Meters from DISASTER! - Air Canada flight 759
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- เผยแพร่เมื่อ 15 เม.ย. 2021
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On the 7th of July 2017 an Air Canada Airbus A320 came within meters from landing on top of FOUR other aircraft in San Francisco international airport. The four other aircraft were standing in line on taxiway C, awaiting takeoff clearance.
How is it possible that a trained and experience flight crew in a modern airliner could make such a mistake? In todays video I will dissect the whole flight from the beginning to try and answer that question for you.
Enjoy!
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Below you will find the links to videos and sources used in this episode. Enjoy checking them out!
NTSB final report:
www.ntsb.gov/investigations/A...
Pilot Sleeping: @OPSGROUP
ops.group/blog/wp-content/upl...
Runway Maintenance: @MAG
www.adsadvance.co.uk/stansted...
Light Maintenance: @MALMS
www.malmsnavaid.com/images/ma...
Pilot Fatigue: @Aviation Voice
aviationvoice.com/wp-content/...
Pilot Rubbing Eyes: @Getty Images
fthmb.tqn.com/sUP4WSDr5zQdoBL...
RAAS System Screens: @Honeywell Aerospace
www.airlinereporter.com/2013/...
UA 737: @Clayton Eddy
i.pinimg.com/originals/c7/d9/...
This video easily beats Hollywood on content, production quality.... I think I stopped breathing for 20 min ))) Thank you!
So happy you think so!
@@K1OIK rude,the comment was in jest and was a compliment to Mentour and his team.
No doubt about it. 👍
@@NewStreamLine He has mentioned at least two of them from time to time and had to "stop down" about a week ago so one of them could get back in action.
@@flagmichael Thx very much for clarification.
I wish them all good luck!
The second ground pilot was smart and quick to turn on lights and avoided a disaster.
Phillipines airlines a340
@@haiwatigere6202 Used to working with less than proficient pilots around him, so good situational awareness.
@@noeldown1952 somehow I feel you have have turned this around.. how about he was just a great pilot huh. Is that too difficult?
I wouldn't not like to be the pilot on the third plane on the taxiway.
@@haiwatigere6202 I take it you're Filipino? What he is saying is that in third world countries they are more lax when it comes to allowing airlines with less than stellar records who may have less than great pilots, it has nothing to do with the country itself.
It's always been fascinating to me how the aviation industry deals with near misses and crashes. Instead of playing 'Blame Game' like many other industries, they actually commit to preventing the incident from repeating itself. It's a shame other industries don't adopt similar policies.
They simply have too, unlike other industries, in aviation a lot of people's lives could be at stake.
Because if flying became unsafe there would be no flying industry.
They don't always do it and other industries do it as well, but I think the aviation industry is the most regulated industry after spatial industry
@@darkmatters3821 the average victim count is larger on a train crash than on a plane crash because the average passenger number per vehicle is higher
I think people are more interested in plane crashes and emergency landing than in train crashes and critical situations
The second pilot talking on the ground is so relaxed! “He’s on the taxiway!” said in the tone of “This is gonna be fun.” 😅
Thankfully, it all ended well.
If I got it right, it was the first pilot who said that, but the second pilot was also smart and responsive by promptly switching on his lights as a warning to the landing plane. I can't agree more with you that it was great and important to have a safe and happy ending!!!
@@user-ix1ji You’re right, it was the same pilot speaking. I had perceived it as a dialogue between two pilots. My bad. 😄
It's a situation where my ass would go on ground ice.
@@user-ix1ji he could have just got on the radio and said "go around" instead of just turning on his lights lol
@@DevinDTV Well, the action that serves the inteneded purpose is the best action. Like I said, the most important point here is that there was a safe & happy ending. 😊
The unsung heroes in this is definitely the flight crew of that 2nd plane in the queue, it’s probably not something trained for or something they had experience with but the quick thinking of “hey maybe flipping on our lights will get this guy’s attention” probably saved a catastrophe
Besides Canada, there were 4 planes taxing..... lets say each plane had 200 passengers and crew in them, so 4 × 200 = 800 people plus what was on the canadian flight, perhaps a thousand people who would have died as Canada cartwheeled over the 4 planes....... maybe even more waiting to go on hoiday or going home......
Did that pilot get any recognition for saving lives? or the insurance companies billions in payments over the 5 planes, or even the airlines who would have got to get new planes, even still the airport for saving them "asphalt costs"........
Nothing, but us here.....
Definitely. Probably some of the same survival instinct that many drivers have when trying to snap another oncoming driver out of a daze by flashing high beams and honking-a last resort to avoid disaster if other evasive maneuvers are impossible
United airlines pilot is the hero too. He is the one who said "where's he going? He's on the taxiway"
@@mohammedisaa9952I love how you're just making shit up despite the facts being out there. Also, it cleared the first place easy enough
yeah, defensive thinking, turn on the lights, his action prevented the accident as it led to sudden corrective action.
Shoutout to the pilots in the second plane for preventing what could have been the deadliest airline disaster in history
exactly. When I first heard about this and read that they ended up at sixty feet I looked up the other aircraft to see how tall that tail was and was shocked to see how fricking close it was.
And lucky UA1 was just in the process of turning, so he would have seen AC759 coming into land on the taxiway trhough his side windows! No wonder he called out, that would have been a bizarre sight!
@@yggdrasil9039 -- By that point, AC759 was already questioning the clearance themselves and had decided to go around then. One of the recommendations out of this is to always use the ILS no matter what the weather.
@@AEMoreira81 As I understand it they shut off the ILS for a very good reason, which was that it would have directed them across populated areas late at night and there were noise complaints as they were late coming in to land. For that reason they made the decision to turn off ILS. The issue I think is redundancy - actually multiple layers of redundancy - a reason why I will still not fly in the Boeing 737 Max as they have only included a single backup AoA sensor, not enough redundancy in my opinion. With AC coming in without ILS, you should be able to shut off a system and still be able to land a plane safely without gizmos.
Yeah, that was really smart of them and shows good situational awareness when they realize communications aren't clear, and to literally shed light on the situation!
This incident had the potential to surpass Tenerife as the worst aviation accident in history. Having seen the CCTV footage from KSFO's tower and heard the ATC recording, the unsung hero was definitely UAL Flight 1's pilot monitoring who barged in on the radio with an unorthodox message that woke everyone up, "Where's this guy going?! He's on the taxiway!"
Yes, that’s one if the reasons I thought it was worth covering. I hope you liked the video
The aircraft behind him also put his light on!
@@MentourPilot Great coverage. It's so important to "Check" then "re-check", then "Check again"! This could have been the worst!
@@MentourPilot .. Would the planes approaching and the ones on the taxiway be in the same frequency?
@@adb012 From what I understand, yes. Tower would give them clearance to take off, and Tower would give the airborne planes clearance to land. The taxiway queue would be listening to tower waiting for their clearances.
I love how pilots are treated as rational, qualified humans. Instead of saying "they fucked up and should be fired" they reasoned about what could have caused such an extreme mistake on a qualified professional, and tackled it
they fucked up and should be fired
I think airlines like to have these fucked up pilots because they are more aware of problems than those with clean records..... assuming they actually love their career (and their lives...) in the sky.
I disagree- they put multiple lives in danger because they couldn’t tell the difference between taxiway and runway lights? No excuse!
@@carterfan82 So let's start firing pilots for every little mistake that could be catastrophic and start recruiting new pilots faster than we can train them. The 2 pilots flying the approach and the 8 other pilots that seen this plane flying straight towards them are now going to be much more aware of the dangers of this happening and will now be much more aware when doing landings at night. 2 pilots that each have thousands of hours on this aircraft and a experience that made them much more aware for landings sounds better then 2 pilots that just came out of training and maybe have 100 hours of flight time in their passenger airline aviation career.
Read TQM and Edwards Deming. Why do things go right, and reliably so? That requires better insight and understanding than "Hit the Pilot!"
Love the A340 pilot that turned on his landing lights. Guy probably saved lives.
Much respect for always taking the fragile psychology of us humans into account, without shaming pilots, in an incident that might allow people to judge them very easily (superficially).
