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Attributes | |
ACN | 102310 |
Time | |
Date | 198901 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 200 msl bound upper : 300 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : sfo artcc : zdv |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 180 flight time total : 17000 flight time type : 13000 |
ASRS Report | 102310 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | conflict : nmac non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course |
Consequence | Other |
Miss Distance | horizontal : 300 vertical : 100 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were arriving from the north at sfo in an large transport. It was a clear night and we were given descent from the VOR on the north side of the airport down the bay. Runway 28 parallel visibility approachs were in progress. We were given base leg turn south of the san mateo bridge when an medium large transport arriving from the big sur arrival was cleared for a visibility approach to 28L to maintain visibility sep from our flight. We were then cleared for the visibility approach to 28R with information traffic medium large transport to follow us for the left runway, which we reported sighting behind us to our left. The copilot was PF and joined final remaining well clear of the 28L approach course to the right while I monitored the medium large transport which gradually disappeared from our field of view behind us, still outside the OM. At about 200' on our approach the medium large transport was heard to request the left runway. Evidently surprised, the tower reclred the medium large transport to land on runway 28L, stating that was their original clearance. After T/D as we cleared 28R at the high speed, the medium large transport was observed clearing 28L at the high speed. I realized with the time lapse involved that we had touched down almost simultaneously, and that the medium large transport must have been virtually on top of us at 200' and probably did not have visibility contact throughout the final approach. I believe the flight was so close that our aircraft had disappeared from view below due to the medium large transport cockpit cut off angle. Sfo tower reported to us that the aircraft was in command of a check airman giving IOE to a new first officer and accepted blame for the mistake. In conclusion: the first error was when the medium large transport incorrectly lined up to land on the wrong runway. The medium large transport failed to maintain visibility contact with our flight. Tower controllers were too busy to maintain positive monitoring of all approaching aircraft. We incorrectly assumed that since the medium large transport disappeared behind us that it would continue to maintain the proper sep with our flight. The close proximity of runways 28 make parallel visibility approachs extremely hazardous. Any reduction in visibility and ceiling parameters for runway 28 visibility approachs would result in a serious reduction in safety at sfo.
Original NASA ASRS Text
Title: NMAC BETWEEN ACR-LGT AND ACR-MLG ON PARALLEL VISUAL APCHS TO SFO.
Narrative: WE WERE ARRIVING FROM THE N AT SFO IN AN LGT. IT WAS A CLEAR NIGHT AND WE WERE GIVEN DSCNT FROM THE VOR ON THE N SIDE OF THE ARPT DOWN THE BAY. RWY 28 PARALLEL VIS APCHS WERE IN PROGRESS. WE WERE GIVEN BASE LEG TURN S OF THE SAN MATEO BRIDGE WHEN AN MLG ARRIVING FROM THE BIG SUR ARR WAS CLRED FOR A VIS APCH TO 28L TO MAINTAIN VIS SEP FROM OUR FLT. WE WERE THEN CLRED FOR THE VIS APCH TO 28R WITH INFO TFC MLG TO FOLLOW US FOR THE LEFT RWY, WHICH WE RPTED SIGHTING BEHIND US TO OUR LEFT. THE COPLT WAS PF AND JOINED FINAL REMAINING WELL CLR OF THE 28L APCH COURSE TO THE RIGHT WHILE I MONITORED THE MLG WHICH GRADUALLY DISAPPEARED FROM OUR FIELD OF VIEW BEHIND US, STILL OUTSIDE THE OM. AT ABOUT 200' ON OUR APCH THE MLG WAS HEARD TO REQUEST THE LEFT RWY. EVIDENTLY SURPRISED, THE TWR RECLRED THE MLG TO LAND ON RWY 28L, STATING THAT WAS THEIR ORIGINAL CLRNC. AFTER T/D AS WE CLRED 28R AT THE HIGH SPD, THE MLG WAS OBSERVED CLRING 28L AT THE HIGH SPD. I REALIZED WITH THE TIME LAPSE INVOLVED THAT WE HAD TOUCHED DOWN ALMOST SIMULTANEOUSLY, AND THAT THE MLG MUST HAVE BEEN VIRTUALLY ON TOP OF US AT 200' AND PROBABLY DID NOT HAVE VIS CONTACT THROUGHOUT THE FINAL APCH. I BELIEVE THE FLT WAS SO CLOSE THAT OUR ACFT HAD DISAPPEARED FROM VIEW BELOW DUE TO THE MLG COCKPIT CUT OFF ANGLE. SFO TWR RPTED TO US THAT THE ACFT WAS IN COMMAND OF A CHK AIRMAN GIVING IOE TO A NEW F/O AND ACCEPTED BLAME FOR THE MISTAKE. IN CONCLUSION: THE FIRST ERROR WAS WHEN THE MLG INCORRECTLY LINED UP TO LAND ON THE WRONG RWY. THE MLG FAILED TO MAINTAIN VIS CONTACT WITH OUR FLT. TWR CTLRS WERE TOO BUSY TO MAINTAIN POSITIVE MONITORING OF ALL APCHING ACFT. WE INCORRECTLY ASSUMED THAT SINCE THE MLG DISAPPEARED BEHIND US THAT IT WOULD CONTINUE TO MAINTAIN THE PROPER SEP WITH OUR FLT. THE CLOSE PROX OF RWYS 28 MAKE PARALLEL VIS APCHS EXTREMELY HAZARDOUS. ANY REDUCTION IN VISIBILITY AND CEILING PARAMETERS FOR RWY 28 VIS APCHS WOULD RESULT IN A SERIOUS REDUCTION IN SAFETY AT SFO.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.