CHAIRMAN SUMWALT: GOOD AFTERNOON, AND WELCOME TO THE BOARD ROOM OF THE NATIONAL TRANSPORTATION SAFETY BOARD. I AM HONORED TO SERVE AS THE CHAIRMAN OF THE NTSB. JOINING US TODAY ARE THE VICE CHAIRMAN, RUTH LANDSBERG, EARL WEENER, BELLEA DINH-ZARR, AND JENNIFER HOMENDY. I WOULD ALSO LIKE TO WELCOME THE PEOPLE WHO ARE VISITING THE NTSB THIS WEEK. TODAY WE ARE IN OPEN SESSION TO CONSIDER AN INCIDENT IN WHICH AN AIR CANADA AIRBUS A320 LINED UP TO LAND ON A TAXIWAY AT SAN FRANCISCO INTERNATIONAL AIRPORT ON JULY 7, 2017. WHEN THE INCIDENT PILOTS LOOKED DOWN AT THE AIRPORT ON A PROJECT HE SAW TWO PARALLEL LIGHTED SERVICE -- SERVICES. HE THOUGHT HE WAS SEEING THE 28 LEFT AND 28 RIGHT. WHAT HE WAS SEEING WAS L28 RIGHT, AND PARALLEL TAXI CHARLIE. A NOTICE TO AIRMEN ADVISED THE RUNWAY 28 LEFT CLOSURE. THE PILOTS RECEIVED THIS IN FLIGHT. THE CLOSED RUNWAY, 28 LEFT, WAS MARKED WITH A FLASHING LIGHT X. WAS IT AN EASY MISTAKE TO MAKE? IF YOU EXPECT TO SEE TWO RUNWAYS, PERHAPS. AS WE WILL DISCUSS, SUCH AN EXPECTATION PLAYED A KEY PART IN THIS INCIDENT. THERE WERE DIFFERENCES BETWEEN THE RUNWAY AND THE TAXIWAY AS WELL. AS EVENTS UNFOLDED, FORTUNATELY, NO LIVES WERE LOST. NO PASSENGERS OR CREW MEMBERS WERE INJURED, AND NO AIRCRAFT WERE DAMAGED. BUT THERE WERE FOUR PASSENGER AIRCRAFT LINED UP ON THE TAXIWAY, TWO BOEING 787'S AND A 737, AND THE AIR CANADA AIRPLANE DESCENDED TO A LOW ALTITUDE ABOVE THE TAXIWAY. THE CREW SENSED SOMETHING WAS NOT RIGHT AND THEY INITIATED A GO OR RIND -- A GO AROUND. I DO NOT WANT TO SENSATIONALIZE IT, BUT THIS WAS A VERY CLOSE CALL. WE HAVE OFTENTIMES FOUND AN ACCIDENT INVESTIGATION THAT A WHOLE CHAIN OF EVENTS MUST GO WRONG, AND FORTUNATELY IN THIS INCIDENT, THE CHAIN WAS EVENTUALLY BROKEN. THIS AFTERNOON WE WILL EXAMINE SEVERAL ASPECTS OF THIS INCIDENT. WE WILL DISCUSS THE CREW'S FATIGUE AND THE ROLE IT PLAYED IN THE MISIDENTIFICATION OF THE INTENDED LANDING SERVICE. WE WILL EXAMINE EXPECTATION BIAS AND HOW THIS MAY HAVE AFFECTED THE CREW'S PERCEPTION OF THE ENVIRONMENT. WE WILL ALSO EXAMINE THE PRESENTATION AND PRIORITY OF THE RUNWAY CLOSURE INFORMATION PROVIDED TO THE FLIGHT CREW. IN ADDITION, WE WILL DISCUSS TECHNOLOGY THAT COULD PROVIDE CRITICAL WARNINGS TO PILOTS AND AIR TRAFFIC CONTROLLERS WHEN AN AIRPLANE IS NOT WIND UP WITH A RUNWAY SURFACE. TODAY THE NTSB STAFF WILL PRESENT THE MOST PERTINENT FACTS AND ANALYSIS FOUND IN THE DRAFT REPORT. THE DRAFT REPORT IS OVER 100 PAGES. OUR PUBLIC DOCUMENT AT NTSB.GOV CONTAINS MORE THAN 700 ADDITIONAL PAGES. STAFF HAS PROPOSED ALL AVENUES TO THE BOARD. THE BOARD WILL CONSIDER THIS WORK, THAT WE WILL ASK QUESTIONS TO ENSURE THE FINAL REPORT TRULY PROVIDES BEST OPPORTUNITY TO ENHANCE SAFETY. NOW DENNIS JONES, IF YOU INTRODUCE THE STAFF.

MR. JONES: THANK YOU. A FEW ANNOUNCEMENTS PRINT I REQUEST THE FOLKS HERE IN THE BOARDROOM IF YOU HAVE NOT ALREADY DONE SO, PLEASE SILENCE YOUR MOBILE PHONES AND OTHER ELECTRONIC DEVICES. THERE ARE TWO EXITS IN THE AUDITORIUM CANNOT WENT TO MY LEFT, WENT TO MY RIGHT. FOLLOW THE ILLUMINATED SIGNS. YOU MAY EXIT TO THE REAR OF THE AUDITORIUM AND PROCEED OUT THAT GLASS DOORS AS YOU ENTERED, GO UP THE STAIRS, AND EXIT TO THE LARGE GLASS DOORS TO THE OUTSIDE. ONCE YOU HAVE ACCIDENT, TURN LEFT AND FAR I FOLLOWED THE SIDEWALK TO THE INDUSTRY. -- THE STREET. DO NOT DELAY. DO NOT RETURN TO THE BOARDROOM UNTIL INSTRUCTED TO DO SO. IF YOU ARE CONCERNS, DO NOT HESITATE TO CONTACT ANY NTSB PERSONNEL. JOINING US AT THE PANEL ARE STAFF MEMBERS FROM THE OFFICE OF AVIATION SAFETY. IN THE FRONT ROW IS THE DIRECTOR OF THE OFFICE. NEXT IS THE INVESTIGATOR IN CHARGE. NEXT IS CAPTAIN SEAN -- WHO WILL BE HANDLING OPERATIONS. THE NEXT WILL HANDLE CONFORMANCE. NEXT IS BETTY -- WHO WILL HANDLE AIR TRAFFIC CONTROL. DIRECTED BEHIND HER ON THE SECOND ROW IS FROM THE OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS. CHARLES -- WHO WILL HANDLE FLIGHT DATA RECORDERS. NEXT IS KAREN STEIN, REPORT WRITER. THE NEXT IS THE DIRECTOR OF THE OFFICE OF RESEARCH AND ENGINEERING. NEXT IS PAUL FROM THE OFFICE OF VACATIONS. BEHIND HIM ON THE THIRD ROW IS THE PERSON WHO WILL HANDLE AIRCRAFT PERFORMANCE. AND LAST AND NEXT WILL BE THE SEQUENCE OF EVENTS ASPECTS. HE WILL START WITH COMMENTS FROM THE OFFICE OF THE DIRECTOR, JOHN DELISI. MR.

DELISI: THIS WILL BE THE FIRST TIME A MAJOR INVESTIGATIVE REPORT IS BEING ROCKED TO THE BOARD FOR AN EVENT IN WHICH THERE WERE NO INJURIES AND THERE WAS NO AIRCRAFT DAMAGE. STAFF HAS PREVIOUSLY INVESTIGATED INCIDENTS INVOLVING TAXIWAY LANDINGS, BUT THOSE LANDINGS RECURRED ON UNOCCUPIED TAXIWAYS. WHEN WE LEARNED OF A PASSENGER AIRLINER ALMOST TOUCHING DOWN ON THE TAXIWAY OCCUPIED BY FOUR OTHER AIRLINERS, WE ELECTED TO LAUNCH A FULL INVESTIGATION. BY APPLYING OUR RESOURCES TO THIS INVESTIGATION, INCLUDING EXPERTS IN OPERATIONS COMPARED TRAFFIC CONTROL, AIRPORT, HUMAN PERFORMANCE, AIRPLANE PERFORMANCE, AND FLIGHT RECORDERS, WE WERE ABLE TO DEVELOP A DRAFT REPORT THAT REPRESENTS THE REAL STRENGTH OF THE NTSB, OUR ABILITY TO PERFORM A DEEP DIVE INTO THE CIRCUMSTANCES OF AN INCIDENT COULD HAVE RESULTED IN A POTENTIAL CATASTROPHE. THE EVIDENCE WE COLLECTED AND ANALYZED IN THIS INVESTIGATION RESULTED IN THE DRAFT REPORT YOU WILL CONSIDER TODAY, WHICH PROPOSES 19 FINDINGS COME A PROBABLE CAUSE, AND MOST IMPORTANTLY SEVEN RECOMMENDATIONS AIMED TO PREVENT A SIMILAR OCCURRENCE. THE INVESTIGATOR IN CHARGE WILL NOW GIVE THE OPENING PRESENTATION. MR. LOVRELL

ELL: GOOD AFTERNOON. ON JULY 7, 2017, AT 11: 50 6 P.M. PACIFIC DAYLIGHT TIME, AIR CANADA FLIGHT 759, AND END -- LINED UP PARALLEL WITH TAXIWAY CHARLIE OVER FOUR AIRPLANES WAITING. THE CANADIAN REGISTERED AIRPLANE WAS OPERATING UNDER TITLE 14 CODE OF FEDERAL REGULATIONS, PART 129 COME AS A SCHEDULED INTERNATIONAL PASSENGER FLIGHT FROM TORONTO, CANADA. NIGHT VISUAL METEOROLOGICAL CONDITIONS PREVAILED AT THE TIME OF THE INCIDENT. THERE WERE NO INJURIES AND THE AIRPLANE WAS NOT DAMAGED. THIS SLIDE SHOWS THE SAN FRANCISCO RUNWAY AND TAXIWAY LAYOUT. RUNWAY 28 LEFT, RUNWAY 28 RIGHT, THE RED LINE SHOWS THE EXTENDED CENTER LINE OF RUNWAY 28 RIGHT, TAXIWAY C OR CHARLIE, AND THIS LITTLE ARROW SHOWS THE APPROACH PATH OF FLIGHT 759. AT THE TIME OF THE INCIDENT, RUNWAY 28 LEFT WAS SCHEDULED CLOSED FOR CONSTRUCTION WORK WITH A FLASHING X POSITION ON THE APPROACHING END OF 28 LEFT. THIS INFORMATION WAS INCLUDED IN THE FLIGHT CREW'S DISPATCHING INFORMATION AND WAS INCLUDED ON THE INFORMATION THAT WAS CURRENT AT THE TIME OF THE INCIDENT. FLIGHT 759'S TAKEOFF, CLIMB, CREWS, AND DISSENT WERE UNEVENTFUL. THE CAPTAIN WAS THE PILOT FLYING COME IN THE FIRST OFFICER WAS THE PILOT MONITORING. AFTER CONTACTING CALIFORNIA APPROACH CONTROL, THE FLIGHT WAS CLEARED TO FLY THE BRIDGE VISUAL APPROACH TO RUNWAY 28 RIGHT. THE BOTTOM OF THIS SLIDE PIX A PROFILE VIEW THAT SHOWS ALTITUDE AS AIR CANADA 759 APPROACHES. FLIGHT DATA RECORDER INFORMATION SHOW THE FLIGHT ALIGNED WITH TAXIWAY CHARLIE WHEN THE AIRPLANE WAS ABOUT 3.6 NAUTICAL MILES FROM THE RUNWAY AT AN ALTITUDE OF ABOUT 1100 FEET ABOVE THE GROUND. WHEN THE FLIGHT WAS ABOUT 2/3 OF A NAUTICAL MILE FROM THE SEAWALL, ABOUT 300 FEET ABOVE GROUND, THE FIRST OFFICER RADIOED THE TOWER CONTROLLER SAYING, JUST WANT TO CONFIRM THIS AS AIR CANADA 759. WE SEE LIGHTS ON THE RUNWAY THERE, ACROSS THE RUNWAY. CAN YOU CONFIRM WE ARE CLEARED TO LAND? THE TOWER CONTROL RESPONDED, ERROR CAN IT -- AIR CANADA 759, CLEARED TO LAND, RUNWAY 28 THERE IS NOTHING ON RUNWAY 28 RIGHT. THE FIRST OFFICER ACKNOWLEDGED THAT TOWER'S TRANSMISSION WHEN THE AIRPLANE WAS 500 FEET FROM THE SEAWALL AND 150 FEET ABOVE THE GROUND. ACCORDING TO DATA, FLIGHT 759 INITIATED A GO AROUND AT 89 FEET. AFTER THE GO AROUND WAS INITIATED, THE AIRPLANE DISSENTED TO A MINIMUM ALTITUDE OF 60 FEET BEFORE BEGINNING TO CLIMB. I WILL NOW PLAY THE VIDEO THAT SHOWS THE FINAL APPROACH AN INITIAL GO AROUND TO ORIENT YOU. HERE IS A STILL PHOTO OF THE AIRPORT SURVEILLANCE VIDEO. THE CAMERA IS LOOKING EAST FROM THE TERMINAL ACROSS THE AIRPORT. AIR CANADA 759 IS CIRCLED IN RED AND APPROACHING FROM THE RIGHT TO GO LEFT. FOUR AIRPLANES ON TAXIWAY CHARLIE ARE CIRCLED IN YELLOW IN THE UPPER LEFT PORTION OF THE PICTURE. THE VIDEO WILL PLAY TWICE.