Agreed. This approach works so much better than finger pointing. The fact that the previous air crew experienced some of the same issues likely helped the Air Canada crew.
Couldn't have put it better myself.
Indeed, they could have just blamed the pilots... instead it led to RAAS, which also seems to have been able to have stopped some past air disasters if it had existed back then.
Here here, nicely said bud!
I was on an AA flight MIA to LAX, as we were in full thrust and rolling fast when the captain dropped the anchor. Just then a rudder of a smaller aircraft went across diagonally in front of us. I always wondered which human screwed up there.
Holy crap I never realized that they were only 15 feet from making contact. I was under the impression that they went around before even crossing the threshold. Terrifying and good move by the pilots on the ground to make the callout and turn on their lights.
Surely this is the stuff nightmares are made from. I hope the flight crew of Air Canada 759 recovered (and for that matter, anyone else that was aware of the danger in those precious moments). Knowing that you were milliseconds away from your biggest (and final) mistake is a heavy burden.
Yeah, I've seen the ATC transcript videos of this incident (shout-out to VASAviation) and I always assumed they had initiated the go-around well before anything could actually happen. That video was extremely scary!
But this goes to show how important it is for all pilots to pay attention to what's being spoken on frequency, even when it doesn't directly affect them. I bet all the pilots on the taxiway perked up and started paying more attention to what's happening when Air Canada said "we think we see some movement on the runway".
@@wloffblizz Aviate, Navigate, Communicate. Communicate is third but this video shows its still very important to do all three, especially if you or someone else makes a mistakes with the Navigate part. Had they not raised thier concerns about seeing the lights and had the pilots on the ground not confirmed thier worries I think there is a very high chance this would have ended in disaster.
@@wloffblizz they had just initiated go around and the engines spooling up when ATC ordered them to go around. At that time, the incident wasn't a mandatory report event and it was reported three days after the incident. As the aircraft had been used in the days following the incident, the CVR had overwritten the flight data. NTSB recommended increasing the recording time from two hours to 25 hours.
15 ft from the altitude sensor, I'd imagine that clearance calc wouldn't include the height of the gear, half the fuselage maybe? Perhaps the tail fin passed between the gear?
I love how NTSB investigations are the perfect example of "No Blame Culture" which so many tech companies profess to value but fail to really embrace. I dream that one day humans will learn to use simillar approach in more areas of their life.
not sure which "tech companies" you refer to. I work in a power plant. All my colleagues in the electrical industry and all my friends in electronics industry experience this no-bullshit, how-can-we-prevent-this culture. Even if it's an *apparent* case of stupidity, we always question, how can we make the procedures better and have better technology and human factors to prevent this
@@iwatchwithnoads7480 I was refering to software development ^^ Where, "who broke it", and "I didn't touched that" are the first things uttered when a bug is spoted.
I wish automobile culture was like this. We've made them into better crash cans but in the USA at least nothing is done about continuously creating dangerous intersections, repeating pedestrian unsafe patterns etc. Everything is just written off as a thing that goes wrong.
@@Thorinbur exactly we have incident reports that have to be completed whenever theres an issue and you don't want to be the main reason on it
@@AntherMoo The insurance company doesn't want this kind of thing and they never will. Without accidents, they're out of business. You can blame capitalism.
I was on the Delta flight that landed four minutes ahead of Air Canada-- whose pilots said that they also had trouble lining up on 28R-- and that was the hardest landing I ever experienced, a carrier flop. I thought at the time that maybe they changed from from the taxiway at the last second in a panic. A strange night all around.
Why do you think is was so weird that night, something going on with the runway lights?
Very possible. Those carrier flops are startling.
The fact that you remember it being a hard landing, and the descriptive way you describe it, instantly painted the picture in my mind: whoa! We better get over quick and get down! Puts me right in the minds of the pilots. Great comment!
Could be!
Anyone who's flown a while would be able to tell if the plane made a "last-minute" bank to get lined up on the runway... Well, maybe not; lots of people don't pay attention to what's going on around them, and might not be sitting next to a window. 🤔
I am always in awe about the aviation community's dedication to safety. *Any* incident is *always* treated as a *collective failure of the community as a whole*. And any investigation always focuses on what the community as a whole can do to improve safety.
The question is never "Whose fault is it?", because the answer is always assumed to be "It's our collective fault as a community because we did not prevent a situation like this occurring!"
The question is *never* "What did the pilots do wrong?" or "What did the controller do wrong?" or "What did the manufacturer do wrong?" etc. but the question is "What can we, as a community, do so that the pilot / controller / manufacturer / etc. never even gets into the position of having to make this decision?"
There is another important feature of accident investigations attached to that, which is that, according to ICAO treaties signed by almost every country on the planet, all countries must enact legislation that disallows any and all usage of incident investigation reports and the information contained therein in both civil and criminal courts as well as prosecution. That way, every person involved can speak completely freely without fear of repercussions. This ensures that nothing gets "hidden". A pilot can own up to a mistake without fear that this information is going to be used against them - it is only going to be used to figure out how to improve procedures and systems in the future such that it is impossible to even get into a position to *make* that mistake.
I really wish this approach were taken in more industries, in more communities, in companies.
In the company I work for, we produce highly complex and highly expensive systems. It is pretty much impossible to make a mistake that *doesn't* cause 4-6 figures (or more) of damage. But if you immediately speak up and own up to it, and ask for help, then it is usually possible to mitigate the damage and fix it. But that *crucially* depends on making sure people are not afraid and know that they can yell for help if they mess up without fear of getting reprimanded or fired.
Great points!
And adding technical data POINTS. I have worked in so many industries and we would have an incident, then we'd have a meeting and the only thing to come of it, was the management saying, "Let's try to be more careful next time" DUMB, DUMB, DUMB.
But, often enough the recommendations aren't adopted. Sometimes the investigators are obviously pressured by commercial implications. Going back to the original Comet catastrophes and further there's a pattern, especially where there's an unsolved mystery, of needing 2 catastrophes before an absolute best effort is made.
In the SaaS/cloud world, lots of tech companies do similar "blameless retrospectives" after incidents, trying to understand the "five whys", drill into the root cause and figure out the right sets of actions to prevent recurrence. You can even see some public retros from Slack, AWS, etc.
@@MentourPilot Continuing off those points, I would be genuinely interested in seeing your thoughts on the ANZ 901 crash and aftermath in a future video. It is by far and away the most revealing investigation into human factors on and off the flight deck that I've ever seen, and I'd love to know how an industry insider sees it.
That being said, I recognize that it is a controversial and difficult case to talk about, not least because it doesn't quite fit the image of airline safety culture, so I appreciate and respect if it's one that you've decided to not discuss.
I feel with the crew. Getting a late flight, getting delayed, then bad weather, landing at 3 am, and seeing what looks (somewhat) like a runway. Good reaction by the pilots on the 2nd plane on the taxiway.
I feel with the passngers. Whew!
@@nabirasch5169 The passengers were probably not aware of the situation. The crews of the airplanes on the taxiway, on the other hand.... ! 😲
@@Milesco I think the passenger heard and maybe feeled that Airbus. A airplane with toga set flying about 10m above your head. I believe they recogniced that there something non-normal happening.
But of course they were not aware of the critcal situation.
Anyone who has done a lot of driving at night in rainy weather will have experienced illusions like this which make it really hard to tell where the road actually goes. This can be bad in the countryside with hardly any lights or in the city with too many, especially reflecting off buildings and tarmac. In a car or on a motorbike we have the option to slow down and puzzle it out - in an aircraft on approach this is impossible.
@@chemistrykrang8065 Indeed, exactly.
I was on this flight, in all fairness to the pilot the actual landing was probably the most buttery smooth landing ive ever experienced.
It almost wasn't.
@@lordmarcusrax lol
I think on the final landing he might have checked his position very carefully
Impossible! CATSA would never have allowed such an item on a flight!
I was also on this flight and when I noticed we were parallel to the active landing runway I opened my window and out my head outside and noticed that there were planes right below us
Your point at the end is spot on. These are experienced pilots who made honest mistakes. So rather than blaming, it is more important to think how could the pilots have been assisted via systems, runway lighting, whatever it is, that would have avoided them making these mistakes, and it looks like that’s exactly the attitude that has been taken. And that makes me feel good about the attitude towards safety in this field.
