SFO Incidente sfiorato
- Autore Discussione I-POV
- Data d'inizio
Abbiamo una risposta.
Sempre da AvHerald, l'NTSB ha affermato che:
Quindi il punto più basso è stato raggiunto tra il primo e il secondo aereo in attesa.
A maggior ragione, mi chiedo come le luci puntate addosso siano state lasciare avvicinare così tanto prima di destare sospetti.
Sempre da AvHerald, l'NTSB ha affermato che:
Quindi il punto più basso è stato raggiunto tra il primo e il secondo aereo in attesa.
A maggior ragione, mi chiedo come le luci puntate addosso siano state lasciare avvicinare così tanto prima di destare sospetti.
Pubblicata la foto della mancata collisione, impressionante
http://www.nbcnews.com/news/us-news/air-canada-jet-just-59-feet-above-ground-near-miss-n789081
http://www.nbcnews.com/news/us-news/air-canada-jet-just-59-feet-above-ground-near-miss-n789081
Rapporto NTSB.
Landing Approach to Taxiway at San Francisco International Airport (SFO)
Update August 2, 2017:
On July 7, 2017, about 2356 Pacific daylight time (PDT), Air Canada flight 759 (ACA759), an Airbus A320, C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), San Francisco, California, but instead lined up on parallel taxiway C, where four air carrier airplanes were awaiting takeoff clearance, including United Airlines flight 1 (UAL1), a Boeing 787; Philippine Airlines flight 115, an Airbus A340; United Airlines flight 863, another Boeing 787; and United Airlines flight 1118, a Boeing 737 (see figure 1). ACA759 descended below 100 ft above the ground, and the flight crew advanced the thrust levers to initiate a go-around about the time it overflew the first airplane on the taxiway. The flight was operating under 14 Code of Federal Regulations Part 129 as an international scheduled passenger flight from Lester B. Pearson International Airport, Toronto, Canada. Night visual meteorological conditions prevailed at the time of the incident.
Figure 1 shows the positions of the airplanes on taxiway C. The top diagram is from Harris Symphony OpsVue radar track data analysis, and the bottom picture is from the SFO airport video. Altitudes are shown in mean sea level (msl); ground level is 13 ft msl. Airplanes in the top diagram are not to scale.
The National Transportation Safety Board (NTSB) was notified of the incident on Sunday, July 9, and initiated an investigation. The NTSB investigator-in-charge has formed the following groups: Air Traffic Control (ATC), Operational Factors, Human Performance, Airports, and Flight Data Recorders (FDR). Parties to the investigation include the Federal Aviation Administration and the National Air Traffic Controllers Association. In accordance with International Civil Aviation Organization Annex 13, the Transportation Safety Board of Canada has appointed an accredited representative for the State of Registration/Operator. The Canadian accredited representative has appointed Air Canada, Transport Canada, and Air Canada Pilots Association as technical advisors.
The ATC group reviewed Airport Surface Detection Equipment Model X (ASDE-X)/Airport Surface Surveillance Capability (ASSC) data associated with the incident. The group, with members of the Operational Factors and Human Performance groups, also conducted interviews with controllers and management personnel at the SFO ATC tower and the Northern California Terminal Radar Approach Control (TRACON).
The Operational Factors and Human Performance groups conducted interviews with the incident flight crew and the flight of the airplane that landed on runway 28R minutes before the incident. The groups obtained statements from the flight crewmembers of the aircraft that were holding on taxiway C at time of the incident. Nighttime observations of the airport lighting from the ground and air were also conducted. The groups will be visiting Air Canada in Toronto, where the flight crew was based, to review records and interview company personnel.
The incident airplane’s cockpit voice recorder had been overwritten, so NTSB investigators did not have that data.
This update does not provide the probable cause for the incident and does not contain analysis of information collected thus far in the NTSB’s ongoing investigation. As such, no conclusions regarding the cause of the incident should be made from this preliminary information.
