[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 from Christine Negroni: http://christinenegroni.com/fatigue-and-...francisco/

Fatigue and Confusion Factors in Air Canada Near Disaster in San Francisco

September 25, 2018 /

[img=565x0]http://christinenegroni.com/wp-content/uploads/2018/05/Air-Canada-near-accident-SFO.jpg[/img]

The pilots whose 2017 flight very nearly landed atop four loaded airliners waiting in line on a taxiway to take off from San Francisco International Airport, failed to manually tune the airplane’s navigation system for the landing. Had they done so, it may have helped them realize they were off the lateral track for the runway, according to investigators looking into the near disaster.

Tuning the instrument landing system frequency was not a typical procedure for the Air Canada crews. This lapse was one but not the only factor that led the pilots of Flight 759 to get “dangerously close to other airplanes” so that at one point it was at the level of the 66-foot high tails of the two United Boeing 787s waiting in the line. A third United airliner, a Boeing 737 and a Philippine Airlines Airbus A340 widebody were also on the taxiway that pilots mistakenly believed to be Runway 28R.

How the experienced Air Canada pilots confused the dimly lit and fully occupied taxiway with the brightly illuminated runway was the subject of the investigation by the National Transportation Safety Board. At its hearing Tuesday, the board indicated that flight preparation, pilot judgment, perception and fatigue were some of many factors that nearly caused a multi-airplane pileup of record-breaking scale.

“This was a very close call,” Robert Sumwalt, the NTSB’s chairman told those gathered for the public hearing at the board’s headquarters in Washington, DC.

Air Canada Flight 759 was finishing a five-and-a-half-hour flight from Toronto to San Francisco on July 7, 2017. By their body clocks, it was 3:00am for the crew. Runway 28 left had been closed an hour earlier – a fact which had been noted on the crew’s 27-page list of NOTAMS, and transmitted via ACARS during the flight. The Airbus A320 was cleared to land on the parallel Runway which is 28R.

The night was clear and the pilots were making a visual approach over San Francisco Bay. But as the two pilots got closer to the airport, the captain asked the first officer to confirm with air traffic control that the runway was clear. The controller said that it was. There were two controllers working that night, but one was out of the tower at the time and the other was occupied with other business.

[size=undefined]The flight continued and as it approached the airport seawall, the pilot of United Flight 1, the first in the line of airliners, saw the plane descending towards him and said over the radio, “Where’s this guy going?”

“The crew sensed something was not right, and they initiated a go-around over the taxiway, avoiding aircraft by very narrow margins,” Sumwalt said. But the near-disaster, which was highly-publicized, prompted the board to take the unusual step of conducting an investigation even though no one was injured and no aircraft was damaged.

Airport surface detection equipment, known as ASDE-X has the capacity to trigger alerts when planes are not lined up over the runway, an enhancement that is being tested at Seattle airport, according to the NTSB investigation.

The NTSB issued seven recommendations including that Canada’s safety authorities review its flight and duty time regulations. The captain of flight 759 would not have been allowed to fly the night of the incident under U.S. rules, the NTSB noted. Transport Canada told investigators it has been trying to update its 22-year old regulations for several years.

The board also issued a general plea to the Federal Aviation Administration to research ways to “more effectively signal a runway closure to pilots during ground and flight operations at night. ”

The safety board did not address the fact that after the plane landed, Air Canada failed to preserve the cockpit voice recorder. The plane was dispatched on further flights so that the information was taped over. It did, however, confirm that the loss of the CVR was detrimental to its investigation. “CVR information, if it had been available, could have provided direct evidence about the events leading to the overflight and the go-around,” the NTSB said.[/size]

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.

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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...  
  

MTF...P2