18 ms·

SFO near miss might have triggered aviation disaster

481 points by milesf 9y ago

milesf 9y ago
How is this even possible? Is it gross negligence on the part of the pilot, a systems problem, or something else? (IANAP)
- csours 9y ago
  SFO is said to be a somewhat abnormal/difficult approach [0]. This could cause stress and fractured attention in the pilot. I wouldn't be surprised to learn that there was some other complicating factor. Planes don't usually crash (or nearly crash) without several safety factors being breached. 0: https://jethead.wordpress.com/2013/07/09/how-do-you-land-at-san-francisco-international-airport/ https://jethead.wordpress.com/2013/07/09/how-do-you-land-at-...
  - dba7dba 9y ago
    When the Asiana flight 214 crash landed in SFO in 2013, there was a blog post from a pilot who claimed to be a Lufthansa Air pilot. He wrote that because of city of San Francisco's unusually stringent noise mitigation rule for airliners flying over the city to land at the SFO airport, an airliner has to make a very steep descent from an altitude higher than normal. So instead of bringing down an airliner gradually, a pilot has to get down to the airport in a hurry, requiring much more stringent management of energy/speed. It sounds simple for a plane that's flying straight in, but for a pilot at end of a 10+ hr flight, it's not always so simple. At least I think that's what the purported Lufthansa pilot claimed. I wonder if this has any bearing on the incident.
    - cycrutchfield 9y ago
      Don't planes approach SFO from over the water? I don't think any planes are landing over San Francisco
    - Taniwha 9y ago
      that's only in the (quite rare) case that the wind is coming from the south and the planes are coming in over Daly City .... normally planes land in the other direction and (like the Asiana flight) come in over the Bay. They do however take off over a lot of homes in Daly City and are required to fly a flight plan that seems to postpone a lot of their climb until they are out over the Pacific
- codeonfire 9y ago
  In Seattle, there have been taxiway landings in 2005 and 2015 because the taxiway looks similar to the runways. Presumably the ILS system should align them with the correct runway, but I guess that in these cases, ILS is not being used. Even it it were, the runways are the same heading and just a few hundred yards apart, so the mistake would not be realized until short final.
  - djsumdog 9y ago
    I'm kinda surprised manufactures don't have full HUDs in commercial airliners yet. For airports that support ILS, it seems like using it should be mandatory, with a HUD providing a visual guide to ensure the pilot is lined up with the correct runway. I mean sure, you could still have mistakes (pilot types in the wrong runway in a parallel runway airport and lands on the wrong one), but it'd be another check/safety system in place.
  - exDM69 9y ago
    Seattle-Tacoma has three parallel runways with unequal horizontal spacing, it's easy to mistake that parallel taxiway between the center and right (north approach) as the right runway. I've only done it in flight simulators but it's really difficult to tell from a distance.
- CaliforniaKarl 9y ago
  I'm not a pilot, or real-world ATC, but I was one a _virtual_ air traffic controller, on VATSIM[1]. I was a member of the virtual Indianapolis ARTCC[2], and have worked positions from Dispatch up to & including Center. Listening to the LiveATC clip, the important bit is the phrase "visual 28 right", meaning the Air Canada pilot had been assigned a visual approach to runway 28 Right. The clip sounds like it's from Tower, so you're not hearing the point where the pilot was assigned that approach (that would've happened with Approach). A visual approach is pretty simple: The controller sets you on a heading & altitude. Then, the controller confirms that you have the runway/field in sight, as well as any other air traffic that may potentially pose a conflict. Once the pilot verbally confirms those things are in sight ("traffic in sight" / "field in sight"), the approach controller will clear the pilot for the "visual runway XXX approach", also issuing appropriate warnings regarding wake turbulence. Once the visual approach has been cleared, and the pilot has acknowledged, it is now the pilot's responsibility to navigate the plane to the runway, while keeping the plane clear of the traffic that has been pointed out to them. If the pilot were assigned an ILS, LOC (localizer), LDA (localizer-type directional aid), or RNAV (area navigation) approach, that approach would have included a lateral component, which would have ensured that the plane was lined up with the runway, and not the taxiway. So, why do a visual approach, when you have so many other options? Mainly because it allows more planes to be put into the same space. If a plane is on a different approach, or is enroute, or is being vectored by the controller ("turn right heading 350"), the controller is responsible for maintaining proper lateral (3 or 5 miles) and vertical (500, 1000, or 2000 feet) separation from other traffic. But traffic cleared on a visual approach does not have that restriction. Visual approaches are an important part of maintaining the high flow rates that Class B airports (SFO, ORD, etc.) want. This comment's gotten pretty long, so I'll post another one with another possibility as to what may have happened! I'll leave you with the FlightAware radar trail, where (if you zoom in on SFO) you can see the go-around taking place. [1]: https://www.vatsim.net https://www.vatsim.net [2]: http://zidartcc.org http://zidartcc.org [3]: https://flightaware.com/live/flight/ACA759/history/20170708/0055Z/CYYZ/KSFO https://flightaware.com/live/flight/ACA759/history/20170708/...
  - CaliforniaKarl 9y ago
    So, I should clarify something: A visual approach is pretty simple from the controller's point of view; it's more work for the pilot. But, the pilot is always the one in command of the plane: If the pilot is unwilling to accept a particular approach, they just need to say so. It may lead to delays, but controllers will accommodate. I originally said that the pilot had been assigned a visual approach to runway 28 Right. Looking at the charts for SFO[1], and the FlightAware trace[2], I have an alternative: The pilot may have been flying the LDA PRM runway 28 Right approach[3]. (You should open up [3] to look at while reading the rest of this comment.) As has been mentioned, SFO is a bit weird: The two main runways are close enough together that it's not possible for you to have normal simultaneous approaches. For example, have a look at the diagram for Cincinnati/Northern Kentucky International (CVG)[7], another Class B field. Now, compare that to SFO[8]. At CVG, the parallel runways are far-enough apart that simultaneous approaches are possible, but with SFO, that's not possible. So, the FAA came up with the PRM (perimeter) approach. Essentially, the plane approaching runway 28 Left is on an ILS approach. The plane on approach to Runway 28 Right is on an approach that is kindof like an ILS approach, but the plane isn't heading towards the runway, the plane is heading to a point to the right of the runway. Notice on [3], the point labelled "CFFKC". That's a fix (a point in lateral space), marking the point that you're being guided to. Note how the fix doesn't line up with the runway; that's why this approach is an "LDA (Localizer-type Directional Aid) with Glideslope" approach. As per the detailed instructions (in [4], and point 4 in [6]), pilots on the LDA PRM runway 28 Right approach switch to a visual approach after the DARNE waypoint (3.4 nautical miles from the runway end). For most of the approach, they are monitoring a second frequency, which is only used if planes get too close together. But, once you pass DARNE, you no longer need to listen on that frequency. And although tower might have a radar view of surrounding traffic, it's not their primary tool (their eyes are). If the Air Canada pilot was flying the LDA PRM RWY 28R approach, I think the final sidestep (from the LDA to the runway) may have been missed, or not completely executed, causing the pilot to line up with what he thought was the runway, but what was actually the taxiway. [1]: http://www.airnav.com/airport/KSFO http://www.airnav.com/airport/KSFO [2]: https://flightaware.com/live/flight/ACA759/history/20170708/0055Z/CYYZ/KSFO https://flightaware.com/live/flight/ACA759/history/20170708/... [3]: http://155.178.201.160/d-tpp/1707/00375LDAPRM28R.PDF http://155.178.201.160/d-tpp/1707/00375LDAPRM28R.PDF [4]: http://155.178.201.160/d-tpp/1707/00375PRMAAUP.PDF http://155.178.201.160/d-tpp/1707/00375PRMAAUP.PDF [5]: http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C.PDF http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C.PDF [6]: http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C2.PDF http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C2.PDF [7]: http://155.178.201.160/d-tpp/1707/00655AD.PDF http://155.178.201.160/d-tpp/1707/00655AD.PDF [8]: http://155.178.201.160/d-tpp/1707/00375AD.PDF http://155.178.201.160/d-tpp/1707/00375AD.PDF
charlietran 9y ago
There's an mp3 of the radio chatter here: https://forums.liveatc.net/atcaviation-audio-clips/7-july-ksfo-ac759-go-around/ https://forums.liveatc.net/atcaviation-audio-clips/7-july-ks... > Audio from the air traffic controller communication archived by a user on LiveATC.net and reviewed by this newspaper organization showed how a the confused Air Canada pilot asks if he’s clear to land on 28R because he sees lights on the runway. > “There’s no one on 28R but you,” the air controller responds. > An unidentified voice, presumably another pilot, then chimes in: “Where’s this guy going. He’s on the taxiway.” > The air controller quickly tells the Air Canada pilot to “go around.” telling the pilot “it looks like you were lined up for Charlie (Taxiway C) there.” > A United Airlines pilot radios in: “United One, Air Canada flew directly over us.” > “Yeah, I saw that guys,” the control tower responds.
