Meters from DISASTER! - Air Canada flight 759

this video is brought to you together with blinkist the first 100 of you who clicks the link in the description below we get a free trial of blinkists okay let's see what we have here now so this is a video taken from the ntsb gov youtube channel and this seems to be a view from the tower we can see an aircraft on approach which has a red ring around it and then we have four yellow rings that looks like aircraft that are waiting for departure okay so that aircraft is getting closer and it looks like it's lined up with the taxiway oh it's getting really really low area the light comes on from one of the aircraft and it's still descending and really really close eh okay i've done some research about this incident and this happened to air canada flight 759 on the 7th of july of 2017 and this is taken in san francisco international airport in the us so the obvious question here is how is it possible that a trained air crew in the modern airliner can find themselves lined up with a parallel tax away in this case taxiway charlie in san francisco instead of the runway that they're clear to land on which is runway two eight right so i'm guessing that you guys are watching this you probably have your ideas already i've read loads of comments on this video and there's some quite critical ones against the flight crew but maybe there is something else at play here in order to understand that we do need to dissect this whole flight from when it started and what we'll start with doing is we'll explain a little bit about san francisco so san francisco have several runways but if you're coming to land from this direction you basically can land the runway two eight left or two eight right okay this date the seventh of july there was what we call a no-time notice to airman which is um basically some information that is sent out to anyone who's interested uh specifically to air crew that are flying in or flying out of san francisco telling them that from 11 o'clock local time they will be closing runway two eight left down for maintenance okay so this means that only runway two eight right is available from this direction this is fairly common okay this happens a lot of times when you have parallel runways maybe some work needs to be done on the runway lights the centerline lights or maybe there's some patching of the asphalt that needs to be done but anyway fairly common the crew that is flying this flight is a very experienced crew the captain is 56 years old he has over 20 000 hours and the first officer has more than 10 000 hours okay they were on standby which means they were on call to potentially fly on the 7th of july and they were called quite late at night to do this flight they reported to the airport in toronto at around 7 30 local time and as they reported they got their briefing material and the briefing material in this case were over pages with weather information and no time information so that's a lot of pages to go through okay and the fact that runway 2 8 left was going to be closed was just a tiny little paragraph on page 8 in this briefing document we know from post incident interviews that the first officer said he didn't read it in the briefing the captain said that he did read that to it left was going to be closed but that he didn't think that was going to be a problem because it was going to be around the time they were arriving so he thought we are probably going to get in there before they close down this runway and in any case it's not a big deal right because you can land on the other runway so they were more concerned about the fact that there were thunderstorms in the area that were overflying and because of those thunderstorms the aircraft that they were going to use was going to be a bit late in and this meant that they when they departed they were about 35 minutes late off the stand and there was some delays further in toronto so at the end they were about an hour late away from toronto the initial part of the flight was perfectly normal they climbed up to the cruising altitude of 36 000 feet and they proceeded towards san francisco and about two hours into the flight they encountered this area of thunderstorms so they started circumnavigating these thunderstorms you know avoiding them looking at different pathways to go through this area and they both stated that around that time as they went through that area they both started feeling a little bit tired which is normal because it would have been about midnight in their time zone now this is important to note because fatigue is something that we have to be really aware of as pilots okay it affects our decision-making it affects our perception of what's going on around us and these guys still had a long way to go at this point it was scheduled for them to land about three o'clock in the morning their time zone which is about midnight in san francisco you also need to know about something called the window of circadian low okay this is something that the human body goes into at about two o'clock in the morning and it reaches up until four five six o'clock in the morning and you notice this it's it's when you start feeling really tired and really cold and it's where the body is used to being in deep sleep okay working in the window circadian low comes with some restrictions for me for example if we are scheduled to work in that time zone that reduces the overall duty that we're allowed to do just because the risk of fatigue is much higher anyway the rest of the cruise part of this flight was reported as uneventful they started getting closer to where they were going to initiate the descent which is where you have to have completed your approach briefing for your destination so the captain was pilot flying for this language meant that he was going to do the approach briefing and they started looking at what approach to fly and they realized that they were going to come so late that it's going to be the quiet bridge visual approach for runway 28 right in san francisco this is a visual approach which brings the aircraft in over a series of bridges in a kind of a curve towards the runway so instead of an eyeless approach where you're lined up far out straight towards the runway here you have to come in over these bridges and it's done to minimize noise impact late at night in san francisco not an issue however when they briefed this they missed one point and that is on this particular visual approach the crew needed to manually tune the ils frequencies right that's in order to get good kind of backup information from when they're going fly their visual approach the issue though is that this approach was the only one in the network of air canada where the crew needed to set up their last frequencies manually in all other approaches when you select the approach from the flight management computer it auto-tuned the ilses for the approach but not on this one and it was missed okay that would have given the crew some crucial both lateral and vertical information about how they're going to fly on their final approach the crew also received what we call 80s