And as a note, is in contrast to road safety, which is always about blaming drivers and never about maybe we need to change some road design philosophy that constantly leads to crashes. Not to say there isn’t a time or place for blaming drivers and pilots, but we should also give them as much help as possible.
I wish more industries started using this thinking
Mistaking a taxiway for a runway at a major airport is "Thank you for your services, please find work doing something else." The requirements to be a commercial pilot should simply have no leeway for error. Go haul cargo or something but stay away from passenger flights.
@@plektosgaming it is literally impossible to not make an error everyday for years.
Most people make dozens of mistakes everyday but it doesn't amount to much, usually a minor inconvenience or split second annoyance.
It completely depends on their history, what happened in the specific incident and if there was actual negligence.
My point being is that your ideal is ridiculous and a complete fantasy, literally impossible.
I do agree that there are plenty of examples of people that simply should not have been pilots and the testing shouldn't just be hard but they need should also have the right personality/mentality.
21:31 Three cheers for the quick-thinking pilot who switched on his landing-lights when he heard the first pilot call out and saw the approaching plane. When the first plane in the queue was suddenly lit up everyone was saved, by 15 feet.
I think it was Philippine Airlines
"Say... why are there bright lights turning on in the middle of the runway?"
Can you imagine being the Captain and First Officer on the Air Canada plan when suddenly the "runway" they are about to land on is illuminated and they can see the plane in front of them. There must a been a second of confusion as their minds process this "new" situation and then the sudden realization of the sheer depth of their mistake. Wow, this was close.
@@KrK007 I doubt they even had time for a second of confusion, I think they had to react on instinct more or less, and it save the day.
I was surprised that they did not add that lighting up the taxi way with landing lights was not an option (at least for clear weather).
And I am really happy that this new system, that has so many other benefits, was the result.
@@KrK007 Not completely. Because the FO had already raised concerns with ATCT about seeing lights on the runway. They were aware something was wrong. But Phillipines and United confirmed what ATCT did not.
Excellent video. I flew with this captain when I was new to the 320 - was shocked to learn that this had happened to him but fatigue is consistently the greatest danger we face as pilots. We simply do not perform well when fatigued. It’s easy to pass judgment when one hasn’t lived the experience. Any airline pilot knows what I’m talking about...
Absolutely, this could have happened to anyone
Excellent point... It's sobering to realise that, never mind how many fail - safe features are introduced, we're dealing with humans who have the frailties that all of us have...
@@MentourPilot Why do these things that could happen to anyone always seem to happen to AIr Canada?
is that captain still flying for ac? was he or the FO reprimanded at all? were all you guys talking about him after this occurred?
@@chrischarla424 I've noticed that too.
Imagine a Captain with 20.000+ hours landing on a taxiway in clear visibility. This tells me how easy our brain can be tricked and the importance of considering confirmation bias in our decision making processes. As usual, thanks Petter !
The pilot flying did not tell pilot monitoring that the intended to use open approach (or whatever the name is). Pilot monitoring did not speak up. Pilot flying obviously was not _quite_ sure about the runway situation, but he did not say it _that_way, pm Are we clear to land is NOT the way to ask for it. Maybe he did not want to admit that sth of the visual situation was ... off. Maybe he could not even put his finger on it what was off.
The ATC answered AS IF they had worries whether there could be another plane ON the runway. but that was NOT question that needed to be asked.
It is possible that both pilots got along very well, but pf made assumptions that it would be O.K. to fly open approach and did not even think of consulting pm - as Petter said, there is nothing on the voice recorder indicating that decision was talked about. It just happened and pm had to make do. Captain can make that decision, but why not just say it.
Lots of ... undercurrents .. things that are not named.
If he had not been as busy he too would have been able to glance outside. Also: isn't there a file on each airport: what to consider when you land in SF (like, short runways, or strong wind from one side can be expected, or can often get foggy .... Wouldn't you "have to switch on ILS MANUALLY" be part of the briefing ?
Maybe both pilots knew but forgot about it when they were busy.
They must have noticed that the ILS info was missing (or did they not register this ?) But it was not essential, it was a clear night.
@@franziskani he asked "are we clear to land", because he did think they were aligned with the runway, but thought there might be planes there (which indeed, there were planes where they were trying to land)
I guess the green center line lights were covered by aircraft and the blue edge markers were masked by the white wingtip lights on the taxi aircraft. So the normal green and blue lights were just not visible.
A pilot who mistook that for a runway would have mistaken anything, regardless of lighting details. It is even worse because the pilot thought there is someone on the runway, then the ATC said no, it's clear, and none of the two parties drew any implied conclusions from that.
So while the pilot did have a spark of skepticism, he still decided that that dimly lit joke of a strip to the right of the bright-white abundantly lit shining example of a runway as seen countless times before must be a runway.
It took amateur-casual pilot Harrison Ford advanced age to get to such a point, hah.
@@Dowlphin You try reasoning at effectively 3 AM while doing 3 checklists at once, as well as flying an aircraft.
@@nikkiofthevalley if you can't then you shouldn't fly. This pilot assumed way too much instead of checking. Yes we learn in a culture of speaking up, but the pilot was utterly at blame for not speaking up, and lucky he didn't cause a disaster. If visibility was low then the plane on the taxiway with dim lights wouldn't have been seen at all. Assuming stuff then would have been deadly. I assume his family would be proud of him then no?
@@nikkiofthevalley doesn’t matter what time of day it is, he was paid to do it and had the experience to show he could.
Imagine being on that plane...As far as you're concerned, the flight crew just did a go-around (somewhat unusual, but understandable). But you find out some time later that you were mere seconds from being in what potentially could have been the worse air disaster in history.
It doesn’t bare thinking about how awful
I always wonder if the passengers in the waiting planes knew if something was up. I imagine it would have been very loud having a full-throttle go-around being initiated right above you.
The pilots sure did - imagine the hair-raising view from the third cockpit in line! Those guys probably needed a bathroom break before taxiing the rest of the way.
A big red X of lights on each end of a closed runway is such an obvious solution, I would have assumed that was already how a closed runway were indicated at night.
Some smaller X'es in light and paint probably in taxiway colors on the end of taxyways that run parallel to a runway also seems like it would be a good idea.
That and the fact that the NOTAMs also made no note that the lights would be off as well. Just "closed" and nothing more. Don't bother to mention that they might not be able to see the left runway, there's no way that can help overcome confirmation bias. Psychology is a strange thing but we just have to work around it, engineer solutions with it in mind.
Scold the guy who made the mistake, and someone else will make it again soon enough. Figure out WHY they made the mistake and engineer systems and procedures to prevent it, and you make the world a safer place.
And why don't Taxiways have distinct lighting? This has happened before - Continental Airlines 1883 in 2006 a plane did a full landing on an impty taxiway, NTSB investigated, but no real change.
@@yggdrasil9039 i think it usually does, but it's easy to overlook a colour difference if you already have convinced yourself that it is a runway, because you were expecting two runways and only see one runway and one parallel taxiway
@@SteinGauslaaStrindhaug Oh right. Well yes if that's so, but I'm thinking if it was made completely obvious you wouldn't. I mean pretty much no-one ever mistakes a red for a green traffic light. So maybe they need a very distinct colour pattern like blue and orange or something, or perhaps a big capital T or the word TAXI illuminated. Even if you've convinced yourself you're on the right runway, and confirmation bias and all that, if you see a massive 'TAXI' illuminated in flashing lights, it would be hard to maintain that conviction.
Taxiways have dim blue edge lights and green centerline lights. Runways have brought white edge and centerline lights, plus approach light systems. Closed runways are marked with a flashing white X.
There's simply no excuse for lining up on a taxiway. You can see the difference in the simulation. I understand they thought it was runway 28R, but did it not occur to them to ask the tower to turn on the lights? They didn't question anything they were seeing.