- desdiv 9y ago
  .
  - grandalf 9y ago
    http://ieeexplore.ieee.org/document/369434 http://ieeexplore.ieee.org/document/369434 On the other hand, AM is simple and cheap and usable worldwide without significant investment.
    - pdelbarba 9y ago
      Except when said AM transceiver is inside an airplane, then it's thousands of dollars :P
  - sigstoat 9y ago
    they still use AM because higher powered transmitters (which will generally be the tower) can overpower weaker transmitters (planes). i'm given to understand aviation is enamored of that feature. > Just imagine the economic damage that a single asshole can do with a high-powered transmitter near an airport. the pilots could probably just pull their cell phones out and call the tower. there is much worse trouble single assholes could get up to.
FiloSottile 9y ago
I am just a passenger, but this looks very over-blown. A pilot aligned with the taxiway, that's bad. But no pilot would ever land on a runway (or taxiway) with 3 planes on it. Just search the Aviation Herald for "runway incursion". And indeed, he spotted them, communicated, went around. Aviation safety margins are so wide that this does not qualify as a near-miss.
- meowface 9y ago
  Right, I'm confused by this. Surely the pilot would notice at least one of the planes he'd be inevitably crashing into well before he started to land?
  - ddeck 9y ago
    >Surely the pilot would notice at least one of the planes he'd be inevitably crashing into well before he started to land In theory yes, but the risk is that the plane you crash into is not yet on the taxiway or that poor visibility or tunneled focus prevents you from noticing it. You don't need to be moving quickly to have a significant accident. The deadliest aviation accident in history (583 fatalities) resulted when two planes collided on a taxiway (edit: actually on the runway) in dense fog [1]. Edit: as correctly pointed out below, the actual collision took place on the runway at significant speed. [1] https://en.wikipedia.org/wiki/Tenerife_airport_disaster https://en.wikipedia.org/wiki/Tenerife_airport_disaster
    - Pinckney 9y ago
      You're mistaken. The KLM plane took off when it was not cleared, and they collided at 260km/h.
      - cyberferret 9y ago
        That was just one of seven distinct mistakes that lead to the crash. The PanAm pilot missed his turnoff, the controllers were busy watching a football match and missed the radio cues that could have alerted them to the fact there was an impending problem etc. etc.
cperciva 9y ago
Can we have "might have triggered" changed to "could have triggered" in the title?
- milesf 9y ago
  Title is from the original article. What's your reason for could instead of might?
  - mc32 9y ago
    The tense/mood is wrong. It implies it could have been the cause of something that did happen rather than it having had a possibility of causing something that did not happen. Text of article has correct tense: "In what one aviation expert called a near-miss of what _could have been_ the largest aviation disaster ever..."
    - milesf 9y ago
      Of course :) I see it now. Didn't intend to be link bait, although the original may have intended that. Changed.
      - tritium 9y ago
        It's still click bait. For clarity, exchange 'might' for 'could' and include 'almost' as an improvement. SFO near miss could have almost triggered aviation disaster This would clearly mark the situation as an event that did not happen, and also did not result in other terrible things.
    - StavrosK 9y ago
      That's exactly right, I parsed the title as "a great aviation disaster happened, and the cause could be an SFO near miss".
      - jakub_g 9y ago
        Being non-native English speaker, I didn't notice the subtle distinction - but it makes sense now with the explanations. Thanks for your comments.
rdtsc 9y ago
Without knowing the cause but if I had to guess this looks like pilot error. At least statistically that the leading cause of crashes. I am surprised pilots still manually land planes. Is the auto-landing feature not implemented well enough? But then it's relied upon in low visibility. So it has to work, they why isn't it used more often?
- rblatz 9y ago
  From what I understand pilots still practice landing in good conditions so they aren't completely out of practice if something goes wrong and they have to manually land the plane.
- Animats 9y ago
  Too soon to tell what the problem was. Possibly there was some other problem in the aircraft that was taking some pilot attention. Give this some time.
  - konschubert 9y ago
    Then it would still be pilot error, no? I mean, pilot error doesn't mean that the pilot is to be blamed. It just means that he made a mistake.
    - waqf 9y ago
      Yes, the pilot made a mistake, but no, the cause of the accident isn't pilot error. From the point of view of preventing similar accidents in future, the cause of the accident is whatever caused the pilot to make the mistake.
- cagataygurturk 9y ago
  When visual conditions are enough, pilots tend to do visual approach/manual landing even there is CATIII equipment and airline/pilot certified to do that. It is faster and more economic: https://aviation.stackexchange.com/questions/24275/what-makes-a-visual-approach-quicker-than-an-ils-approach https://aviation.stackexchange.com/questions/24275/what-make...
ddeck 9y ago
Attempts to take off from or land on taxiways are alarmingly common, including those by Harrison Ford: Harrison Ford won't face disciplinary action for landing on a taxiway at John Wayne Airport [1] Serious incident: Finnair A340 attempts takeoff from Hong Kong taxiway [2] HK Airlines 737 tries to take off from taxiway [3] Passenger plane lands on the TAXIWAY instead of runway in fourth incident of its kind at Seattle airport [4] [1] http://www.latimes.com/local/lanow/la-me-ln-ford-taxiway-agreement-20170331-story.html http://www.latimes.com/local/lanow/la-me-ln-ford-taxiway-agr... [2] https://news.aviation-safety.net/2010/12/03/serious-incident-finnair-a340-attempts-takeoff-from-hong-kong-taxiway/ https://news.aviation-safety.net/2010/12/03/serious-incident... [3] https://www.flightglobal.com/news/articles/hk-airlines-tries-to-take-off-from-taxiway-316283/ https://www.flightglobal.com/news/articles/hk-airlines-tries... [4] http://www.dailymail.co.uk/travel/travel_news/article-3378645/Passenger-plane-lands-TAXIWAY-instead-runway-fourth-incident-kind-Seattle-airport.html http://www.dailymail.co.uk/travel/travel_news/article-337864...
- wfunction 9y ago
  Why in the world is this even a problem? Shouldn't what's a taxiway and what's not be indicated on maps or diagrams or something that pilots can see?
  - Tuxer 9y ago
    (pilot here) Yes, they are very well shown on maps, but it can be hard to map your diagram to what you're seeing, especially if it's raining or if it's at night, and even more if you're tired. I never made the mistake, but can see how somebody in bad conditions would.
    - wfunction 9y ago
      Thanks! But why do you even have to map your diagram to what you're seeing? Isn't there a GPS system that shows you exactly where you are on the map and where you are going to go in the next few minutes? It doesn't seem like there should be any mental or visual processing to figure out that you're heading toward the wrong runway, right?
blhack 9y ago
People "could" run their cars off of bridges every day, but they don't because they can see, and because roads have signs warning them of curves. This sounds like a story of how well the aviation system works more than anything. The pilot is in constant communication with the tower. The system worked as intended here and he went around. It seems like a non story.
- dbroockman 9y ago
  Seems like disaster was only avoided because there was good visibility. If there was fog that day, it sounds like this wouldn't have been avoided.
  - chrisper 9y ago
    If there is fog you do not fly by hand. You use an automated landing system (ILS) in that case.
    - bake 9y ago
      ILS does not entail automation -- it provides guidance to humans operating the controls.
      - dingaling 9y ago
        ILS does not necessarily indicate automation, but about 5% of ILS approaches are autolandings.
    - jiqiren 9y ago
      SFO's ILS isn't always functioning. It was turned off for months when Asiana crashed (June 1st - Aug 2nd)[1]. [1] http://www.popularmechanics.com/flight/a9124/what-went-wrong-in-the-777-crash-in-san-francisco-15670446/ http://www.popularmechanics.com/flight/a9124/what-went-wrong...
      - mikeash 9y ago
Animats 9y ago
Here's a night approach on 28R at SFO.[1] Same approach during the day.[2] The taxiway is on the right. It's a straight-in approach over the bay. The runway, like all runways at major airports worldwide, has the standardized lighting that makes it very distinctive at night, including the long line of lights out into the bay. This was in clear conditions. WTF? Looking forward to reading the investigation results. The planes on the taxiway are facing incoming aircraft as they wait for the turn onto the runway and takeoff. So they saw the Air Canada plane coming right at them. That must have been scary. [1] https://www.youtube.com/watch?v=rNMtMYUGjnQ https://www.youtube.com/watch?v=rNMtMYUGjnQ [2] https://www.youtube.com/watch?v=mv7_lzFKCSM https://www.youtube.com/watch?v=mv7_lzFKCSM