The following facts are provided as an investigative update:
o Automatic Terminal Information Service Q was current and included an advisory that runway 28L was closed and that its approach lighting system was out of service.
o Runway and approach lighting for runway 28R were on and set to default settings, which included a 2,400-ft approach lighting system, a precision approach path indicator, touchdown zone lights (white), runway centerline lights (white at the approach end), runway threshold lights (green), and runway edge lights (white at the approach end).
o Lights for taxiway C were also on and set to default settings that included centerline lights (green) along its length. Default settings also included edge lights (blue) and centerline lights (green) illuminating the transition or stub taxiways from the runway to the taxiway.
o The captain was the pilot flying ACA759, and the first officer was the pilot monitoring. Both pilots held Canadian airline transport pilot certificates.
o The captain had over 20,000 total flight hours, of which about 4,797 hours were as captain in Airbus A320‑series airplanes. The first officer had about 10,000 total flight hours, of which over 2,300 hours were in Airbus A320-series airplanes.
o There were no known ATC equipment discrepancies.
o Normal air traffic staffing for the ATC tower midnight shift included two controllers. On the evening of the incident, one controller was in the tower cab.
o At 2349 PDT (7 minutes before the incident), all positions in the ATC tower (controller-in-charge local control, local control assist, ground control, flight data, and clearance delivery) were combined at the local control position.
o At 2346:30 PDT, Northern California TRACON cleared ACA759 for the FMS bridge visual runway 28R approach.
o FDR data indicate that, during the final 3 nautical miles of the approach, the airplane’s flightpath was lined up with the taxiway and maintained the runway heading.
o At 2355:46 PDT, when ACA759 was about 0.7 mile from the landing threshold and about 300 ft above ground level (agl), the flight crew contacted the ATC tower, mentioned seeing lights on the runway, and requested confirmation that the flight was cleared to land.
o As ACA759 approached SFO, at 2355:52 PDT, the airplane flew too far right of course to be observed by the local controller’s ASDE-X/ASSC and was not visible on the ASDE-X/ASSC display for about 12 seconds.
o At 2355:56 PDT, when ACA759 was about 0.3 mile from the landing threshold, the local controller confirmed and recleared ACA759 to land on runway 28R.
o The flight crew of the first airplane in queue on taxiway C (UAL1) transmitted statements regarding ACA759, one of which mentioned the alignment of ACA759 with the taxiway while ACA759 was on short final (see figures 2 and 3). The flight crew of the second airplane in queue on taxiway C switched on their airplane’s landing lights as the incident airplane approached.
Figure 2 shows UAL1’s transmission at 2356:01 and ACA759’s position as it approaches the taxiway.
Figure 3 shows UAL1’s transmission at 2356:04 and ACA759’s position as it overflies the first airplane waiting on the taxiway; note that the second airplane has turned on its landing lights.
o The incident pilots advanced the thrust levers when the airplane was about 85 ft agl. FDR data indicate that the airplane was over the taxiway at this time, approaching the vicinity of taxiway W.
o At 2356:04 PDT, ACA759 reappeared on the local controller’s ASDE-X/ASSC display as it passed over the first airplane positioned on taxiway C.
o About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.
o At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point (see figure 4).
Figure 4 shows the local controller’s transmission to ACA759 at 2356:10 to go around and ACA759’s position after overflying two airplanes on the taxiway.
Additional information will be released as warranted. The docket for the investigation will be opened to the public before release of the final report. NTSB investigations generally take 12 to 18 months to complete. Any updates can be found on this page.
The following is initial information on the incident investigation as of July 17, 2017:
Additional information will be released as warranted.
https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx
Landing Approach to Taxiway at San Francisco International Airport (SFO)
- Accident No: DCA17IA148
- Accident Type: Office of Aviation Safety
- Location: San Francisco , CA
- Date: 7/7/2017
Update August 2, 2017:
On July 7, 2017, about 2356 Pacific daylight time (PDT), Air Canada flight 759 (ACA759), an Airbus A320, C-FKCK, was cleared to land on runway 28R at San Francisco International Airport (SFO), San Francisco, California, but instead lined up on parallel taxiway C, where four air carrier airplanes were awaiting takeoff clearance, including United Airlines flight 1 (UAL1), a Boeing 787; Philippine Airlines flight 115, an Airbus A340; United Airlines flight 863, another Boeing 787; and United Airlines flight 1118, a Boeing 737 (see figure 1). ACA759 descended below 100 ft above the ground, and the flight crew advanced the thrust levers to initiate a go-around about the time it overflew the first airplane on the taxiway. The flight was operating under 14 Code of Federal Regulations Part 129 as an international scheduled passenger flight from Lester B. Pearson International Airport, Toronto, Canada. Night visual meteorological conditions prevailed at the time of the incident.