MR. LOVELL: THE SAFETY ISSUES IDENTIFIED INVESTIGATION RELATE TO THE NEED FOR CONSISTENT FMS CAPABILITY, EFFECTIVE PRESENTATION OF RELEVANT FLIGHT OPERATIONS INFORMATION, EQUIPMENT TO ALERT FLIGHT CREW'S LANDING WHEN THE AIRPLANE IS NOT ALIGNED WITH THE RUNWAY SURFACE, MODIFICATION OF SURFACE DETECTION EQUIPMENT TO IDENTIFY POTENTIAL TAXIWAY LANDINGS, MORE EFFECTIVE SIGNALING THE FLIGHT CREWS OF THE CLOSURE OF RUNWAYS WHEN ONE OR MORE RUNWAYS ARE CLOSED AT AN AIRPORT, AND REVISION TO DERE GULATIONS TO REVIEW FLIGHT CREW FATIGUE. PARTIES TO THE INVESTIGATION WERE THE FEDERAL AVIATION ADMINISTRATION, THE NATIONAL AIR TRAFFIC CONTROLLER'S ASSOCIATION, AND HONEYWELL. IN ACCORDANCE WITH THE EXPERT TINKHAM THE FRENCH -- THE FRENCH APPROVED A STATE OF MANUFACTURE AND DESIGN OF THE AIRPLANE, WITH AIRBUS DESIGNATED AS TECHNICAL ADVISOR. IN ADDITION, THE TRANSPORTATION SAFETY BOARD OF CANADA APPOINTED AN ACCREDITED REPRESENTATIVE AS STATE OF REGISTRATION AND OPERATOR. AIR CANADA, THE CANADA PILOTS ASSOCIATED COME AND TRANSPORT CANADA DESIGNATED AS TECHNICAL ADVISORS. THE FOLLOWING NTSB STAFF PARTICIPATED IN THE INVESTIGATION. MR. CHAIRMAN, THIS CONCLUDES MY OPENING PRESENTATION. CAPTAIN SEAN -- WILL GIVE A PRESENTATION ON THE OPERATIONAL FACTORS OF THIS INCIDENT.

GOOD AFTERNOON. I WILL DISCUSS THE FLIGHT CREW'S REQUIREMENT TO MANLEY TUNE THE INSTRUMENT LANDING SYSTEM, OR ILS FREQUENCY SYSTEM, SO THAT WOULD HAVE PROVIDED BACKUP GUIDANCE TO THE VISUAL APPROACH. I WILL DISCUSS THE PLACEMENT OF THE FREQUENCY INFORMATION WITHIN THE APPROACH GUIDANCE. AIR TRAFFIC CONTROL ISSUED INSTRUCTIONS TO THE FLIGHT CREW TO FLY THE FMS BRIDGE VISUAL APPROACH TO RUNWAY 28 AIR CANADA VISUAL APPROACH FOR RUNWAY 28 RIGHT RECORD HIGHLIGHTS -- PILOTS TO MANUALLY ENTER OR TUNE THE ILS FREQUENCY INTO THE AIRPLANE'S FLIGHT MANAGEMENT COMPUTER. THE FIRST OFFICER WHO WAS A COLLEGE OR -- A PILOT MONITORING DID NOT ENTER, NOR DID THE CAPTAIN VERIFY THAT THE ILS FREQUENCY WAS TOO. DURING POST INCIDENT INTERVIEWS HIM THE FIRST OFFICER REPORTED THAT HE MUST HAVE MISSED SETTING THE FREQUENCY, BUT WAS UNABLE TO PROVIDE A REASON AS TO WHY. BECAUSE THE ILS WAS NOT ENTERED AND VERIFY, THE FLIGHT CREW COULD NOT TAKE ADVANTAGE OF THE LATERAL GUIDANCE CAPABILITY TO ENSURE PROPER ALIGNMENT WITH THE INTENDED RUNWAY SURFACE. A POST-INCIDENT REVIEW OF THE A320 DATABASE SOUGHT THAT THE VISUAL APPROACH WAS THE ONLY APPROACH IN THAT DATABASE THAT REQUIRED MANUAL TUNING OF THE ILS FREQUENCY. THE FLIGHT CREW MIGHT HAVE FAILED TO TUNE AND VERIFY THE TUNING OF THE ILS FREQUENCY BECAUSE AIR CANADA A320 FLIGHT CREWS WERE NOT TO TAKE ANOTHER APPROACH. ONLY REQUIRING MANUAL TO ANY ON THIS APPROACH CREATED THE OPPORTUNITY TO MISS THIS STUFF, AND OMISSION ERROR. ALSO THE PRESENTATION AND POSITION OF THE STEP TO MANUALLY TUNE THE FREQUENTS WOULD NOT HAVE BEEN PROMISED TO THE FLIGHT CREW DURING THE REVIEW OF THE APPROACH PROCEDURE. THE FMS PROCEDURE TO RUNWAY 28 RIGHT CONSISTED OF TWO PAGES. THE FIRST PAGES, TURN ON THE SCREEN, INCLUDED A PICTORIAL VIEW OF THE APPROACH. THE SECOND PAGE, WHICH IS SHOWN ON THE SCREEN, INCLUDED GUIDANCE FOR AIR CANADA AND AIRBUS A320 FLEET'S. FOR THE EIGHTH AIRBUS FLEET, THE GUIDANCE INCLUDE THE INSTRUCTION TO TUNE THE ILS TO 28 RIGHT. THIS INSTRUCTION WAS EMBEDDED IN THE MIDDLE OF THE PARAGRAPH ON THE LAST PAGE OF THE APPROACH, AND THE POSITION AND PRESENTATION OF THIS PRESENTATION WERE NOT OPTIMAL FOR CAPTURING PILOT ATTENTION. AFTERWARDS, AIR CANADA PROVIDES ITS PROCEDURES SO THAT THE APPROACH WOULD BE FLOWN AS AN INSTRUMENT APPROACH. STAFF'S INVESTIGATION OF THIS INCIDENT DETERMINE A SAFETY ISSUE EXISTS REGARDING MANUAL TUNING AND THE PROMINENCE OF THAT INFORMATION ON APPROACH CHARTS. IN SUMMARY, STAFF DETERMINED THAT HAD THE REQUIREMENT TO MANUALLY TUNE THE FREQUENCY BEEN MORE CONSPICUOUS AND THAT EACH MEMBER REVIEWED AND CROSS CHECKED THE REQUIREMENT, THE CREW WOULD'VE HAD THE REQUIRED BACKUP LATERAL GUIDANCE TO ALIGN WITH RUNWAY 28 RIGHT. WITHOUT THIS GUIDANCE, THE CREW WAS NOT AWARE THAT THE FLIGHT HAD UNKNOWINGLY ALIGNED WITH TAXIWAY CHARLIE. STAFF IS PROPOSING A RECOMMENDATION TO THE FEDERAL AVIATION ADMINISTRATION TO WORK WITH AIR CARRIERS TO ASSESS ALTERNATIVE VISUAL APPROACHES REQUIRING A BACKUP FREQUENCY TO AUDIT CAPABILITIES FOR CHARTED SURE APPROACHES. THEN IDENTIFY APPROACHES THAT ARE REQUIRING ABNORMAL MANUAL TUNING AND DEVELOP SOLUTIONS TO ADDRESS REQUIRED MANUAL FREQUENCY INPUT. THIS CONCLUDES MY PRESENTATION. WE WILL NOW BE PROVIDED A PRESENTATION ON HUMAN PERFORMANCE FOR THIS INCIDENT.