- lucb1e 9y ago
  > WTF? Looking forward to reading the investigation results. I'm not an expert, but given what you said, I suppose it'll just end up equating to "Human error. Happens."
  - hueving 9y ago
    I suggest you read ntsb investigations of some major commercial aviation events like this. It is never just "human error. Happens." They are always full of excellent recommendations, points of failure, etc.
    - verytrivial 9y ago
      I agree. Check out the NTSB report[1] for the crash into a neighborhood in Queens[2]. 200-odd pages of very sober, rational (and interesting) discussion of how a pilot ended up snapping the vertical stabilizer off an A300. There are many factors leading up to what ends up being summarized as pilot error. [1] https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0404.pdf https://www.ntsb.gov/investigations/AccidentReports/Reports/... [2] https://en.wikipedia.org/wiki/American_Airlines_Flight_587 https://en.wikipedia.org/wiki/American_Airlines_Flight_587
      - 9y ago
deleted 9y ago
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stygiansonic 9y ago
Wow, I landed on the next day on the same flight (AC 759)
- bbcbasic 9y ago
  You missed out on the fun
leoharsha2 9y ago
Reporting on disasters that didn't happen.
tmsh 9y ago
The moral of this story for me is: be that "another pilot." To be clear, "another pilot" of another aircraft. Not as clear as it could be just like the title of this article is ambiguous. The moral of this story for me is: call out immediately if you see something off. He's the real hero. Even if the ATC controller immediately saw the plane being misaligned at the same time - that feedback confirming another set of eyes on something that is off couldn't have hurt. All 1000 people on the ground needed that feedback. Always speak up in situations like this.
- theGimp 9y ago
  Good observation. If you're wrong, you suffer a brief moment of embarrassment. If you're right, you might prevent a disaster. Speaking up is a no-brainer.
  - bovitclan 9y ago
    I don't mean to be a downer, but you could certainly cause an accident by calling out an observation which was faulty. I agree with the sentiment that you should speak up when you see something amiss, but let's not kid ourselves that, like every decision, it comes with inherent risk.
    - mckoss 9y ago
      Making an aircraft go-around can never cause an accident - the missed approach path for any landing aircraft is always kept clear.
  - khazhoux 9y ago
    I wonder how many people have died throughout history due to embarrassment, or (similarly) going against your instinct. The number exists but is unavailable to us. - Not having that dark mole near your privates checked out. - Not wanting to turn the car around. - Not walking away when those shady guys walked in. ...
    - avh02 9y ago
WalterBright 9y ago
In the early 1960s, a pilot mistook a WW2 airfield for Heathrow, and landed his 707 on it, barely stopping before the end of the runway. The runway being too short to lift a 707, mechanics stripped everything out of it they could to reduce the weight - seats, interiors, etc. They put barely enough gas in it to hop over to Heathrow, and managed to get it there safely. The pilot who landed there was cashiered.
- abritinthebay 9y ago
  “Cashiered”?
  - schoen 9y ago
    It means 'fired' (maybe more common in English outside the U.S.?). https://en.wiktionary.org/wiki/cashier#English https://en.wiktionary.org/wiki/cashier#English
    - ajeet_dhaliwal 9y ago
      I've lived 22 years of my life in the UK and 12 in North America and never heard of this before so I don't think it can be particularly common. I've heard of being 'laid off', 'fired', 'let go', 'terminated', 'made redundant', 'purged', but never this. Based on this link https://en.wikipedia.org/wiki/Cashiering https://en.wikipedia.org/wiki/Cashiering it might be a military way of saying it so perhaps the poster has some background in that field.
      - abritinthebay 9y ago
        That would make a lot of sense
      - schoen 9y ago
        That's quite possible. I feel like The Economist also uses it, but maybe they're trying to cultivate a retro aesthetic. :-)
      - deleted 9y ago
heeen2 9y ago
Aren't there lights that have to line up if you're on the right course for the runway like with nautic harbors? Or warning lights that are visible when you're not aligned correctly?
watson 9y ago
English is not my native language, but shouldn't the headline have read "SFO near miss would have triggered aviation disaster"? "Might" seems to indicate that something else happened afterwards as a possible result of the near miss
- batiudrami 9y ago
  Yes, it's awkward phrasing which implies the near miss led to something else happening.
- pluma 9y ago
  Not a native speaker either (though I've been fluent for decades) and I find the title horribly misleading as well. "Might have triggered" implies the disaster happened, or at least that it's not known whether a disaster happened. "Would have triggered" implies neither the disaster nor the near-miss happened, so I think the most unambiguous phrasing would have been "could have triggered". OTOH I've seen native speakers use headlines like "Why this works?" (which by my understanding of the language shouldn't have a question mark), so IDK.
- grecy 9y ago
  I agree. English is my first language, and the more I read the headline, the more I see it as "Something terrible happened, and the near miss is possibly the cause".
  - MBCook 9y ago
    When I fist saw the headline that's why I went to read it. I wanted to know how a near miss 'possibly caused' the biggest disaster in airline history. The story was very interesting. The title is technically valid. But as another native speaker I think it's very confusing.
- bryanrasmussen 9y ago
  the problem is that while Could is technically preferable to Might in this situation for exactly this reason, the proper distinguishing between the two conditions has long been vague. People will often use Could have when they mean might have. To be accurately and unambiguously understood by everyone it should be SFO near miss could have triggered aviation disaster but didn't. Since the completely unambiguous phrasing is not very elegant then Could have would be preferable, but with the understanding that for some people it will still have some ambiguity that needs resolving by actually reading the article.
petre 9y ago
Paint the runway and the taxiway in different colors and also use different colors for the light signals that illuminate them at night. Blue/white is rather confusing. Use clearly distinguishable colors such as red/blue or orange/blue or magenta/yellow.
- pluma 9y ago
  Another comment mentioned green vs white. Even though it's practically impossible to get an aviation license with deuteranopia that just seems like it's asking for trouble. White light is rarely pure white and depending on the weather conditions I have a hard time believing the contrast is unambiguous. Heck, maybe aviation should take a page from basic accessibility and figure out that information should be conveyed more than one way. Don't rely on color alone (and no, spacing of the rows of lights isn't unambiguous either, especially when looking at varying distances and angles).
kwhitefoot 9y ago
Why is instrument landing not routinely done? Is it because it is not good enough?
mate_soos 9y ago
Before crying pilot error, we must all read Sydney Dekker's A Field Giude to Understading "Human Error" (and fully appreciate why he uses those quotes). Don't immediately assign blame to the sharp end. Take a look at the blunt one first. Most likely not a pilot error. Assigning blame is a very human need, but assigning it to the most visible and accessible part is almost always wrong.
- michaelbarton 9y ago
  I second this. This book has quite a boring cover, and quite boring "clip art" diagrams, but the message is astonishingly useful and can be applied in all situations, particulary in software development. In hindsight it's easy to say something like "the red light was flashing to indicate the widget wasn't working. The pilot didn't do anything about it, he's obviously negiligent". At the time though the pilot may be dealing with 100s of stimuli and he doesn't know that this single red light is "the one" he should especially be paying attention too. There's a quote about assigning blame - "Looking for scape goats is like peeing your pants, in the short term it feels pretty good but in the long term it makes you look pretty stupid."
- danieltrembath 9y ago
  Adding to that, "Normal Accidents" by Charles Perrow is a great read.
- mckoss 9y ago
  I can't imagine any scenario where this is not pilot error (unless you had a power failure of the airport lighting systems).
  - woliveirajr 9y ago
    The point is that it doesn't help to know that it was a pilot error, because a pilot is human, and humans in the same situation might make the same mistake - and the main goal is to prevent accidents, not to have accidents happening all the time and saying "it was again human error". It boils down to: 1 - Was the "error" intentional? If so, how to prevent someone from doing it again? 2 - Was it a real error, with no intention of any kind? If so, how to prevent that someone makes it again?
ryenus 9y ago
This reminds me of the runway incursion incident at Shanghai, in Oct 2016: http://www.jacdec.de/2016/10/11/2016-10-11-china-eastern-a320-and-a330-in-runway-incursion-at-shanghai/ http://www.jacdec.de/2016/10/11/2016-10-11-china-eastern-a32...
- ryenus 9y ago
  tl;dr: the taking-off pilot took an immediate pull-up and avoided the disaster.