Reading the crew interview summaries in the Accident Docket is, if possible, even more chilling. Neither the Captain nor the FO recognized that they were looking at aircraft on a taxiway, and neither remembered seeing traffic at any point immediately before or after the go-around. Neither of them remembered any specific transmission on the radio or specific thing that made them do the go-around. The most concrete thing that either of them remembered was just a feeling of unease and confusion, essentially that something wasn't adding up, something wasn't right, that it didn't fit their mental map. The aircraft switching on its landing light, the call on the radio; if these things made any sort of impression on the crew, they had no memory of it.
They actually admitted to not remembering any of those things? Omg that is chilling! They reacted to the situation at hand so I believe they did hear and saw the warnings but the mind is so powerful that can also erase any memory of crucial facts
The fundamental reality of spatial disorientation is that one does not perceive that it is happening. It is not necessarily that the brain is erasing memories, though that does occur; it is equally if not more likely that the brain is not perceiving (processing) the inputs in the first place. The essential lesson here is that the primary warning sign that the crew perceived was a general sense of unease, that something "wasn't quite right". They may have "seen" other warning signs, but their brains did not "perceive" them strongly enough to form a memory.
We know that the second nonstandard radio call and the illumination of the landing light on the PAL happened at around 2356:03 and the throttles advanced at 2356:05, but allowing for decision and reaction time on the flight deck, even by trained pilots, we have to assume that the go-around decision and call probably occurred slightly earlier than the throttle advance. Based on the reaction times of drivers, and that the pilots were tired and disoriented, I would assume that the initial call for go-around probably happened around 1-2 seconds previous to throttle increase, which would place it more or less concurrent with the landing light and second nonstandard call. Given that timing, it is possible, but not particularly convincing, that these actions had a conscious impact on the crew's decision to go around. I'd personally find a subconscious impact more believable, similar to someone ducking instinctively in response to motion seen "out of the corner of the eye", seen and reacted to but not necessarily processed.
@@PABadger13 I would expect that they actually were experiencing the things they should have remembered, but due to their state of exhaustion, the brain simply wasn't writing those memories down very well, so to speak. They did do the go around (though the pilot who made the dumb comment should have called it earlier rather than pulling a road rage moment). "AIR CANADA GO AROUND!" Would have been a much better choice.
The nature of memory is very fascinating to me. Humans are not particularly good at recording accurate memories, and each time the memory is recalled it is re-recorded with possible changes. There are drugs that stop the recording of memories (same effect as being blackout drunk) where you're still acting as yourself but your brain is not recording memories.
No one should ever need to work through that point in their circadian rhythm, much less airline pilots, responsible for hundreds of lives.
In that case I think the turning on of the landing lights of the taxi 2 plane was probably even more ingenious than I first thought. Reading that the pilots have no memory of the radio calls going on or much of anything else actually reminded me of something Petter has mentioned in another video, that in situations like this (especially the ones pilots haven't trained for) they often don't hear acoustic warnings and therefore things like a warning light on their instruments turning on is much more helpful.
I wonder thus, that that one plane switching on its landing lights might have unconsciously influenced the flight crews decision making.
@@wiredforstereo That's definitely possible, although depending on how accurate the video/voice overlap is, they may have already been in a go aound. But that's split second differences. Bottom line, i think the landing lights probably helped more than nonstandard voice callouts by other crews, and even if they weren't the precipitating factor that triggered the go-around, using them seems like a good choice to me
When I saw one of the runways turn dark, I was immediately understanding of how it could happen.
PRecisely. And why didn't SFO ATCT think about this mistake being a definite possibility when AC759 asked about lights on the runway?
You mean when you looked on the flag at the tail?
@@familytvbox5218 What?
@@familytvbox5218 😄
Petition to get this man his own netflix show. THE PRODUCTION QUALITY IS BLOODY AMAZING!
I seconf this. You've come a long way, Petter. This channel is amazing!
That, or a set of hand picked pilots like him.
Nice show but never replies... Even when he ask a question
...
@@diegodossantos4384 Patently untrue.
Where do I sign?
"I hope I earned a subscription from you" Sir, you earned that a long time ago. Love the channel.
Thank you 💕💕
I wish there was a second "Subscribe" button on this channel! I'd hit that in a heartbeat.
@@theAessaya well actually there is...it's called patreon! Lolol
@@MentourPilot question for you, I've heard San Francisco is a difficult airport to land at. Is that true?
Also if you as a pilot have landed there in SF in those conditions ( ie night time ) what markers or landmarks would you look for? Driving a car I am trying to imagine what the pilot saw or thought he saw in visual cues to indicate he was in line with the runway.
@@wowihaveachannel4862 Asiana crashed at SF
A frightening thing happened to me in San Fran. in the eighties. We were taking off when another plane was coming in. Our nose just left the ground when it suddenly came slamming back down and another plane just skimmed over top of us. Terrifying !
Was it ever reported?
I always find it amusing that most of these incidents are caused by the most mundane things, not something breaking or exploding, a pilot mistaking a taxi way for a runway, or a mis heard local pressure reading putting the pilot too low, or a chair reclining too suddenly! The world of aviation is fascinating
"or a chair reclining too suddenly!"
which one is this, it sounds interesting
@@nathanpierce7681 If I'm not mistaken, it was Air India Express 611. The captain's backrest collapsed shortly before reaching VR.
@@torgejh9189 thanks!
@@nathanpierce7681 You're welcome ;D
I so wish that this system of wanting to get to the 'why' of a problem/failure/issue instead of finding or appointing 'the guilty' would become the norm in more areas, such as the culture within companies. As always, awesome content, and great explanations, even for someone like me. Closest I get to a plane is when I fly in it as a passenger!
drug companies use CAPA - corrective and preventative actions
Very rarely is it an individual's fault and, even when it is, there's almost always a systemic fault that let them be in the position to make the mistake or error of judgement. Punishing individuals inevitably leads to a CYOA culture (cover your own ass) meaning people end up being much less likely to report their own mistakes and makes managers less likely to listen to their underlings when they report potential problems.
Indeed, this is exactly my experience and wish.
I wholly agree. That said, when an individual in a decision making role screws up, they should still be held liable. I'm sick of companies not treating people like people, but I'm also sick of individuals using companies to hide their law breaking. I don't care if you did it for the business during business hours, _you_ broke the law, go to jail personally.
@@ashkebora7262 Agreed. But there's a difference between someone making an honest mistake, based on the information they had when they made a decision, vs someone simply making the wrong decision when by all rights they should have known better. Had the pilot in this clip been out partying hard right before, nursing a hangover, had there not been a manual procedure needed for this particular airport in this situation, had the notices about the work been on the first page in blinking neon signs, then I am sure the evaluation might have been gone quite differently. And same for a management type who is only thinking of his next big bonus so he can pay his ex-wife, his 4th house at the cote d'azur and his new bentley.
This is the best explanation of that very near disaster I've seen , had no idea Air Canada got that low to the ground ( and the other aircraft ) till seeing the security video footage,.
Yeah, I knew they had gotten close, but I didn't realize they had gotten *_that_* close!
Really! Thank goodness.
I've seen the video of this incident many times but never heard it explained so clearly and in an unbiased way! Excellent documentary and it makes me feel better that it wasn't a case of negligence but rather a series of small mistakes compounded by various other issues. I've had that exact same thing happen late at night when I'm driving. You see lights that appear to be a road but in face are construction barrels or a reflections on wet pavement that just happen to form a pattern similar to streetlights. Luckily there weren't several large passenger jets in front of me!
Window of circadian low - experienced it during my surgical training, was never taught about it. Academic leaders in medicine talk about emulating aviation safety culture. Watching your videos, I see that we have a long way to go.
In my experience, even a nap of an hour or less after midnight can make an enormous difference. Unfortunately, this situation did not offer that luxury. The Wikipedia article mentioned the crew would have been too fatigued to fly under FAA regulations.
Aviation (and aeruspace) are the leaders in this culture. The main question is why? The higher danger is a factor, but it can't be the whole of it.
Then we have things like the can opener bridge and various train routes on the high street of small towns, a culture that clearly shows a complete disregard for the human factor.
Yeah, here in Romania doctors have 24h shifts and I could never understand how a human being can function like that. Shifts in medicine are gruesome.