Figure 1 shows the positions of the airplanes on taxiway C. The top diagram is from Harris Symphony OpsVue radar track data analysis, and the bottom picture is from the SFO airport video. Altitudes are shown in mean sea level (msl); ground level is 13 ft msl. Airplanes in the top diagram are not to scale.
The National Transportation Safety Board (NTSB) was notified of the incident on Sunday, July 9, and initiated an investigation. The NTSB investigator-in-charge has formed the following groups: Air Traffic Control (ATC), Operational Factors, Human Performance, Airports, and Flight Data Recorders (FDR). Parties to the investigation include the Federal Aviation Administration and the National Air Traffic Controllers Association. In accordance with International Civil Aviation Organization Annex 13, the Transportation Safety Board of Canada has appointed an accredited representative for the State of Registration/Operator. The Canadian accredited representative has appointed Air Canada, Transport Canada, and Air Canada Pilots Association as technical advisors.
The ATC group reviewed Airport Surface Detection Equipment Model X (ASDE-X)/Airport Surface Surveillance Capability (ASSC) data associated with the incident. The group, with members of the Operational Factors and Human Performance groups, also conducted interviews with controllers and management personnel at the SFO ATC tower and the Northern California Terminal Radar Approach Control (TRACON).
The Operational Factors and Human Performance groups conducted interviews with the incident flight crew and the flight of the airplane that landed on runway 28R minutes before the incident. The groups obtained statements from the flight crewmembers of the aircraft that were holding on taxiway C at time of the incident. Nighttime observations of the airport lighting from the ground and air were also conducted. The groups will be visiting Air Canada in Toronto, where the flight crew was based, to review records and interview company personnel.
The incident airplane’s cockpit voice recorder had been overwritten, so NTSB investigators did not have that data.
This update does not provide the probable cause for the incident and does not contain analysis of information collected thus far in the NTSB’s ongoing investigation. As such, no conclusions regarding the cause of the incident should be made from this preliminary information.
The following facts are provided as an investigative update:
Airport
o Runway 28L was closed to accommodate construction; its approach and runway lights were turned off, and a 20.5-ft-wide lighted flashing X (runway closure marker) was placed at the threshold. Construction on runway 28L was part of a project that started on February 21, 2017, and notices to airmen were issued to alert operators of its operational status.
o Automatic Terminal Information Service Q was current and included an advisory that runway 28L was closed and that its approach lighting system was out of service.
o Runway and approach lighting for runway 28R were on and set to default settings, which included a 2,400-ft approach lighting system, a precision approach path indicator, touchdown zone lights (white), runway centerline lights (white at the approach end), runway threshold lights (green), and runway edge lights (white at the approach end).
o Lights for taxiway C were also on and set to default settings that included centerline lights (green) along its length. Default settings also included edge lights (blue) and centerline lights (green) illuminating the transition or stub taxiways from the runway to the taxiway.
· Pilots
o The captain was the pilot flying ACA759, and the first officer was the pilot monitoring. Both pilots held Canadian airline transport pilot certificates.
o The captain had over 20,000 total flight hours, of which about 4,797 hours were as captain in Airbus A320‑series airplanes. The first officer had about 10,000 total flight hours, of which over 2,300 hours were in Airbus A320-series airplanes.
· ATC
o There were no known ATC equipment discrepancies.
o Normal air traffic staffing for the ATC tower midnight shift included two controllers. On the evening of the incident, one controller was in the tower cab.
o At 2349 PDT (7 minutes before the incident), all positions in the ATC tower (controller-in-charge local control, local control assist, ground control, flight data, and clearance delivery) were combined at the local control position.
