[Peetwo]

Air Canada Flight 759: Seconds from disaster.

I was reflecting on the disturbing evidence that the Australian aviation safety bureaucracy, that is supposedly fully compliant and operating under a ICAO Annex 19 SSP, has been obfuscating it's safety promotion and oversight responsibilities for identified safety issues such as fatigue - see FRMS & the timeline of regulatory embuggerance - for the better part of two decades...

It was therefore heartening to be provided another perfect 'other hemisphere' point of comparison with the NTSB final investigation report into the Air Canada FL759 taxiway overflight at San Francisco Airport on July 7 2017: see abstract here - 
https://ntsb.gov/news/events/Documents/D...stract.pdf

Note the way the NTSB in their recommendations do not pull any punches...  
 

Recommendations

As a result of this investigation, the NTSB makes safety recommendations to the FAA and Transport Canada:

To the Federal Aviation Administration:

1. Work with air carriers conducting operations under Title 14 Code of Federal Regulations Part 121 to (1) assess all charted visual approaches with a required backup frequency to determine the flight management system autotuning capability within an air carrier’s fleet, (2) identify those approaches that require an unusual or abnormal 
manual frequency input, and (3) either develop an autotune solution or ensure that the manual tune entry has sufficient salience on approach charts.
2. Establish a group of human factors experts to review existing methods for presenting flight operations information to pilots, including flight releases and general aviation flight planning services (preflight) and aircraft communication addressing and reporting system messages and other in-flight information; create and publish guidance on best practices to organize, prioritize, and present this information in a manner that optimizes pilot review and retention of relevant information; and work with air carriers and service providers to implement solutions that are aligned with the guidance.
3. Establish a requirement for airplanes landing at primary airports within class B and class C airspace to be equipped with a system that alerts pilots when an airplane is not aligned with a runway surface.
4. Collaborate with aircraft and avionics manufacturers and software developers to develop the technology for a cockpit system that provides an alert to pilots when an airplane is not aligned with the intended runway surface and, once such technology is available, establish a requirement for the technology to be installed on airplanes landing at primary airports within class B and class C airspace.
5. Modify airport surface detection equipment (ASDE) systems (ASDE-3, ASDE-X, and airport surface surveillance capability) at those locations where the system could detect potential taxiway landings and provide alerts to air traffic controllers about potential collision risks.
6. Conduct human factors research to determine how to make a closed runway more conspicuous to pilots when at least one parallel runway remains in use, and implement a method to more effectively signal a runway closure to pilots during ground and flight operations at night.

To Transport Canada:
7. Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low.

And for the Oz take:

Runway mix-ups cause concern

ROBYN IRONSIDE
Aviation authorities are watching the US response to a series of incidents in which aircraft have mixed taxiways for runways.

---

Aviation authorities keep eye on runway mix-ups

Australian aviation authorities are closely watching the US response to a series of incidents in which aircraft have mistakenly lined up for landing on an airport taxiway rather than a runway.

The National Transportation Safety Board released its report this week on an incident in San Francisco last year in which an Air Canada jet came within a couple of metres of landing on four aircraft lined up for departure on a taxiway. With each aircraft filled with passengers and tonnes of fuel, the incident could have been a disaster of monumental proportions. The NTSB report found pilot fatigue was a factor, along with ineffective review of airport information.

But after a series of similar close calls in the past three years, the NTSB is considering whether further measures are needed, such as enhanced cockpit warning systems and new technology in air traffic control towers.

In November last year, a Delta 737 approaching Atlanta in cloudy weather came within 20m of landing on a taxiway, and a month later a turboprop operated by Horizon Air mistakenly landed on a taxiway at Pullman, Washington.

Research has found such ­errors tend to occur at night, when taxiway lights are mistaken for runway lights, and when one of two parallel runways is closed to traffic. Any extra measures to guard against these mistakes have previously been resisted by regulators due to airline opposition and cost concerns.

In Australia, there has been only one confirmed incident of an aircraft landing on a taxiway.

According to the Australian Transport Safety Bureau, a Cessna 206 landed on the taxiway at Archerfield Airport in Brisbane on July 20, 2011. There was no ­effect on any other aircraft as a result of the incident.

The ATSB has also recorded seven other incidents since 2015 relating to aircraft inadvertently approaching a taxiway rather than a runway. “None of these incident involved regular public transport or passenger carrying aircraft,” an ATSB spokeswoman said. “In each instance, air traffic control intervened and advised of the error and the issue was ­resolved.”

Airservices Australia provides air traffic control and does not have any specific concerns in relation to taxiways being mistaken for runways at Australian airports. But a spokeswoman said occurrences such as the Air Canada incident and the subsequent NTSB report were used by Airservices to check and learn.

“We will take this information as a lessons learned activity across our operation,” she said.

“The report does not trigger any need for changes here in ­Australia.”