GOOD AFTERNOON. I PRESENTATION -- MY PRESENTATION INCLUDES CREW AWARENESS OF THE APPROACH, MISALIGNMENT, MITIGATIONS OVER COME EXPECTATIONS, AND CREW FATIGUE. THE CREW HAD AN IMPROPER EXPECTATION THAT TWO PARALLEL RUNWAYS WERE AVAILABLE AS THEY APPROACHED THE AIRPORT AND HAD INTENDED TO LINE UP WITH THE RIGHT SIDE RUNWAY. HOWEVER, WITH 28 LEFT CLOSED AND UNLIT, THE CREW MISIDENTIFIED THE LIGHTED RUNWAY AS 28 LEFT AND CONSIDERED TAXIWAY CHARLIE THINKING IT WAS 28 THE CAPTAIN DESCRIBE THE CREW PERFORMANCE ERRORS IN HIS PRESENTATION. WHILE THESE CAN BE DESCRIBED AS BREAKDOWNS IN RESOURCE MANAGEMENT, IT WAS ULTIMATELY THE CREW'S EXPECTATION THAT BUYS THEIR INTERPRETATION OF THE AVAILABLE QUEUE THAT LED TO THE DELAYED GO AROUND. EXPECTATION BUYS FIRST TO THE TENDENCY -- TO CONFIRM A NEGOTIATION HIGHER THAN CONTRADICTORY QUEUE. IT HAPPENS IN VARIOUS CIRCUMSTANCES, AND SINCE PEOPLE CANNOT BE AWARE IT IS HAPPENING, IT CAN BE DIFFICULT TO RECOGNIZE. A RUNWAY CLOSURE NOTICE TO AIRMEN WAS ISSUED AND REVIEWED BY THE CREW. THIS INFORMATION WAS NOT RECALLED WHEN IT WAS NEEDED DURING THE APPROACH. UPON REVIEW, THE INFORMATION WAS NOT EFFECTIVELY PRESENTED. BEFORE DEPARTURE, THAT NOTE INCLUDED ON THE FLIGHT RELEASE PAGE, HERE. ALTHOUGH SOME FEATURES OF THE -- WERE EMPHASIZED, ITS POSITION IN THE MIDDLE OF A DOCUMENT WAS NOT OPTIMAL. IN FLIGHT THIS INFORMATION WAS DISPLAYED AS A TEXT MESSAGE IN THE COCKPIT. THE FORMATTING AND CLOSURE OF THE INFORMATION REDUCED ITS USEFULNESS IN THE FLIGHT. STAFF HAS PROPOSED TO MORE EFFECTIVELY PRESENT THIS INFORMATION THE PILOTS. QUEUES SUPPORTING THE CREW'S EXPECTATION INCLUDED CONSTRUCTION LIGHTING, RUNWAY 28 RIGHT, LOOKING SIMILAR TO RUNWAY 28 LEFT, IN SEVERAL FEATURES ON THE TAXIWAY THAT WERE CONSISTENT WITH THE RUNWAY. THIS ILLUSTRATION REPRESENTS LIGHTING ON THE RUNWAY AND TAXIWAY WITH AIRCRAFT HOLDING ON THE TAXIWAY. THE TAXIWAY WITH AIRPLANES HAD FEATURES CONSISTENT WITH RUNWAY CENTER LINES, EDGE, CAN APPROACH LIGHTING. CLUES CONTRADICTING THE EXPEDITION INCLUDE TAXIWAY NOT HAVING NORMAL APPROACH LIGHTING, TAXIWAY CENTERLINES SEEN AS GREEN INSTEAD OF WHITE, AND FLASHING GUARD LIGHTS BEING POSITIONED ACROSS THE TAXIWAY. ALTHOUGH THESE EFFORTS AS MAY SEEM OBVIOUS, EXPECTATION BUYS CAN BE A POWERFUL INFLUENCE ON HUMAN PERCEPTION, WHERE CONFLICTING FEATURES ARE OFTEN OVERLOOKED. THE FIRST INDICATION THE CREW WAS ATTEMPTING TO RECONCILE THE DIFFERENCE BETWEEN THEIR OBSERVATION AND THEIR EXPECTATION OCCURRED WHEN THE FIRST OFFICER CALLED THE TIRE -- TOWER TO VERIFY THAT THE RUNWAY WAS CLEAR AFTER THE CAPTAIN NOTICED LIGHTS ACROSS HIS RUNWAY. THE CONTROL HE RELAYED THAT THE RUNWAY WAS CLEAR. THIS CONTRADICTED THE LIGHTS THEY WERE SEEING. SEVERAL ADDITIONAL CUES THAT CONTRADICTED THE EXPENSE VACATION INCLUDED IN THE MOMENTS BEFORE THE GO AROUND, INCLUDING RADIO TRANSMISSION FROM THE PER FIRST PLANE, A LANDING LIGHT SWITCH ON THE CREW OF THE SECOND AIRPLANE ON THE TAXIWAY CAN AND THE AIRPLANE'S LIGHTS ILLUMINATING WHAT WAS ON THE GROUND. IT IS LIKELY THESE CU ES CONTRIBUTED TO THEIR DECISION TO GO AROUND. THE MISALIGNMENT IS ALSO INCONSISTENT WITH EXPECTATION BIAS. HUMAN FACTORS RESEARCH SUGGESTS SEVERAL METHODS TO OVERCOME EXPECTATION BIAS. PROVIDING PILOTS WITH INFORMATION THAT CLEARLY IDENTIFIES ASPECTS OF THEIR ENVIRONMENT THAT THEY BE DIFFERENT FROM NORMAL IS ONE METHOD. FOR EXAMPLE, NEITHER CREWMEMBER CALLS SEEING THE FLASHING X ON RUNWAY LEFT INDICATING ITS CLOSURE. HAD THEY RECOGNIZE THAT WAS A RUNWAY, IT WOULD HAVE MET THEIR EXPECTATIONS TO SEE TWO PARALLEL RUNWAYS AND WOULD NOT HAVE MISIDENTIFY TAXIWAY CHARLIE. GIVEN THE FLASHING X WAS DESIGNED ONLY FOR AIRCRAFT TO LINE UP ON THAT RUNWAY, STAFF HAS PROPOSED A RECOMMENDATION TO IMPROVE RUNWAY CLOSURE CUES AS WELL. ANOTHER WAY TO OVERCOME EXPECTATION I IS IS BY INTRODUCING SALIENT CUES THAT REFLECT THE ACTUAL SITUATION. PEACOCK ALERT OR ADVISORY REFLECTING THE PROJECTED LANDING SERVICE COULD IMPROVE CREW AWARENESS AND PREVENT MISALIGNMENTS. STAFF HAS PROPOSED RESIGNATIONS TO EQUIP AIRPLANES WITH THESE TECHNOLOGIES -- RECOMMENDATIONS TO EQUIP AIRPLANES WITH THESE TECHNOLOGIES. THE CREW HAD BEEN AWAKE FOR AN EXTENDED TIME AND REPORTED FEELING TIRED AS THEY CONDUCTED THE APPROACH, WHICH WAS AROUND 3:00 A.M. EASTERN. CT CAN DEGRADE PERFORMANCE. -- FATIGUE CAN DEGRADE PERFORMANCE. U.S. REGULATIONS, IF THEY HAD APPLIED, THE CAPTAIN OR THE RESERVE PILOT WOULD NOT HAVE BEEN ABLE TO TAKE THE INCIDENT FLIGHT. STAFF HAS PROPOSED THAT CANADIAN REGULATIONS BE IMPROVED TO THAT ARE ADDRESSED FATIGUE FOR PILOTS OPERATING LATE-NIGHT FLIGHTS. AS A RESULT OF THE HUMAN PERFORMANCE RELATED SAFETY ISSUES IDENTIFIED, STAFF HAS PROPOSED EMANATIONS TO IMPROVE PRESENTATION OF INFORMATION DEPOSITS -- TWO PILOTS, EQUIP AIRPLANES WITH ALERTS WHEN AN AIRPLANE IS NOT ALIGNED WITH A RUNWAY SURFACE, FURTHER, EVOLVED TECHNOLOGY WHEN THE AIRPLANE IS NOT ALIGNED WITH ASSIGNED RUNWAY CAN RESEARCH WAYS TO EFFECTIVELY SIGNAL CLOSED RUNWAYS AND NIGHT, AND BETTER ADDRESS THE TEA. THANK YOU. -- FATIGUE. THANK YOU.

GOOD AFTERNOON. I WILL DISCUSS STAFFING, THE OPERATION OF THE AIRPORT SURFACE DETECTION EQUIPMENT SYSTEM, , PREVIOUS RECOMMENDATIONS ABOUT THIS TECHNOLOGY, AND SAFETY IMPROVEMENTS WITH TECHNOLOGY THAT HAVE ADVANCED THE RECOMMENDATIONS WERE ISSUED. SAN FRANCISCO TOWER WAS STAFFED WITH TWO CONTROLLERS ON THE NIGHT OF THE INCIDENT. ONE CONTROLLER WAS WORKING ALL POSITIONS AND FREQUENCIES, COMBINING THE TOWER CAM, AND THE OTHER CONTROLLER WAS ON A BREAK IN THE BUILDING. THE CONTROLLER WORKING IN THE TOWER AT THE TIME OF THE INCIDENT STATED THAT THE TRAFFIC COMPLEXITY WAS NORMAL BEFORE THE INCIDENT OCCURRED AND WAS NOT OVERLY BUSY. ASDI IS A RUNWAY SAFETY TERM THAT IS DETECTING VEHICULAR MOVEMENT ON THE SERVICE AND PRESENTS THOSE IMAGES ON A TOWER DISPLAY. THE LOGIC IN THE SYSTEM CRITICS A POTENTIAL COLLISION ON A RUNWAY TASTE ON THE CURRENT AND PROJECTED MOVEMENT OF AN AIRCRAFT OR VEHICLE. WHEN THE SYSTEM PREDICTS A POTENTIAL COLLISION ON A RUNWAY, IT PRODUCES A VISUAL AND OUR OLD ALERT TO THE CONTROLLER. WHEN AN ALERT IS ACTIVATED, THE CONTROLLER MUST IMMEDIATELY ASSESS THE SITUATION AND THEN TAKE APPROPRIATE ACTION. THE ASDE SYSTEM WAS NOT DESIGNED TO PREDICT A TAXIWAY LANDING. THEREFORE, THE SYSTEM WORKED AS DESIGNED A DID NOT PRODUCE AN ALERT. IN MARCH 2011, THE NTSB RECOMMENDED THAT THE FAA PERFORMED A TECHNICAL REVIEW OF THE ASDE SYSTEM TO DETERMINE IF THE CAPABILITY EXISTED TO DETECT TAXIWAY LANDINGS. THAT RECOMMENDATION SPECIFICALLY REFERRED TO ONE OF THE THREE ASDE SYSTEMS, THE ASDE MODEL X. NTSB ALSO RECOMMENDED THAT THE FAA GIVE FEASIBLE MODIFICATIONS TO THE ASDE TO PROVIDE ALERTS TO THE CONTROLLERS. THE FAA DID NOT PERFORM TECHNICAL REVIEW. YET THEY DETERMINED THAT THE PERFORMANCE TRADE-OFF WOULD OUTWEIGH THE SAFETY BENEFITS OF PROVIDING RECOMMENDED CAPABILITIES. IN SEPTEMBER 2011, THE NTSB CLASSIFIED BOTH RECOMMENDATIONS AS CLOSED, AND ACCEPTABLE ACTION. IN THIS INCIDENT, HAD THE SAN FRANCISCO ASDE SYSTEM BEEN CAPABLE OF DETECTING A TAXIWAY LANDING, VISUAL AND AURAL ALERTS COULD HAVE ASSISTED THE CONTROLLER AND IDENTIFYING THE POTENTIAL TAXIWAY LANDING. AS THE TIME THAT THE RECOMMENDATIONS WERE CLOSED, THE FAA HAS DEVELOPED TAXIWAY ARRIVAL PREDATION SOFTWARE AND CONDUCTED TESTS TO DETERMINE IF THE ASDE X COULD PRODUCE -- PREDICT TAXIWAY LANDINGS. RESULTS SHOWED THAT THE SYSTEM WAS ABLE TO PREDICT TAXIWAY LANDINGS AND PROVIDE VISUAL AURAL ALERTS THE CONTROLLERS WHEN THE AIRCRAFT WAS WITHIN 20 SECONDS OR 3000 FEET OF LANDING ON A TAXIWAY. IN MAY 2018, THE ASDE X AT SEATTLE WAS ENHANCED WITH THE TAXIWAY ARRIVAL REDUCTION CAPABILITY. THE FFA IS EVALUATING OTHER AIRPORTS. STAFF IS PROPOSING A RECOMMENDATION TO THE FAA TO MODIFY ALL ASDE SYSTEMS AT THOSE LOCATIONS WHERE THE SYSTEM COULD DETECT POTENTIAL TAXIWAY LANDINGS AND PROVIDE ALERTS TO AIR TRAFFIC CONTROLLERS ABOUT POTENTIAL COLLISION RISK. THIS CONCLUDES MY PRESENTATION.