· The Incident
o At 2346:30 PDT, Northern California TRACON cleared ACA759 for the FMS bridge visual runway 28R approach.
o FDR data indicate that, during the final 3 nautical miles of the approach, the airplane’s flightpath was lined up with the taxiway and maintained the runway heading.
o At 2355:46 PDT, when ACA759 was about 0.7 mile from the landing threshold and about 300 ft above ground level (agl), the flight crew contacted the ATC tower, mentioned seeing lights on the runway, and requested confirmation that the flight was cleared to land.
o As ACA759 approached SFO, at 2355:52 PDT, the airplane flew too far right of course to be observed by the local controller’s ASDE-X/ASSC and was not visible on the ASDE-X/ASSC display for about 12 seconds.
o At 2355:56 PDT, when ACA759 was about 0.3 mile from the landing threshold, the local controller confirmed and recleared ACA759 to land on runway 28R.
o The flight crew of the first airplane in queue on taxiway C (UAL1) transmitted statements regarding ACA759, one of which mentioned the alignment of ACA759 with the taxiway while ACA759 was on short final (see figures 2 and 3). The flight crew of the second airplane in queue on taxiway C switched on their airplane’s landing lights as the incident airplane approached.
Figure 2 shows UAL1’s transmission at 2356:01 and ACA759’s position as it approaches the taxiway.
Figure 3 shows UAL1’s transmission at 2356:04 and ACA759’s position as it overflies the first airplane waiting on the taxiway; note that the second airplane has turned on its landing lights.
o The incident pilots advanced the thrust levers when the airplane was about 85 ft agl. FDR data indicate that the airplane was over the taxiway at this time, approaching the vicinity of taxiway W.
o At 2356:04 PDT, ACA759 reappeared on the local controller’s ASDE-X/ASSC display as it passed over the first airplane positioned on taxiway C.
o About 2.5 seconds after advancing the thrust levers, the minimum altitude recorded on the FDR was 59 ft agl.
o At 2356:10 PDT, the local controller directed ACA759 to go around. The airplane had already begun to climb at this point (see figure 4).
Figure 4 shows the local controller’s transmission to ACA759 at 2356:10 to go around and ACA759’s position after overflying two airplanes on the taxiway.
· In postincident interviews, both incident pilots stated that, during their first approach, they believed the lighted runway on their left was 28L and that they were lined up for 28R. They also stated that they did not recall seeing aircraft on taxiway C but that something did not look right to them.
Additional information will be released as warranted. The docket for the investigation will be opened to the public before release of the final report. NTSB investigations generally take 12 to 18 months to complete. Any updates can be found on this page.
The following is initial information on the incident investigation as of July 17, 2017:
- Parties to the investigation are the Federal Aviation Administration and the National Air Traffic Controllers Association.
- In accordance with International Civil Aviation Organization Annex 13, the Transportation Safety Board (TSB) of Canada has appointed an accredited representative for the State of Registration/Operator. The Canadian accredited representative has appointed Air Canada, Transport Canada, and Air Canada Pilots Association as technical advisors.
- The NTSB investigator-in-charge has initially formed the following groups:
- Air Traffic Control (ATC)
- Flight Crew Operations (Ops)
- Human Factors (HF)
- Flight Data Recorder (FDR)
- The Ops and HF groups interviewed the captain of the incident airplane on Friday and will be interviewing the first officer on Tuesday (July 18).
- The ATC and HF groups began interviewing the ATC controllers at SFO and Northern California TRACON on Sunday and expect them to run through about Wednesday.
- The TSB has provided the NTSB with the FDR data from the incident airplane.
- The NTSB has obtained a security camera video from SFO of the incident approach that will be released along with the other factual information when the public docket for this incident is opened in the next several months.
Additional information will be released as warranted.
https://www.ntsb.gov/investigations/Pages/DCA17IA148.aspx
Ultima modifica:
avrebbe fatto un bel filotto; senza parole la riattaccata quando finalmente si son svegliati, forse proprio la luce accesa dai filippini ha salvato tutti!