4ad 9y ago
It's not a near miss, it's a near hit. https://www.youtube.com/watch?v=zDKdvTecYAM https://www.youtube.com/watch?v=zDKdvTecYAM
martijn_himself 9y ago
I get that this was a manual (non-ILS) landing, but why is there no audio warning to indicate the aircraft is not lined up with the runway?
- mrunkel 9y ago
  That audio warning is only available on the newest planes, but even if it is available, if the ILS is off/not tuned in, there is no way for the plane to know it's not lined up. I can understand wanting to hand-fly the plane, but ILS should always be on just as a reference/check. I also think the linked article is making much to big a deal about this: * The pilot checked in because he saw lights on the runway, he was probably very close to aborting the landing anyway. * We don't know how far away the plane was when the go-around command was given. * People overestimate how easy it is to see the runway/airport at night. You only really get to see real resolution when you're pretty close.
briandear 9y ago
I wonder why on 35R they wouldn’t have the taxiway to the left of the runway. Then the “right” is always the runway. Same for the left. Basically have parallel taxiways on the opposite side of the R/L designation of the runway. So at SFO, the parallel taxiways would be inside the two runways. However, approach lighting is pretty clear, but at dusk, I agree with another comment that it can be rather hard to distinguish depending on angles. I think that approach would be landing into setting sun, so that could have some bearing.
mannykannot 9y ago
AFAIK (not that I follow the issue closely) the problem of radio interference that ended the last-chance attempt to prevent the Tenerife crash has not been addressed [1]. If so, then it may be very fortunate that only one person called out that the landing airplane had lined up its approach on the taxiway, and not, for example, the crews of every airplane on the taxiway, simultaneously. [1] http://www.salon.com/2002/03/28/heterodyne/ http://www.salon.com/2002/03/28/heterodyne/ TL;DR: At Tenerife, both the Pan-Am crew and the tower realized that the KLM aircraft had started its take-off roll, and both tried to warn its crew at the same time, but the resulting radio interference made the messages unintelligible. The author states that a technical solution is feasible and relatively easily implementable.
dba7dba 9y ago
I'd like to suggest that if you are still interested in learning more about what happened, you should look for a video from "VASAviation" on youtube. I'm sure his subscribers have asked him already for analysis and he's working on the video. The channel focuses on aviation comms channel. I find it informative because the youtube channel provides detailed voice/video/photo/analysis of incidents (actual/close-calls) involving planes/passengers taxing/landing/taking-off in/around airports.
EGreg 9y ago
Obligatory George Carlin https://m.youtube.com/watch?v=zDKdvTecYAM https://m.youtube.com/watch?v=zDKdvTecYAM
vermontdevil 9y ago
Found a cockpit video of a landing approach to 28R to give you an idea (daylight, good weather etc) https://www.youtube.com/watch?v=I0Y6GTI9pg4 https://www.youtube.com/watch?v=I0Y6GTI9pg4
mikeash 9y ago
I wonder just how likely this was to end in disaster. It feels overstated. The pilot in question seemed to think something was wrong, he just hadn't figured it out yet. I imagine he would have seen the aircraft on the taxiway in time to go around on his own if he hadn't been warned off. I'm having trouble figuring out the timeline. The recording in the article makes it sound like this all happened in a matter of seconds, but it's edited down to the highlights so that's misleading. LiveATC has an archived recording of the event (http://archive-server.liveatc.net/ksfo/KSFO-Twr2-Jul-08-2017-0630Z.mp3 http://archive-server.liveatc.net/ksfo/KSFO-Twr2-Jul-08-2017..., relevant part starts at about 14:45) but even those appear to have silent parts edited out. (That recording covers a 30 minute period but is only about 18 minutes long.) In the archived recording, about 40 seconds elapse between the plane being told to go around and the "flew directly over us" call, but I don't know how much silence was edited out in between. Certainly this shouldn't have happened, but I wonder just how bad it actually was.
radialbrain 9y ago
The avherald article has a slightly more factual account of the event (with links to the ATC recording): https://avherald.com/h?article=4ab79f58 https://avherald.com/h?article=4ab79f58
exabrial 9y ago
Wouldn't the word be "near hit" instead of "near Miss"? If you were close too missing, you'd hit something...
- mikeash 9y ago
  "Near miss" parses as "a miss which was near," not "nearly a miss." I love George Carlin, bless his soul, but this is one thing he got wrong.
jjallen 9y ago
Does anyone know just how close of a call this was? Was the landing aircraft 100, 200 meters above ground? How many more seconds until they would have been too slow to pull up?
TrickyRick 9y ago
> Off-Topic: Most stories about politics, or crime, or sports, unless they're evidence of some interesting new phenomenon. Videos of pratfalls or disasters, or cute animal pictures. If they'd cover it on TV news, it's probably off-topic. [1] Is it just me or is this blatantly off-topic? Or is anything major happening in the bay area automatically on-topic for Hacker News? [1] https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
- mikeash 9y ago
  Aviation safety is a common recurring topic here. I don't think the fact that this happened at SFO is related.
- rkuykendall-com 9y ago
  There's something about air traffic that is very HackerNews. Search for "air traffic" to see what I mean. Maybe it's something about coordinating big complex systems, or maybe radio chatter is nerdy, I don't know, but it does make sense to me.
  - TrickyRick 9y ago
    Maybe that's it then, still find it odd how the news that something almost happened is related to HN. I would understand it if the investigation showed a system failure or something similar.
phkahler 9y ago
A different kind of error... I was returning from Las Vegas in the middle of the day and the tower cleared us for departure on 9 and another plane on 27. We had taxied out and then the pilot pulled over, turned around and waited for the other plane to depart. He told us what had happened - there was a bit of frustration in his voice. Imagine pulling up and seeing another plane sitting at the opposite end of the runway ready to go. (it may not have been 9 and 27 I don't know which pair it was) Earlier waiting in the terminal I had seen a different plane go around, but didn't know why. Apparently there was a noob in the tower that day. This is why you look out the window and communicate.
lisper 9y ago
Possible explanation for why this happened: it was night, and the parallel runway 28L was closed and therefore unlit. The pilot may have mistaken 28R for 28L and hence the taxiway for 28R. This comes nowhere near excusing this mistake (there is no excuse for a screwup of this magnitude) but it makes it a little more understandable.
cmurf 9y ago
Near as I can tell HIRL could not have been on, they were not following another aicraft to land, and the runway and taxiway lighting must've been sufficiently low that the taxi lights (low intensity version of a landing light) on the queued up airplanes on the taxiway, made it look like the taxiway was the runway. Pilot fatigue, and experience at this airport also are questions. http://flightaware.com/resources/airport/SFO/IAP/ILS+RWY+28R+(CAT+II+-+III)/pdf http://flightaware.com/resources/airport/SFO/IAP/ILS+RWY+28R... All runways have high intensity runway lighting (HIRL) and 28R has touchdown zone and centerline lighting (TDZ/CL). Runway lights are white, taxiway lights are blue. If you see these elements, there's no way to get confused. So my assumption is the pilots, neither of them, saw this distinction. HIRL is typically off for visual landings even at night. That's questionable because night conditions are reduced visibility situations and in many other countries night flying is considered as operating under instrument rules, but not in the U.S. You do not need instrument rated aircraft or pilot certification. For a long time I've though low intensity HIRL should be enabled briefy in the case of visual night landings, where an aircraft is not following behind another, at the time "runway in sight" verbal verification happens between ATC and pilot.
TheSpecialist 9y ago
I always wondered what about SFO makes it so much more dangerous than the other airports in the area? It seems like they have a potential disaster every couple years.
BusinessInsider 9y ago
Theoretically - if the plane had landed, how many planes would it have taken out? It obviously wouldn't have been pretty, but I doubt the AirCanada would have reached the fourth plane, or maybe even the third.
perseusprime11 9y ago
How will an autonomous system handle this issue? Will it figure out the light colors of runways vs. taxiways or will it rely close geolocation capabilities?
URSpider94 9y ago
Incidentally, I heard a story on KQED (SF Bay Area public radio) today that mentioned a potential clue. There are two parallel runways on this heading -- however -- the left runway is closed for repairs and therefore is currently unlit. If the pilot didn't remember this (it would have been included in his briefings and approach charts for the flight, but he may not have internalized it), he would likely have been looking for two parallel runways and would have lined up on the right one, which in this case would have been the taxiway...

