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SFO near miss might have triggered aviation disaster

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Re: SFO near miss might have triggered aviation disaster

#291

Post by kbutler »

ncallaway wrote: post #259
briandear wrote: post #238

Earlier quoted context omitted.

It’s SFO though. And he’s an airline captain, so he should know.

The absolutely stellar safety record of the airline industry exists because they have repeatedly and consistent pushed past human error as an explanation for a crash. Understanding that if a human made this mistake, another future human will likely make the exact same mistake, they push to understand _why_ an airline captain that should know made this error. Then try to correct for that. If every crash was written of…

Someday, perhaps computer programmers will start applying this principle.

Re: SFO near miss might have triggered aviation disaster

#292

Post by bronco21016 »

cyberferret wrote: post #54
wfunction wrote: post #40

Earlier quoted context omitted.

Thank you! That raises the question, (a) why is there no kind of warning system for when you're about to land on the wrong runway (there's a GPS system in the aircraft that knows where you're going, right?) and (b) why is the pilot (or at least co-pilot) never looking at a map on final approach? Is it really that dangerous for anyone to take a quick glance?

Yes, autolanding, or if the pilot was using ILS (Instrument Landing System), then this problem would almost never happen, as they would be aware there was a problem. However, most pilots eschew automation especially on short finals, and prefer the 'hand fly' the aircraft in so that they can maintain complete control over the aircraft. Not a bad thing, and pilots want to actually fly the plane at crucial times. When h…

I have to disagree about the maps and charts being stowed away at this point.

I personally can only think of one 121 certificated carrier in the US that isn't using an EFB setup. These are typically mounted to the side of the pilot and there's no reason at all they can't still be on and open to either the airport diagram or the approach in use. In fact I frequently do this and do reference it on approach to parallel runways and to reference the turn offs for taxi.

As this discussion progressed, the lack of progress in the FAA adopting technology was addressed. It seems to me that the FAA is completely missing the boat on tons of safety to be gained with these EFBs due to the bureaucracy. My carrier was recently certified for EFBs and the vendor has the capability to have GPS geo-referenced charts but because of the complicated certification process the airline chose to get certified without to save money and time. As part of that we also received devices without GPS so now there's no way it's coming until the next cycle of devices. Personally I can't understand why there would need to be additional certification for something GA pilots have been using for years now.

Re: SFO near miss might have triggered aviation disaster

#293

Post by jon-wood »

wfunction wrote: post #268
njloof wrote: post #265

Earlier quoted context omitted.

Also, iPads have become a vector for bringing new tech into the cockpit, since it's not physically installed in the plane and therefore doesn't require certification. You can pull up charts, set courses and upload to the autopilot.

You can "upload" something from your iPad to the autopilot system without any kind of certification?

I have a feeling by "upload" they mean the iPad can display all the numbers that need to be manually punched into your autopilot.

Re: SFO near miss might have triggered aviation disaster

#295

Post by thrill »

PhasmaFelis wrote: post #178
dx034 wrote: post #120

Earlier quoted context omitted.

It's likely that the controller would've seen it as well after the Air Canada pilot indicated that he saw planes on what he believed was the runway. Even if not, the pilot would've probably aborted the landing since he saw the other aircrafts. So it was certainly a dangerous situation but I doubt that a crash would've happened without that pilot's comment (it was certainly helpful though).

Yeah. When reading about modern air disasters, you often hear that five different things had to go wrong at once for them to happen. In this case, one or two things went wrong, the rest of them went right, and everything was fine.

This is spot on. The strength and weakness in doing something as complex as safely landing an airliner full of people is all in the capability of the human mind to use technology. Especially in flying, I think (I did this for a career, a whole other career ago) it's easy to have everything going smoothly, then some "minor" thing be out of expectation, but hey things are going smoothly, so dismiss the minor thing because here's this other thing that does look just right, and ... and ... suddenly several mistakes have compounded.

It's sometimes harder when there's nothing impeding you at all to do everything right because the routine-ness of habit takes over. Being busy (but not overwhelmed), while more mentally and physically tiring, is sometimes easier, because you pay attention to the right things at the right time.

Re: SFO near miss might have triggered aviation disaster

#296

Post by [deleted] »

PhasmaFelis wrote: post #178
dx034 wrote: post #120

Earlier quoted context omitted.

It's likely that the controller would've seen it as well after the Air Canada pilot indicated that he saw planes on what he believed was the runway. Even if not, the pilot would've probably aborted the landing since he saw the other aircrafts. So it was certainly a dangerous situation but I doubt that a crash would've happened without that pilot's comment (it was certainly helpful though).

Yeah. When reading about modern air disasters, you often hear that five different things had to go wrong at once for them to happen. In this case, one or two things went wrong, the rest of them went right, and everything was fine.