information so this is information that's sent out from an airport and it gives pertinent information like weather at the airport and if there's any anything that's not working properly and in the 80s there was once again information about runway 28 left being closed so you have to put yourself in the head of the pilot now he is expecting once they break visual and disconnect the autopilot that he is going to be lining up with the right out of two parallel runways okay that's that's what he has in his mind and that's what he's building his mental model on said and on the crew starts their descent down towards san francisco they're using um what in the air bus is called the manage descent mode i'm not an airbus pilot so i don't know the details of it but at a certain point towards the later part of the descent the captain decides to go from the manage descent mode to the open descent mode now i don't know exactly if this is a good parallel but i think it's similar to when we go from v-nav in the boeing which is where the aircraft's descending according to a model made by the computer into level change which is where the aircraft is just descending depending on what we tell it to do now the captain said that he changed from the manage to the open descent mode because he was anticipating uh direct vectors that would have given him less track mouse and the computer wouldn't know about that so it's in anticipation of this which is perfectly correct and allowed to do the only reason i'm telling you this is because the first officer said in his interview that he was a bit confused and a little bit worried about this changes in modes because he thought that it would put more workload on him but the point i want to make here is that he never communicated that right so even though he didn't really fully understand it and felt that it was potentially an issue he didn't speak up and it says a little bit about the crm going on right now anyway the crew goes from being in contact with the area atc controller to the approach atc controller and the approach atc controller asked them if they have the bridges in sight okay so these bridges you need to see and it's good weather in san francisco it's nice clear but completely dark obviously and if you see these bridges well then you can initiate the visual approach which will then curve you in towards the runway the crew states that they can see it they are cleared for the visual approach and they initiate it following the l-nav kind of guidance from their computer as they're descending down the procedure of our canada states that as they reach the last waypoint of this official approach procedure they need to disconnect the autopilot and they need to turn off the flight directors so when the captain passes this waypoint this is exactly what he does and he makes a 14 degree right turn to align himself with runway 2 8 right and this is where the mistakes are starting to pile up because unbeknownst to the crew runway 2 8 left is completely blacked out none of the lights are on because there's works on that runway instead there are these big work lights that have been put up and those work lights actually from afar looks very similar to the likes that you will find on an apron so they don't see runway two eight left but they see what looks like apron lights where two white left should be instead they're seeing the lights from way to eight right and the approach lights and the pop is and all of that and to the right of that they see what they think is another runway okay and remember how they are expecting to land on runway two eight right in front of them they have what they think are two parallel runway so naturally the captain is turning to line up with the right one of those runways now you would ask yourself how can a trained flight crew believe that a taxiway is a runway aren't there many many cues showing them that they're going down the wrong path but here is where the way that our brains are wired comes into effect because over the millennia the human brain has been trained to attach to certain patterns and once we find those patterns that we are expecting to see then we have a tendency to disregard anything that doesn't conform with that pattern right it happens on a daily basis and it makes us in most cases become much much quicker in our decision making okay we find a pattern we act on that pattern but during situations where the lighting is bad for example like during a nighttime approach or where we are getting tired so our brains is not as sharp as it normally is those patterns can actually lead us down the wrong path so in this example the crew the captain here is seeing the well-lit runway to it right which is the way it is supposed to land and then he looks to the right and he sees the position light on the aircraft that are standing on the taxiway awaiting clearance to take off from it to it right and he believes that those white position light are actually the runway edge lights subsequently the taxi light on those wheels of those aircraft looks like the centerline lighting of course after that there are green centerline lights that we have on all taxiways but that's been disregarded also the fact that there's no approach like the system and there's no poppies but he is so focused on just the picture that he's expecting landing on the right runway that that's what he's focusing on also remember how the crew had not tuned the ils frequencies from the two eight right well that is to become really important right now because if the crew would have tuned the ils frequencies they would have been able to look down onto their primary flight display and that would have shown them that they were actually a bit over to the right and weren't tracking the center line from a two-eight right but since they didn't do that they didn't have that crucial information in fact only four minutes ahead of air canada flight 759 a united airlines 737 had landed and in some post flight interviews the pilots of that flight said that they had a very similar villa as they were coming in for the approach but since they had the frequencies tuned they could look down and they saw that yeah actually i am on the correct runway here because they could back it up with another navigational system now the first officer is not actually looking outside at this point because as the autopilot has been disconnected his task is to set the missed approach altitude and also the captain asks him to set the runway heading for a potential go around now the first officer doesn't remember that runway heading by heart so he has to go in and look through the plate so he's face down now looking through plates to find the runway heading and when he looks up he also thinks that it looks a little bit strange right and at this point there are about 600 feet descending and the captain sees something that he believes are lights that are crossing the runway ahead of him so he asked the first officer to please contact our traffic control and verify that they're clear to land they do so here is the recording of it and uh and of course the air traffic controller just looks up