the taxiway." As far as I know, that voice hasn't been identified, except as maybe another pilot on the frequency. But in this case he might be labeled as the voice of reason, the clear light of reality, the last chance of averting disaster."

Whose voice was the new voice?

Luck is not a robust barrier.

Posted by: Bill Corcoran | July 12, 2017 7:52 AM    Report this comment

Since this all just yakking around the virtual water cooler, I am betting that the unknown voice came from one of the planes on the taxiway, seeing the landing lights of the Air Canada flight bearing down on them.

Posted by: MARK NEUMANN | July 12, 2017 8:52 AM    Report this comment

I'll be honest. When I saw the initial comments on the article here hawking about overblown news stories, I was pretty astonished. It was immediately apparent listening to the recording that the AC pilot was uncomfortably low while still lined up on the TWY.

Kirk's point about the 28L runway lights being out is an interesting one. I'm checking the SFO NOTAMS and there is one for the runway being closed intermittently and one about the approach lights out of service, but none specifically do call out the runway lights being off.

Posted by: Joshua Levinson | July 12, 2017 9:13 AM    Report this comment

Note this is the same runway that Asiana 214 hit the seawall exactly four years to the day earlier.

Posted by: A Richie | July 12, 2017 9:16 AM    Report this comment

SFO rarely uses the ILS28R when VMC. It's the Quiet Bridge visual. A complex approach that does not appear in my A320 database and must be build. My company posts two pages of cautions including getting the "TOO STEEP APPROACH" message on the FMS. It converges towards 28L on an angle not lined up on centerline until close in final. It has altitudes to comply with. No excuses for the pilot but there's a systemic problem with SFO in regards to separation. Airport/approach design is part of the problem. I'm in there at least once a month.

Posted by: SHANNON FORREST | July 12, 2017 5:01 PM    Report this comment

I wonder whether the tower has the 28R ALSF-II approach light system active on the night of the incident--and if not, why not? Even operating it as a SSALR on low intensity, the rabbit might have given Air Canada a hint that they weren't lined up on the runway.

Posted by: MICHAEL MATISKO | July 12, 2017 5:48 PM    Report this comment

Definitely a disaster averted. This was not braking for a stoplight. This was driving up an off ramp about to go the wrong way on the highway.

Posted by: Andy Goldstein | July 12, 2017 8:47 PM    Report this comment

Three days after the fact, it now devolves into what probabilities do you believe in.

I heard a talking head aviation expert on NPR this morning say that, yeah, it looks pretty bad. But he thought the likelihood of the crew continuing on and landing into the face of all those stationary lit-up airplanes was relatively low. I think that's reasonable. This was a low-probability, high-consequence incident.

It doesn't sound like the crew was exactly clueless. They saw something they didn't like and queried it and given how quickly the local controller issued the go around directive, I wonder if he was just figuring it out, too. Kudos to the see-something-say-something pilot looking at an array of landing lights approaching at 140 knots.

Now it remains to find out how and why they got lined up on the wrong pavement to begin with. I'm sure no one reading this blog would ever do that, so this will be an especially bright illumination round.
Here's the Quiet Bridge visual:

resources.globalair.com/dtpp/globalair_00375QUIETBRIDGE_VIS28LR.PDF

Posted by: Paul Bertorelli | July 13, 2017 9:36 AM    Report this comment

Fatigue? Long day/night? I agree Paul, there was awareness of something not quite in place. Would be of interest to find out the physical and mental efficiency of the crew at the time.

Posted by: Rafael Sierra | July 13, 2017 9:49 AM    Report this comment

Definitely some fatigue I think. Looking at the flightaware track log, I see altitudes around a three minute gap that make the 175' altitude figure reasonable. That's less than a half mile from the threshold!

I also looked at a cockpit video of a 172 landing on that runway and don't see how one could mistake the taxiway for the runway, but a combination of fatigue, fixation on the bright lights (beyond which the blue lights might have been difficult to see), and the likely absent left runway lights may explain what happened. I am guessing the crew was quite a bit more awake and aware on their second approach!

Posted by: Eric Reed | July 13, 2017 3:50 PM    Report this comment

From Transport Canada: "On Jul 11th 2017 the Canadian TSB reported the crew of C-FKCK asked ATC to confirm landing clearance as they were seeing lights when the aircraft was 0.6nm before the runway threshold. The controller was coordinating with another facility when a flight crew of another airliner taxiing on taxiway C queried ATC where AC-759 was going and stated it appeared the aircraft was lined up with taxiway C. AC-759 had already overflown taxiway C by about 0.25nm when ATC instructed the aircraft to go around. 4 aircraft were on taxiway C at the time of the occurrence. It is estimated that AC-759 overflew the first two aircraft by 100 feet, the third by about 200 feet and the last by 300 feet. The closest lateral proximity between AC-759 and one of the aircraft on taxiway C was 29 feet."

