Problema a San Francisco

[JT8D]

"On Sep 25th 2018 the NTSB, while holding the board meeting to determine the causes of the serious incident, reported that the crew initiated the go around at 89 feet AGL, after the go around was initiated the aircraft descended to a minimum of 60 feet before climbing again, the minimum distance to one of the aircraft on the taxiway was 13 feet. The first officer (more than 10,000 hours of experience, the captain had more than 20,000 hour of flight experience) had missed to tune the ILS frequency for runway 28R. The crew was in possession of the NOTAM indicating runway 28L was closed, however, this information was buried in the middle of page 9 on a 28 page flight release package and thus was less than optimal, The crew was provided with three pages of NOTAMs and 5 pages of other information within the release package. When the information was needed, it could not be recalled by the flight crew. The visual impressions of runway 28R and taxiway C, while on approach to taxiway C, were clearly different, however, confirmation bias is a strong human factor overriding such visual impressions. The flashing X on runway 28L was not properly recognized, had the crew been able to identify the runway surface it is likely they'd have identified the flashing X correctly, the crew reported in post flight interviews it was all black to the left, the investigators stated therefore it remained unclear whether the crew had seen the flashing X at all. The ASDE-X (ground movement surveillance) was not designed to predict a taxiway landing, the system thus worked as designed and did not issue an alert. A safety recommendation to review ASDE-X with respect to predict taxiway landings, however, the FAA did not perform such actions, the safety recommendations were closed after "unacceptable" response. The lead investigator stated: "The safety issues identified investigation relate to the need for consistent FMS autotuning capability, effective presentation of relevant flight operations information, equipment to alert flight crew when the airplane is not aligned with the runway surface, modification of surface detection equipment to identify potential taxiway landings, more effective signalling the flight crews of the closure of runways when one or more runways are closed at an airport, and revision to deregulations to review flight crew fatigure." The NTSB chairman worked out on the base of an example that the NOTAMs were a "pile of garbage", for example the flight release documents included a NOTAM about taxiway limitations for aircraft with more than 114 feet wingspan, however, the A320 had only 101 feet wingspan, so why was that NOTAM included? The captain (20,000+ hours of experience) had been up for 19 hours since the last rest he had taken, the first officer was up 12 hours since his last rest. The severity of the incident was not recognized initially, only after review by the FAA and assessment the severity, which the NTSB chairman rated a "close call", was recognized. There was only one controller on the tower staffing all frequencies, as such there was frequency congestion with the controller being distracted on other frequencies. The board voted on and accepted the following proposed probable cause: "The NTSB determine the probable cause of this incident was the flight crew's misidentification of taxiway C as intended landing runway that resulted from the crew members' lack of awareness of the parallel runway closure due to their ineffective review of NOTice to AirMen throughout the flight and during the approach briefing. Contributing to the incident were: 1) the flight crew's failure to tune the instrument landing system frequency for backup lateral guidance, expectation bias, fatigue and break downs in crew resource management and 2) Air Canada's ineffective presentation of approach procedure and NOTAM information" (Summary of the meeting concluded)"

(http://avherald.com/h?article=4ab79f58&opt=0)

Paolo

[Yavapai]

The NTSB chairman worked out on the base of an example that the NOTAMs were a "pile of garbage"

Parole sante

[JT8D]

The NTSB chairman worked out on the base of an example that the NOTAMs were a "pile of garbage"

Parole sante

Sono d'accordo con te .

Oggi su AvHerald è stato ampliato l'articolo, oltre a quanto ho riportato ieri nel post qui sopra:

http://avherald.com/h?article=4ab79f58&opt=0

E' importante porre l'accento anche sull'aspetto fatica operazionale, che ha influito sull'evento e che troppo spesso negli ultimi anni si è costretti a menzionare come causa di incidenti.

Paolo

[sardinian aviator]

The NTSB chairman worked out on the base of an example that the NOTAMs were a "pile of garbage"

Parole sante

Sono d'accordo con te .

Oggi su AvHerald è stato ampliato l'articolo, oltre a quanto ho riportato ieri nel post qui sopra:

http://avherald.com/h?article=4ab79f58&opt=0

E' importante porre l'accento anche sull'aspetto fatica operazionale, che ha influito sull'evento e che troppo spesso negli ultimi anni si è costretti a menzionare come causa di incidenti.

Paolo

E' possibile che una notizia così importante non fosse anche diffusa via ATIS?

[sigmet]

4 Title 14 CFR Part 117, “Flight and Duty Limitations and Rest Requirements: Flightcrew Members.” described the window of circadian low as 0200 through 0559 (body clock time zone).


12. The captain and the first officer were fatigued during the incident flight due to the number of hours that they had been continuously awake and circadian disruption, which likely contributed to the crewmembers’ misidentification of the intended landing surface, their ongoing expectation bias, and their delayed decision to go around.

13. Current Canadian regulations do not, in some circumstances, allow for sufficient rest for reserve pilots, which can result in these pilots flying in a fatigued state during their window of circadian low.

7. Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low.


Toh, hanno scoperto che i piloti se li fai stancare diventano pericolosi...

[tartan]

Però, siccome il risparmio, cioè l'investimento, cioè il capitale, cioè il guadagno degli investitori che, magari, sono anche i passeggeri stessi che poi channo (leggi cianno) paura di volare, è costantemente al primo posto, allora al posto dei piloti ci mettiamo uno o due o tre computers che lavorano sempre senza stancarsi e sono molto più sicuri dei piloti quando tutto funziona così come ha stabilito il tizio che ha programmato i computers secondo la casistica conosciuta fino al momento della programmazione. Se, poi, ci si trova in ambiente sconosciuto e succede un impiccio, la colpa sarà comunque dei piloti, che essendo riposati avrebbero dovuto risolvere il topico con brillante facilità. Amen,

[air.surfer]

Leggendo di questo evento in giro mi sono imbattuto in questo:
http://www.aviazionecivile.org/vb/showt ... ost1816294
"Gli FD su airbus sono generati dalla funzione Flight Guidance di ciascuno dei due FMGC: essi possono lavorare in maniere interdipendente, ovvero scambiandosi informazioni in modo da generare lo stesso risultato (latch mode) oppure indipendente quando fisicamente non si scambiano più info e lavorano ognuno per conto proprio."

Questo pensa che il Latch sugli airbus sia il modo normale di funzionamento dell'FMGS...

[JT8D]

Rilasciato il Final Report da parte di NTSB:

https://www.ntsb.gov/investigations/Acc ... IR1801.pdf

Paolo