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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]

#111

Post by michaelt »

DocTomoe wrote: post #102
powercf wrote: post #62

Earlier quoted context omitted.

Outputting that in lower case could be a small step to making them easier to parse, and therefore more likely to be read. I find the text you posted tiring even to look at. THE REF (B) TURKISH NOTAM A3009/16 LTAAYNYX (111139 EUECYIYN JUL 2016) HAS NO GROUND, CANNOT PRODUCE ANY INTERNATIONALLY LEGAL EFFECT WITHIN ATHINAI FIR/ HELLAS UIR AND IS CONSIDERED NULL AND VOID. vs The ref (B) Turkish NOTAM A3009/16 LTAAYNYX (1…

Yeah, good luck with changing hundreds of established, life-or-death-systems, most of them actually embedded in planes in the airline industry worldwide, at the same cutover date, to suddenly support mixed-case script. Have a one-hour watch to understand what kind of beast you are wrestling here: https://media.ccc.de/v/31c3_-_6308_-_en_-_saal_1_-_201412281...

  good luck with changing hundreds of established, 
  life-or-death-systems, most of them actually
  embedded in planes
Seems to me that's precisely the sort of thing the NTSB _is_ supposed to be able to do?

Of course IMHO a mere change of case doesn't go far enough.

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

#112

Post by tyingq »

SaberTail wrote: post #13

If anyone would like to listen to the ATC radio: https://www.youtube.com/watch?v=ZW-ETmZU0u8

This one is interesting also:

https://youtu.be/WKf7sfgSjjc

The pilot sounds calmer than the ATC. Former fighter pilot.

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

#113

Post by wmblaettler »

jonah wrote: post #20
wmblaettler wrote: post #11

Earlier quoted context omitted.

The very first thing I thought of upon reading your comment "The list of things tried so far to resolve the issue..." was "What about a big lighted 'x'?" then I clicked the link.

I'd like to know why they removed it.

Indeed, the article does not give any reason for its removal, other than the fact that it was removed. My guess is that it was in disrepair and/or they deemed it ineffective since there were landings in the years preceding the removal.

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

#114

Post by lbriner »

mortenjorck wrote: post #43
nutcracker46 wrote: post #3

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…

The recommendations look like important steps, especially the concept of a system that alerts pilots to runway surface non-alignment. I have to wonder, though, does it always take a close call like this (or worse) to bring up such a proposal? Does the NTSB also study otherwise safe flights to identify risks in pilot, tower, or ground crew human factors and make proactive recommendations?

Also, what Air France 447 showed us was that excessive automation becomes a problem when it is assumed to always work. The recommendations about more systems are all very well but there are 1000s of international airports who are either not going to have these systems or sometimes they won't work. What is critical is that pilots follow their checklists and that 1 action would have prevented this happening despite the fact that the other systems could have warned about it.

Making NOTAMs and the like more clear just seems like good design. They should certainly be able to prioritise information or only show what is relevant for a particular flight/aircraft/location/approach so you only have to read 3 things instead of 50.

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

#115

Post by kejaed »

zkms wrote: post #23
aeternus wrote: post #12

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. I'm surprised that forward-looking infrared cameras aren't more commonly used in civilian aircraft, especially given the availability of staring arrays with decent resolution/framerate that don't require cooling. Even without the requisite certification for use as a for-realsies landing aid, it's nevertheless a useful tool to get situational…

In aviation these are called Enhanced Vision Systems (EVS) cameras and when paired with a Head Up Display (HUD) are called Enhanced Floght Vision Systems (EFVS). EFVS give ‘credit’ to land in bad weather using the camera and display to see the runway.

Anyways, in the last couple years the FAA has changed the regulations to allow EFVS for credit on Part 121 (passenger aircraft), you can read the rulemaking change proposal that was implemented [0].

The generation of camera that existed at the time of this rulemaking was generally a cryogenically cooled InSb sensor type. The main (certified for credit) cameras here were the CMA-2600/2700 from CMC Electronics (I worked on these) and the Kollsman EVS I and II. These were mostly on BizJets before the rules were changed , except for the FedEx fleet that had an exemption.

As the rules were changed, airport lighting started to change form incandescent to LED, which made those expensive and heavy InSb cameras useless at seeing the approach lights in bad weather.

Over the years microbilometer LWIR tech has improved, and while they won’t help you see any lighting at all, LWIR sensors will help you see the ground and have better weather penetration than other wavelengths.

All that leads to the next gen of cameras being fused multi sensor cameras, 2,3, or even 4 sensors. Rockwell Collins EVS-300 and Elbit’s Clearvision EVS are examples.

The non-certified for credit systems have mostly used microbolometers over the years although some have used SWIR sensors as well.

As others have said the ITAR comes into play with anything approaching usable frame rates and resolution, although these are being slightly relaxed. Also, don’t buy American and you don’t have this problem.

After camera-based systems they are database driven Synthetic Vision Systems (SVS) that would have helped greatly in this particular near disaster. Then you can get even fancier and fuse synthetic with infrared to get a Combined Vision System (EVS + SVS = CVS), while Elbit and Rockwell offer. Sometimes I miss working on these vision systems.

[0] https://www.federalregister.gov/documents/2013/06/11/2013-13...

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

#116

Post by joncrane »

joezydeco wrote: post #74
joncrane wrote: post #59

Earlier quoted context omitted.

I watched way more of that than I should have. It was way more interesting than I thought it would be. I would love to be an airline captain.

