Air Canada AC759 Incident: Neglected Safety Culture and Training Standards

I feel that there are a number of important aspects of the investigation that have been left out by NTSB in the AC759 overflight of taxiway at KSFO 07 July 2017.

The NTSB full report .

The investigation itself is fixated on the lateral deviation of the aircraft. It aims to understand why it aligned with the parallel taxiway instead of the runway 28R. The vertical profile was flown and how was it flown is not questioned at all.

The investigation lays emphasis on the aspect of NOTAMS. I agree that NOTAMS are a hazard. The risk associated can be detrimental to the crew performance. However, I would like to question the basics of safety.
Has any Airline or FAA directed an Airline to carry out a Safety Risk Assessment? Should this be done under their Safety Management System? This assessment should address the issue.
There has been a failure of the SMS program and the existence of a poor Safety culture in the Airline. They are still at the pathological or reactive stage of safety culture development.

The flight crew received the NOTAM for Rwy 28L closure. It was a part of the ACARS message along with SFO weather. The Captain gave the statement in the interview. He said that when he first sighted the runway, he knew that runway 28L was closed. However, he assumed that it was still open. Therefore NOTAM could not have played an important role in this incident. The crew awareness was there.

There are other glaring issues that have been missed out/unanswered.
1. The procedural manual tuning of LOC frequency for lateral guidance with the LOC was not carried out. A visual approach was carried out for RWY 28R. Therefore, vertical guidance could be through PAPI for RWY28R. It could also be through the YoYo on the PFD.

The investigation does not query the crew on the vertical mode for flying the approach. It also does not ask what guidance was available. Did they use or sight the PAPI? PAPI is also an identifier of a runway when visual reference is needed to be acquired.

2. The flight crew of DAL521, which landed before, confirmed that the Captain saw the painted “28R” on the runway surface. The Captain saw the painted “28R” on the runway surface. He visually acquired it. The Captain confirmed this. He saw it when the airplane was at an altitude of about 300 ft. The Crew of AC759 could not identify any of the aircraft even while flying over two of them.
The investigation does not query the crew of visual sightings at 100’. The first officer is not at all asked any question on his role or scanning below 300’.

3. AC759 crossed position abeam 1000’ marker of RWY28R at 100’ AAE over taxiway C. The vertical profile was too high and neither pilot recognized this.
The investigation does not query the crew on their vertical profile. It also does not ask what aids were used to descend from the final fix. F101D was 1200′ AAE and 4 nm from the threshold. At night and almost a black hole approach, there were no approach lights for the assumed runway. There has to be a reference.

4. The PM was 42 years old and had failed to qualify for an upgrade to Captain twice. Thereafter he had elected to remain as a First Officer.

The simulator instructors and check airmen conducted the incident first officer’s upgrade attempt. They said the reason for the unsatisfactory upgrade was the first officer’s lack of situational awareness. He failed to correctly identify a mandatory altitude on an arrival. He also had issues with non-precision approaches and did not perform to the Transport Canada required performance standards. Some of the instructors and check airmen categorized the incident first officer as “nervous” and “a weak candidate.”

The First Officer was known to have issues that were identified in the upgrade programme but never before. He was re-qualified as a First Officer after his failure to upgrade. How did he magically regain his situational awareness and NPA, etc.?

The investigation does not question the training standards of Air Canada. The role of the First Officer during the approach as the PM was vital. The CRM standards and situational awareness do not change with the role in the cockpit. Both Capt. and First Officer need to have the same standards. What is the standard defined in Air Canada training manual has not been investigated?

7. The First Officer stated that he had to go head down. He looked for the runway heading when the Captain instructed him to do so. The information is readily available on the Approach chart. It is mentioned boldly as Final Apch Crs 284 on the briefing strip. It is also on the LOC symbol on the plan view. With 10,000 hrs of experience, there is a question on his competency level. There is also a question on the training and checking standards at Air Canada.

8. From the final fix F101D, which is about 4nm to touchdown. The aircraft was 1100’ AAE. It was about 100’ below the required height for crossing the fix. Typical time to reach the threshold would have been 2 minutes approx. The first officer was heads down for the entire segment and did not notice anything out of the ordinary? If he was heads down, what was the aircraft’s position with respect to the final track? What was the aircraft’s position concerning the runway on the ND? The investigation does not question these aspects.

9. The psychological concept of Expectation Confirmation theory (Anmol Bhattachargee 2001) is out of context. It cannot be used in this scenario. The paper is primarily based on consumer behavior and their post-purchase behavior and service marketing in general. There could have been expectation and confirmation bias. However, it could have been broken due to the fact that there was no external vertical guidance available. The Capt would have been forced to scan the instruments to judge his vertical profile. The re-scanning will give a fresh perspective every time he looks out after scanning the instrument inside.

10. The responsibility of the ATC officer during a visual approach is following the flight till touchdown. This is as per FAA Order JO 7110.65. The ATC officer clearly wasn’t doing that.

11. Crew fatigue could have been a contributory cause. Instances of micro-sleep could have impaired their situational awareness, decision-making ability, and CRM.

https://safetymatters.co.in/2019/01/15/whats-common-between-a-phone-conversation-what-could-have-been-the-worlds-worst-air-disaster