481 points by milesf 9y ago

How is this even possible? Is it gross negligence on the part of the pilot, a systems problem, or something else? (IANAP)

csours 9y ago
SFO is said to be a somewhat abnormal/difficult approach [0]. This could cause stress and fractured attention in the pilot. I wouldn't be surprised to learn that there was some other complicating factor. Planes don't usually crash (or nearly crash) without several safety factors being breached. 0: https://jethead.wordpress.com/2013/07/09/how-do-you-land-at-san-francisco-international-airport/ https://jethead.wordpress.com/2013/07/09/how-do-you-land-at-...
- dba7dba 9y ago
  When the Asiana flight 214 crash landed in SFO in 2013, there was a blog post from a pilot who claimed to be a Lufthansa Air pilot. He wrote that because of city of San Francisco's unusually stringent noise mitigation rule for airliners flying over the city to land at the SFO airport, an airliner has to make a very steep descent from an altitude higher than normal. So instead of bringing down an airliner gradually, a pilot has to get down to the airport in a hurry, requiring much more stringent management of energy/speed. It sounds simple for a plane that's flying straight in, but for a pilot at end of a 10+ hr flight, it's not always so simple. At least I think that's what the purported Lufthansa pilot claimed. I wonder if this has any bearing on the incident.
  - cycrutchfield 9y ago
    Don't planes approach SFO from over the water? I don't think any planes are landing over San Francisco
  - Taniwha 9y ago
    that's only in the (quite rare) case that the wind is coming from the south and the planes are coming in over Daly City .... normally planes land in the other direction and (like the Asiana flight) come in over the Bay. They do however take off over a lot of homes in Daly City and are required to fly a flight plan that seems to postpone a lot of their climb until they are out over the Pacific
codeonfire 9y ago
In Seattle, there have been taxiway landings in 2005 and 2015 because the taxiway looks similar to the runways. Presumably the ILS system should align them with the correct runway, but I guess that in these cases, ILS is not being used. Even it it were, the runways are the same heading and just a few hundred yards apart, so the mistake would not be realized until short final.
- djsumdog 9y ago
  I'm kinda surprised manufactures don't have full HUDs in commercial airliners yet. For airports that support ILS, it seems like using it should be mandatory, with a HUD providing a visual guide to ensure the pilot is lined up with the correct runway. I mean sure, you could still have mistakes (pilot types in the wrong runway in a parallel runway airport and lands on the wrong one), but it'd be another check/safety system in place.
- exDM69 9y ago
  Seattle-Tacoma has three parallel runways with unequal horizontal spacing, it's easy to mistake that parallel taxiway between the center and right (north approach) as the right runway. I've only done it in flight simulators but it's really difficult to tell from a distance.
CaliforniaKarl 9y ago
I'm not a pilot, or real-world ATC, but I was one a _virtual_ air traffic controller, on VATSIM[1]. I was a member of the virtual Indianapolis ARTCC[2], and have worked positions from Dispatch up to & including Center. Listening to the LiveATC clip, the important bit is the phrase "visual 28 right", meaning the Air Canada pilot had been assigned a visual approach to runway 28 Right. The clip sounds like it's from Tower, so you're not hearing the point where the pilot was assigned that approach (that would've happened with Approach). A visual approach is pretty simple: The controller sets you on a heading & altitude. Then, the controller confirms that you have the runway/field in sight, as well as any other air traffic that may potentially pose a conflict. Once the pilot verbally confirms those things are in sight ("traffic in sight" / "field in sight"), the approach controller will clear the pilot for the "visual runway XXX approach", also issuing appropriate warnings regarding wake turbulence. Once the visual approach has been cleared, and the pilot has acknowledged, it is now the pilot's responsibility to navigate the plane to the runway, while keeping the plane clear of the traffic that has been pointed out to them. If the pilot were assigned an ILS, LOC (localizer), LDA (localizer-type directional aid), or RNAV (area navigation) approach, that approach would have included a lateral component, which would have ensured that the plane was lined up with the runway, and not the taxiway. So, why do a visual approach, when you have so many other options? Mainly because it allows more planes to be put into the same space. If a plane is on a different approach, or is enroute, or is being vectored by the controller ("turn right heading 350"), the controller is responsible for maintaining proper lateral (3 or 5 miles) and vertical (500, 1000, or 2000 feet) separation from other traffic. But traffic cleared on a visual approach does not have that restriction. Visual approaches are an important part of maintaining the high flow rates that Class B airports (SFO, ORD, etc.) want. This comment's gotten pretty long, so I'll post another one with another possibility as to what may have happened! I'll leave you with the FlightAware radar trail, where (if you zoom in on SFO) you can see the go-around taking place. [1]: https://www.vatsim.net https://www.vatsim.net [2]: http://zidartcc.org http://zidartcc.org [3]: https://flightaware.com/live/flight/ACA759/history/20170708/0055Z/CYYZ/KSFO https://flightaware.com/live/flight/ACA759/history/20170708/...
- CaliforniaKarl 9y ago
  So, I should clarify something: A visual approach is pretty simple from the controller's point of view; it's more work for the pilot. But, the pilot is always the one in command of the plane: If the pilot is unwilling to accept a particular approach, they just need to say so. It may lead to delays, but controllers will accommodate. I originally said that the pilot had been assigned a visual approach to runway 28 Right. Looking at the charts for SFO[1], and the FlightAware trace[2], I have an alternative: The pilot may have been flying the LDA PRM runway 28 Right approach[3]. (You should open up [3] to look at while reading the rest of this comment.) As has been mentioned, SFO is a bit weird: The two main runways are close enough together that it's not possible for you to have normal simultaneous approaches. For example, have a look at the diagram for Cincinnati/Northern Kentucky International (CVG)[7], another Class B field. Now, compare that to SFO[8]. At CVG, the parallel runways are far-enough apart that simultaneous approaches are possible, but with SFO, that's not possible. So, the FAA came up with the PRM (perimeter) approach. Essentially, the plane approaching runway 28 Left is on an ILS approach. The plane on approach to Runway 28 Right is on an approach that is kindof like an ILS approach, but the plane isn't heading towards the runway, the plane is heading to a point to the right of the runway. Notice on [3], the point labelled "CFFKC". That's a fix (a point in lateral space), marking the point that you're being guided to. Note how the fix doesn't line up with the runway; that's why this approach is an "LDA (Localizer-type Directional Aid) with Glideslope" approach. As per the detailed instructions (in [4], and point 4 in [6]), pilots on the LDA PRM runway 28 Right approach switch to a visual approach after the DARNE waypoint (3.4 nautical miles from the runway end). For most of the approach, they are monitoring a second frequency, which is only used if planes get too close together. But, once you pass DARNE, you no longer need to listen on that frequency. And although tower might have a radar view of surrounding traffic, it's not their primary tool (their eyes are). If the Air Canada pilot was flying the LDA PRM RWY 28R approach, I think the final sidestep (from the LDA to the runway) may have been missed, or not completely executed, causing the pilot to line up with what he thought was the runway, but what was actually the taxiway. [1]: http://www.airnav.com/airport/KSFO http://www.airnav.com/airport/KSFO [2]: https://flightaware.com/live/flight/ACA759/history/20170708/0055Z/CYYZ/KSFO https://flightaware.com/live/flight/ACA759/history/20170708/... [3]: http://155.178.201.160/d-tpp/1707/00375LDAPRM28R.PDF http://155.178.201.160/d-tpp/1707/00375LDAPRM28R.PDF [4]: http://155.178.201.160/d-tpp/1707/00375PRMAAUP.PDF http://155.178.201.160/d-tpp/1707/00375PRMAAUP.PDF [5]: http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C.PDF http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C.PDF [6]: http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C2.PDF http://155.178.201.160/d-tpp/1707/00375PRMAAUP_C2.PDF [7]: http://155.178.201.160/d-tpp/1707/00655AD.PDF http://155.178.201.160/d-tpp/1707/00655AD.PDF [8]: http://155.178.201.160/d-tpp/1707/00375AD.PDF http://155.178.201.160/d-tpp/1707/00375AD.PDF

charlietran 9y ago

There's an mp3 of the radio chatter here: https://forums.liveatc.net/atcaviation-audio-clips/7-july-ksfo-ac759-go-around/ https://forums.liveatc.net/atcaviation-audio-clips/7-july-ks... > Audio from the air traffic controller communication archived by a user on LiveATC.net and reviewed by this newspaper organization showed how a the confused Air Canada pilot asks if he’s clear to land on 28R because he sees lights on the runway. > “There’s no one on 28R but you,” the air controller responds. > An unidentified voice, presumably another pilot, then chimes in: “Where’s this guy going. He’s on the taxiway.” > The air controller quickly tells the Air Canada pilot to “go around.” telling the pilot “it looks like you were lined up for Charlie (Taxiway C) there.” > A United Airlines pilot radios in: “United One, Air Canada flew directly over us.” > “Yeah, I saw that guys,” the control tower responds.

desdiv 9y ago
.
- grandalf 9y ago
  http://ieeexplore.ieee.org/document/369434 http://ieeexplore.ieee.org/document/369434 On the other hand, AM is simple and cheap and usable worldwide without significant investment.
  - pdelbarba 9y ago
    Except when said AM transceiver is inside an airplane, then it's thousands of dollars :P
- sigstoat 9y ago
  they still use AM because higher powered transmitters (which will generally be the tower) can overpower weaker transmitters (planes). i'm given to understand aviation is enamored of that feature. > Just imagine the economic damage that a single asshole can do with a high-powered transmitter near an airport. the pilots could probably just pull their cell phones out and call the tower. there is much worse trouble single assholes could get up to.