THANK YOU. STAFF'S INVESTIGATION CONCLUDED THAT THE CREW LAND TO LAND AT 28 BUT THEIR LACK OF AWARENESS THAT 28 LEFT WAS CLOSED LED THEM TO MISIDENTIFY TAXIWAY C AS RUNWAY RIGHT. THEIR EXPECTATION BIAS, THE EFFECTS OF FATIGUE ON AN OVERNIGHT FLIGHT, AND A BREAKDOWN IN THEIR CREW RESOURCE IS MEANT ALL COUNTRIES IT -- ALL CONTRIBUTED TO THE MISIDENTIFICATION. HOW CAN WE PREVENT AN EVENT LIKE THIS FROM HAPPENING AGAIN? STAFF HAS PROPOSED RECOMMENDATIONS TO DEVELOP A SOLUTION TO AUTOTUNE THE BACKUP NAVIGATION AIDS, TO BETTER PRESENT AND PRIORITIZE INFORMATION AND FLIGHT RECEIVED -- RELIEF PACKAGES, AND DEVELOP WARNINGS TO PILOTS AND CONTROL TOWER PERSONNEL WHEN AN APPROACHING AIRPLANE IS NOT ALIGNED WITH THE CORRECT RUNWAY. IN A VISION, WE PROPOSE A RECOMMENDATION TO TRANSPORT CANADA TO BETTER COMBAT FATIGUE FOR PILOTS WERE CALLED UP FROM RESERVE DUTY AND ASK TO FLY OVERNIGHT FLIGHTS. THAT CONCLUDES OUR PRESENTATIONS, AND WE WELCOME YOUR DISCUSSION ON THE DRAFT REPORT. CHAIRMAN SUMWALT: THANK YOU, AND TO THE ENTIRE STAFF OF AVIATION SAFETY. VERY, VERY RELEVANT REPORT AND I THINK THE RECOMMENDATIONS, IF ADOPTED, WILL GO A LONG WAY TOWARDS IMPROVING SAFETY. WE WILL NOW TURN TO BOARD MEMBER QUESTIONS. VICE CHAIR LANDSBERG: THANK YOU, MR. CHAIRMAN. IT IS AMAZING TO ME THAT IN 20 WE GOT THIS CLOSE. WE HAVE BEEN FLYING AIRPLANES FOR A LONG TIME, AND THIS IS PERHAPS A CLASSIC INDICATION OF THE ACCIDENT CHAIN OF LINK AFTER LINK AFTER LINK, GETTING US EVER CLOSER UNTIL JUST AT THE VERY LAST MINUTE, YOU COULD PROBABLY GET DIFFERENT OPINIONS ON WHAT EXACTLY BROKE THE CHAIN. WE COULD NOT HAVE GOTTEN LITERALLY OR FIGURATIVELY ANY CLOSER TO HAVING A MAJOR DISASTER. I THINK THIS MAY BE SELF-EVIDENT EVIDENT, BUT I WILL ASK THE QUESTION ANYWAY. HAVING TO DO WITH NOTICE AND SO FORTH. IT SEEMS LIKE THERE IS A GREATER INTEREST IN MAKING SURE THAT NOTHING, REGARDLESS OF ITS IMPORTANCE, IS LEFT OUT AS OPPOSED TO MAKING SURE THAT CRITICAL ITEMS ARE HIGHLIGHTED. AS ONE FORMER ASSOCIATE ADMINISTRATOR OF SAFETY SAID, IF EVERYTHING IS IMPORTANT, NOTHING IS IMPORTANT, AND THIS IS NOT A NEW PROBLEM. THIS HAS BEEN GOING ON FOR AT LEAST TWO DECADES. OUR AVIATION SAFETY REPORTING SYSTEM HAS HAD ANY REPORTS OF POOR USER FRIENDLINESS ON THE PART OF THE SYSTEM FOR BOTH THE AIR CARRIER AND GENERAL AVIATION OPERATIONS. CAPTAIN, APPROXIMATELY HOW MANY -- WERE PROVIDED TO THIS CREW IN THEIR PREDEPARTURE PACKAGE AND ON THEIR -- YOU HAVE ANY IDEA?

ON THEIR PREDEPARTURE, THEIR FLIGHT RELEASE PACKAGE FROM THE GROUP HAD ABOUT THREE PAGES FOR SAN FRANCIS HEIL, BUT THAT INCLUDED FIVE OTHER -- SAN FRANCISCO, BED THAT INCLUDED FIVE -- BUT THAT INCLUDED FIVE OTHER PAGES. VICE CHAIR LANDSBERG: AND THE REALLY CRITICAL ONE, WHICH I WOULD CONSIDER RUNWAY CLOSED, THAT WOULD NOT BE HIGHLIGHTED IN ANY WAY?

WHEN THE PRESENTATION OCCURRED, SHE HAD A SPOT THAT SHOWED AIR CANADA ON THE FLIGHT RELEASE ACTUALLY PUT A RED ASTERISK WITH THE TERM NEW BESIDE EACH RUNWAY CLOSURE TO MAKE IT STAND OUT A LITTLE BIT MORE, WHICH HAS HER PRESENTATION SHOWED, WAS ON PAGE 8. VICE CHAIR LANDSBERG: OK, SAID THAT SOUNDS LIKE IT WAS NOT CONSIDERED THAT CRITICAL, BUT THEY WOULD DO SOMETHING THERE. THE RED ASTERISKS, BUT NOT REALLY HIGH UP. HAVE WE BEEN ABLE TO DETERMINE IF THE RUNWAY THEY WOULD DO SOMETHING THERE. CLOSURE SYMBOL, THE FLASHING X, WAS VISIBLE TO THE FLIGHT CREW AT ANY POINT AS THEY WERE ON THE APPROACH? WE HAVET TWO PARALLEL RUNWAYS IN CLOSE PROXIMITY TO EACH OTHER. I'M CURIOUS WHERE THE CREW -- IF IT WOULD HAVE BEEN POSSIBLE FOR THEM TO HAVE SEEN THAT.

WHEN WE INTERVIEWED THE CREW, THEY MADE NO MENTION OF SEEING ANYTHING OFF TO THE LEFT SIDE OF WHAT WE KNOW WAS 28 RIGHT. THEY SAID IT WAS DARK, SO WE DO NOT KNOW IF THEY ACTUALLY SAW THE LIGHTED X. VICE CHAIR LANDSBERG: OK. ANOTHER POINT THAT HAS BEEN WELL MADE, I THINK WE NEED A NEW ACRONYM, HCT, AND THAT WOULD BE HUMAN CIRCADIAN TIME, THE FACT THAT THEY WERE OPERATING AT 3:00 IN THE MORNING THEIR TIME AND THAT THE CAPTAIN WAS AWAKE FOR 19 HOURS. IT IS JUST AMAZING TO ME THAT IN TODAY'S ENVIRONMENT AND IN AS MANY TIMES THAT WE ON THIS BOARD HAS MADE A STATEMENT OF THE FATIGUE ACROSS ALL MODES, AND THEN SOMEHOW THESE THINGS CONTINUE TO HAPPEN IS JUST AMAZING, AND FOR RESERVE PILOTS TO BE ON DUTY FOR THAT LONG IS JUST NUTS. THAT IS A TECHNICAL TERM. NO FURTHER QUESTIONS. CHAIRMAN SUMWALT: THANK YOU. I WILL NOTE ON THAT IN A FEW MINUTES. MEMBER WEENER? MEMBER WEENER: THANK YOU. I WOULD LIKE TO EXPLORE THE PROCESS OF PASSING INFORMATION ABOUT THE SITUATION IN THE OVERFLIGHT. ONE OF THE REASONS WE DO NOT HAVE A CDR IS IT WAS NOT RECOGNIZED BY THE RIGHT PEOPLE. WITHIN TWO HOURS, THE CDR RAN OUT. HAD THE SERIOUSNESS OF THE SITUATION BEEN RECOGNIZED, THEY WOULD HAVE PULLED THE CIRCUIT BREAKER AND IT WOULD HAVE SAVED THE CDR. WE WOULD HAVE KNOWN A LOT MORE ON THE FLIGHT DECK IF WE HAD THAT. HYPOTHETICALLY, IF A CONTROLLER IS WORKING ALONE AND BECOMES AWARE OF A NEAR CANISTER CAP EVENT SUCH AS A COLLISION WITH MULTIPLE AIRPLANES IN THIS CASE, WHAT OBLIGATION DOES A CONTROLLER HAVE TO REPORT THIS EVENT, MEANING HOW SOON MUST IT BE REPORTED AND TO WHOM?

AIR TRAFFIC CONTROL LER WAS REQUIRED TO THEM IN A MANDATORY REPORT, THAT HAS TO BE DONE NO LATER THAN THE END OF THE SHIFT. THEY USUALLY SUBMIT THAT INTO THE SYSTEM, WHICH THEN IT WILL GO UP THE CHAIN, AND IN THIS CASE, THAT IS WHEN THE SUPERVISOR CAME IN THAT MORNING, AT THE END OF THE SHIFT, THEY REVIEWED THE REPLAYS, AND THEN IT STARTED GOING FORWARD WHEN THEY FOUND OUT THE SEVERITY. MEMBER WEENER: SO NO MATTER WHAT THE SERIOUSNESS OF THE SITUATION IS?

NO, SIR. IT FALLS UNDER THAT CATEGORY OF AIRCRAFT ATTEMPTED TO LAND ON A SURFACE ON AN AIRPORT, THE SEVERITY DOES NOT PLAY INTO IT AT THAT POINT. HE DID NOT UNDERSTAND THE SEVERITY AT THAT POINT, THE CONTROLLER. MEMBER WEENER: PART OF THE REASON WE HAVE SUCH A AIRLINE OPERATION IS BECAUSE OF THE ROOM PORTING CULTURE -- THE RECORDING CULTURE AND SO FORTH. WHAT ABOUT THE PILOT'S RESPONSIBILITY, THE FLIGHT CREW'S RESPONSIBILITY, TO REPORT A SITUATION LIKE THIS?

IN AIR CANADA'S MANUALS, THEY HAVEN'T SPECIFIED, 47 EVENTS IN WHICH THEY NEED TO REPORT, OF WHICH A SELECT FEW NEED TO BE REPORTED IMMEDIATELY. HOWEVER IN THIS EVENT, THE CREW CONSIDERED IT A GO AROUND, AND SOMETHING THAT HAS TO BE REPORTED UNDER THEIR GUIDANCE AS SOON AS POSSIBLE. AND THAT IS WHAT THE CREW HAD DONE THE NEXT DAY, WHEN THEY FILE THEIR AIR SAFETY REPORT. MEMBER WEENER: AND GOING INTO THE DOCKET, IT'S LOOKS LIKE THE CONTROLLER WAS PRETTY SHOOK UP ABOUT IT AS WELL AS THE PILOTS. WE TALKED TO THEM ON THE PHONE. THEY WERE PRETTY SHOOK UP ABOUT IT, WHICH SEEMS TO BE DIFFERENT FROM SOMETHING THAT WAS JUST CASUALLY REPORTED MANY HOURS LATER. DO WE HAVE ANY UNDERSTANDING OF WHY THE PILOTS TENDED TO MINIMIZE THE SITUATION?

