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Air Canada flight crew almost causes second major incident at KSFO

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Two days ago (October 22), an Air Canada A320 flight crew almost caused a second major incident this year at KSFO after failing to respond to a Go Around request from controllers. According to reports, the A320 did not respond to the tower's landing clearance or the subsequent Go Around order, even after repeating the call 5 times. The pilots later said the radio had malfunctioned, but controllers also attempted to signal the flight deck with a red light gun and the plane landed anyways. Apparently the preceding flight had radioed the tower and voiced concerns that they would not be able to clear the runway in time, but thankfully they made it off prior to Air Canada's arrival.

Full article and ATC audio: http://www.avgeekery.com/breaking-another-close-call-for-air-canada-at-sfo-as-they-miss-critical-radio-call/

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This sounds harsh, but this is the second MAJOR incident in just a short time.  Seems like Air Canada needs an investigation from NTSB/FAA and if I were running SFO, I might consider suspending Air Canada's operations at my airport.

This is almost more concerning, as a go-around from ATC really shouldn't be questioned.  Perhaps their radio did malfunction, but they were signaled with the signal gun as well.  I'd be curious to see if they responded to the ground handoff without issues (i.e., used their radio afterwards). 

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Speculation here on one of the Canadian pilots forums that I frequent is that the ground frequency was put in as the standby freq after receiving the landing clearance and they accidentally hit the button to make it the active frequency so did not hear the tower.  Kind of makes you wonder why landing clearances are not given only once the tower is confident that the landing can proceed.  

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4 minutes ago, MarkW said:

Kind of makes you wonder why landing clearances are not given only once the tower is confident that the landing can proceed.  

Would be rather interesting to know if this was a classic FAA "Cleared to land, number five" situation.

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49 minutes ago, MarkW said:

Kind of makes you wonder why landing clearances are not given only once the tower is confident that the landing can proceed.  

I too am quite surprised at that practise. From listening to Live ATC, that doesn't seem to be the case at European airports and indeed at EIDW, with a busy single runway operation, is quite common to hear the tower tell an aircraft on approach to "expect late landing clearance" and that clearance isn't given until the runway is confirmed completely clear. Has always seemed to me that issuing landing clearance to an aircraft in trail to others on approach is a disaster waiting to happen.

Bill

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Obviously didn't hear the radio and I agree with Mark, perhaps they already switched it to Ground but they shouldn't have at that time.

Also hard to see the light signal from the tower when you have a city in the background with lots of red lights from brake lights and traffic lights and other things, and if you weren't looking at the tower you wouldn't see it anyways.

Couldn't the tower flash the Runway Lights? Not sure if they have access to do that. Anyhow looks bad for the pilots.

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21 minutes ago, Matthew Kane said:

Couldn't the tower flash the Runway Lights? Not sure if they have access to do that. Anyhow looks bad for the pilots.

I was under the impression that controllers - at least ground controllers - are directly responsible for operation of the lights because I've heard ops crews asking ground controllers to turn lights on and off before. And I also wondered if flashing lights was an option...any ATC people on here?

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24 minutes ago, Matthew Kane said:

Anyhow looks bad for the pilots.

Although the real failure is a system that fails dangerous: i.e. where an aircraft can be cleared to land in the hope that the runway will be clear, because after all if it's not ATC can just order a GA...

...unless the aircraft in question subsequently loses comms for any reason, of course. Oops.

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Oh man, not even challenge with this one, too easy to have a go with it.

 

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4 hours ago, skelsey said:

Although the real failure is a system that fails dangerous: i.e. where an aircraft can be cleared to land in the hope that the runway will be clear, because after all if it's not ATC can just order a GA...

...unless the aircraft in question subsequently loses comms for any reason, of course. Oops.

And that is exactly how FSX/P3D  ATC works:

ATC: Air Canada 781, you are Cleared to land, follow the Boeing on the Runway

ATC: Air Canada 781, Go Around 

Me: I'll just land anyways because I feel like having a beer and going around takes too long. :laugh:

But you are correct, you shouldn't be clear unless the runway is actually clear. 

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I don't see the big deal with the way ATC does it here in the states.

It's a simple concept, if you are cleared to land,but something is still on the runway......GO AROUND!

This shouldn't even be up for discussion.

 

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Multiple landing clearances are given many many thousands of times a day in many countries around the world.  As much as some of you guys may think that it's dangerous without knowing the actual rules and standards, the FAA, ICAO, Transport Canada to name a few think otherwise. Speculating on simisms or rules and standards that you've heard about doesn't do anyone any good. Wait for the actual report to come out to see what actually happened. 

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1 minute ago, ahsmatt7 said:

I don't see the big deal with the way ATC does it here in the states.

It's a simple concept, if you are cleared to land,but something is still on the runway......GO AROUND!

This shouldn't even be up for discussion.