Posted by: Kirk Wennerstrom | July 14, 2017 5:25 AM    Report this comment

Observation: A precursor is a situation that includes some, but usually not all, of the causation of a severely harmful event.

Observation: A near miss is a situation in which a severely harmful event was averted by a fragile barrier.

Observation: The 2017 Air Canada Flight 759 Runway/ Taxiway Mix-up Go Around was a precursor to the worst accident in aviation history.

Observation: The 2017 Air Canada Flight 759 Runway/ Taxiway Mix-up Go Around was a near miss to the worst accident in aviation history.

Posted by: Bill Corcoran | July 14, 2017 7:29 AM    Report this comment

Flying into LAS at night is interesting. City lights everywhere about the airport. It's difficult to positively identify the runway. I was on the ILS RWY 01L, needles centered, followed by several 737s and decided to request from the tower to turn runways lights off and on. It made a difference, runway identified, several thank yous transmitted.

Posted by: Rafael Sierra | July 14, 2017 9:16 AM    Report this comment

Holy moly, 29 feet. We just avoided another Tenerife...

Posted by: A Richie | July 14, 2017 9:25 AM    Report this comment

It would be interesting to see a transcript of the cockpit voice recorder.

Posted by: John McNamee | July 14, 2017 10:33 AM    Report this comment

The AirCanada flight was making a visual approach. These approaches are often hugely underestimated concerning risks involved. Time pressure and convenience, as well as a can-do mentality, often lead to a visual approach.
But in airline operations, we must ask ourselves if the risks involved are fully mitigated. Multiple parralel runways or unusual light set-ups (approach lights inop, works, weather) might very well lead to situations where the risks cannot be mitigated sufficiently.
An airline pilot not choosing to fly a visual approach is not being a whimp... he/she is conducting a professional flight operation with a complex machine in complex environments. These guys/gals did not porposely line up on a taxiway. So we must all keep an open mind to be able to unde stand the decision making proces and give the next crew a better chance of avoiding the same situation.

Posted by: Mauro Hernandez | July 14, 2017 10:40 AM    Report this comment

Richie:
It was 29 feet LATERALLY. The closest vertical separation was 100 feet. But I still can't figure out how two ATPs can almost land between two rows of BLUE edge lights, regardless of the count of parallel runways.

Posted by: Tom Yarsley | July 14, 2017 11:26 AM    Report this comment

"But I still can't figure out how two ATPs can almost land between two rows of BLUE edge lights, regardless of the count of parallel runways."

It's simple. They made a mistake. Humans do that for all kinds of inexplicable reasons regardless of how many back-up systems and procedures we put in place. If you examine the relatively few recent airline accidents, it becomes clear that human error still inhabits the system.

Posted by: Paul Bertorelli | July 14, 2017 2:02 PM    Report this comment

Observation: The causation of the Air Canada Flight 759 Runway/ Taxiway Mix-up included the absence of any effective barriers to prevent the mix-up. Fortunately there was at least one effective barrier to the approaching aircraft's actually landing on the aircraft lined up on the taxiway. The robustness of the first effective barrier (the unknown voice) is questionable.

Posted by: Bill Corcoran | July 14, 2017 3:23 PM    Report this comment

Ok Yars, not sure exactly how they define lateral separation; is it wingtip to wingtip as projected on the ground? If so, and it was 29 feet laterally, then he must have been either not completely lined up on taxiway C or already turning away at the time of closest approach to the first airliner. So, let's assume 100 feet min separation on the y-axis and 29 feet min separation on the x-axis. Pythogoreas says that's 104 feet from sheet metal to sheet metal (or composite to composite). Still, too darn close for comfort with 1000 souls aboard! Thank God... I'm glad this is only an academic exercise.

Have a good weekend!

Posted by: A Richie | July 14, 2017 4:21 PM    Report this comment

A visual with the localizer dialed in is a good thing.

Posted by: Rafael Sierra | July 14, 2017 4:28 PM    Report this comment

This was not "a mistake" but gross negligence. This flight crew failed to exercise command authority over their aircraft. Many of us seem to be minimizing the gravity of this flight crews' negligence and explaining away the enormity of their failure, some of us by complaining about the burden of actually using automation(!) to protect us from ourselves, or blaming the complexity or perceived poor design of the airport, airspace, approach, whatever. Hogwash.

This was an abject failure to apply the most rudimentary Cockpit Resource Management (CRM). CRM is intended to mitigate the predictable mistakes brought on by issues such as fatigue and unusual runway, lighting, construction and approach outages. CRM aims to do this by disciplined and diligent Management of available Resources within the Cockpit. By "resources" is meant, among other things, backup navigation systems to verify and validate the primary navigation system in use. By "discipline" is meant the presence of mind and foresight to configure said resources appropriately for the current and anticipated future navigation tasks, including to configure backup navigation for likely tasks.