checks the runway verify that's clear and says yeah yeah there is no one there so you're clear to land okay it came to 759 confirmed clear to land runway 2a right there is no one on to it right but you now the pilots that are sitting on the aircraft that are on the taxiway they're obviously looking at this happening and they can see the big landing lights from the airbus 320 pointing straight at them so at a point where the airbus 320 is just a few hundred feet above the runway the captain of the boeing 787 from united airlines which is first in the queue speaks up and said where is this guy going and then it's on the tax away okay the air traffic controller doesn't understand where this transmission is coming from because it's not using standard phrasiology but this would likely have been heard by the pilots in the air canada cockpit going he's on the taxiway and at the same time now the pilots in the second aircraft switches on their landing lights illuminating the aircraft in front of them and the taxiway giving some extra visual cues to the aircraft that are on final approach so things happened very rapidly now they pass overhead the first boeing 787 of the tax taxiway about 100 feet altitude and then it descends further and right about here both the captain and the first officer realizes that something is wrong and the captain executes the go around at the same time as the first officer calls out go around the aircraft start spooling up it continues to descend another 20 feet or so which all aircraft do when we execute the go around it will always descend a little bit before it starts climbing and the lowest altitude that is indicated is about 60 feet over the runway now the tail as in the top of the fin of the airbus a340 that is the second aircraft in the queue is about 45 feet high so this means that at the lowest point this aircraft is only 10 to 15 feet away from crashing into the tail of the second aircraft this is an extremely serious situation right and this is the reason why the national transportation safety board decided to do a full and thorough investigation into this incident so what was the actual recommendations that came out of this ntsb investigation then well if you just stand by one second after this message i'll tell you what this video has been brought to you together with blinkist now if you're like me and i suspect that you are you would like to read more books than you have time for and if that's the case then blinkist is the perfect tool for you they have taken over 3 000 non-fictional books and they have distilled them down into their essence the most important bits which they call blinks this means that you can sit on your way to work or in the subway or wherever you might be and listen to a full book in only 15 to 20 minutes which is great a book that i am listening to right now is the science of storytelling by will store and if you're interested in checking this out well then the first 100 of you that uses the link here in the description of the video you'll get a free week where you can check out blinkis and all of its different titles and then you'll get another 25 of the full year subscription so go down click the link and start enjoying it right now after the investigation was done and the final report was issued which by the way i've linked to in the description the national transportation safety board came with a couple of recommendations first of all they said that in the cockpit there should be some kind of warning system installed that would highlight to the pilot that they're not lined up with the correct runway and in fact we have actually been issued with such a system right now it's it's a system called ras it's runway awareness and advisory system and it does just that okay if we were to do a visual approach lining up with the taxiway instead of a runway then we will get a warning and it's based on the gps position of the aircraft together with the ground proximity warning system database and it will tell us caution tax away caution tax away if we would do that they also have loads of other warnings installed as well like long landing like that we're approaching a runway when we're taxing it's a great great system also they said a similar system should be installed in the atc towers so that the air traffic controller can be alerted if our aircraft inadvertently is heading toward the wrong runway also the ntsb highlighted the fact that really important operational information needed to be highlighted in the no times so that something like a runway closure wouldn't be kind of messed into the text at page number eight out of a 27 page document that should be coming very early so it became obvious for the flight crew that this was of a big operational impact then they're also highlighting the fact that there needs to be a better system to show that a closed runway is still a runway so maybe not you know closing down all of the lights but keeping the edge lights on or at least having some kind of cross that can be seen from multiple directions not only in the approach direction and last but not least they're highlighting to the aviation authorities in canada that you know maybe you should have a look at your flight time limitations especially when crews are being called off standby and having to operate into the window of circadian low so what you'll notice from this is that none of these recommendations talks about the flight crew or saying that the flight crew were incompetent there's no question that mistakes were made on this approach right of course there was but the way that ntsb and other authorities that are looking into incidents like this are working is that they want to get to the bottom of why did this happen how can we stop it from happening in the first place so unless there is gross negligence on the part of the flight crew which it wasn't in this case this was an honest mistake well then the next question is okay let's build systems that make sure that these mistakes cannot happen and that's what i wanted you to get from this video guys i hope that you're enjoying this i hope that i have earned a subscription from you and if you like it then make sure that you both subscribe and highlight the little notification bell so you know what i'm coming with new videos on the channel also i'd love to see you in my discord server or in the mentor aviation app there are links to download it here in the description have an absolutely fantastic day wherever you are and i'll see you next time [Music] bye [Music] you

Channel: Mentour Pilot

Views: 592,944

Keywords: air canada 759 atc, air canada 759 san francisco near miss, air canada 759 video, air canada 759 taxiway, aviation incidents, aviation incidents and accidents, Aircrash, air crash documentary, air crash investigation, Mentour Pilot, Mentour Pilot Air Canada, mentour pilot crash investigation, Pilot life, how to become a pilot, Airbus A320, Airbuas A320 Incident, san francisco, Boeing 777, airbus a340, airbus a340-600, flight simulator 2020, flight simulator 2020 gameplay

Id: bLEGir9lzBo

Length: 22min 33sec (1353 seconds)

Published: Fri Apr 16 2021