Pilots believe the more pressing issue is that of fatigue, with the Civil Aviation Safety Authority recently deferring the implementation of new fatigue risk ­management guidelines from October to next September.

Australian Air Line Pilots Association acting president Murray Butt said CASA’s response was hugely disappointing.

Reference: Frank and Ernest.

"..What a bloody shambles. What a disgrace. What a horrendous cost – but most of all; what an unashamed arrogance it is to ignore the worlds best practice set by the USA..."

Indeed 'what a bloody shambles ' the state of aviation safety is in the 'lucky land' Downunda - TICK TOCK miniscule McDo'Naught...  
  

Cont/-

Via the CBC news today:

Air Canada plane was 'a few feet' from 'worst crash in aviation history,' NTSB report says

'Over 1,000 people were at imminent risk of serious injury or death,' board member says of 2017 near-collision

The Associated Press · Posted: Oct 12, 2018 9:29 AM ET | Last Updated: 5 hours ago


The Air Canada captain was supposed to report the San Francisco incident to the airline as soon as possible, but waited until the next day because he was 'very tired' and it was late on the night of July 7, 2017, according to the final U.S. NTSB report. (Darryl Dyck/Canadian Press)

A near-collision of airliners in San Francisco last year was a few feet from becoming the worst crash in aviation history and underscores the need for faster reporting of dangerous incidents before evidence is lost, U.S. safety officials say.

The U.S. National Transportation Safety Board issued a final report Thursday on the incident involving an Air Canada plane, which nearly crashed into planes lined up on the ground at San Francisco International Airport.

The pilots were slow to report the incident to superiors. By the time they did, the plane had made another flight and the cockpit voice recording of the close call was recorded over.

The NTSB says the recording could have helped investigators understand why the Air Canada pilots missed the runway and were about to land on a taxiway where four other planes were idling before they halted their landing.

The Air Canada jet swooped to just 18.2 metres above the ground while passing over other planes packed with passengers waiting to take off shortly before midnight on July 7, 2017.

"Only a few feet of separation prevented this from possibly becoming the worst aviation accident in history," NTSB vice-chairman Bruce Landsberg said in a statement accompanying the report.

Over 1,000 people at risk
Another board member, Earl Weener, said the Air Canada plane came close to hitting another plane and colliding with several others.


A preliminary report Canadian air safety regulators released about a week after the near-disaster said the aircraft, arriving from Toronto, came within 30 metres of crashing into two of four planes lined up to take off. The NTSB's final report says the jet swooped to just 18.2 metres above the ground. (CBC)

"Over 1,000 people were at imminent risk of serious injury or death," he said.

The deadliest aviation accident occurred in 1977, when two Boeing 747 jets collided on a runway in Tenerife on the Canary Islands, leaving 583 people dead.

The Air Canada captain, identified in NTSB documents as Dimitrios Kisses, was supposed to report the San Francisco incident to the airline as soon as possible but didn't because he was "very tired" and it was late. He waited until the next day. By that time, the plane was used for another flight, and the audio loop on the cockpit voice recorder was taped over.

Watch video of the close call released by the NTSB:

Video shows Air Canada plane narrowly missing several planes as it attempts to land on taxiway instead of runway 1:16

The NTSB did not allege that Kisses and co-pilot Matthew Dampier deliberately delayed reporting the incident, but it did say investigators could have gained a better understanding of what the crew was doing before the close call.

The NTSB is considering recommending that cockpit recorders capture the last 25 hours of flying time, up from two hours under current rules.

Critical of reliance on self-reporting
Weener also criticized the airline industry's reliance on self-reporting of safety issues, saying the industry and the Federal Aviation Administration should consider stronger measures to intervene after a dangerous situation.

Weener noted that other pilots were alert enough to turn on lights to warn the off-course Air Canada jet. Yet once the danger passed, he said, they took no action to prompt "an intervention and evaluation of the Air Canada crew."

The five-member board determined last month that the incident was caused by the Air Canada pilots being confused because one of two parallel runways was closed that night. The closure was noted in a briefing to the pilots, and nine other planes had made routine landings after the runway was shut down.

1 controller on duty
The safety board also criticized the FAA for having just one controller on duty at the time of the incident, and recommended better lighting to tell pilots when a runway is closed at night.

"It is noteworthy that the NTSB's recommendations were not directed at Air Canada specifically and address many areas for improvement," said Air Canada spokesperson Peter Fitzpatrick.

Air Canada told the NTSB it has taken steps to increase safety since the event, including emphasizing proper procedures for landing approaches and specific training to familiarize pilots with the San Francisco airport.
The NTSB recommended development of technology to better warn pilots and air traffic controllers when a plane appears to be off-course for a runway.

Ref: https://www.ntsb.gov/investigations/Acci...IR1801.pdf

MTF...P2