WE DID NOT THINK THAT THEY MINIMIZED THE SITUATION AT THIS POINT. THE EVIDENCE THAT WE HAVE REGARDING THEIR KNOWLEDGE OF THE EVENT WAS CONSISTENT IN DIFFERENT ASPECTS AS WELL AS CONSISTENT WITH HUMAN PERFORMANCE WHEN IT COMES TO PROCESSING INFORMATION WITHOUT YOUR BRAIN ACTUALLY REALIZING WHAT IT WAS YOU ARE PROCESSING. SO ALL THAT IS PRETTY CONSISTENT. BOTH THE CONTROLLER DID STATE IN THE INTERVIEW THAT HE FELT THAT THE CREW OR THE CAPTAIN WAS SHAKEN, BUT OUT OF CONST TEXT -- CONTEXT, WE DO NOT WANT TO PUT ANY ASSUMPTION ON TO WHY. KEEP IN MIND THIS IS A FOREIGN CREW TALKING TO, CALLING SOMEONE IN IT AND AUTHORITY POSITION -- IN AN AND AUTHORITY POSITION, ABOUT LINING UP TO A TAXIWAY. NO ANXIETY WAS CONSIDERED WITH ANY MORE INFORMATION THEY HAD. MEMBER WEENER: OK, LET ME YIELD MY TIME HERE. CHAIRMAN SUMWALT: THANK YOU. DINH-ZARR THANK YOU, AND THANKS TO THE STATS FOR PUTTING TOGETHER THIS INVESTIGATION, ALTHOUGH I KNOW YOU ARE CONFRONTED WITH A LOT OF GAPS IN THE AVAILABLE INFORMATION THAT WOULD HAVE BEEN HELPFUL. GOOD JOB ON THAT. I WANTED TO CLARIFY ON THIS LINE OF QUESTIONING ABOUT THE REPORTING. CAPTAIN ETEC CHER, YOU SAID THAT ERIC CANADA IS HARD TO REPORT ON 47 TYPES OF INCIDENTS AS SOON AS POSSIBLE. WHAT WAS THE MERE FACT THAT IT WAS A GO AROUND IN THIS CASE THAT REQUIRED THE RECORDING -- THE REPORTING? MR. ETCHER: WHEN WE INTERVIEWED THE CRUISE AND PERSONNEL AT AIR CANADA, THEY ALIGNED WITH THE FACT THAT IT WAS BECAUSE IT WAS A GO AROUND THAT IT WAS NOT NEEDED TO BE REPORTED AS SOON AS POSSIBLE. MEMBER DINH-ZARR: AND THAT IS WHY THEY DECIDED TO REPORT IT. IS THERE A DEFINITION GIVEN BY AIR CANADA FOR WHAT AS SOON AS POSSIBLE MEANS? MR. ETCHER: AT THE TIME THERE WAS NOT A CLEAR DEFINITION OF IT. SINCE THE EVENT, THEY HAVE REDEFINED AS SOON AS POSSIBLE TO GIVE BETTER CLARIFICATION ON WHAT THAT TERM MEANS. MEMBER DINH-ZARR: THANK YOU, AND WHAT IS IT NOW? THE PILOTS REPORTED IT THE FOLLOWING DAY, IS THAT CORRECT? MR. ETCHER: THAT IS CORRECT, YES, MA'AM, AND NOW THAT IT ACTUALLY SAYS TO CONGRESS PROMPTLY OR AS SOON AS TIME PERMITS -- TO ACCOMPLISH PROMPTLY OR AS SOON AS TIME PERMITS. MEMBER DINH-ZARR: THANK YOU. I THINK WE ARE ALL HUMAN AND MISTAKES HAPPEN, BUT I WAS CURIOUS ABOUT THE TIMING OF THE REPORTING. AND THAT MAY COME IN THE NEXT ROUND. I DO WANT TO ASK ABOUT THE LIGHTING ON THE RUNWAY. LOOKING AT THE PHOTOS COME EVEN AS A NON-PILOT, IT SEEMS THAT TAXIWAY C IS MARKED WITH A GREEN COLOR, BUT I UNDERSTAND THERE'S EDUCATION I.S. AND A LOT OF THINGS THAT CAN COME IN TO PLAY. WILL YOU EXPLAIN TO ME WHY WE SAY IN THE FINDINGS THAT AIRPORT LIGHTING WAS NOT A FACTOR .

ULTIMATELY, IN FINDING ONE, WE SIT AIRPORT LIGHTING WAS NOT A FACTOR, AND THE REASON WE SAY THAT IS BECAUSE THE LIGHTING ITSELF WAS UP TO STANDARD, MET STANDARDS, AND IT WAS ALSO USED PER THE GUIDANCE. HAD APPROACH RUNWAY LIGHTS THAT WERE ON 28 RIGHT, THE LIGHTING FOR THE CLOSED RUNWAY WAS OFF TO AVOID HAVING SOMEONE LAND ON RUNWAY. AND ALSO THE LIGHTING SETTINGS IN THIS CASE WERE CONSISTENT WITH THE REGULATION. SO FOR THIS INCIDENT, EVERYTHING REGARDING AIRPORT LIGHTING MET STANDARDS, AND WHEN IT COMES TO HOW THEY MAY HAVE IMPROVED, THAT IS WHERE THE RECOMMENDATION COMES IN. MEMBER DINH-ZARR: THANK YOU, AND I KNOW THAT STAFF HAS PROPOSED RECOMMENDING THAT FAA CONDUCT HUMAN FACTORS RESEARCH TO DETERMINE HOW TO MAKE A CLOSED RUNWAY MORE CONSPICUOUS. SO WHAT ARE THE CONSIDERATIONS THAT HAVE TO BE TAKEN IN TO ACCOUNT FOR DEVELOPING THIS KIND OF EFFECTIVE LIGHTING?

IT IS TWOFOLD, ONE OF WHICH IS YOUR SIGNALING A CLOSED RUNWAY, SO YOU HAVE TO MAKE SURE THAT YOUR SIGNALS DO SHOW THAT CLEARLY THAT THE RUNWAY IS CLOSED. THE OTHER ASPECT THAT IT CAN PROVIDE IS IF IT IS VISIBLE TO OTHER PARALLEL RUNWAYS, FOR EXAMPLE, THEN YOU PROVIDE THAT SITUATIONAL AWARENESS. IF YOU EXPECT TO SEE TWO SURFACES, WHAT CAN QUEUE ME? THAT IS A RUNWAY, BUT IT IS CLOSED, SO I AM NOT GOING TO WORRY ABOUT ME, BUT IT IS CONSISTENT WITH MY EXPECTATION. SO THERE ARE THINGS YOU WOULD CONSIDER. BIGGEST PICTURE, WHICH IS WHY WE WENT WITH THE RESEARCH RECOMMENDATION, IS YOU HAVE TO IF I WAIT FOR UNINTENDED CONSEQUENCES, AND THERE ARE A LOT OF OPTIONS ON HOW TO IMPROVE THE SYSTEM, AND IT IS RELEVANT THERE FURTHER RESEARCH THERE TO BE ALL-ENCOMPASSING. MEMBER DINH-ZARR: AND THE LIGHTING COULD BE DISTRACTING AS WELL?

YES, THAT WOULD BE AN UNDER THE CONSEQUENCE. -- AN UNINTENDED CONSEQUENCE. THERE IS A LOT OF WORK TO BE DONE FOR AWARENESS ON PARALLEL RUNWAYS. MEMBER DINH-ZARR: THANK YOU. CHAIRMAN SUMWALT: THANK YOU. MEMBER HOMENDY? MEMBER HOMENDY: THANK YOU. THERE HAS BEEN AN ASSERTION THAT THE AIR TRAFFIC CONTROLLER HAD BEEN TASKED SATURATED OR OVERLOADED. I WAS HOPING TO CLEAR THAT UP. YOU'LL HAVE TO FORGIVE ME. I AM NOT ON AVIATION OR MILITARY TIME. I AM ON RAILROAD TIME. SO FOR ME, IT IS AT 11: 55 P.M. AND 45 SECONDS. THE FLIGHT CREW CONTROLLER THOUGHT THEY SAW LIGHTS ON THE RUNWAY. THEY ASKED THE CONTROLLER IF THEY WERE CLEARED TO LAND. HOW LONG DID THE TRANSMISSION TAKE, THE FLIGHT CREW'S PORTION?

IT TOOK THE FLIGHT CREW SIX SECONDS TO SAY THAT. HOMENDY OK, -- MEMBER HOMENDY: SIX SECONDS FOR THE FLIGHT CREW TRANSMISSION TO BE COMPLETED. THEN THE AIR TRAFFIC CONTROLLER RESPONDED IMMEDIATELY --

A SECOND LATER. MEMBER HOMENDY: ONE SECOND. AND THAT TIME, SEVERAL DOCUMENTS SAY THAT THE CONTROLLER IN THAT ONE SECOND DID NOT JUST RESPOND, BUT ALSO CHECKED THE RADAR DISPLAY AND ANOTHER DISPLAY AND RESCANNED THE RUNWAY. IS THAT CORRECT?

AS SOON AS THE PILOT STARTED ASKING THE QUESTION, THE CONTROLLER WILL AUTOMATICALLY LOOK AT THE AIRPLANE. SO HE IS GOING THROUGH HIS PROCESS AT THAT TIME SCANNING AS THE PILOT IS TALKING. MEMBER HOMENDY: OK, SO WAS THERE ANY INDICATION IN YOUR INVESTIGATION THAT THE CONTROLLER AT THIS TIME LOST SITUATIONAL AWARENESS OF AIR CANADA 759 OR SEEM CONFUSED IN ANY WAY?

NO, NO. MEMBER HOMENDY: AND AT THE TIME THERE WAS ONE CONTROLLER IN THE TOWER. AND THE OTHER WAS ON BREAK. WAS IT UNUSUAL TO COMBINE POSITIONS AND HAVE A SINGLE PERSON OPERATIONS IN THE TOWER AT THAT TIME OF DAY?

IT WAS NOT UNUSUAL. MEMBER HOMENDY: DOES FAA ALLOW THAT?

YES, MA'AM. MEMBER HOMENDY: AND FINALLY, TO THE CONTROLLER PROVIDED IN THE INDICATION THAT THE SINGLE PERSON OPERATION EFFECTIVE -- AFFECTED HIS WORKLOAD AT THE TIME OF THE INCIDENT?

NO, MA'AM. MEMBER HOMENDY: GREAT. SINCE I STILL HAVE A LITTLE BIT OF TIME, I HAVE OTHER QUESTIONS THAT I WILL CONTINUE WITH LATER, BUT THE NOTAMS. ON PAGE 8 OF 27, IT WAS UNDER THE HEADER OF RUNWAY, CORRECT? IT WAS NUMBER ONE UNDER RUNWAY HEADING, CORRECT? SO IT WAS NUMBER ONE, BUT THEN YOU HAD IN RED, 1, 2, 3, 4, WITH NUMBER ONE AS THE RUNWAY CLOSURE, CORRECT?

THAT IS CORRECT. MEMBER HOMENDY: OK, AND IT WAS NOT JUST THIS OPPORTUNITY THAT THE FLIGHT CREW HAD TO SEE THAT THERE WAS A RUNWAY CLOSURE AND THEY HAD TO TAKE SOME ACTIONS. ALSO THEY HAD A MESSAGE THAT CAME THROUGH. IS THAT RIGHT?

THAT IS CORRECT. MEMBER HOMENDY: BECAUSE I BROUGHT MY OWN, AND ON THE FOURTH LINE IT TALKS ABOUT RUNWAY 4 WAS CLOSED ON THIS DAY. MY POINT WAS IT WAS NOT JUST ONE OPPORTUNITY AT THE BEGINNING. PREDEPARTURE, IT WAS AGAIN WHILE IT WAS ON THE FLIGHT.

RIGHT, AND NOTE THAT THE CREW DID RECALL REVIEWING NOTAMS. MEMBER HOMENDY: OK, GREAT, AND I WILL HOLD SOME QUESTIONS. CHAIRMAN SUMWALT: THANK YOU AND I SAID IN THE OPENING STATEMENT THAT THIS WAS A VERY CLOSE CALL. I'M NOT SURE WE HAVE HEARD IN THIS BOARD MEETING WHAT STAFF IS ESTIMATING THIS TO BE BETWEEN THE TWO AIRCRAFT. HAVE WE SAID THAT? AND WHAT WOULD THAT DISTANCE BECOME A VERTICALLY SPEAKING?