I often drive at night. You have to recognize your personal indicators, and not ignore them. Your body can cycle in and out of microsleeps without you even being aware of it. Sometimes even a random off-topic thought, or a lost thread of conversation is the only warning you’ll get.
As if I needed another reason to dislike getting up at 3:00 am to go to work. At least at that hour, there is very little traffic on the road.
Only Harrison Ford is allowed to land on a taxiway with airplanes on it.
:-)
GET OFF OF MY PLANE!
@@1450JackCade Boohoo
@@1450JackCade OK, make a better one! :-)
@Peter Mortensen Real. Harrison Ford landed on a taxiway at John Wayne Airport, south of LAX. Feb 13, 2017.
He thought he was landing on 20L, but really landed on Taxiway C. After the near miss with an airliner on the taxiway, he asked the tower why their was an aircraft on his runway, and he was informed of his mistake.
Search Google for "Harrison Ford land taxiway", and it will pull up news stories about it. It probably got a lot more attention because it was him. Really, I'd expect absolutely no
news coverage if it was anyone else. A little Googling finds that they do in fact happen, but didn't become newsworthy. It's pretty damned newsworthy, when you almost park an airliner full of people on top of two or more airliners.
"Wheres this guy going?" "Hes on the taxiway". Its truly amazing how these 2 small sentences saved hundreds of peoples lives.
I watch these videos to fine-tune my Risk Cause Analysis skills as an Ergonomics Engineer and Human Factors Engineer. This video did a fantastic job of pointing out the importance of recognizing the problems that can arise when working overnight shifts (in all industries) and the importance of double-checking information so that confirmation bias does not take over the situation. Finally, the (critical) information in the briefing material regarding Runway 28-L not only needed to be listed at the beginning of the briefing material but should be highlighted with something like a box around it so I will stand out to the reader.
I remember seeing some red ink used...... ive virtually forgot it now which validifys your point 🙂
what would make it stand out more is if it was in plain english rather than a string of shorthand letters and abreviations. I suppose to a trained pilot it may all be crystal clear, but I paused the video and it took me a while to decipher "most" of the notam. A couple of the other notams were gibberish to me.
“Really, really close, eh?” - as a Canadian I see what you did there eh
It's not the rest of the world's fault if the part of ANZAC uses 'eh' as a filler! Nice one, eh?
The pilots are hosers and were having a pint on the approach.
@@annatamparow4917 good answer eh mate
sorry
@@The_Original_forresttrump Take off, eh?😃
Video released 45 seconds ago. I'm here not by notification bell, but by call of my heart
💕💕💕
Good teamwork by all - first plane UAL more or less yelling then the second plane turned on lights to illuminate the runway. Saved a lot of lives.
I found it odd that the first plane had no headlights on, though. The second seemed to eventually go from dim to bright and the third plane had brighter all the time.
It took the leading plane quite a while considering the approach was from straight ahead, and they could have flashed their headlights a couple times.
I was flying in and out of SFO monthly during that time on the 320 and know the procedures quite well.
When flying the FMS Bridge Visual to 28R, one was directed to manually tune the ILS frequency but fly the approach in NAV mode. The problem with manually tuning the ILS frequency and doing that approach in an Airbus, is that you have to constantly press the "LS" button on the EFIS panel to display the ILS information, which then takes away the NAV information from view. So you would press the LS button to check, and then press it again to shut it off. During the approach, there would be an amber "ILS" flashing in the PFD the entire approach because you had not programmed the ILS approach but had tuned the frequency.
Immediately after this serious incident, the FMS Bridge Visual changed and no longer required tuning of the ILS frequency. Additionally, the NAV routing for the approach now turns and lines up the aircraft with the runway. Most will disconnect autopilot at that point anyway, if doing a parallel approach with traffic, because the NAV turn can be aggressive and trigger an RA. One can make that turn much smoother by hand.
What's an RA please? (My acronym bank is FULL!)
@@philipboug RA = Resolution Advisory. It pertains to the TCAS, Traffic Collision Avoidance System.
When flying in parallel to another aircraft in SFO, if you get too close to the other plane, a TCAS Resolution Advisory can be triggered, giving instructions to climb or descend to avoid a collision. This RA must be followed. And following the RA would lead to a go-around.
@@bv3700 Thank you so much Ben for responding! I have been a lover and student of aviation all my life (I am 79). But I do wonder these days how pilots keep so much stuff in their heads, as despite amazing advances in automation, the job becomes mor complex every day. I do understand TCAS, an amazing system, so many lives saved, but ... So many acronyms! LOL. Thanks again Ben. Oh.. and Petter for creating Mentour!
@@philipboug If you love aviation then you have come to the right channel with @Mentour Pilot! He has great content.
As a pilot for the airline in question with 10 years experience in the same aircraft type and at SFO, and having personally flown with the Captain of this flight in the past, I know many details that others might not.
Most people get some details wrong because they may not understand the full SOPs (Standard Operating Procedures) of the specific airline, and what company-specific charts they may have been using.
Acronyms have become like words, in a sense. Once you learn them you just know them. And just when you've figured them out, new ones come along!
Thanks for the info. I wondered why the Canadian pilots did not notice the ILS support being missing. It was not crucial, and it was a mess to use (at least in the Airbus that you flew), so they likely did not even bother. If it is so distracting and suppressing NAV info, it would be almost an hazard to have ILS under those circumstances.
Interesting how a better routine (that actually supports pilots) can be implemented - but only after an almost disaster.
Fantastic new warning system that fortunately doesn’t have hundreds of deaths behind it. But very nearly did.
Just soggy chairs from everyone that realized how easily they could have made the same mistakes and not been blindingly lucky.
I guess the saying should read as "regulations are written in blood and soiled underwear" from now on.
Hopefully this incident will remind any airline that hasn't deployed RAAS yet (despite being available since 2008) to actually implement it.
Indeed.
Warning systems are only useful when they get installed. Quite a few plane crashes out there where the findings include ‘Could have been prevented with but the aircraft was not equipped’ I can think of several for GPWS and even one where the plane crashed for lack of a transponder
Fatigue is the cause of so many accidents. My brother, as a doctor in charge of the Covid response, has found himself working 48 hours in some exceptional circumstances. This is ridiculous.
There is no excuse for having to work that long! The whole system needs to be changed so fatigue isn’t problematic.
@@JustinLHopkins No-one is properly prepared for a pandemic.
@@JustinLHopkins "Exceptional circumstances" ... It takes anything between 10 and 14 years to make a new doctor. You might be able to call retirees in and offload some work to nurses and other health care workers, but you can't just magically make more capacity. Sadly.
Same with my brother, paramedic huge hours. Just crazy.
Under FAA rules, this crew would not have been legal to fly. Transport Canada is different. That is also why at work, no one is allowed to work more than 16 consecutive hours (in a hospital lab).
I see what you meant about using clear language!
“where’s this guy going” is pretty chill when an airplane is coming straight towards you
Something similar happened to us from Lisbon to Paris. We were just about to land and just before touchdown, the airplane instantly took off almost vertically.
After we eventually landed, we saw the first oficer white like a ghost and he was being consoled by the captain.
Omg can't imagine, vertical lift, that was an experience for all
Perhaps some individuals that are commenting are young, perhaps do not remember the tenerife accident that involved two 747's that were directed to another airport, the airport was a regional airport that was ill equipped to handle jumbo jets. Since that did have other jets awaiting clearance and depart. A very sad incident that involved many lives lost. So many if's, if the tower had refused klm to refuel, If both planes waited 5-10 minutes, the weather had improved.
Confirmation bias is a pretty scary thing when it works against us. Thank you for the video interesting insight as always
Thank YOU for watching
@@MentourPilot thank you. If you have time, could you answer this. In the case of how far the plane is from the ground (ground proximity) what part of the plane does that refer too? The lowest part or a specifically calculated part.
Doesn't confirmation bias always work against us? Otherwise it's simply correct and not bias, right?
@@bluepvp900 I would've thought so I initially just put confirmation bias is a pretty scary thing. I added to that afterwards as thought sometime might reply not always.
@@bluepvp900 Sometimes it is positive, but always by accident. It allows us to deal with common situations (oh - this again) quickly. The dark side is if safety or large cost is at stake, as it was here.