FiloSottile 9y ago

I am just a passenger, but this looks very over-blown. A pilot aligned with the taxiway, that's bad. But no pilot would ever land on a runway (or taxiway) with 3 planes on it. Just search the Aviation Herald for "runway incursion". And indeed, he spotted them, communicated, went around. Aviation safety margins are so wide that this does not qualify as a near-miss.

meowface 9y ago
Right, I'm confused by this. Surely the pilot would notice at least one of the planes he'd be inevitably crashing into well before he started to land?
- ddeck 9y ago
  >Surely the pilot would notice at least one of the planes he'd be inevitably crashing into well before he started to land In theory yes, but the risk is that the plane you crash into is not yet on the taxiway or that poor visibility or tunneled focus prevents you from noticing it. You don't need to be moving quickly to have a significant accident. The deadliest aviation accident in history (583 fatalities) resulted when two planes collided on a taxiway (edit: actually on the runway) in dense fog [1]. Edit: as correctly pointed out below, the actual collision took place on the runway at significant speed. [1] https://en.wikipedia.org/wiki/Tenerife_airport_disaster https://en.wikipedia.org/wiki/Tenerife_airport_disaster
  - Pinckney 9y ago
    You're mistaken. The KLM plane took off when it was not cleared, and they collided at 260km/h.
    - cyberferret 9y ago
      That was just one of seven distinct mistakes that lead to the crash. The PanAm pilot missed his turnoff, the controllers were busy watching a football match and missed the radio cues that could have alerted them to the fact there was an impending problem etc. etc.

cperciva 9y ago

Can we have "might have triggered" changed to "could have triggered" in the title?

milesf 9y ago
Title is from the original article. What's your reason for could instead of might?
- mc32 9y ago
  The tense/mood is wrong. It implies it could have been the cause of something that did happen rather than it having had a possibility of causing something that did not happen. Text of article has correct tense: "In what one aviation expert called a near-miss of what _could have been_ the largest aviation disaster ever..."
  - milesf 9y ago
    Of course :) I see it now. Didn't intend to be link bait, although the original may have intended that. Changed.
    - tritium 9y ago
      It's still click bait. For clarity, exchange 'might' for 'could' and include 'almost' as an improvement. SFO near miss could have almost triggered aviation disaster This would clearly mark the situation as an event that did not happen, and also did not result in other terrible things.
  - StavrosK 9y ago
    That's exactly right, I parsed the title as "a great aviation disaster happened, and the cause could be an SFO near miss".
    - jakub_g 9y ago
      Being non-native English speaker, I didn't notice the subtle distinction - but it makes sense now with the explanations. Thanks for your comments.

rdtsc 9y ago

Without knowing the cause but if I had to guess this looks like pilot error. At least statistically that the leading cause of crashes. I am surprised pilots still manually land planes. Is the auto-landing feature not implemented well enough? But then it's relied upon in low visibility. So it has to work, they why isn't it used more often?

rblatz 9y ago
From what I understand pilots still practice landing in good conditions so they aren't completely out of practice if something goes wrong and they have to manually land the plane.
Animats 9y ago
Too soon to tell what the problem was. Possibly there was some other problem in the aircraft that was taking some pilot attention. Give this some time.
- konschubert 9y ago
  Then it would still be pilot error, no? I mean, pilot error doesn't mean that the pilot is to be blamed. It just means that he made a mistake.
  - waqf 9y ago
    Yes, the pilot made a mistake, but no, the cause of the accident isn't pilot error. From the point of view of preventing similar accidents in future, the cause of the accident is whatever caused the pilot to make the mistake.
cagataygurturk 9y ago
When visual conditions are enough, pilots tend to do visual approach/manual landing even there is CATIII equipment and airline/pilot certified to do that. It is faster and more economic: https://aviation.stackexchange.com/questions/24275/what-makes-a-visual-approach-quicker-than-an-ils-approach https://aviation.stackexchange.com/questions/24275/what-make...

ddeck 9y ago

Attempts to take off from or land on taxiways are alarmingly common, including those by Harrison Ford: Harrison Ford won't face disciplinary action for landing on a taxiway at John Wayne Airport [1] Serious incident: Finnair A340 attempts takeoff from Hong Kong taxiway [2] HK Airlines 737 tries to take off from taxiway [3] Passenger plane lands on the TAXIWAY instead of runway in fourth incident of its kind at Seattle airport [4] [1] http://www.latimes.com/local/lanow/la-me-ln-ford-taxiway-agreement-20170331-story.html http://www.latimes.com/local/lanow/la-me-ln-ford-taxiway-agr... [2] https://news.aviation-safety.net/2010/12/03/serious-incident-finnair-a340-attempts-takeoff-from-hong-kong-taxiway/ https://news.aviation-safety.net/2010/12/03/serious-incident... [3] https://www.flightglobal.com/news/articles/hk-airlines-tries-to-take-off-from-taxiway-316283/ https://www.flightglobal.com/news/articles/hk-airlines-tries... [4] http://www.dailymail.co.uk/travel/travel_news/article-3378645/Passenger-plane-lands-TAXIWAY-instead-runway-fourth-incident-kind-Seattle-airport.html http://www.dailymail.co.uk/travel/travel_news/article-337864...

wfunction 9y ago
Why in the world is this even a problem? Shouldn't what's a taxiway and what's not be indicated on maps or diagrams or something that pilots can see?
- Tuxer 9y ago
  (pilot here) Yes, they are very well shown on maps, but it can be hard to map your diagram to what you're seeing, especially if it's raining or if it's at night, and even more if you're tired. I never made the mistake, but can see how somebody in bad conditions would.
  - wfunction 9y ago
    Thanks! But why do you even have to map your diagram to what you're seeing? Isn't there a GPS system that shows you exactly where you are on the map and where you are going to go in the next few minutes? It doesn't seem like there should be any mental or visual processing to figure out that you're heading toward the wrong runway, right?

blhack 9y ago

People "could" run their cars off of bridges every day, but they don't because they can see, and because roads have signs warning them of curves. This sounds like a story of how well the aviation system works more than anything. The pilot is in constant communication with the tower. The system worked as intended here and he went around. It seems like a non story.

dbroockman 9y ago
Seems like disaster was only avoided because there was good visibility. If there was fog that day, it sounds like this wouldn't have been avoided.
- chrisper 9y ago
  If there is fog you do not fly by hand. You use an automated landing system (ILS) in that case.
  - bake 9y ago
    ILS does not entail automation -- it provides guidance to humans operating the controls.
    - dingaling 9y ago
      ILS does not necessarily indicate automation, but about 5% of ILS approaches are autolandings.
  - jiqiren 9y ago
    SFO's ILS isn't always functioning. It was turned off for months when Asiana crashed (June 1st - Aug 2nd)[1]. [1] http://www.popularmechanics.com/flight/a9124/what-went-wrong-in-the-777-crash-in-san-francisco-15670446/ http://www.popularmechanics.com/flight/a9124/what-went-wrong...
    - mikeash 9y ago