Intanto Repubblica plaude ai riflessi del pilota....
https://video.repubblica.it/mondo/s.../303857/304488?ref=RHPPBT-BS-I0-C4-P6-S1.4-T1
https://video.repubblica.it/mondo/s.../303857/304488?ref=RHPPBT-BS-I0-C4-P6-S1.4-T1
Non sono le trascrizioni vere e proprie, ma questo e' un video con le comunicazioni:
Pare che all'NTSB non sia venuto in mente di bloccare e controllare l'Airbus C-FKCK dopo l'incidente. Per cui tutte le registrazioni del CVR – che sarebbero state le più interessanti da ascoltare in sede di indagine – si sono automaticamente cancellate durante il nuovo volo del giorno successivo. L'ente americano si è limitato ad effettuare delle interviste post-volo all'equipaggio dell'aereo canadese.
La distanza minima tra i due aerei è scesa fino a 3-6 metri. Non mi vengono in mente situazioni recenti dove si sia arrivati ad un passo da un disastro di simili proporzioni.
Pilot error behind Air Canada A320 near-miss at San Francisco
The flight crew also failed to manually tune the instrument landing system frequency while on approach, and both pilots reported feeling fatigued - factors that contributed to the incident, said NTSB investigators in a board meeting today as they reached the final stages of the investigation into the incident.
The Air Canada A320, registered C-FKCK, executed a go-around when the crew realised it was aligned with the taxiway instead of runway 28R. At that time, four other aircraft were on taxiway C preparing to take off, and the A320 overflew them. NTSB investigators have noted that the A320 was at one point between "10 and 20 feet" away from another aircraft.
"I do not want to sensationalise it, but this was a very close call," says NTSB chairman Robert Sumwalt during the board meeting. No one was injured in the incident involving flight AC759, and there was no damage to the A320 which had carried 135 passengers and five crew members.
Approach of Air Canada A320 towards San Francisco, 7 July 2017
NTSB human performance investigator Sathya Silva points out that information on the runway closure was buried in the pages of NOTAMs, and that the presentation was "not effective".
Sumwalt was harsh in his criticism of NOTAMs, saying that pilots often have to sift through dozens of pages of sometimes-irrelevant information. "The NOTAM system is really messed up," he says. "It's written in a language that only a computer programmer could understand… just a bunch of garbage that nobody pays attention to."
The Air Canada crew was required to manually tune the ILS frequency while conducting a flight management system (FMS) visual approach to runway 28R, but the first officer did not do so and the captain did not verify this was completed, say NTSB investigators.
The first officer subsequently told investigators he "must have missed" tuning the frequency, but could not explain why, says NTSB air safety investigator Shawn Etcher. As a result, the crew was unable to take advantage of the ILS frequency to ensure that the aircraft was properly aligned with the runway, he adds.
While the need to tune the frequency was included in the approach chart, it was not conspicuous, say investigators.
Contributing to the incident was pilot fatigue, notes Silva. The captain of the flight had gone for 19h without significant rest, and the first officer 12h. At the time of the incident (23:56 Pacific daylight time), the crew's body clock was at 03:00 Eastern Time - the time zone in Toronto, where the flight had taken off from.
Under US pilot fatigue rules, the captain of the flight would not have been allowed to operate the flight, says Silva.
Canadian regulators had previously proposed changing its pilot rest rules, to bring them more in line with US and international standards. Those rules have yet to be finalised. The NTSB says it is recommending to Canadian regulators to consider rules to combat fatigue in pilots operating overnight flights.
Transport Canada says it plans to finalise its proposed pilot duty rules later this year, and that it is reviewing the NTSB's findings and recommendations. "Transport Canada shares the National Transportation Safety Board’s goal of improving aviation safety and we take their recommendations seriously," says the Canadian agency.
The NTSB issued six recommendations for the US Federal Aviation Administration. These include the need to identify approaches that require an unusual manual frequency input, and to make such information more noticeable on approach charts.
In addition, the agency calls for a group of experts to be established, to review NOTAMs and to create guidance on how to prioritise and present relevant information for flight operations.
The NTSB suggested establishing requirements for aircraft landing at airports in class B and C airports to have equipment that alerts pilots when the aircraft is not aligned with a runway surface. The FAA was also called on to work with manufacturers to develop technology for an aircraft system to issue such alerts.
At airports, the NTSB suggested modifying equipment to provide alerts on potential collision risks and for more research to be conducted to determine how to make closed runways more conspicuous.