 

That is correct but sometimes you can be on a short final when the aircraft ahead of you makes the turn. It happens to me more than often in small GA fields. For example once I was flying to KLNS and there was a 152 landing ahead. The 152 had touched down and I was at a 1-2 mile final. We immediately saw that the aircraft was still on the runway but it possibly could get out of it in time for us to land. So we went to the slowest speed possible and by the time I was starting to cross the threshold the aircraft had crossed the hold line when he was leaving the runway. So in that scenario we legally landed and did not have to go around. 

Had the tower controller told us to go around we would have forgotten our attempt immediately to try to squeeze in and just gone around. That call however never came and we made it in. 

If that crew in fact had a radio failure and the preceding aircraft had vacated the runway they legally did not thing wrong. 

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32 minutes ago, Dave_YVR said:

Speculating on simisms or rules and standards that you've heard about doesn't do anyone any good. Wait for the actual report to come out to see what actually happened. 

Dave, actually I quite enjoy this thread! You're correct about "conditional landing clearances" but I am enjoying how well educated most of our  fellow Avsim pilots are.  Just remember guys, when controllers are really humpin' they don't want to go back to number two and then clear him to land. Two TX instead of one makes for a really long day. I say you'll probably never get the truth out of the cockpit; they knew it was a SAFE situation and landed anyway. JMTCW!

Whats even more fun to watch is when you are landing on intersecting runways instructing one aircraft to land and hold short of the other runway and a third a/c on short final being told to "continue". Now that's FUN!

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12 hours ago, Matthew Kane said:

Couldn't the tower flash the Runway Lights? Not sure if they have access to do that. Anyhow looks bad for the pilots.

At most Tower-controlled airports, it is the Tower which controls the lighting, including turning them on and off and varying the intensity of them, so it is likely they could have flashed the runway lights at KSFO since it probably has a mix of high and medium intensity lights. The problem with that is you'd have to be careful that the intent of the signal was clear to everyone it was intended to inform. In this case, that would be the aircraft on the runway which was the reason for calling the go-around, and the aircraft on approach which was being asked to go-around. This is where there may have been the slight possibility of making matters more confusing.

Flashing the runway lights is a recognised signal in aviation, it means: 'anyone, or any vehicle, or any aircraft on the runway must immediately vacate it'. But to an aircraft on the approach, this presents a possible issue, because runway lights can include red, green and white lights, and flashing those different colours means different things, i.e. a flashing green light means cleared to land, whereas a flashing red light means do not land, so you can see where that might appear confusing if there were flashing green and flashing red lights on the runway when you were on finals.

Having said that, I suppose any reasonably intelligent pilot who saw the runway lights were flashing and who was not clear as to the intent of the signal would either query it on the radio, in which case if the radio was bust on that Air Canada aeroplane they'd have known there was an issue and acted accordingly, i.e. sorted it out, or squawked 7600, or noticed they'd accidentally transferred to the ground frequency and flipped it back, or looked at the tower to see if they were using a signal light, which apparently they were and that would have been a flashing red light, for which the intention is in no way ambiguous, and you can respond to it by either rocking your wings (not necessarily a good idea at approach speeds for obvious reasons), or flashing your own lights, either of which would mean you acknowledge having received the signal, or they could have just erred on the side of caution if they were unclear as to a signal's intent and gone around anyway.

Mishaps occur, radios do go U/S, and visual signals are usually only looked for when you know your radios are U/S. They can easily be missed and are perhaps not as expected by younger pilots as they would be by those who are used to them of old, after all, when was the last time you saw a Very Light being used? Having said that, every control tower does have a signal light available for that purpose, so it is definitely something pilots should know about. Some other flying experiences can make you more aware of the use of visual signals, such as if you were for example a glider pilot, where the use of signal lights and wing rocking etc are really quite common indeed, but it's not really a common thing for airliner operations, so it is kind of understandable that they might miss such a signal.

All that aside, short of the crew of that Air Canada jet having been cleared, then owing to expectation bias not considered the possibility their landing clearance might be cancelled and not noticing their radio had gone U/S, it's difficult to defend their actions. That's not an impossible scenario, and if that was the case then they really would not have done anything wrong other than to have not seen a visual signal, but it seems more likely to me that they'd flipped to the ground frequency too early, and that is something they should be pulled up for if that was what happened, although it's kind of difficult to prove, I doubt the CVR would pick up the sound of a frequency transfer button being pressed, and even if it did they might have wiped the CVR upon reaching the gate anyway, and I bet you they wouldn't own up to it if that's what they did do.

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33 minutes ago, Chock said:

All that aside, short of the crew of that Air Canada jet having been cleared, then owing to expectation bias not considered the possibility their landing clearance might be cancelled and not noticing their radio had gone U/S, it's difficult to defend their actions. That's not an impossible scenario, and if that was the case then they really would not have done anything wrong other than to have not seen a visual signal, but it seems more likely to me that they'd flipped to the ground frequency too early, and that is something they should be pulled up for if that was what happened, although it's kind of difficult to prove

But if that is what happened, disciplining the pilots won't help avoid an incident in future where perhaps the frequency is blocked or the aircraft (or tower) radio fails in similar circumstances.