Animats 9y ago

Here's a night approach on 28R at SFO.[1] Same approach during the day.[2] The taxiway is on the right. It's a straight-in approach over the bay. The runway, like all runways at major airports worldwide, has the standardized lighting that makes it very distinctive at night, including the long line of lights out into the bay. This was in clear conditions. WTF? Looking forward to reading the investigation results. The planes on the taxiway are facing incoming aircraft as they wait for the turn onto the runway and takeoff. So they saw the Air Canada plane coming right at them. That must have been scary. [1] https://www.youtube.com/watch?v=rNMtMYUGjnQ https://www.youtube.com/watch?v=rNMtMYUGjnQ [2] https://www.youtube.com/watch?v=mv7_lzFKCSM https://www.youtube.com/watch?v=mv7_lzFKCSM

lucb1e 9y ago
> WTF? Looking forward to reading the investigation results. I'm not an expert, but given what you said, I suppose it'll just end up equating to "Human error. Happens."
- hueving 9y ago
  I suggest you read ntsb investigations of some major commercial aviation events like this. It is never just "human error. Happens." They are always full of excellent recommendations, points of failure, etc.
  - verytrivial 9y ago
    I agree. Check out the NTSB report[1] for the crash into a neighborhood in Queens[2]. 200-odd pages of very sober, rational (and interesting) discussion of how a pilot ended up snapping the vertical stabilizer off an A300. There are many factors leading up to what ends up being summarized as pilot error. [1] https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0404.pdf https://www.ntsb.gov/investigations/AccidentReports/Reports/... [2] https://en.wikipedia.org/wiki/American_Airlines_Flight_587 https://en.wikipedia.org/wiki/American_Airlines_Flight_587
    - 9y ago

deleted 9y ago

[deleted]

stygiansonic 9y ago

Wow, I landed on the next day on the same flight (AC 759)

bbcbasic 9y ago
You missed out on the fun

leoharsha2 9y ago

Reporting on disasters that didn't happen.

tmsh 9y ago

The moral of this story for me is: be that "another pilot." To be clear, "another pilot" of another aircraft. Not as clear as it could be just like the title of this article is ambiguous. The moral of this story for me is: call out immediately if you see something off. He's the real hero. Even if the ATC controller immediately saw the plane being misaligned at the same time - that feedback confirming another set of eyes on something that is off couldn't have hurt. All 1000 people on the ground needed that feedback. Always speak up in situations like this.

theGimp 9y ago
Good observation. If you're wrong, you suffer a brief moment of embarrassment. If you're right, you might prevent a disaster. Speaking up is a no-brainer.
- bovitclan 9y ago
  I don't mean to be a downer, but you could certainly cause an accident by calling out an observation which was faulty. I agree with the sentiment that you should speak up when you see something amiss, but let's not kid ourselves that, like every decision, it comes with inherent risk.
  - mckoss 9y ago
    Making an aircraft go-around can never cause an accident - the missed approach path for any landing aircraft is always kept clear.
- khazhoux 9y ago
  I wonder how many people have died throughout history due to embarrassment, or (similarly) going against your instinct. The number exists but is unavailable to us. - Not having that dark mole near your privates checked out. - Not wanting to turn the car around. - Not walking away when those shady guys walked in. ...
  - avh02 9y ago

WalterBright 9y ago

In the early 1960s, a pilot mistook a WW2 airfield for Heathrow, and landed his 707 on it, barely stopping before the end of the runway. The runway being too short to lift a 707, mechanics stripped everything out of it they could to reduce the weight - seats, interiors, etc. They put barely enough gas in it to hop over to Heathrow, and managed to get it there safely. The pilot who landed there was cashiered.

abritinthebay 9y ago
“Cashiered”?
- schoen 9y ago
  It means 'fired' (maybe more common in English outside the U.S.?). https://en.wiktionary.org/wiki/cashier#English https://en.wiktionary.org/wiki/cashier#English
  - ajeet_dhaliwal 9y ago
    I've lived 22 years of my life in the UK and 12 in North America and never heard of this before so I don't think it can be particularly common. I've heard of being 'laid off', 'fired', 'let go', 'terminated', 'made redundant', 'purged', but never this. Based on this link https://en.wikipedia.org/wiki/Cashiering https://en.wikipedia.org/wiki/Cashiering it might be a military way of saying it so perhaps the poster has some background in that field.
    - abritinthebay 9y ago
      That would make a lot of sense
    - schoen 9y ago
      That's quite possible. I feel like The Economist also uses it, but maybe they're trying to cultivate a retro aesthetic. :-)
    - deleted 9y ago

heeen2 9y ago

Aren't there lights that have to line up if you're on the right course for the runway like with nautic harbors? Or warning lights that are visible when you're not aligned correctly?

watson 9y ago

English is not my native language, but shouldn't the headline have read "SFO near miss would have triggered aviation disaster"? "Might" seems to indicate that something else happened afterwards as a possible result of the near miss

batiudrami 9y ago
Yes, it's awkward phrasing which implies the near miss led to something else happening.
pluma 9y ago
Not a native speaker either (though I've been fluent for decades) and I find the title horribly misleading as well. "Might have triggered" implies the disaster happened, or at least that it's not known whether a disaster happened. "Would have triggered" implies neither the disaster nor the near-miss happened, so I think the most unambiguous phrasing would have been "could have triggered". OTOH I've seen native speakers use headlines like "Why this works?" (which by my understanding of the language shouldn't have a question mark), so IDK.
grecy 9y ago
I agree. English is my first language, and the more I read the headline, the more I see it as "Something terrible happened, and the near miss is possibly the cause".
- MBCook 9y ago
  When I fist saw the headline that's why I went to read it. I wanted to know how a near miss 'possibly caused' the biggest disaster in airline history. The story was very interesting. The title is technically valid. But as another native speaker I think it's very confusing.
bryanrasmussen 9y ago
the problem is that while Could is technically preferable to Might in this situation for exactly this reason, the proper distinguishing between the two conditions has long been vague. People will often use Could have when they mean might have. To be accurately and unambiguously understood by everyone it should be SFO near miss could have triggered aviation disaster but didn't. Since the completely unambiguous phrasing is not very elegant then Could have would be preferable, but with the understanding that for some people it will still have some ambiguity that needs resolving by actually reading the article.

petre 9y ago

Paint the runway and the taxiway in different colors and also use different colors for the light signals that illuminate them at night. Blue/white is rather confusing. Use clearly distinguishable colors such as red/blue or orange/blue or magenta/yellow.

pluma 9y ago
Another comment mentioned green vs white. Even though it's practically impossible to get an aviation license with deuteranopia that just seems like it's asking for trouble. White light is rarely pure white and depending on the weather conditions I have a hard time believing the contrast is unambiguous. Heck, maybe aviation should take a page from basic accessibility and figure out that information should be conveyed more than one way. Don't rely on color alone (and no, spacing of the rows of lights isn't unambiguous either, especially when looking at varying distances and angles).

kwhitefoot 9y ago

Why is instrument landing not routinely done? Is it because it is not good enough?

mate_soos 9y ago

Before crying pilot error, we must all read Sydney Dekker's A Field Giude to Understading "Human Error" (and fully appreciate why he uses those quotes). Don't immediately assign blame to the sharp end. Take a look at the blunt one first. Most likely not a pilot error. Assigning blame is a very human need, but assigning it to the most visible and accessible part is almost always wrong.

michaelbarton 9y ago
I second this. This book has quite a boring cover, and quite boring "clip art" diagrams, but the message is astonishingly useful and can be applied in all situations, particulary in software development. In hindsight it's easy to say something like "the red light was flashing to indicate the widget wasn't working. The pilot didn't do anything about it, he's obviously negiligent". At the time though the pilot may be dealing with 100s of stimuli and he doesn't know that this single red light is "the one" he should especially be paying attention too. There's a quote about assigning blame - "Looking for scape goats is like peeing your pants, in the short term it feels pretty good but in the long term it makes you look pretty stupid."
danieltrembath 9y ago
Adding to that, "Normal Accidents" by Charles Perrow is a great read.
mckoss 9y ago
I can't imagine any scenario where this is not pilot error (unless you had a power failure of the airport lighting systems).
- woliveirajr 9y ago
  The point is that it doesn't help to know that it was a pilot error, because a pilot is human, and humans in the same situation might make the same mistake - and the main goal is to prevent accidents, not to have accidents happening all the time and saying "it was again human error". It boils down to: 1 - Was the "error" intentional? If so, how to prevent someone from doing it again? 2 - Was it a real error, with no intention of any kind? If so, how to prevent that someone makes it again?

ryenus 9y ago

This reminds me of the runway incursion incident at Shanghai, in Oct 2016: http://www.jacdec.de/2016/10/11/2016-10-11-china-eastern-a320-and-a330-in-runway-incursion-at-shanghai/ http://www.jacdec.de/2016/10/11/2016-10-11-china-eastern-a32...

ryenus 9y ago
tl;dr: the taking-off pilot took an immediate pull-up and avoided the disaster.