In this case, the primary navigation system selected for the Visual Approach was the flight crews' eyes. The backup would then be any of the seven published approaches to runway 28R, or other techniques available using FMS or conventional navigation instruments. The absence of discipline to configure something - anything! - to act as backup was negligence of the first order. To continue the approach despite the visual evidence that the selected landing surface was contaminated with the lights of airplanes (indicating, perhaps, the presence of actual airplanes as obstacles on the landing surface!) and to fail to initiate a go-around until instructed to do so by Air Traffic Control (at the behest of an anonymous third party) attests to not just negligence, but a complete abdication of control authority.

When your ONE chosen navigation instrument (your eyes) tells you that the path ahead is not safe (airplane lights on the "runway") yet you choose to continue the approach (not believing your own eyes) and abandon it only when told to do so by somebody else, you have adopted a grossly negligent behavior pattern that will, likely, one day prove fatal. Thank God you didn't take a thousand others with you on this day!

Posted by: DAVID GALL | July 14, 2017 7:19 PM    Report this comment

Incompetence.

Posted by: Rafael Sierra | July 14, 2017 11:22 PM    Report this comment

Gentlemen, it is too easy and very wrong to say "incompetence", "gross negligence", or saying the made gross mistakes. In the complex world of complex aircraft operations in complex environments it would do ALL aviation professionals a disservice. They deserve a proper and professional look at the sequence of events followed by a correct conclusions and recommendations.
This would benefit the whole aviation community, the customers using the system, and also YOU who iare baselessly yelling accusations prior to the facts.

Posted by: Mauro Hernandez | July 15, 2017 2:02 AM    Report this comment

@David Gall, yours is the most hard-hitting post on this incident I've read across 3 different sites, 2 of them being well known aviation forums.
Few others are so bold as yourself. One who was nearly as blunt suggested firing the training dept, given that at Halifax in a very botched landing 2 years ago an aircrew almost sent themselves and all their pax to the morgue.
Historically the swiss cheese model seems to be applicable to many ac accidents/incidents, and in this case too there were many "holes" that lined up to almost bring about disaster.
A common thread for both screwed up landings may have been "It wasn't in our SOPs". But you are saying that as professionals, pilots have a responsibility to use everything at hand to catch errors themselves. In this case through using an onboard nav system as a secondary check. Makes sense to me, as mere SLF.

Posted by: Stewart Shaw | July 16, 2017 6:11 AM    Report this comment

"...you choose to continue the approach (not believing your own eyes) and abandon it only when told to do so by somebody else..."

As I understand it, the crew had already initiated the go-around process by the time the tower called for it.

But, none of us are privy to all that occurred that night. We have bits and pieces (the tower controller was working alone and not monitoring, the Air Canada crew's 'Body Clock' was at 3AM, Runway 28L lights were partially or completely off, etc.), but not the whole picture.

I agree that his should Never Happen(tm). But it (almost) did - if there's an unknown hole in the swiss cheese model, hopefully it'll be found and plugged up.

Posted by: Kirk Wennerstrom | July 16, 2017 10:25 AM    Report this comment

@Stewart Shaw: "...you are saying that as professionals, pilots have a responsibility to use everything at hand to catch errors themselves."

Almost.

For Airline Transport Pilots conducting Common Carriage in Air Transportation (Part 121 operations or ICAO equivalent), the burden goes beyond "mere" responsibility to the level of a Profession: a moral mandate, an ethical obligation, and a fiduciary relationship with not just the travelling public, but also the general public at large (don't crash on their houses, etc.). At this level, we are no longer just pilots, we are keepers of a particular public trust and confidence. We must conduct ourselves accordingly.

We are "doctors of the air" and potentially open to a charge of malfeasance or malpractice similar to what a doctor (or lawyer) might face. It's not good enough to "almost always" and to "usually" and to "most of the time" apply due diligence; it is, by definition, negligent on the occasion of each and every exception to "always." It is incumbent on us to not just "catch errors," but to anticipate likely situations and imagine plausible scenarios and to proactively mitigate such events before they can rise to the level of "error." In airline operations, we must ask ourselves at every opportunity whether the risks involved are fully mitigated and act in response so as to ensure that they are fully mitigated.

Posted by: DAVID GALL | July 20, 2017 12:43 AM    Report this comment

Lights on the "runway" should have been sufficient to prompt a go-around. The pilots should not have waited to ask about the lights.

The unknown voice was a lucky barrier.

What is the standard of action?

Posted by: Bill Corcoran | August 3, 2017 7:54 PM    Report this comment

The lights on the "runway" should have prompted a go-around. The pilots should not have waited to ask about the lights.

The unknown voice was a lucky barrier.

What is the standard of action?

Posted by: Bill Corcoran | August 3, 2017 7:57 PM    Report this comment

To me the conversation between 759 and ATC indicates that ATC was not aware of the mix-up and would have done nothing to resolve it.

What do you think?

Posted by: Bill Corcoran | August 4, 2017 6:11 AM    Report this comment

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