Alerts should be on the first page, basically anything that is not normal. start with alerts for departure to inflight updates, such as weather alerts, then destination alert updates. Then it can go into SOP of the flight briefing. just my opinion.
Pretty much all of the NOTAMs are for things that are not normal; that's why we have NOTAMs. But when you're flying across almost the entire width of the continent from Toronto to San Francisco, that's quite a lot of stuff, which is how you end up with the 27-page document. It literally mentions every single tower whose aircraft hazard warning lights aren't working, every navigational aid that's out-of-service, every closed runway, every large crane set up nearby, planned skydiving operations, planned fireworks shows, etc. It can be really quite a lot of stuff, even for relatively short flights. Basically, anything that's different from what's on the charts or chart supplements will be documented in a NOTAM, whether it's something that lasts for a short time or for months or years.
But I completely agree that something like "one of the runways at your planned destination airport will be closed" is much more important than the lights being out on a tower you're going to be clearing by a mile or more vertically and should be highlighted. That being said, the ATIS specifically mentioned, not only that 28L was closed, but also that it was unlit. Unfortunately, that still didn't seem to fully register with the crew, likely due to the fact that it was just before 3am in their local time.
I'd be curious to know how the standby scheduling works there. Are they on standby for the whole day or are they on standby for particular hours? I would certainly hope that it's the latter so that they can plan their sleep schedule for the day around still being awake at 3 am. I know it's a set number of hours that you can work in a normal duty period after which the crew times out and can't operate the flight, but I'm curious whether standby works in the same way or not. If it doesn't, it certainly should.
They should make it colour coded based on the severity and perhaps in an order customized to which ones are going to be most impactful for individual flights. So the first couple of pages would highlight the notices regarding the critical portions of the flight (takeoff and landing), and the particularly important ones, like runway closures, would stand out from the others.
@@StarkRG The trouble with colour coding is that the priorities of the person writing may not be the priorities of the person reading. It's human nature to look at the most important bits of we are pressed for time.
Perhaps adding some more structure to the assembly of notams would be better that trying to add colour coding: separate the notams related to the departure, the cruise and the destination into three sections?
@@vbscript2 NOTAM in current format is passing the liability on pilots. It need a complete overhaul.
4:28 ground crew casually walking behind the engine gave me a chuckle
This has been the traditional problem with ATC & pilots using imprecise communication with each other. The Air Canada pilot said to ATC that they are seeing lights on the "runway" and to confirm that they are cleared. The ATC said to him yea the runway is clear and you're the only one on it. Instead of questioning the pilots about what exactly are they asking about, the ATC rather took a dismissive attitude. If they are seeing unusual lights on the "runway", maybe they aren't looking at the same runway that you're looking at ATC. Another case of this was the Eastern Airlines L-1011 crash into the Florida Everglades. The ATC there sees on his radar screen that the plane's altitude is much lower than their assigned altitude. The ATC asked them "how's it going up there?" Instead of telling the pilots, hey check your altitude, how's it coming with your landing gear problem? - in that order. It might've directed the pilots' attention to their altitude right away and given them precious extra seconds in preventing the crash. But those pilots actually allowing it to happen while they spend so much time and effort on a burnt out light bulb ....well, that's another unfortunate story in itself.
That's over idealized. You have to remember this is a field of extremely trained personnel all around. So there is a higher expectation. Secondly ATC has to juggle multiple aircraft at once both airborne and on the ground. Yet you want them to continuously be 100% vigilant no accounting for human aspects of it. Especially in a scenario like this where they had seconds.
At your job are you always on 100% mode, focused from the beginning of your shift to the end? When having to constantly multi-task?
In this case pilots asked a valid question and got a good answer, it's not up to tower to wonder "if pilots actually meant what they meant", especially if the question wasn't unusual in a given context. And they got 20+ other planes to take care of.
It would be better to ask "if both runways are light up". But it's easy being a smartass after the fact and knowing all the details.
What Mentour is helping me to appreciate is that they learn from every dangerous event. It’s never an “oh well, that was bad.” They always come up with a solution on how to never let it happen again. Never letting today’s “near miss” become tomorrow’s “horrific accident.” 🤝
As a nervous flyer, Mentour is my friend. ☺️✈️
Indeed, this is the way we humans have (almost) always improved the use of technology by fallible humans. Another example is the railways board in Britain going back to about 1830.
On the other hand, often enough they were warned in advance about a lot of possibilities.
I'm sure that the pilots' "circadian lows" switched to extreme "adrenaline highs" instantly, along with their sudden need for fresh underwear. 😱
Yep. CL is one of those perfect excuses--something like PTSD. Babysitting all those dials must be sleep inducive. Need to work out a few more wake-up alarms.
Captain, I have no words to describe how good, how well researched and how educational these videos are, for us. Everything well researched, objective, clear and concise. Absolute amazing content, and I'm so happy that I came across this channel.
True 💯
i could not agree more - and petter is carismatic , intelligent , number one pilot and great personality
Amazing content❤
Great to see how you peel the onion of events, on every incident and getting to the bottom of it, without looking for a 'blame', but for 'reasons' in stead.
If people would do this more in the whole society, we would evolve to a better world more rapidly.
Even as a non-pilot, I enjoy your video's a lot. Great work Petter! Thanks for sharing your knowledge and views.
"Peeling the onion of events", perfect image ! Furthermore, that tends to explain why tears often come to eyes while watching this kind of videos ;)
Regardless of how trained pilots are, at the end of the day they are human and all makes mistakes
Correct
I had never seen that footage from the tower! What a frightening close call! Thanks for your analysis!
Yes! I was familiar with the event but have never seen this footage before. It was a lot closer then I had thought.
I love how constructive the reports usually are.
Thanks for another great video that was well-thought out and professionally presented!
Just a couple of thoughts from someone who has some personal experience with this approach:
One factor is that the FMS Bridge Visual to 28R approach course does not actually align with Rwy 28R until reaching the F101D waypoint, so the whole time the crew would be approaching from the right side of the runway centerline from ARCHI to F101D. This is because under ordinary circumstances (i.e.: with Rwy 28L is open and available), other aircraft would be making a straight-in visual approach to Rwy 28L, using the Quiet Bridge Visual Approach.
This right-hand offset allows for aircraft separation between the two runways, until the aircraft for 28L visually acquires the aircraft for 28R, and receives an ATC instruction to follow that aircraft to the airport, to stay behind it and not to pass it. Having actually flown this approach in the Boeing 737, the 15-degree right turn at F101D (as well as a pitch-down movement to intercept the glide slope, at an altitude of about 1,800 feet) to line up with Rwy 28R, requires a little extra attention to negotiate properly and in a timely fashion.
This also points up a significant difference in flying this visual approach in the A320 vs. the Boeing 737:
When it is flown in the Boeing 737, we always manually tuned the Rwy 28R localizer (frequency 111.7) on our nav radios. As we would fly the approach, the localizer needle would be offset to the left, gradually moving more toward center as distance to the runway decreased. The glide slope needle also would show 'above glide path until reaching waypoint F101D (so, in effect, both needles would center at the same time, just as we were configuring for landing (gear down/final flaps extension), plus contacting the tower for landing clearance -- a lot going on in a critical phase of flight.
I have only ridden the jumpseat in the A320, but I have noted that they do not tune the localizer frequency manually (on a radio control head), but instead program it into their FMC (Flight Management Computer), when they initially load the approach for the runway. This, in turn, "auto-tunes" the localizer on the control head, upon reaching the appropriate waypoint on the ILS approach. Since this crew loaded the FMS Bridge Visual using the database in their FMC (not the ILS Rwy 28R, which is a separate approach), it did not auto-tune the localizer for this visual approach.
It's also easy to see how the manually "tuning the localizer"-step might be missed, since they weren't used to manually tuning it on any of the other visual approaches in Air Canada's route system.