4ad 9y ago

It's not a near miss, it's a near hit. https://www.youtube.com/watch?v=zDKdvTecYAM https://www.youtube.com/watch?v=zDKdvTecYAM

martijn_himself 9y ago

I get that this was a manual (non-ILS) landing, but why is there no audio warning to indicate the aircraft is not lined up with the runway?

mrunkel 9y ago
That audio warning is only available on the newest planes, but even if it is available, if the ILS is off/not tuned in, there is no way for the plane to know it's not lined up. I can understand wanting to hand-fly the plane, but ILS should always be on just as a reference/check. I also think the linked article is making much to big a deal about this: * The pilot checked in because he saw lights on the runway, he was probably very close to aborting the landing anyway. * We don't know how far away the plane was when the go-around command was given. * People overestimate how easy it is to see the runway/airport at night. You only really get to see real resolution when you're pretty close.

briandear 9y ago

I wonder why on 35R they wouldn’t have the taxiway to the left of the runway. Then the “right” is always the runway. Same for the left. Basically have parallel taxiways on the opposite side of the R/L designation of the runway. So at SFO, the parallel taxiways would be inside the two runways. However, approach lighting is pretty clear, but at dusk, I agree with another comment that it can be rather hard to distinguish depending on angles. I think that approach would be landing into setting sun, so that could have some bearing.

mannykannot 9y ago

AFAIK (not that I follow the issue closely) the problem of radio interference that ended the last-chance attempt to prevent the Tenerife crash has not been addressed [1]. If so, then it may be very fortunate that only one person called out that the landing airplane had lined up its approach on the taxiway, and not, for example, the crews of every airplane on the taxiway, simultaneously. [1] http://www.salon.com/2002/03/28/heterodyne/ http://www.salon.com/2002/03/28/heterodyne/ TL;DR: At Tenerife, both the Pan-Am crew and the tower realized that the KLM aircraft had started its take-off roll, and both tried to warn its crew at the same time, but the resulting radio interference made the messages unintelligible. The author states that a technical solution is feasible and relatively easily implementable.

dba7dba 9y ago

I'd like to suggest that if you are still interested in learning more about what happened, you should look for a video from "VASAviation" on youtube. I'm sure his subscribers have asked him already for analysis and he's working on the video. The channel focuses on aviation comms channel. I find it informative because the youtube channel provides detailed voice/video/photo/analysis of incidents (actual/close-calls) involving planes/passengers taxing/landing/taking-off in/around airports.

EGreg 9y ago

Obligatory George Carlin https://m.youtube.com/watch?v=zDKdvTecYAM https://m.youtube.com/watch?v=zDKdvTecYAM

vermontdevil 9y ago

Found a cockpit video of a landing approach to 28R to give you an idea (daylight, good weather etc) https://www.youtube.com/watch?v=I0Y6GTI9pg4 https://www.youtube.com/watch?v=I0Y6GTI9pg4

mikeash 9y ago

I wonder just how likely this was to end in disaster. It feels overstated. The pilot in question seemed to think something was wrong, he just hadn't figured it out yet. I imagine he would have seen the aircraft on the taxiway in time to go around on his own if he hadn't been warned off. I'm having trouble figuring out the timeline. The recording in the article makes it sound like this all happened in a matter of seconds, but it's edited down to the highlights so that's misleading. LiveATC has an archived recording of the event (http://archive-server.liveatc.net/ksfo/KSFO-Twr2-Jul-08-2017-0630Z.mp3 http://archive-server.liveatc.net/ksfo/KSFO-Twr2-Jul-08-2017..., relevant part starts at about 14:45) but even those appear to have silent parts edited out. (That recording covers a 30 minute period but is only about 18 minutes long.) In the archived recording, about 40 seconds elapse between the plane being told to go around and the "flew directly over us" call, but I don't know how much silence was edited out in between. Certainly this shouldn't have happened, but I wonder just how bad it actually was.

radialbrain 9y ago

The avherald article has a slightly more factual account of the event (with links to the ATC recording): https://avherald.com/h?article=4ab79f58 https://avherald.com/h?article=4ab79f58

exabrial 9y ago

Wouldn't the word be "near hit" instead of "near Miss"? If you were close too missing, you'd hit something...

mikeash 9y ago
"Near miss" parses as "a miss which was near," not "nearly a miss." I love George Carlin, bless his soul, but this is one thing he got wrong.

jjallen 9y ago

Does anyone know just how close of a call this was? Was the landing aircraft 100, 200 meters above ground? How many more seconds until they would have been too slow to pull up?

TrickyRick 9y ago

> Off-Topic: Most stories about politics, or crime, or sports, unless they're evidence of some interesting new phenomenon. Videos of pratfalls or disasters, or cute animal pictures. If they'd cover it on TV news, it's probably off-topic. [1] Is it just me or is this blatantly off-topic? Or is anything major happening in the bay area automatically on-topic for Hacker News? [1] https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html

mikeash 9y ago
Aviation safety is a common recurring topic here. I don't think the fact that this happened at SFO is related.
rkuykendall-com 9y ago
There's something about air traffic that is very HackerNews. Search for "air traffic" to see what I mean. Maybe it's something about coordinating big complex systems, or maybe radio chatter is nerdy, I don't know, but it does make sense to me.
- TrickyRick 9y ago
  Maybe that's it then, still find it odd how the news that something almost happened is related to HN. I would understand it if the investigation showed a system failure or something similar.

phkahler 9y ago

A different kind of error... I was returning from Las Vegas in the middle of the day and the tower cleared us for departure on 9 and another plane on 27. We had taxied out and then the pilot pulled over, turned around and waited for the other plane to depart. He told us what had happened - there was a bit of frustration in his voice. Imagine pulling up and seeing another plane sitting at the opposite end of the runway ready to go. (it may not have been 9 and 27 I don't know which pair it was) Earlier waiting in the terminal I had seen a different plane go around, but didn't know why. Apparently there was a noob in the tower that day. This is why you look out the window and communicate.

lisper 9y ago

Possible explanation for why this happened: it was night, and the parallel runway 28L was closed and therefore unlit. The pilot may have mistaken 28R for 28L and hence the taxiway for 28R. This comes nowhere near excusing this mistake (there is no excuse for a screwup of this magnitude) but it makes it a little more understandable.

cmurf 9y ago

Near as I can tell HIRL could not have been on, they were not following another aicraft to land, and the runway and taxiway lighting must've been sufficiently low that the taxi lights (low intensity version of a landing light) on the queued up airplanes on the taxiway, made it look like the taxiway was the runway. Pilot fatigue, and experience at this airport also are questions. http://flightaware.com/resources/airport/SFO/IAP/ILS+RWY+28R+(CAT+II+-+III)/pdf http://flightaware.com/resources/airport/SFO/IAP/ILS+RWY+28R... All runways have high intensity runway lighting (HIRL) and 28R has touchdown zone and centerline lighting (TDZ/CL). Runway lights are white, taxiway lights are blue. If you see these elements, there's no way to get confused. So my assumption is the pilots, neither of them, saw this distinction. HIRL is typically off for visual landings even at night. That's questionable because night conditions are reduced visibility situations and in many other countries night flying is considered as operating under instrument rules, but not in the U.S. You do not need instrument rated aircraft or pilot certification. For a long time I've though low intensity HIRL should be enabled briefy in the case of visual night landings, where an aircraft is not following behind another, at the time "runway in sight" verbal verification happens between ATC and pilot.

TheSpecialist 9y ago

I always wondered what about SFO makes it so much more dangerous than the other airports in the area? It seems like they have a potential disaster every couple years.

BusinessInsider 9y ago

Theoretically - if the plane had landed, how many planes would it have taken out? It obviously wouldn't have been pretty, but I doubt the AirCanada would have reached the fourth plane, or maybe even the third.

perseusprime11 9y ago

How will an autonomous system handle this issue? Will it figure out the light colors of runways vs. taxiways or will it rely close geolocation capabilities?

URSpider94 9y ago

Incidentally, I heard a story on KQED (SF Bay Area public radio) today that mentioned a potential clue. There are two parallel runways on this heading -- however -- the left runway is closed for repairs and therefore is currently unlit. If the pilot didn't remember this (it would have been included in his briefings and approach charts for the flight, but he may not have internalized it), he would likely have been looking for two parallel runways and would have lined up on the right one, which in this case would have been the taxiway...