PilotsEyeTV is a really really neat thing. They sell entire box sets of whole flights. It's pretty cool that the European airlines allow this amount of camera work in the cockpit: http://pilotseye.tv/en/flightroutes/ If you really want to see something captivating, watch this clip of a Swiss A340 crew handling an overheating engine in-flight. It's incredibly well done. https://www.youtube.com/watch?v=rEf35NtlBLg

Reminds me how those "Simulator" games are so popular in Germany!

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

#117

Post by DocTomoe »

michaelt wrote: post #111
DocTomoe wrote: post #102

Earlier quoted context omitted.

Yeah, good luck with changing hundreds of established, life-or-death-systems, most of them actually embedded in planes in the airline industry worldwide, at the same cutover date, to suddenly support mixed-case script. Have a one-hour watch to understand what kind of beast you are wrestling here: https://media.ccc.de/v/31c3_-_6308_-_en_-_saal_1_-_201412281...

good luck with changing hundreds of established, life-or-death-systems, most of them actually embedded in planes Seems to me that's precisely the sort of thing the NTSB _is_ supposed to be able to do? Of course IMHO a mere change of case doesn't go far enough.

You do realize that US planes still have to be able to fly to countries other than the US, and vice versa, right?

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

#118

Post by cpitVoxRec »

tialaramex wrote: post #65
cpitVoxRec wrote: post #27

Earlier quoted context omitted.

They actually do clearly state in this PDF that a degree of fault lies in the crew being compromised by fatigue. Operating for 19 hours straight definitely places an individual in an area where one can be fighting to pay strict attention, even when it really counts. There's also plenty of communication with Air Traffic Control in the tower, and not a whole lot of gaps to introduce significant mystery, so it's pretty…

What I'd expect the CVR to provide good evidence of is the extent to which crew were actually doing the checks that should have caught this error, and their reaction when they belatedly discovered their true position. Without even trying to mislead investigators a human will report a sanitised version of events when not cued by facts. "Then I scratched my arse and sniffed my finger" is not going to appear in this san…

  I struggle to believe that it took 
  over 30 minutes to get this thing 
  back down after the incident
If your inferring that a 30 minute offset was introduced, in order to dump the stale audio buffer, before permitting access to the CVR instrument on the ground, I'd offer the idea that there were 4 other planes on the taxiway, waiting to take off, and that the intervening 30 minutes could be eaten up by letting those planes depart, based on an array of other factors.

A concerted effort to dump the recorder buffer would require the participation of more than just the flight crew, since it manipulates the standing traffic pattern. Not an impossibility, and we know that in-group "walls of silence" definitely accumulate in high-intensity industries, but the air traffic control audio suggests a really minor transgression of situational awareness, even if the circumstances are assuredly unforgiving ones.

In the radio audio, the pilot clearly states that he's noticing lights on what he imagines to be his runway, and asks for confirmation as to what they might be. The tower reaffirms that he's all clear. Only then does a pilot from one of the planes on the ground speak up, and complain.

At that moment, both ATC and the plane realize the error. It's arguable that the pilot anticipated a likely go-around, based on intuition that the lights he was observing were definitely other planes, and that what appears to be an extremely close call proves it's own margin of error as reasonable, given that the participants recovered from the error.

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

#119

Post by cpitVoxRec »

PhantomGremlin wrote: post #68
cpitVoxRec wrote: post #27

Earlier quoted context omitted.

They actually do clearly state in this PDF that a degree of fault lies in the crew being compromised by fatigue. Operating for 19 hours straight definitely places an individual in an area where one can be fighting to pay strict attention, even when it really counts. There's also plenty of communication with Air Traffic Control in the tower, and not a whole lot of gaps to introduce significant mystery, so it's pretty…

Operating for 19 hours straight Nobody was operating for that length of time. The captain had been awake for 19 hours, the first officer had been awake for 12 hours. Granted, most people can't function anywhere near their peak performance after being awake for 19 hours. Also there's not enough information in the summary to know the captain's recent history; how much rest time did he have before that flight?

To call attention to my use of the word "operating" in this context, and highlight strict use of the word as ...technical(?) vocabulary, to form a rationale for censure of the general thrust of my statement, is pretty pedantic, and a semantic criticism at best.

Nonetheless, I'll put forward, that even if a direct flight from Toronto to San Francisco only takes about 5 or 6 hours, 19 hours, and rounding out the time of day to midnight as a circadian cue, definitely puts the pilot 3 hours past the usual 16 hour limit for bedtime (right, 12 hours for the co-pilot, okay). Both the pilot and co-pilot probably had at minimum another entire hour before they'd even have a chance to wind down and turn in for the night, so pile up the anticipatory nature of having to deplane and get to a hotel room onto their psychological state.

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

#120

Post by joezydeco »

joncrane wrote: post #116
joezydeco wrote: post #74

Earlier quoted context omitted.

PilotsEyeTV is a really really neat thing. They sell entire box sets of whole flights. It's pretty cool that the European airlines allow this amount of camera work in the cockpit: http://pilotseye.tv/en/flightroutes/ If you really want to see something captivating, watch this clip of a Swiss A340 crew handling an overheating engine in-flight. It's incredibly well done. https://www.youtube.com/watch?v=rEf35NtlBLg

Reminds me how those "Simulator" games are so popular in Germany!

I'll hand it to the Germans. When they get into a hobby, they really get into it.
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