A perfect storm of events: A tired crew (backside of the clock flying). Buried Rwy 28L closure-NOTAM information. At night. SFO ATIS only mentions that the Rwy 28L centerline lights are out of service -- not that the entire runway is closed. Rwy 28L is dark, with only a few worker's lights visible (Was there a "lighted X" at the approach end of Rwy 28L that showed that it was closed?). FMS Bridge offset course to the last waypoint. CRM: F/O didn't let Captain know that he was uncomfortable with the mode change. An "anticipated" outcome -- by their time of arrival, Rwy 28L 'would probably' still be open. White wingtip position lights of aircraft on Taxiway Charlie visible to crew, and spaced approximately at the same distance apart as runway-edge lights would have been. Tower controller didn't notice Air Canada's offset path on his radar screen. How about SFO airport familiarity/currency on the part of the crew -- how often did they fly there?
It's easy to see how this chain of events could continue, unchecked.
The NOTAM issue is one I have wondered about before. Sometimes these can run into several pages. How can the pilots possibly absorb all this information and decide which may be critical, especially with fast turnaround times?
It is a real issue
Here we have a summary at the start of important points, such as new hazards etc ie tower crane in this spot or nearby works on taxiways etc. That way you can recap or skip to a section easily. But i believe this case it was all about fatigue. And we found on building runways that construction lights can very easily confuse people.
We had an a380 line up on a newly constructed runway that hadnt been surfaced yet. Not sure what happened with that as i left that airport and city.
Like NOTAM goes 1) it’s COVID 2) trans border restrictions followed by a bunch of other stuff, then it goes 25) and the runway lights are out
@@MentourPilot 27 pages is just asking for trouble..
Well, thats their job. If they're not capable of doing that - of absobing all that information - they they should not be pilots. It's not a question of 'deciding which may be critical', it's reading it all, remembering it all, because it all has the potential to become critical.
The captain after he landed the plane, “I’m too old for this shit” 😆🙃
😂
Just imagine the pilots on the taxiway nervously sharing glances as the Air Canada grows ever closer
The real hero is the pilot or first officer of the second plane lining up, who turned on his landing lights.
This very much reminds me of pilots at my radio club in the early 80s discussing a Garuda flight trying to land in Bell St in the north of Melbourne in the late 70s. They explained that, at night, the lights on Bell St resemble a runway. Fortunately disaster was averted when Tullamarine ATC realised the Garuda flight was not approaching the runway when final approach was advised. They also said that a few pilots mistake Bell St for a runway.
Yep!
in which suburb?
Bell Street is in Preston, it runs parallel to Murray Street
@@Wenlocktvdx wtf Garuda flew 747s in the 70s. So they tried to land a 747 in a Melbourne Street in Preston????😆😆
@@yggdrasil9039 Yup, they must have ignored instruments and relied on visual.🤣
Perhaps the most stressful part of all of this was on the pilots sitting on Charlie at the time. Just imagine beginning a 15-hour flight mere minutes after that having that kind of adrenaline rush from an airplane almost landing on top of you, knowing you just came within about a second of dying, along with hundreds of others. Honestly, I think I probably would have tapped out in that situation and just taxied back to the gate (not saying that they necessarily should have done that, just that I think I personally probably would have been freaked out enough that I would have deemed myself unsafe to operate the flight.)
I live in British Columbia, Canada! We fly into San Fran occasionally. I heard about this near-miss. My understanding is that the San Fransisco Airport is tough - sometimes - to fly in and take off from.
Thank you so much for covering this. You are absolutely brilliant.
that had to have been one of the most terrifying things to experience for everyone involved…. yet everybody sounds so relaxed lol
Heard the ATC for this one. Never realised just HOW close it was to the highest point of the aircraft under it.
Quick thinking of the plane that put on the landing lights!
The ATC was alone in the Tower, the other ATC was on a break. I'd say he was crapping in his pants when he issued the go-around.
Oh tell me about circadian low. :D I used to be a van driver for about three years. So, when I was driving on a motorway in Germany at night and suddenly I was sitting in my sun lit garden grilling some sausages with my best friend I knew something is off. And sure enough as I awaken in shock there is a bridge/other deadly object with my name on it. The fact that I question everything and won't settle with comfy lie over a cruel truth really saved my life a few times.
Ofc wise thing to say would be, don't drive while tired, but sadly that isn't always possible. I have taken habit to take water bottle next to me every time i drive. A small sip of a drink, will brighten up you quite a lot. Well not for long time, but enough to get next bus stop or somewhere you can take short walk around car or something.
Once you start to feel the eyelids begin to squeeze, take that small sip and find place for short break. Ofc better take break before we get to that point, but least there is something to do, to avoid immediate crash.
Fine - but you didn't get the sausages!
@@Xydroos I had alertness problems due to sleep apnea (as I learned later). What I soon realized is that nothing is a substitute for sleep. I let my boss know that if I got sleepy in one of my nighttime callouts I would pull over and take a nap.
Think of it this way: If you do something to try to stay awake but fall asleep and crash, the opposing lawyers will point out you were aware you were sleepy and took only ineffective actions - as proven by falling asleep.
What a fantastic storyteller this presenter is. His knowledge, experience as a commander and thoroughly researched videos are most thrilling to watch. Definitely my favorite TH-cam channel on aviation right now.
Fantastic series! Well explained, without the typical drama of TV documentaries. And also focused on quasi accidents. Way to go! Congratulations!
I was there aboard Phil. Airlines A340 bound to Manila. Really scared to know lately that we're near to that collision.
Wow! It was your fin they overflew
I remember the engine was screaming. I thought it was the engine of our aircraft. It's the engine of Air Canada A320.
@@rudenvincentt.caguitla761 I bet that's enough excitement for a long time to come!
@@rudenvincentt.caguitla761 wala bang sinabi ang flight crew ng PAL nung nangyari yung gabing yun?
Your pilots had a hand in saving potentially hundreds of lives. I hope you clapped once the plane landed !
I really appreciate how your series handles these events, some of which I was familiar with ahead of the video others not. I greatly respect how you stick to the official report, your experience as a pilot and, most importantly, how the aviation industry adapted in response of the event. Keep up the fantastic work.
Fantastic production values in this video, and your staging and vocal delivery is getting even more engaging! Love this channel!
I work in mining exploration and am underneath helicopters every day. Can be dangerous work.
I want to thank you for explaining these close calls in such a way that it has prompted me to examine our safety culture at work and strive to make every day safer than the last.
Wishing you good health and further success with your channel
the second traffic holding short of runway did a brilliant job, whoa~ and I LOVE UR CONCLUSION FOR THIS
Mentour you do a great job of defending the pilots and showing that the systems in place were much more the problem rather than the pilots' error, which I totally agree with, but I want to take the CA pilots' side even more than you. You let ATCT off the hook (which to be fair, so did NTSB report) but really, if a pilot says 'We see lights on the runway' and they are trying to double check that they are clear on 28R shouldn't ATCT be trained to enquire furthur? Eg ask 'What lights do you see?" Why would ATCT ignore this comment? Shouldn't ATCT be alert to precisely these kinds of anomalies?
So far the best explanation of the scenario !!! I was believed in thinking that how can someone be so stupid to miss a runway. But no more😄😄
That’s exactly what I wanted to explain. Thanks for watching
@@MentourPilot Yet I read somewhere the captain of Air Canada got fined $15,000 for this mistake. Is that true? If so then Air Canada need to watch your video!
Thank you for such a wonderful documentary
Glad you liked it!
Polished presentation with just the right pace and level of detail for laymen to understand. Thank you.
Wow, that is a truly scary potential accident. - Imagine being the flight crew in 2nd plane in line!!!
05:20 A while ago I read an article about fatigue in the German newspaper "Spektrum der Wissenschaft" and that article said that parts of our brain can fall asleep when we are awake without us realizing it parts of our brain are sleeping! When that happens, "crazy doing" begins. And later we ask ourselves what we were thinking at that special moment.
11:50 Nice explanation! 👍
I work in electronic health systems and frequently work on software to help catch mistakes. I really appreciate you highlighting how technology is used to make us safer.
Just wanted to say, this channel has one of the most amazing videos I have seen in youtube. Thank you for doing this, it's everything how it should be when it comes to media & entertainment. High quality videos, high quality teachings, high quality scripts, high quality overall.
Can you imagine being in the plane when Air Canada went full power right over you? They must have thought they were going to be the next Tenerife. Would love to know what the pilot told the passengers in their respective planes.....