THE DISTANCES BETWEEN THE AIRCRAFT WAS ABOUT 13 FEET, THAT WE TRIED TO INDICATE THAT IT WAS CLOSE, BUT GIVEN SOME OF THE CHALLENGES, WE WANTED TO JUST GIVE MORE OF AN OVERVIEW AND NOT SO MUCH FOCUS ON THAT DETAIL. CHAIRMAN SUMWALT: THAT IS FINE. I THINK THE REPORT MENTIONED -- BUT IN THE GENERAL SENSE, AND WOULD YOU LIKE TO ADDRESS THAT?

THERE WERE A NUMBER OF DIFFERENT WAYS IT WAS MEASURED. THERE WAS THE ULTIMATE ARE ON BOARD, BUT WE SAY IT WAS BETWEEN 10 AND 20 FEET. CHAIRMAN SUMWALT: THAT IS WHAT I AM LOOKING FOR, THAT IS WHAT THE REPORT SAID, BETWEEN 10 AND 20 FEET. SO, YES, IT WAS A VERY CLOSE CALL. I TELL YOU, I HAVE FLOWN THIS APPROACH LATE AT NIGHT BEFORE. I WILL TELL YOU THAT IT IS A VERY DEMANDING AND HIGH WORKLOAD APPROACH. YOU ARE TRYING TO MAKE CROSSING RESTRICTIONS OF THE RIGHT ALTITUDES. YOU HAVE TO CROSS -- AT ABOUT 8000, AND AT ABOUT 2500, AND THEN THE F101D SIX AT 1200 FEET. YOU HAVE GOT TO MAKE THIS OUT THE DITZ. IF YOU ARE TOO LOW, YOU ARE BELOW THE ALTITUDE YOU SHOULD BE. IT IS IMPORTANT TO BE ON THOSE OUT THE DITZ. -- THOSE OUTAGES. IS THIS RUNWAY -- CAPTAIN ETCHER? MR. ETCHER: THERE IS A FEW DEGREES OFFSET FROM THE RUNWAY FROM THE APPROACH. CHAIRMAN SUMWALT: OK, AND IN ADDITION TO WORKLOAD, YOU ARE COMING IN OVER WATER. IT IS A BLACK HOLE. I REMEMBER LOOKING OUT ABOUT THE SAME TIME OF DAY THIS CREW IS COMING IN THERE, 2:00 OR 3:00 IN THE MORNING ON MY CLOCK AS I AM COMING IN FROM THE EAST COAST. YOU SEE THESE APPROACH LIGHTS IN THE WATER. IT IS EERIE, A TOUGH APPROACH, AND IT IS THE MAIN THING. I CAN UNDERSTAND BASED ON WHAT DR. SILVA IN THE REPORT HAS SAID, I CAN UNDERSTAND HOW THIS ERROR WOULD HAVE A OCCURRED. THE CAPTAIN HAD 20,000 HOURS. THE FIRST OFFICER HAD 10,000 HOURS. BASED ON MY EXPERIENCE AND MY COMBINED 12 YEARS AND SITTING HERE AT THIS DIOCESE, I HAVE, UP WITH TWO SALIENT POINTS. ONE IS THE NOTAMS, THEY DID NOT COMPREHEND THE NOTAMS THAT THE RUNWAY 28 LEFT WAS CLOSE, AND IF THESE HAD BEEN DONE, WE WOULD NOT BE SITTING HERE TODAY TALKING ABOUT THIS TRULY DISTURBING EVENT. BUT THE NOTAMS, THE NOTAM SYSTEM IS REALLY MESSED UP. THEY'RE NOT EIGHT PAGES CAPTAIN ETCHER, THERE ARE 10 PAGES OF NOTAMS FOR THIS RELEASE, AND IT IS ON PAGE 8 OF THE DISPATCH RELEASE, WHICH THEY ARE READING ON AN IPAD. AND THESE NOTAMS, THERE IS ONE ON HERE THAT SAYS -- AND THEY ARE WRITTEN IN SOME KIND OF LANGUAGE THAT ONLY A COMPUTER PROGRAMMER WOULD REALLY UNDERSTAND, BUT THE BOTTOM LINE IS COMING OUT OF TORONTO, TAXIWAY BETWEEN B, B1, AND R, NOT AUTHORIZED TO AIRCRAFT WITH WING SPANS GREATER THAN 200 AND 14 FEET?

I DID NOT FLY THE A320. I WISH I HAD THE SPRINTS YOU DID. CHAIRMAN SUMWALT: IT IS 101 FEET, EIGHT INCHES. WHY IS THAT ON THEIR? THAT IS WHAT NOTAMS ARE, A BUNCH OF GARBAGE. A COUPLE WEEKS AGO, PAGES AND PAGES OF NOTAMS, INCLUDING BIRDS IN THE VICINITY OF THE AIRPORT HIM AND YOU ASK ME, WHENEVER OUR BIRDS NOT IN THE VICINITY OF AN AIRPORT? THESE THINGS COME IF YOU WERE TO READ THEM, EVERY ONE OF THEM, YOU WOULD SPEND AT LEAST 20 MINUTES GOING THROUGH THE NOTAM S. IT IS YOUR TURN.

THANK YOU, CHAIRMAN SUMWALT. YOU HAVE VERY ADEQUATELY DRIVEN THE NAIL IN. WELL, THIS PROBLEM WITH NOTAM S IS NOTHING NEW. THIS HAS BEEN GOING ON FOR A LONG TIME. UNLIKE THE CHAIRMAN, I STILL TAKE TO THE AIR PERIODICALLY, AND MAYBE THEY SHOULD ISSUE A NOTAM WHEN I DO. OPERATING IN A LIGHTER AIRPLANE, WE GET PAGES OF IRRELEVANT MATERIAL. IMPORTANT STUFF GETS BURIED. I WOULD HOPE OUR RECOMMENDATION WILL THOROUGHLY ADDRESS THIS AND MAKE A STRONG CASE. THIS CREW, THEY HAVE HAD A LONG DAY. HAD THEY BEEN AWARE OF WHAT WAS GOING ON, I DO NOT THINK HE WOULD HAVE BEEN THIS HAD THEY THOUGHT TO TUNE THE PRIMARY NAVIGATION SYSTEM, A NORMAL PROCEDURE FOR THIS AIRPLANE AND APPROACH THAT WOULD NOT HAVE HAPPENED EITHER. I HAVE ANOTHER QUESTION HERE. I THINK IT GOES TO MAY BE A BIGGER ONE. IT IS EASY TO SECOND-GUESS MONDAY MORNING QUARTERBACK WHAT THE CREW DID OR DID NOT DO. AND SO FORTH. IT TOOK THEM 16 HOURS TO GET AROUND. THERE WAS NO INDICATION THAT THE CREW WAS AWARE THEY HAD OVERFLOWED N FOUR CARRIERS. HE IS ON THE TAXIWAY. TWO MORE TRANSMISSIONS FROM UNITED AIRLINES SAYING AIR CANADA FLEW OVER US. I FIND IT HARD TO THINK WE WERE JUST OFFSET. ON THE TAXIWAY, THEY STATED THEY HAD TURNED DOWN ALL OF THEIR LIGHTS. THE CONTROLLER SAID HE WAS TRYING TO CALM THE PILOT DOWN. IT IS NATURAL TO FEEL CONCERN OR EMBARRASSMENT FOR HAVING HAD THIS. MY QUESTION AFTER THAT PREAMBLE IS DID YOU GET ANY SENSE FROM THEM THEY WERE AFRAID WE TALK A LOT ABOUT JUST CULTURE AND THE FACT THAT IF YOU SELF IDENTIFY YOU MADE A MISTAKE, AND WE ALL DO, THEY WERE AFRAID THAT IF THEY SAID WE SCREWED UP BIG TIME, WE MISSED SEVERAL THINGS, WE WERE TIRED THAT THEY WERE AFRAID THEY WERE GOING TO GET HAMMERED FOR IT?

DURING THE INTERVIEWS WITH THE CREW AND THE PERSONNEL AIR CANADA QUESTIONS LIKE THAT CAME UP. THEY HAD A COULTER SYSTEM IN PLACE. CREWS COULD FEEL FREE TO STATE THE FACTS AND NOT BE CONCERNED OF MAY BE -- MAYBE DEVASTATING RETRIBUTION. THERE WOULD BE THINGS THEY HAD TO RETRAIN BUT THERE IS NO CONCERN OF POSSIBLE LOSING OF CERTIFICATES OR THEIR JOB.

DR. SILVA, DO YOU HAVE ANY THOUGHTS ON THAT? DR. SILVA: WE DID NOT SEE ANY EVIDENCE DURING OUR VISITS THERE WERE ANY ISSUES. THEY HAD A ROBUST SAFETY PROGRAM AND REPORTING COULTER FROM WHAT WE COULD TELL. WHEN IT COMES TO THE HUMAN PERFORMANCE ASPECT OF THE EVIDENCE YOU STATED EARLIER, AT THE END OF THE DAY WHEN YOU PUT YOURSELF INTO THE CREW PERSPECTIVE, RIGHT AT THE TIME OF THAT WILL AROUND WHEN EVERYTHING PROCESS IN A HIGH STRESS SITUATION , THEY NEVER HEARD ANY COMMENT ON THE FREQUENCY UNTIL THEIR CALLSIGN WAS MENTIONED. AGAIN THAT IS CONSISTENT WITH THE ATTENTION. YOU ARE GOING TO TUNE OUT OTHER TRANSMISSIONS. SO YOU ARE SEEING THE MISSION THE CREW MISSED ARE CONSISTENT WITH THE WAY OF HUMAN PERFORMANCE IN THIS ENVIRONMENT. WHILE IT IS POSSIBLE, WHILE WE KNOW THAT EXISTED TO THEM, IT IS CONCEIVABLE THAT WITH HUMAN LIMITATIONS IT WOULD NOT HAVE ACTUALLY BEEN COMMITTED TO MEMORY.

THANK YOU. MEMBER WEENER: FOR THE ATC TOWER , WHAT INFORMATION IN THE TOWER WAS THERE IN TERMS OF WHERE THE AIRPLANE ACTUALLY WAS? IS THERE INDICATION OF A HEIGHT? OTHERS HAVE THE LATEST SYSTEM AND IT.

YES. AT THAT POINT, NO MONDAY DID NOT KNOW THE HEIGHT ON IT.

BECAUSE HE DID NOT KNOW THE HEIGHT THE CONTROLLER DIDN'T HAVE THE AWARENESS OF HOW SERIOUS THIS EVENT WAS? QUITE SEE DID NOT KNOW THE SEVERITY. HE WAS NOT LOOKING AT THE DISPLAY. HE WAS LOOKING AT THE AIRCRAFT WHICH WAS HIS RESPONSIBILITY. EVEN LOOKING AT IT HE COULD NOT PROCESS THE SEVERITY OF IT. IT WAS HARD TO TELL. IT WAS NIGHT.

SO HE MARKED IT AS NONSIGNIFICANT.

YES. ORIGINALLY.

IT IS AN FMC OR FMS APPROACH. WHAT IS THE FUNCTION OF THE LOCALIZER? IT IS AN FMS APPROACH.

THE LOCALIZER WOULD PROVIDE THE CREW WITH THE GUIDANCE SO THEY DIDN'T CROSS THE CENTER LANE INTO TO WAIT LEFT. THEY WOULD GIVE POSITIONAL AWARENESS TO MAKE SURE THEY WERE ALIGNED WITH THE RUNWAY AS WELL.