While NTSB investigators say the lighting at San Francisco met all standards at the time of the incident, a number of visual cues had supported the crew's expectation bias that taxiway C was actually runway 28R. These include construction lighting on runway 28L that looked similar to ramp lighting, notes Silva.
In a report to the NTSB, Air Canada says it has taken several actions since the incident. These include simplifying its approach charts for San Francisco, including San Francisco-specific training in aircraft simulators and launching training aimed at reducing expectation bias among operations staff. The Star Alliance carrier has also chosen to retrofit new aircraft like the Boeing 737 Max and Airbus A220 with dual heads-up displays to enhance situational awareness for crewmembers during high-risk and low-visibility approaches.
An Air Canada spokesman says in a statement to FlightGlobal that the airline will review the NTSB's final report on the incident once it is issued.
"Based on internal reviews and work with US and Canadian Authorities, Air Canada has implemented measures to refine its training and procedures, and it has acquired new technology to further advance safety," he adds.
https://www.flightglobal.com/news/a...hind-air-canada-a320-near-miss-at-san-452180/
Pilot error behind Air Canada A320 near-miss at San Francisco
- 25 SEPTEMBER, 2018
The flight crew also failed to manually tune the instrument landing system frequency while on approach, and both pilots reported feeling fatigued - factors that contributed to the incident, said NTSB investigators in a board meeting today as they reached the final stages of the investigation into the incident.
The Air Canada A320, registered C-FKCK, executed a go-around when the crew realised it was aligned with the taxiway instead of runway 28R. At that time, four other aircraft were on taxiway C preparing to take off, and the A320 overflew them. NTSB investigators have noted that the A320 was at one point between "10 and 20 feet" away from another aircraft.
"I do not want to sensationalise it, but this was a very close call," says NTSB chairman Robert Sumwalt during the board meeting. No one was injured in the incident involving flight AC759, and there was no damage to the A320 which had carried 135 passengers and five crew members.
NTSB
Runway 28L, which was parallel to runway 28R, was closed during the time of the incident. While this was noted in the NOTAMs that were reviewed by the crew before the flight, it appears that the pilots were not aware of the closure and ended up mistaking the taxiway for runway 28R.NTSB human performance investigator Sathya Silva points out that information on the runway closure was buried in the pages of NOTAMs, and that the presentation was "not effective".
Sumwalt was harsh in his criticism of NOTAMs, saying that pilots often have to sift through dozens of pages of sometimes-irrelevant information. "The NOTAM system is really messed up," he says. "It's written in a language that only a computer programmer could understand… just a bunch of garbage that nobody pays attention to."
The Air Canada crew was required to manually tune the ILS frequency while conducting a flight management system (FMS) visual approach to runway 28R, but the first officer did not do so and the captain did not verify this was completed, say NTSB investigators.
The first officer subsequently told investigators he "must have missed" tuning the frequency, but could not explain why, says NTSB air safety investigator Shawn Etcher. As a result, the crew was unable to take advantage of the ILS frequency to ensure that the aircraft was properly aligned with the runway, he adds.
While the need to tune the frequency was included in the approach chart, it was not conspicuous, say investigators.
Contributing to the incident was pilot fatigue, notes Silva. The captain of the flight had gone for 19h without significant rest, and the first officer 12h. At the time of the incident (23:56 Pacific daylight time), the crew's body clock was at 03:00 Eastern Time - the time zone in Toronto, where the flight had taken off from.
Under US pilot fatigue rules, the captain of the flight would not have been allowed to operate the flight, says Silva.
Canadian regulators had previously proposed changing its pilot rest rules, to bring them more in line with US and international standards. Those rules have yet to be finalised. The NTSB says it is recommending to Canadian regulators to consider rules to combat fatigue in pilots operating overnight flights.
Transport Canada says it plans to finalise its proposed pilot duty rules later this year, and that it is reviewing the NTSB's findings and recommendations. "Transport Canada shares the National Transportation Safety Board’s goal of improving aviation safety and we take their recommendations seriously," says the Canadian agency.
The NTSB issued six recommendations for the US Federal Aviation Administration. These include the need to identify approaches that require an unusual manual frequency input, and to make such information more noticeable on approach charts.
In addition, the agency calls for a group of experts to be established, to review NOTAMs and to create guidance on how to prioritise and present relevant information for flight operations.
