WARNING: Smokin’ Hole is about to put on his curmudgeon hat!..
Yeah that does put a completely different spin on it. But what the hell, man! We all have eye-balls! I just don’t get this new professional pride in pushing a couple of buttons and then locking your head completely up inside your own a@@. After Air France we were all supposed to know better. But episodes like this and the WestJet incident in Aruba plus many more show us we don’t. We were supposed to take pride in our flying again. We were supposed to hand-fly more and get back to basics. ICAO and the FAA mandated these things. Our airlines are encouraging it. Yet some line pilots just don’t want to get it. They see flying as a low skill and so they study to pass the bar while the autopilot runs the show.
They were almost CERTAINLY* hand-flying when they lined up. My point about hand-flying was just one brick in the bigger wall about being a fully aware and engaged pilot. It’s about being there mentally. You don’t need to hand-fly from 18000 feet to be a proficient airline pilot. But practicing it helps to keep you in the moment. There is a lazy, dismissive mindset than can creep into a crew. They can feed off each other’s own ineptitude. I make no accusations to the SFO crew in question, mind you.
*“almost certainly”. There is a fair chance that they were doing the FMS Bridge Visual. RNAV approaches are often misaligned at runway to taxiway distances. This is why they have high-ish minimums. In the case of RNAV VISUAL approaches, they are by definition intended just to get you pointed in the right direction without hitting anything. The runway environment is all up to the pilot flying.
Maybe, from some trick of perspective, and lighting, they thought that 28R was in fact 28L. That would make the taxiway look to be where 28R should be in relation. Just hypothesizing.
Honestly - I partially blame the FAA for some of this. The perception of punitive action whenever something is slightly out of whack or if you do something that is unusual is definitely there. I aborted a takeoff after being cleared at around 40 knots because something “didn’t feel right” on a trip a few years ago. Turns out the rudder boost was activating near the takeoff power setting. I had no idea I was supposed to file some mechanical interruption report even though we fixed the problem (turned off the rudder boost and MEL’d it) and the tower apparently automatically generates a query to the POI of operators that abort takeoffs. It was a no harm / no foul phone call from our POI asking if we had done something that day - I said yes, described it, and that was all fine and good…but the process kind of made me angry. To me, it might discourage a pilot from going around, or aborting a takeoff if they think they missed something that might have a disciplinary action as a follow up.
Our company has a “no fault” go-around procedure which they have emphasized…which is nice. Basically saying “we don’t care why you are going around…just do it and we will stand behind you”. That is nice that they put that in writing.
I haven’t read all the reports about this specific incident. It was obviously a major screwup…but as one who has had my eyes tell me the wrong thing due to fatigue or just not being in the loop…I can sympathize perhaps. Did that runway not have REILs flashing?
Some new info from the NTSB. 28L was closed and unlit. That certainly didn’t help. The runway was NOTAM’d as closed and unlit though.
While the go around was initiated pretty late in the game, I am pretty certain (as in 99.999999%) that the crew would not have landed on top of aircraft that they could see.
Poor guys…I can actually see how that could happen. Seeing what you think you should see. It is a huge mistake…deserves punishment…and I could totally see how it might happen.
That last photo (in the linked report) looks like they might have. They didn’t see UAL at, say, 200’. What would be different at 85’ when the go-around was called? I can see how it could happen too.
Plus SFO is such a cluster-****! And can we have a nice, in the weeds, discussion about NOTAMS. Every flight plan I get has 20 pages of airport and navigational NOTAMs, plus RAIM data all presented in single-spaced barely English text. I am responsible for every letter of it. We have the technology. Why not just present NOTAMs graphically where applicable? It’s almost as if the FAA WANTS us to step on our ****s and buries the killer information inside pages of “I don’t care about cranes”. This doesn’t fully apply here as I am sure this crew was fully aware of the closure regardless of the NOTAMs.
Completely agree on the NOTAMS. There is way too much clutter and noise that can often make the pertinent information hard to pick out. I have seen some attempts to color code headings and keywords, but that is only any good if you are reading on a color display or a color printout.
This is my sentiment too the more i hear about this incident. It really seems like luck prevailed and not procedures or attention to the environment on the crews part.
Agreed on the NOTAMS and METARS. There’s better ways now that we just do not want to employ as an industry as a whole.
On the other hand, in maintenance we now have certain parts completely digitized, which really adds to the clarity of the tasks at hand. Two steps forward, one step back I suppose?
My favorite is when they NOTAM a runway out at a one runway airfield…but don’t say the airport is closed (I guess because helicopters can still use it?)… That is always a setup for embarrassment when you get called out at midnight and your bleary eyes don’t pick out every detail.
And yeah - I think some online wx providers are starting to implement some sort of color coding for grabbing the attention for certain NOTAMs. Personally - all I generally care about are METAR, TAF, runway and approach NOTAMS…and if it is a 24 hour international airport, I generally don’t much care for the taxiway NOTAMs. In Podunk, USA I might need them to keep from getting stuck on a no-outlet taxiway…but most places they just clutter up the brief. CLT NOTAMS since they are doing major runway construction and lighting changes are really, really long. Around eight pages last time I printed them out… Throw in the drone/UAV pages and the printer starts wheezing…
Those taxiway NOTAMS can end your career. Ask me offline how I almost discovered this the hard way in Aguadliia, PR. There’s a saying involving “god”, “luck”, “fools” and “drunks”. He/she/they was really looking out for me that night!
BTW Beach, as you know I had a small taste of your job back when New Kids On The Block were really kids (and a thing). Little has changed I am sure. You have 30 minutes from getting the call to review reams of information and plan how to get to the patient safely. You are your own show. The Air Canada crew had a dispatcher, each other and gobs of time to form a picture of what they were getting themselves into. You guys should be proud of what you do, night (usually) after night.
Well that is actually really understandable to me. The CVR has a pretty limited recording length depending on the box. If you think about it, recording should stop at the crash with the important stuff happening at crash minus. But in this case there was no crash but instead a certain amount of flight after the incident to include parking and shutdown. I would guess that there was enough time in that last bit to overwrite the needed data. The overwrite may well not have been due to a nefarious or negligent act. Too bad though. There would have been a lot to learn about how they briefed the approach and how they interacted on the way in.
