Air Canada flight 759 report

"Just Jeepin'" (macintux) 09/26/2018 at 16:46 • Filed to: Planelopnik

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For those who don’t recall (like me) , last year San Francisco almost suffered what could have been the worst aviation disaster in history, when !!!error: Indecipherable SUB-paragraph formatting!!! nearly landed on a taxiway with four flights waiting to take off.

NTSB is apparently still preparing its final report on the incident, but they’ve released a summary here:

https://ntsb.gov/news/events/Documents/DCA17IA148-Abstract.pdf

The ATC audio is available here:

!!! UNKNOWN CONTENT TYPE !!!

Wrong Wheel Drive (41%) > Just Jeepin' 09/26/2018 at 17:07

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Interesting that they mention the “interference with the pilot’s circadian low” which is similar to some of the results of the two USN Destroyers last year. Not just that the people paying attention are simply “tired” but because its just odd hours, the body naturally has trouble staying awake and focused 100%. And in high velocity scenarios where you might be just doing “run of the mill” stuff it only seems natural to forget about details like that. I am sure if glaring and immediate danger were present ahead of time, the adrenaline would have brought them into awareness. But its the little stuff that jumps out last second that will get you in that scenario. 

Spanfeller is a twat > Just Jeepin' 09/26/2018 at 17:14

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But they were doing IFR, how did they fuck up with IFR, plus, doesn’t the runway have an ILS receiver that can tell the pilot he’s lined up wrong why didn’t they tune it ?

Just Jeepin' > Spanfeller is a twat 09/26/2018 at 17:17

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They never tuned the ILS receiver;  that’s a significant part of the report.

facw > Spanfeller is a twat 09/26/2018 at 17:20

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As Jeppin’ said, they had to manually tune it and didn’t (the first office didn’t do it like he was supposed to, and the captain didn’t confirm like he was supposed to). Additionally, manually fiddling with the ILS settings meant that the first officer was distracted, and so didn’t see the captain lining up wrong.

Spanfeller is a twat > facw 09/26/2018 at 17:22

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All of this seems like a sequence of overconfidence that really shouldn’t be present in the cockpit of an airliner. 

Quadradeuce > Just Jeepin' 09/26/2018 at 18:09

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Wow, I didn’t realize they got down to 60'. A 787 is 55' 10" tall...

Just Jeepin' > Quadradeuce 09/26/2018 at 18:16

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Brutally thin margin between life and death that night.

ttyymmnn > Quadradeuce 09/26/2018 at 18:57

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And a 747 is 65 feet tall....

facw > Quadradeuce 09/26/2018 at 19:30

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Watch the video...

This could have very easily been a T enerife-level disaster.

ttyymmnn > Just Jeepin' 09/27/2018 at 10:11

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Quadradeuce > facw 09/27/2018 at 12:56

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Oh man, they got so close to the tail on that second taxiway jet. At least Tenerife had survivors because the Pan Am 747 was turning off the runway and the nose missed getting hit. This would have been total destruction of at least 3 planes.

Also, HOW DID YOU MISTAKE ALL THOSE STROBES FOR ANYTHING BUT AIRCRAFT?!?  They even asked ATC about it.  WTF!  Are those pilots still flying?

facw > Quadradeuce 09/27/2018 at 13:12

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The pilots were Dimitrios Kisses and Matthew Dampier, but I can’t find any indication if anything has happened to them. Reports did indicate that Dampier had previously been passed over for promotion due to sloppy flying (though in this case, the captain seems to bear more responsibility) . The NTSB report seems to leave room to say that they were sabotaged by poor training and a work schedule that would have been illegal on a domestic flight, but it seems hard to imagine that they’d let them out there again without significant retraining/re-certification.

You can tell a Finn but you can't tell him much > ttyymmnn 09/27/2018 at 14:48

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Why does everyone raise their hand whenever the guy talking says the word “read”?

ttyymmnn > You can tell a Finn but you can't tell him much 09/27/2018 at 15:05

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I can only guess that it is to signify that they read it too. 

Quadradeuce > facw 09/27/2018 at 15:10

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I felt the report when awfully light on the pilots. I’m sure it’s more challenging when you come into an airport that you have to manually set your IFR, but they knew something was off when they saw the lights on the runway. And there’s no excuse for ignorance of a NOTAM.

Reminds me of the Asiana 787 crash where the pilots are so used to the aircraft doing most of the work, they forgo t the basics of just landing properly.

facw > Quadradeuce 09/27/2018 at 15:15

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The Asiana crash was a 777 (first fatal accident involving one), but yeah it was scary because reading that report, it seemed apparently that the pilots simply didn’t know how to properly use their autopilot, and then were even less knowledgeable about flying the aircraft manually when they tried to avoid the crash (granted they were probably freaking out at that point, but they still made incredibly basic mistakes).