The NTSB suggested establishing requirements for aircraft landing at airports in class B and C airports to have equipment that alerts pilots when the aircraft is not aligned with a runway surface. The FAA was also called on to work with manufacturers to develop technology for an aircraft system to issue such alerts.
At airports, the NTSB suggested modifying equipment to provide alerts on potential collision risks and for more research to be conducted to determine how to make closed runways more conspicuous.
While NTSB investigators say the lighting at San Francisco met all standards at the time of the incident, a number of visual cues had supported the crew's expectation bias that taxiway C was actually runway 28R. These include construction lighting on runway 28L that looked similar to ramp lighting, notes Silva.
In a report to the NTSB, Air Canada says it has taken several actions since the incident. These include simplifying its approach charts for San Francisco, including San Francisco-specific training in aircraft simulators and launching training aimed at reducing expectation bias among operations staff. The Star Alliance carrier has also chosen to retrofit new aircraft like the Boeing 737 Max and Airbus A220 with dual heads-up displays to enhance situational awareness for crewmembers during high-risk and low-visibility approaches.
An Air Canada spokesman says in a statement to FlightGlobal that the airline will review the NTSB's final report on the incident once it is issued.
"Based on internal reviews and work with US and Canadian Authorities, Air Canada has implemented measures to refine its training and procedures, and it has acquired new technology to further advance safety," he adds.
https://www.flightglobal.com/news/a...hind-air-canada-a320-near-miss-at-san-452180/
Insomma: gram bel casotto.
Io direi che la dichiarazione più rilevante è da attribuire all'efficacia dei NOTAM: pagine e pagine di sigle ed abbreviazioni, non sempre standard e intuitive, rendono complicata la loro praticità.
Sui 10/20 piedi di separazione bisogna chiarire che l'inerzia del velivolo nel passare da un sentiero di discesa di 3 gradi con motori al 40/50% di potenza ad una salita con motori al massimo, ti porta a perdere quei 50 piedi minimo prima di avere un "positeve climb".
Il fattore stanchezza invece gioca la sua parte in modo ambiguo: se da una parte è vero che seguendo brutalmente l'ILS non avrebbero avuto titti sti problemi, è anche vero che staccando tutti gli automatismi ti dai una "svegliata" e ti eviti di svegliarti quando la voce sintetica ti dice "fifty-fourty-thirty..."
Tutte le altre cose su allarmi che ti dicono che stai atterrando sulla pista sbagliata, HUD ecc, sono solo per accontentare l'opinione pubblica efar vedere che qualcosa si è fatto.
Io direi che la dichiarazione più rilevante è da attribuire all'efficacia dei NOTAM: pagine e pagine di sigle ed abbreviazioni, non sempre standard e intuitive, rendono complicata la loro praticità.
Sui 10/20 piedi di separazione bisogna chiarire che l'inerzia del velivolo nel passare da un sentiero di discesa di 3 gradi con motori al 40/50% di potenza ad una salita con motori al massimo, ti porta a perdere quei 50 piedi minimo prima di avere un "positeve climb".
Il fattore stanchezza invece gioca la sua parte in modo ambiguo: se da una parte è vero che seguendo brutalmente l'ILS non avrebbero avuto titti sti problemi, è anche vero che staccando tutti gli automatismi ti dai una "svegliata" e ti eviti di svegliarti quando la voce sintetica ti dice "fifty-fourty-thirty..."
Tutte le altre cose su allarmi che ti dicono che stai atterrando sulla pista sbagliata, HUD ecc, sono solo per accontentare l'opinione pubblica efar vedere che qualcosa si è fatto.
Speriamo serva veramente a far cambiare qualcosa riguardo ai NOTAM, un sistema pensato negli anni '50, quando si doveva limitare il numero dei caratteri visto che non c'era la possibilità di trasmettere molti dati a grandi distanze, e che al giorno d'oggi non ha motivo di essere ancora in questo modo
NOTAMs spesso scritti da avvocati solo per evitare denunce, senza un minimo di sintesi e di rilevanza verso quello che somo le informazioni operative realmente necessarie
Lo dice anche la NTSB, speriamo qualcuno recepisca la raccomandazione
https://youtu.be/LWLPDOXF7e4
NOTAMs spesso scritti da avvocati solo per evitare denunce, senza un minimo di sintesi e di rilevanza verso quello che somo le informazioni operative realmente necessarie
Lo dice anche la NTSB, speriamo qualcuno recepisca la raccomandazione
https://youtu.be/LWLPDOXF7e4
Anche a me la questione dei NOTAM "disturba" un po', e la dichiarazione del chairman è abbastanza eloquente
Domanda semplice (e forse anche un po' stupida)...