[deleted]

Re: SFO near miss might have triggered aviation disaster

#297

Post by oasisbob »

gambiting wrote: post #226
anovikov wrote: post #212

Earlier quoted context omitted.

This is facilitated by the fact that in some airports, taxiways and runways are similar and sometimes even used interchangeably (!), i.e. a runway may be remarked as taxiway and vice versa. So it's not 'how can he be so dumb' moment, in some case you have no way to tell the difference unless you just know.

It feels like it could be solved incredibly easily by a row of lights at the beginning/end of both the taxiway and the runway, bright red for taxiway, bright green for the runway. If you are attempting to land on the strip marked red, then you are doing something wrong. In case that the taxiway is legitimately used for landing, change the colours around. I guess it hasn't been done for "reasons", I'd be quite interes…

Things like this are being tried. SeaTac airport has a taxiway which is large, parallel, and frequently (enough) mistaken for a runway.

> SEA-TAC personnel have been very proactive in trying to reduce the problem, including the installation of an unlit, nonreflective elevated lighted X at the threshold of taxiway Tango; broadcasting a notice on the Automatic Terminal Information Service (ATIS) not to mistake the parallel taxiway for the adjacent runway; posting warnings on aeronautical charts not to mistake the taxiway for runway 16R; and the development of numerous training aids and brochures that explain the problem to transient pilots traveling through SEA-TAC.

(Testing of multiple methods begins on page 5)

http://www.airtech.tc.faa.gov/safety/downloads/TN07-54.pdf

Re: SFO near miss might have triggered aviation disaster

#298

Post by Analemma_ »

kbutler wrote: post #291
ncallaway wrote: post #259

Earlier quoted context omitted.

The absolutely stellar safety record of the airline industry exists because they have repeatedly and consistent pushed past human error as an explanation for a crash. Understanding that if a human made this mistake, another future human will likely make the exact same mistake, they push to understand _why_ an airline captain that should know made this error. Then try to correct for that. If every crash was written of…

Someday, perhaps computer programmers will start applying this principle.

They do, or at least the big-scale places who know what they’re doing do. When Gmail or aws-east-1 or something goes down for hours, nobody is fired: they figure out why it was allowed to happen and change procedures so it can’t happen again.

Re: SFO near miss might have triggered aviation disaster

#299

Post by goblin89 »

kbutler wrote: post #291
ncallaway wrote: post #259

Earlier quoted context omitted.

The absolutely stellar safety record of the airline industry exists because they have repeatedly and consistent pushed past human error as an explanation for a crash. Understanding that if a human made this mistake, another future human will likely make the exact same mistake, they push to understand _why_ an airline captain that should know made this error. Then try to correct for that. If every crash was written of…

Someday, perhaps computer programmers will start applying this principle.

Perhaps not all tech companies care to push past human error in each postmortem (or even have a proper formal process at all), but some are known to do just that. Etsy and Google are among the well-documented cases.

> This idea of digging deeper into the circumstance and environment that an engineer found themselves in is called looking for the “Second Story”. In Post-Mortem meetings, we want to find Second Stories to help understand what went wrong.

— Blameless PostMortems and a Just Culture,

https://codeascraft.com/2012/05/22/blameless-postmortems/

> Blameless postmortems are a tenet of SRE culture. … Blameless culture originated in the healthcare and avionics industries where mistakes can be fatal. These industries nurture an environment where every "mistake" is seen as an opportunity to strengthen the system. When postmortems shift from allocating blame to investigating the systematic reasons why an individual or team had incomplete or incorrect information, effective prevention plans can be put in place. You can’t "fix" people, but you can fix systems and processes to better support people making the right choices when designing and maintaining complex systems.

— Site Reliability Engineering — Postmortem Culture: Learning from Failure

https://landing.google.com/sre/book/chapters/postmortem-cult...

Re: SFO near miss might have triggered aviation disaster

#300

Post by jrockway »

jrockway wrote: post #243
ubernostrum wrote: post #184

Earlier quoted context omitted.

You might enjoy this classic video: https://www.youtube.com/watch?v=pN41LvuSz10 Just be sure to make a note of the video title so you can find it again -- copies of it tend to get taken down, since American Airlines got in some trouble after other parts of this training course were blamed for the crash of AA flight 587: https://en.wikipedia.org/wiki/American_Airlines_Flight_587

> American Airlines got in some trouble after other parts of this training course were blamed for the crash of AA flight 587 More specifically, the pilots manipulated the rudder on that airplane so aggressively that it sheared off in flight. They were trained to react aggressively in the "Advanced Aircraft Maneuvering Program", which this video is a part of. (There are also related videos that I'm going through now t…

Ah, here's the wake turbulence one: https://www.youtube.com/watch?v=FxXwqAm1a-Y
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