BECAUSE THEY ARE INTERSECTING AN 11 DEGREE ANGLE?

ABOUT 11 DEGREES. I CAN'T DO MATH TODAY.

I GET INTO TROUBLE WHEN I DO IT IN PUBLIC.

SO THE LOCALIZER'S ROLE HERE IS TO KEEP THE SPACE FROM GOING THERE BECAUSE THAT IS AS CLOSE AS WE HAVE, IS IT NOT?

I BELIEVE IT IS ONE OF THE CLOSEST, YES.

ON ANOTHER SUBJECT, THEY REPORTED THEY WERE FATIGUED. 19 HOURS SINCE HE HAD TO GIVE THE CAN'T REST, 12 HOURS FOR THE COPILOT. WHAT WAS AIR CANADA'S POLICY ON CALL IT NAPPING?

AIR CANADA DOES HAVE A POLICY FOR CONTROLLED REST IN THE COCKPIT. THEY HAVE PROCEDURES THAT DICTATE HOW LONG A PILOT CAN BE RESTING AND PROCEDURES FOR TRANSFERRING CONTROL OR PILOT MONITORING TO ONE SINGLE PILOT AS WELL AS TRANSFERRING OUT BACK. THEY DO HAVE A POLICY.

WHAT ARE THE RESTRICTIONS IN TERMS OF WHAT PHASE OF FLIGHT THAT CAN BE ACCOMMODATED.

IT WOULD BE IN CREWS.

DID THEY TAKE ADVANTAGE OF THAT POLICY AT ALL?

IN THIS TRIP THEY DID NOT.

I YIELD THE BALANCE OF MY TIME.

DR. SILVA, APOLOGIES FOR USING YOUR INCORRECT TITLE BEFORE. TO GO BACK TO IDENTIFYING THE SEVERITY, IT SEEMS THAT WE WERE -- IT WAS DIFFICULT TO DETERMINE WHO IDENTIFIED THE SEVERITY OF THIS INSTANT. IS THAT CORRECT?

THIS DID NOT SIT THE NORMAL REPORTING. IT NEEDED TO BE LOOKED AT BY THE MANAGER, AFTER IT WAS FILED. THEY HAD TO TRY AND ASSESS WHAT INFORMATION THEY HAD. IT WAS NOT READILY AWARE. THEY WERE NOT AWARE OF THE SEVERITY.

THEY EXPLAIN WHY THE SAFETY TRAFFIC DIDN'T IDENTIFY THE SEVERITY. WHY WAS IT THE PILOT DIDN'T IDENTIFY THE SEVERITY? I ASSUME THEY WOULD HAVE REPORTED IT MORE QUICKLY. SINCE IT WAS AS SEVERE AS IT WAS.

AS WAS DISCUSSED, THEY DIDN'T HAVE THE CONVERSATION WITH THE CONTROLLERS AND THEY DID MEET THE FOLLOWING DAY AND DID SIGN A REPORT. WE DON'T HAVE SUFFICIENT DETAIL TO REALLY ASSESS THEM ON A MORE PERSONAL NOTE AS TO THEIR FEELINGS, THEIR ASSESSMENT OF IT BEYOND THE INFORMATION WE HAVE. SO, THE REPORT TRIED TO REFLECT THINGS OF BALANCE BASED ON THE INFORMATION THEY HAVE.

I KNOW THE OTHER AIRCRAFT THAT WERE ON THE TAXIWAY, SOME OF THEM EXPRESSED THEIR CONCERN IN SOME STATEMENTS. IS THERE ANY MANNER FOR OTHER -- THIS IS NOT TO CAST LAME BUT MERELY TO IDENTIFY PERHAPS POTENTIAL SEVERE INCIDENTS, A WAY FOR OTHER PILOTS TO REPORT POTENTIALLY SEVERE INSTANCE SUCH AS THIS? THEY WERE PROBABLY READY TO GET ON THEIR WAY AT THAT POINT BUT IT DID SEEM THAT THERE WAS SOME CONCERN.

THERE ARE ALWAYS WAYS TO AIR CONCERN AND DRAW ATTENTION TO WHAT IS CONCERNING TO THEM, AS FAR AS THE UNITED FLIGHTS. A FEW OF THEM HAD ACTUALLY THE ONES REACH THEIR DESTINATION WHICH WAS SYDNEY AND SINGAPORE ONCE THEY GOT THERE THEY NOTIFIED THEIR COMPANY TO DRAW ATTENTION TO IT SO THE ASAP PROGRAM COULD LOOK INTO IT EVEN CLOSER TO SEE IF SOMETHING NEEDS TO BE DONE.

ALL OF THE REPORTING WOULD BE IN THE COMPANY.

YES, UNDER ASAP IT IS. ASAP IS ALSO DIRECTLY FED TO NASA A SRS DATA. THE COMPANY WOULD TYPICALLY REACH OUT TO AIR TRAFFIC CONTROL TO GET MORE INFORMATION AS THEY GET THEIR INVESTIGATION.

IT DOES SEEM UNFORTUNATE. THE INFORMATION WOULD HAVE PROVIDED MORE EVIDENCE FOR KEY ISSUES. COULD YOU TELL US BRIEFLY WHAT WE MIGHT HAVE BEEN ABLE TO DETERMINE OR OTHER FINDINGS IF THE CBR HADN'T BEEN OVERWRITTEN, IF IT HAD BEEN AVAILABLE?

CBR PROVIDES USEFUL FACTUAL INFORMATION THAT CAN GUIDE THE OTHER GROUP CHAIRMAN, THINGS LIKE CONVERSATIONS INSIDE THE COCKPIT, VERBALIZATIONS OF ACTIONS THE PILOTS MAY BE TAKING. STATE OF THE AIRCRAFT ALERTS THEY MAY HAVE RECEIVED. THINGS LIKE THAT OTHER GROUP MEMBERS CAN USE TO MAKE THEIR ANALYSIS OF WHAT WAS HAPPENING.

IS IT COMMON PRACTICE THIS IS OVERWRITTEN? ALL THE AIRLINES, DO THEY ALL FOLLOW THAT STANDARD OF OVERRIDING?

THE STANDARD IS FOR TWO HOURS. THAT IS PRETTY CONSISTENT.

THANK YOU. CHAIRMAN SUMWALT: THANK YOU. MEMBER HOMENDY: I WANT TO CIRCLE BACK. YOU ANSWERED THIS BEFORE, WAS THE CONTROLLER ABLE TO VISUALLY DISCERN THAT THE FLIGHT WAS ALIGNED WITH THE TAXIWAY INSTEAD OF THE RUNWAY?

NO, HE WAS NOT. MEMBER HOMENDY: THE AIR TRAFFIC CONTROL TOWER, IS EQUIPPED WITH A SYSTEM THAT CONTENT -- CAN TO DETECT IMMINENT COLLISION, BUT CAN THE EXISTING SYSTEM PREDICT AN IMMINENT COLLISION INVOLVING AND ARRIVING AIRPLANE LINED UP WITH THE TAXIWAY?

THE SYSTEM CANDID TACT A POTENTIAL COLLISION ON THE RUNWAY, BUT THAT IS WHAT OUR RECOMMENDATION IS FOR, THAT IT WILL DETECT COLLISIONS ON TAXIWAYS. SEATTLE HAS THAT IMPLEMENTED IN THEIR SYSTEM.

CAN YOU TALK ABOUT THE DIFFERENCE BETWEEN THEM?

THERE ARE DIFFERENT SYSTEMS THE FAA HAS. ASD-3 THE MODEL ACTS -- THE MO DEL X, AND THE ASFC IS THE LATEST VERSION. IT INCORPORATES MORE ABILITIES TOGETHER. IT IS COMPARABLE TO THE A SSC. MEMBER HOMENDY: HAVE THERE BEEN RECOMMENDATIONS?

IN 2011 WE ISSUED A RECOMMENDATION THE FAA DO A REVIEW TO SEE IF IT WAS CAPABLE OF TAXIWAY LANDINGS AND THAT REVIEW DID NOT HAPPEN. THEY DID NOT APPLY THAT CAPABILITY TO THE SYSTEM SO WE CLOSED IT UNACCEPTABLE. MEMBER HOMENDY: UNACCEPTABLE. THAT WAS BASED ON ANOTHER INCIDENT?

YES. OUT OF THE ATLANTA AIRPORT, WE HAD A DELTA THAT LANDED ON A TAXIWAY. MEMBER HOMENDY: HOW DID THE FAA RESPOND? DID THEY RESPOND IN WRITING?

THE FAA WROTE TO US IN THEIR INITIAL RESPONSE AND ESSENTIALLY SAID IT WOULD DEGRADE THE PERFORMANCE TO A LEVEL THAT IT WOULD BE UNSAFE FOR THE INTENDED PURPOSE OF ANY RUNWAY COLLISIONS. WE DID NOT SEE THE DETAILS OF THEIR ANALYSIS SO WE CLOSE IT UNACCEPTABLE BECAUSE IT APPEARED THEY WERE NOT GOING TO DO IT. WE INVITED THEM TO GIVE US DETAILS OF THE ANALYSIS THEY HAD DONE AND WE WOULD RECONSIDER. THEY NEVER TOOK US UP ON THAT. MEMBER HOMENDY: THERE WAS TESTING OF THE SYSTEM THAT NTSB WITNESSED, CORRECT? DID YOU SEE ANY PERFORMANCE DEGRADATION OR EVIDENCE OF THAT?

WE DID NOT. THE TESTING STARTED HAPPENING LAST YEAR. THE TECHNOLOGY HAS ADVANCED CONSIDERABLY SINCE OUR RECOMMENDATION AND I BELIEVE NOW IT IS TO THE POINT THEY CAN -- THE DEGRADATION DOESN'T HAPPEN. 4 DO YOU KNOW -- MEMBER HOMENDY: UNIFORM MANY AIRPORTS ARE EQUIPPED WITH THAT?

35. MEMBER HOMENDY: THANK YOU FOR A MUCH. CHAIRMAN SUMWALT: THANK YOU. THE SMALLER , I'M STILL ON THIS BED FOR THE NOTAMS. CAN YOU ON HIGHLIGHT THAT PART. YOU CAN PULL IT BACK UP AGAIN. THAT IS WHAT IT LOOKS LIKE. ANYBODY CAN SAY IT IS RIGHT THERE. IT SAYS THAT RUNWAY IS CLOSED. THIS IS ONE OF 10 PAGES OF JUNK. THIS HAPPENS NOT TO BE JUNK AREA DID THIS IS SOMETHING YOU NEED TO KNOW. READ THIS TOPLINE TO ME. WHAT DOES THAT MEAN? TELL ME IN ENGLISH WITH THAT MEANS.

YOU ARE PUT ME ON THE SPOT NOW, AREN'T YOU? CHAIRMAN SUMWALT: THEY HAVE TO READ EVERY ONE OF THEM AND COMPREHEND THEM EVERY FLIGHT.

I CAN SEE WHERE IT SAYS SAN FRANCISCO RUNWAY 10, THE PORTION AFTER THAT IS IT IS CLOSE BETWEEN JULY 8 TO JULY 9 AT 1500 ZULU. THE GLARE KEEPS GETTING WORSE.

WHAT ON CURSE -- WHAT ON EARTH IS ZULU? WHAT DOES THAT MEAN? THIS IS A CRUEL LEAVING TORONTO ON EAST COAST TIME. DOES THAT MEAN THAT RUNWAY IS GOING TO BE CLOSE WHEN THEY GET THERE?

