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Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

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Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#31
post #17

> Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident. How long are recordings normally kept? I would assume at least a few days for mundane flights (storage is cheap, isn't it?) but any sort of incident similar to this I would assume they keep recordings for much longer, if only…

The tower recordings are posted above.

>(storage is cheap, isn't it?)

Not on ancient planes where everything needs a billion certifications from all sorts of regulatory bodies.

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#32
post #17

> Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident. How long are recordings normally kept? I would assume at least a few days for mundane flights (storage is cheap, isn't it?) but any sort of incident similar to this I would assume they keep recordings for much longer, if only…

It's a loop recorder. When that aircraft was certified, only a 30 minute loop was required. If that aircraft was newly certified, it would now require a 2 hour loop.

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#33

The report identifies good preventive measures. Autotuning the ILS would be handy, as would an aural alert for lateral deviation, perhaps announcing, "Localizer, Localizer." The crew may have caught the closure of 28L and planned better with a review of NOTAMS before top of descent and including them in the approach briefing. When I'm up there, and sleepy, I ask for a coffee and pull out the NOTAMS for one last look…

How difficult is it to see what's happening on the ground at night from a plane? I've never been in a cockpit at night. I'd have to hope that taxiways are marked in some explicit way to make it clear that they're not runways, like with an X or some pattern of lights that's not on runways; or have all runways marked with an obvious pattern that indicates "land here" (so if you don't see that, you know you're not landing on a runway). Don't the runways have their names labeled in lights near the entrances? (Or is that only paint?)

I guess I'm surprised that it took so long for the pilots to see that there were other planes where they were landing.

Is it routine to keep binoculars in a cockpit? Could they have seen what was on the ground sooner if they'd looked through binoculars briefly (after noticing unexpected lights?)

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#34
post #26

Gotta hand it to the NTSB - they are thorough. This is just the abstract.

Also that they cite fatigue / circadian low as one of the core causes. I thought they might avoid it because of the potential cost implications for the airline industry.

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#35
post #5

I'm not operationally familiar with SFO. But based on experience at other airports, a taxiway at night can be a sea of black at even 100' above the ground. I would probably see airplane navigation lights at some point, but would I bet my life on it? No. So this incident has to be taken seriously. However, I'm still not clear from this reporting how the crew mistook blue taxiway lighting for white runway lighting. Thi…

Watch this A380 landing at SFO, and watch the pilot's reaction when he's told he's cleared to land visually on 28L, but to expect the ILS for 28R.

https://www.youtube.com/watch?v=ENe89j89tBA

What's up with that?

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#36
post #5

I'm not operationally familiar with SFO. But based on experience at other airports, a taxiway at night can be a sea of black at even 100' above the ground. I would probably see airplane navigation lights at some point, but would I bet my life on it? No. So this incident has to be taken seriously. However, I'm still not clear from this reporting how the crew mistook blue taxiway lighting for white runway lighting. Thi…

Human consciousness tries to form a coherent model that integrates current sensory perception with knowledge. During an approach at night, scarce sensory input is interpolated to form a full model by the brain. The report uses the term "expectation bias" for this phenomenon. This drive for coherence runs below consciousness and we only notice when the coherence falls apart: When our sensory input cannot be reconciled anymore with the current model. We blink, shift our head, and our model rebuilds anew.

What happened here is that the pilots were locked into a wrong model: In an environment with very little light there is no visual source to compare taxiway lighting against. If we know from experience that a light is white, our brain will use this to calibrate. Without this ever becoming a conscious thought. Color correction happens automatically for us and we don't feel it. This process can easily lead to nominally weird things like blue lights being percieved as white.

Fatigue and stress would contribute to ward off looming decoherence such as "why are the lights on 28L redder than on 28R?" When under pressure, we go with the strongest signal. And that signal may very well come from our knowledge, not our perception.

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#37
post #34
post #26

Gotta hand it to the NTSB - they are thorough. This is just the abstract.

Also that they cite fatigue / circadian low as one of the core causes. I thought they might avoid it because of the potential cost implications for the airline industry.

Worth noting that the Canadian regulations are looser than USA in that respect - the Air Canada pilots were in compliance with home regs, but would have been in breach of FAA regs.

Other point is that the NTSB isn't generally particularly shy about calling out the need for expensive changes (one example being their recommendation for fuel tank inerting systems after TWA 800). They have no power to mandate their recommendations be implemented after all: that's the job of the FAA.

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#38

I'm surprised that remote video cameras aren't used by tower controllers. The perspective of the control tower makes it difficult to catch issues like this, but a simple video camera aligned with the center-line of each runway would allow controllers to more easily verify that planes are lined up as well as other possible issues like gear down & locked, etc.

> I'm surprised that remote video cameras aren't used by tower controllers. There are software and hardware/network setups designed to do this now, in fact London City Airport is about to move to a fully virtual control tower, with a bunch of super high res pan/tilt/zoom cameras on a mast instead of an on-site tower. https://www.google.com/search?client=ubuntu&channel=fs&q=lon...

what happens when the camera lens gets a smudge?

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#39
post #31
post #17

> Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident. How long are recordings normally kept? I would assume at least a few days for mundane flights (storage is cheap, isn't it?) but any sort of incident similar to this I would assume they keep recordings for much longer, if only…

The tower recordings are posted above. >(storage is cheap, isn't it?) Not on ancient planes where everything needs a billion certifications from all sorts of regulatory bodies.

There's other issues at play. Pilots hate the idea of more monitoring of the cockpit, and have been vocal in trying to prevent e.g. a video recording of the cockpit being part of the "black box", even though it would have helped to shed light on a lot of aviation incidents[1].

1. https://www.wired.com/2014/07/malaysia-370-cockpit-camera/

Re: Abstract of the NTSB Report on Air Canada flight 759's taxiway overflight at SFO [pdf]

#40
post #31
post #17

> Cockpit voice recorder (CVR) information was not available for this incident because the data were overwritten before senior Air Canada officials became aware of the severity of this incident. How long are recordings normally kept? I would assume at least a few days for mundane flights (storage is cheap, isn't it?) but any sort of incident similar to this I would assume they keep recordings for much longer, if only…

The tower recordings are posted above. >(storage is cheap, isn't it?) Not on ancient planes where everything needs a billion certifications from all sorts of regulatory bodies.

It also needs to survive a couple of years at the bottom of the ocean or a similarly extreme environment and still be readable afterwards.
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