In casi di una pista chiusa per lavori, quando la torre fornisce le ultime indicazioni di vento e dice "clear to land on runway 28R", non potrebbe aggiungere (prima) che la "runway 28L is closed"? Ci sarebbe forse il rischio di creare più confusione? Immagino che cambiare la "fraseologia standard" non sia una cosa semplice, e sicuramente bisogna studiare bene tutte le possibili conseguenze...
Secondo voi (piloti e controllori) sarebbe una barriera di protezione in più oppure un "buco" ancora più grosso nella fetta di formaggio?
Un altro punto che mi sembra abbastanza "forte" è la Raccomandazione di Sicurezza fatta a Transport Canada. La NTSB dice che in alcuni casi la normativa canadese non permette il tempo di riposo necessario ai piloti di riserva.
ps: pensare che una tragedia sia stata sfiorata per solo 4 metri è veramente pazzesco
(da AvHerald http://avherald.com/h?article=4ab79f58&opt=0)
Domanda semplice (e forse anche un po' stupida)...
In casi di una pista chiusa per lavori, quando la torre fornisce le ultime indicazioni di vento e dice "clear to land on runway 28R", non potrebbe aggiungere (prima) che la "runway 28L is closed"? Ci sarebbe forse il rischio di creare più confusione? Immagino che cambiare la "fraseologia standard" non sia una cosa semplice, e sicuramente bisogna studiare bene tutte le possibili conseguenze...
Secondo voi (piloti e controllori) sarebbe una barriera di protezione in più oppure un "buco" ancora più grosso nella fetta di formaggio?
Un altro punto che mi sembra abbastanza "forte" è la Raccomandazione di Sicurezza fatta a Transport Canada. La NTSB dice che in alcuni casi la normativa canadese non permette il tempo di riposo necessario ai piloti di riserva.
ps: pensare che una tragedia sia stata sfiorata per solo 4 metri è veramente pazzesco
Mi sono occupato recentemente di trovare soluzioni ad un problema simile, e ti assicuro che non è facile
Ci sono tante variabili da considerare e la radice "dell'errore" non è sempre la stessa, quindi le barriere non sono mai abbastanza e alcune potrebbero anche essere controproducenti
Ciò che tu proponi potrebbe avere senso di giorno, ma di notte? LA pista ha le luci o no? Ci sono dei messi al lavoro o no? PErchè potrei aspettarmi di vedere una pista accesa ma non utiizzata, o potrei aspettarmi di non vedere niente... e se vedessi dei mezzi sulla pista? E' quella una pista o un apron (come è successo a SFO?)
Attenzione, non è un pilota di riserva, ma un pilota "in" riserva casomai
Sto cercando più dettagli sulla normativa canadese, ma per il momento non trovo niente, comunque non bisogna andare troppo lontano per trovare una situazione simile, in Europa con le regole attuali, puoi essere ai comandi di un aereo, 18 ore dopo l'inizio del tuo standby...
Certo, sono d'accordo che gli aspetti da tenere in considerazione sono molti (e non ci avrei mai pensato ad alcuni di questi), e che anche le situazioni di contorno possono cambiare l'efficacia di una cosa simile a quanto avevo scritto.
Grazie per il post, tutto molto interessante!
ps: Scusate la "scivolata" linguistica tra di riserva e in riserva. Chiedo un attenuante per non essere madrelingua...
Grazie per il post, tutto molto interessante!
ps: Scusate la "scivolata" linguistica tra di riserva e in riserva. Chiedo un attenuante per non essere madrelingua...
Figurati, pensavo più ad un refuso di una persona non pratica con il gergo aeronautico che non ad un errore grammaticale!