I started wondering at what it sounded like inside the cabin as well. Must have been a really unusual and loud sound 😬
Passengers probably didn't even notice.
The same situation happened many times before back at 90 at old Athens Airport LGAT witch had the runway parallel with an avenue. Many airlines at nights tried to land their airplane in the new illumination Avenue., specially the non familiar with the airport.
"Mistakes happen. We're all human. Lets try to make sure this kind of mistake will not be repeated by the next guy!"
or the next pilot or the next pilot after him/her, etc.. Let's learn so this mistake NEVER EVER happens again!!
I know it kind of seems bad that such experienced crew can make simple mistakes like this, but I think we learn more about these kind on incident's because it makes it so much clear that this can happen to everyone, no matter how experienced you are. In the end we are only humans, this is also why we use checklist's, we can't trust ourselves, always need to keep asking ourselves if we are in right. But with fatigue we are so distracted that we stop asking those questions. So more and more systems are implemented to make the flight computer ask those questions for us, but really we should also focus on keeping the pilots well rested.
Yes, especially that I read the pilot done 2 long haul flight and doing this flight as well. The pilot must been very tired
This near miss produced some really good changes and recommended changes and thank God for the pilot's quick thinking in turning on their landing lights to show they were there and avoided a terrible tragedy.
The second plane truning on the tail light was fantastically done
I watched that video of the plane coming in several times, but without the highlighting of where the other planes were. It was scary enough when I didn't see the first two planes lined up, but now... holy crap that was so close!
If he didn't pull up in time, he would have plowed into the Australia-bound B789 and the Mexico-bound B739 behind it.
@@AEMoreira81 Indeed.
Wow, very cool video and so happy about the safe outcome!
This is a superlative analysis of this "near miss" event. You elucidate all of the critical points of the NTSB findings and provide unique insight into what was really going on in the cockpit. And the animation is outstanding. I've been reading NTSB reports for nearly 40 years and I have to say that your presentation here made this report come alive in a way that most everyone can understand and appreciate whether they are in the industry or not.
Just wanted to say thank you for this and all your videos!
I'm not a pilot, just an aviation enthusiast and love watching, and re watching your posts. Keep up the great work👍😃
I actually feel sorry for the captain, honest mistake and he’ll feel terrible about doing it. Great video and information as always 👍🏻
Honestly I'd feel more sorry for him if he hadn't tried to cover it up by overwriting the cockpit voice recorder data.
@@RK-252 im fairly sure it automatically rewrites with the next flight and bc this wasnt an full accident they didnt stop the plane from flying its next flight. I think theyve changed that policy tho
@@amillionemptybranches9553 yes and no. he deliberately waited until the following evening to report the incident to his company dispatch, which ensured the CVR data was overwritten by the morning and afternoon flights. if he had reported promptly, the CVR would have been pulled from the aircraft before it was overwritten by subsequent flights. for obvious reasons, he did not want this to happen.
@@RK-252 What _exactly_ do you think was in the CVR that he would want to 'cover up'? Because he sure as hell wasn't covering up that the incident happened.
@@RK-252 interesting. I wasn’t aware that it was deliberate. I was under the impression it was more like nobody was quite sure what to do and the policy was unclear. Ill have to look into it.
I really liked the way that you go more in depth than other people. The first time i heart of that, i did not realize how close it was and also all the circumstance around it
With depth perception and mere seconds before the realization a jetliner was landing on top and into a line of others on the taxi way - the "what's this guy doing...." was slow, casual and somewhat sarcastic in the final words he's on a taxi way. Mystifying, We're all subject to human behavior which you'd hope would have produced an urgent command YOU'RE LANDING ON A TAXI WAY GO AROUND. The spotlighting from the second jetliner was superb as well as the final reaction of the Canadian crew despite where they had gotten themselves. Excellent series Mentour Pilot.
Amazing work by the second ground pilot. shows what we should all be doing be aware of your situation at all times, that quick reaction saved hundreds of lives
Woa, I have listened the ATC radio at VASAviation channel, but seeing the video really shows how close that was!! Scary!
I was in the Bay Area when this happened so I'm fairly familiar with the incident. The window of circadian low was a new concept for me and the top quality visualizations really take it to the next level!
I've felt this several times when driving overnight. I never knew what it was or why I would start to wake up around 5:00 a.m. even though I hadn't gotten any rest. The worst part of driving overnight is just like he said, between 2am and sunrise
Petter once again you knocked it out of the park. Your description is precise and your animations are fantastic. Better than the Air Disaster series on tv.
Not sure why it took this long to find you but im very grateful it happened. your perspective on how the brain is wired in addition to all of the technical details on landing made for one of the best videos on aviation ive seen on YT.
i hope the captain and FO of the Air Canada flight see this video. I can only imagine how they must feel after that incident.
Currently watching this in the Window of Circadian Low
Love the way you and NTSB focus on the system loophole instead of the human mistakes. My first impression was pilots sounds so so so tired when I first heard the ATC recording on another TH-cam channel. Secondly, I thought the tower control should have noticed something going out wrong when pilots raised concerns about "lights on runway". If not watched this video, I would have continued to believe pilots and tower are to blame for this instance.
Well I wouldnt write off the tower, as I think anyone else would have been what do you mean what lights, like what is your heading and you GPS please.
not look up from a magazine and go uh hu there, your fine, I mean if it wasnt for that pilot going what in tarnation is this
instead of saying what he should of, AIRCRAFT LANDING ON FULL TAXI WAY AIRCRAFT LANDING ON FULL TAXI WAY!
and the real savorir of the day, the guy who turned on his landing lights
they woudlnt have even F'ing noticed and it would have been either just a giantic fireball or one hell of a head on collision with the third jet or so.
You guys shouldn't be blaming tower at all here. You're taking your stance based off of you already knowing the situation the plane is in and claiming that tower could have done more, but you're failing to understand that even though Air Canada communicates they see traffic confirm we're clear, Tower is looking at the runway and confirming that it is indeed clear and communicating that back. What the tower does NOT have, is the line of sight down the runway or taxiway in this case that the pilots DO have. The tower is off to the side, they cannot judge the line up of the approach. It's just not physically possible for them to do so. So to accuse them of not having your awareness well after the fact, or even the same awareness of the pilots flying, or even the same awareness of the pilots sitting on the taxiway during this is absolutely crazy. Do realize that the United pilot who finally chimes in has been staring at this plane making his approach the whole time, literally staring straight in the face at them and does not determine there's a problem until it's almost too late. Same with the pilot in the second plane, same with the pilot in the third plane. All of the pilots have line of sight, tower does not. When pilots confirm they have an airport in sight, the tower's responsibility switches from controlling the approach to monitoring. They cannot be on the radio asking for headings and GPS coordinates, nor should the pilots be answering those questions for tower. Those are distractions from landing safely. I imagine the tower is NOT sitting there looking at a magazine and is instead frantically scanning the runway looking to see if any of the construction vehicles have wandered over too far and are now on the wrong runway or anything else that might be on the runway that these guys are seeing which would be a disaster if a plane landing ran over them and crashed. They have no reason to believe Air Canada is lined up wrong. The pilots/first officers all of whom have line of sight, any of 8 of them out there, could have figured it out sooner, but didn't. It's an impossibility for tower to figure it out and do more than what they did.
@@kavinskysmith4094 Well, it isn't just the tower, but also the NTSB; I've been wondering here why it wasn't standard practice from the first first runway maintenance closure to verbally warn/remind an aircraft that's going to land by the air traffic controller of the closed runway, "Reminder, closed runway, only one of the parallel runways is lit." And it apparently still isn't the practice as I didn't see this recommendation in the report.
Maybe I'm missing something, but I can't think of a way that could cause issues, rather than solve ones like this.
This airport design is pretty bad as well. A recommendation out of this was to always use ILS into SFO.
Wasn't there only ONE ATC employee at this instance? The second was on a restroom (etc) break. I believe they said a minimum of TWO must be there at all times after that.
I absolutely love the constructive thinking of aviation!
Fantastic!!! I wondered about this since it happened. Glad to see it was a lot of recommendations