Not clearing aircraft to land on an occupied runway, however, might do. Heathrow, Gatwick, Amsterdam et al all seem to be able to push large amounts of tin without just clearing everybody to land and hoping the Swiss cheese holes don't line up.

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Just now, skelsey said:

But if that is what happened, disciplining the pilots won't help avoid an incident in future where perhaps the frequency is blocked or the aircraft (or tower) radio fails in similar circumstances.

Not clearing aircraft to land on an occupied runway, however, might do. Heathrow, Gatwick, Amsterdam et al all seem to be able to push large amounts of tin without just clearing everybody to land and hoping the Swiss cheese holes don't line up.

Yup, this is true. It could have been another Tenerife, and as far as I know most Civil Aviation Authorities regard missed communications as one of the major priorities they have to address, since there have been quite a few major collisions on runways as a result of bungled communications.

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9 hours ago, warriorpilot said:

That is correct but sometimes you can be on a short final when the aircraft ahead of you makes the turn. It happens to me more than often in small GA fields. For example once I was flying to KLNS and there was a 152 landing ahead. The 152 had touched down and I was at a 1-2 mile final. We immediately saw that the aircraft was still on the runway but it possibly could get out of it in time for us to land. So we went to the slowest speed possible and by the time I was starting to cross the threshold the aircraft had crossed the hold line when he was leaving the runway. So in that scenario we legally landed and did not have to go around. 

Had the tower controller told us to go around we would have forgotten our attempt immediately to try to squeeze in and just gone around. That call however never came and we made it in. 

If that crew in fact had a radio failure and the preceding aircraft had vacated the runway they legally did not thing wrong. 

Yeah I totally agree with you. That's what I woukd expect from a pilot.

It comes down to a pilot having a point at which at any given time, if there is something that makes them feel uncomfortable, they go around, whether or not they are told to.

My point is thst just because the faa allows controllers to give consecutive landing clearances has nothing to do with this incident.

 

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2 hours ago, skelsey said:

But if that is what happened, disciplining the pilots won't help avoid an incident in future where perhaps the frequency is blocked or the aircraft (or tower) radio fails in similar circumstances.

Not clearing aircraft to land on an occupied runway, however, might do. Heathrow, Gatwick, Amsterdam et al all seem to be able to push large amounts of tin without just clearing everybody to land and hoping the Swiss cheese holes don't line up.

The problem is in trail spacing on final. Not clearing someone to land.

I can't tell you how many times I have landed at ord or sfo and then told to hurry off the runway because traffic is on a 1 mile final.

 

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I just love reading your posts, Alan, So analytical, so educating too. In one thread, I have gleaned so much knowledge of r/l ops.

Kudos to all.

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3 hours ago, Chock said:

could have been another Tenerife,

Hope in what's left of my lifetime, we never go there again.

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21 minutes ago, vc10man said:

Hope in what's left of my lifetime, we never go there again.

Amen to that bro, can remember when that happened, it was horrific.

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16 minutes ago, Chock said:

Amen to that bro, can remember when that happened, it was horrific.

And I am of that age to remember too. Just thankful that we did not have the superfast modern wireless world of today for this to have gone pear-shaped in whys, wherefores,and could haves.

Somewhere somebody is still grieving a loved one's loss there.

R.I.P. all.

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2 hours ago, ahsmatt7 said:

The problem is in trail spacing on final. Not clearing someone to land.

I can't tell you how many times I have landed at ord or sfo and then told to hurry off the runway because traffic is on a 1 mile final.

Of course, as with many other major airfields. Heathrow manages to land 45-55 an hour on (mostly) one runway with a fair proportion of heavies (hence longer rollouts and greater wake spacing on final). Gatwick manages 50-60 movements per hour (both arrivals and departures) off a single runway. Neither routinely clear aircraft to land without the runway actually being available. Likewise Amsterdam.

To suggest that the fact that the flight was cleared to land before the runway was in fact clear has nothing to do with this is ridiculous -- it has everything to do with it. If Air Canada had not been cleared to land, there would have been no question about whether they should have gone around or not -- there is no excuse not to. Incident avoided.

However, as it turns out, the last instruction they received was "Cleared to land". Then, for whatever reason (which isn't important -- whether it was finger trouble, a technical issue or anything else), they were unable to receive further instructions. In the absence of receiving further instructions, they did precisely what their last received clearance was -- land!

On this occasion, although the result was a technical loss of separation, no actual harm was done. However, this should serve as a wake-up call to highlight what could happen if, as I mentioned above, the holes in the Swiss cheese line up and there is a radio failure or a blocked frequency (stuck mike?) with a more critical situation on the ground after everyone and his wife has already been cleared to land. I suspect however the investigation will focus more on why the comms were lost rather than on the overall system which unquestionably failed dangerous.

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Some here were too quick to blame the crew in this case...

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