IT DOES. YOU HAVE TO SUBTRACT SEVEN YEAR -- SEVEN HOURS. IT IS THAT SIMPLE. SO, ANYWAY. IF I SHOW SOME DISPLEASURE WITH THE NOTAM SYSTEM, IT IS BECAUSE I AM. YOU ARE BEING HELD RESPONSIBLE FOR IT. MOST OF THE TIME 99.9% OF THE TIME IT IS JUST GARBAGE. THE VICE-CHAIRMAN TOLD ME A FEW WEEKS AGO THERE WAS, CONGRESS PASSED A LAW THE FAA WAS SUPPOSED TO DO SOMETHING TO CLEAN UP THIS NOTAM PROCESS. IN 2012. HAS ANY WORK IN DONE ON THAT? TO ANYBODY'S KNOWLEDGE?

THE FAA INFORMED US THERE WERE NO OPEN ITEMS REMAINING FROM THE ISSUES THEY WERE TOLD TO TACKLE IN THE PILOT BILL OF RIGHTS. CHAIRMAN SUMWALT: WE WILL ISSUE SOME RECOMMENDATIONS TODAY, I THINK. WAS THIS THE ONLY CREW THAT HAD PROBLEMS WITH THIS IDENTIFYING THE PROPER RUNWAY ON THAT NIGHT?

THE CREW THAT LANDED PRIOR ALSO HAD STATED THEY HAD DIFFICULTIES. CHAIRMAN SUMWALT: WHAT MADE THE DIFFERENCE BETWEEN THAT LIGHT IN THIS FLIGHT?

THEY CROSS CHECKED THEIR LATERAL GUIDANCE TO VERIFY THEIR POSITION. CHAIRMAN SUMWALT: ANOTHER CREW ALSO NOTICED PROBLEMS WITH THAT. WE KNOW THAT EARLIER THIS IS THE ONLY APPROACH IN THE AIR CANADA DATABASE THAT REQUIRES A MANUAL INJURY -- ENTRY. WHAT HAS AIR CANADA DONE SINCE THEN TO RECTIFY THAT ISSUE?

SINCE THE EVENT AIR CANADA HAS TAKEN STEPS TO ALLOW AIRCREWS TO FLY USING THE COMPUTER GUIDANCE PROGRAM IN AS AN APPROACH. THAT WAY THE RUNWAY, THE AIRCRAFT CAN BE FLOWN ALMOST TO THE THRESHOLD OF THE RUNWAY. CHAIRMAN SUMWALT: SO THEY HAVE RECTIFIED THAT ISSUE. IT WILL GIVE THEM THE LEVERAGE THEY NEED. I ASKED EARLIER IF THIS RUNWAY WAS OFFSET FROM THE FINAL APPROACH. THE FINAL APPROACH ON THE FMS BRIDGE, 275 DEGREES. RUNWAY IS 284 DEGREES. ALSO HAVING A RELUCTANCE TO DO MATH IN PUBLIC, I HAVE PULLED OUT MY CALCULATOR. IT IS A NINE DEGREE OFFSET. IT IS LIKE I SAID, A TOUGH APPROACH. YOU HAVE A LOT GOING ON. VICE-CHAIRMAN?

JUST ONE. ON THE FINDING 14, PAGE 121 WE MAKE THE STATEMENT FLIGHT SAFETY WOULD BE ENHANCED IF ALL AIRPLANES WERE EQUIPPED WITH A COCKPIT SYSTEM THAT IS INDEPENDENT AND DISSIMILAR FROM THE CURRENT IOS BACKUP CAPABILITY. WHAT DATA DO WE HAVE TO SUPPORT THAT? THAT ALL AIRCRAFT , WOULD LEAD TO SIGNIFICANTLY REDUCE THE RISK? I KNOW THERE WAS AN FAA SUMMIT ON THIS TOPIC. THERE WERE SOME DIFFERENCES OF OPINION RELATIVE TO THAT. GENERAL AVIATION IN PARTICULAR WAS IDENTIFIED AS A MODERATE RISK, WHEREAS THE LARGER AIRCRAFT WERE IDENTIFIED AS A SIGNIFICANT RISK. I'M CURIOUS AS TO WHY WE WOULD MAKE ALL-ENCOMPASSING RECOMMENDATION IN THAT REGARD AS OPPOSED TO FOCUSING ON THE AREA WHERE THE PRIMARY RISK IS.

WE LOOK FOR THAT SYSTEM TO BE APPLICABLE TO ALL AIRCRAFT. UPON FURTHER REVIEW A DISCUSSION WITH WARD MEMBERS THAT WE SENSE TO BE AN OVERREACH. WE FOCUSED EFFORTS ON THIS RECOMMENDATION. LOOKING AT THIS INCIDENT, THE POPULATION WERE PASSENGER SITTING ON AIRLINERS. WE TRIED TO SCOPE THIS APPROPRIATELY SO THE THREAT ON THE TAXIWAY ARE COVERED BY THIS RECOMMENDATION.

IT IS STILL A BROAD REACH. WHEN YOU THROW IN CLASS CHARLIE, YOU GOT A LOT OF TERRITORY INCLUDED. I THINK WE CAN HAVE THAT DISCUSSION FURTHER. MEMBER WEENER: IT IS NOT ABOUT NOTAMS. THE AIR CANADA CREW, AS WE TALKED ABOUT, CAME WITHIN 10-20 FEET OF THE AIRCRAFT. THE CREW REPORTED THAT THEY NEVER DISSENTED 500 FEET.

IN THIS CASE THE CREW DID STATE THAT BELIEVE THEY CONDUCTED THE GO AROUND AT 400 FEET, OPERATIONALLY, NOT LOOKING AT THE POSSIBILITY THAT SOME OF THE CUES IN FRONT OF THEM COULD HAVE AFFECTED THEIR PERCEPTION. THAT IS NOT UNHEARD OF.

SO IT HAD NOTHING TO DO WITH THE OUTLYING OF THE TAXIWAY?

THERE WAS NOT AT LIGHTING ON THE TAXIWAY. THE AIRCRAFT ON THREE OF THE AIRCRAFT THAT WERE HOLDING DID HAVE WING SPANS THAT WERE ABOUT THE WIDTH OF THE RIGHT THAT COULD HAVE CREATED AN ILLUSION OF A PARTIAL EDGE PROFILE BUT THERE WERE NO TAXI LIGHTS. MEMBER WEENER: LAST QUESTION, HAVE THE RUNWAY TO THE LEFT BEEN ILLUMINATED, WOULD THAT HAVE LIKELY ELIMINATED THIS MISS LINEUP?

IF THE CREW IDENTIFIED THE RUNWAY IT LIKELY WOULD HAVE ALLEVIATED THE RISK. WHEN IT COMES TO LIGHTING UP A RUNWAY THAT IS CLOSED THERE ARE RISKS ASSOCIATED WITH THAT. THAT IS SOMETHING WE WOULD NOT NECESSARILY ADVOCATE FOR UNLESS THERE WAS RESEARCH TO SUPPORT THAT. MEMBER WEENER: TODAY DO ANY SORT OF RISK ASSESSMENT OF CLOSING A RUNWAY OFF?

AS FAR AS WE KNOW THEY DID NOT.

THANK YOU.

I HAVE NO MORE QUESTIONS. CHAIRMAN SUMWALT: MEMBER HOHMAN MENDY? MEMBER HOMENDY: NUMBER QUESTIONS. -- MEMBER HOMENDY: THE SYSTEM THAT POINT RIGHTED FLIGHT CREWS WITH ADDITIONAL INFORMATION, YOU MENTIONED THAT IN THE FIRST VERSION, IT WAS BROADER. WE HAVE PROPOSED LIMITING IT TO CLASS B AND CLASS C AIRSPACE. IN MY VIEW FOCUSING MORE ON THIS INCIDENT BECAUSE -- CAN YOU DEFINE CLASS A AND CLASS B FOR A SECOND?

I MIGHT BE EASIER TO HANDLE THE DEFINITION OF CLASS A AND CLASS B. THERE IS ALSO, WHEN IT COMES TO THE AIRSPACE, SPECIFIC REQUIREMENTS FOR AIRPLANES TO BE EQUIPPED WITH TWO-WAY RADIO COMMUNICATIONS. CLASS B AND CLASS C AIRSPACE. MEMBER HOMENDY: THAT WOULD BE SAN FRANCISCO.

CORRECT.

YOU HAVE NARROWED THIS A LITTLE MORE TO TAKE INTO ACCOUNT THIS PARTICULAR INCIDENT. THANK YOU. CAN WE GO BACK TO THE REPORTING? I AM WONDERING IF SOMEONE COULD WALK US THROUGH WHAT OCCURRED. THERE MAY BE SOME DISCUSSION OR ASSUMPTION THAT THE CREW KNEW HOW SERIOUS THIS WAS. THERE COULD BE SOME QUESTIONS WITH SOME TRANSCRIPTS BUT I'M NOT SURE WE CAN JUMP TO THAT. THERE ARE OTHER THINGS THAT INDICATE THEY WEREN'T REALLY AWARE OF HOW SERIOUS IT WAS. THEY DID AT ONE POINT, AT LEAST IMMEDIATELY CALLED BACK TO AIR TRAFFIC CONTROL, CORRECT? CAN YOU WALK US THROUGH WHAT HAPPENS ONCE THE LANDING OCCURRED AND THEY WERE BACK AT THE GATE?

THE INCIDENT HAPPENED ON FRIDAY NIGHT JUST BEFORE MIDNIGHT. AFTER THAT THE CREW TALK WITH THE CONTROLLERS AND IN TERMS OF OTHER THINGS THAT WENT ON, SATURDAY, THE FLIGHT DEPARTED WITH ANOTHER CREW. SATURDAY MORNING YOU HAVE THE AIR TRAFFIC MANAGER REVIEW THE TAPE. MIDDAY, ATC SPOKE WITH THE PILOTS ON SATURDAY. THAT IS PRETTY MUCH IT FROM ATC STANDPOINT UNTIL SUNDAY WHEN WE WERE NOTIFIED. FROM THE CREW STANDPOINT, I MENTIONED THEY TALKED WITH THE CONTROLLER ABOUT MIDDAY, WE WERE TOLD THEY MET AND DISCUSSED WHAT HAPPENED, AND LATER SATURDAY DAY FOUND OUT MORE DETAILS. SATURDAY AFTERNOON THEY CALLED THEIR DISPATCH AND SPOKE WITH THEIR DISPATCH. MEMBER HOMENDY: AT SOME POINT THEY FILED A SAFETY REPORT THAT THERE WAS NO WI-FI, CORRECT?

THAT IS CORRECT. SWITCHING GEARS, THERE WAS ANOTHER AIR CANADA INCIDENTS THREE MONTHS AFTER THIS ONE IN OCTOBER AND THEN THERE WAS AN AIR MEXICO INCIDENT AT SFO THREE MONTHS AFTER THAT. DID WE LOOK AT THOSE? WE DIDN'T? OK. THAT BEGS THE QUESTION, IS THERE A PROBLEM AT SFO? IT OCCURRED IN SIX MONTHS.

WE DO NOT HAVE THAT INFORMATION.

CAN YOU DISCUSS -- I'M OVER MY TIME. SORRY ABOUT THAT. CHAIRMAN SUMWALT: WE WILL COME BACK. ONE OF THE OTHER EVENTS IN SAN FRANCISCO WAS NOT CHECKING IN ON THE WRONG FREQUENCY OR SOMETHING LIKE THAT AND THE LANDING WITHOUT LANDING CLEARANCE. SO, I WANT TO ASK ABOUT FATIGUE. YOU HAVE MENTIONED THIS. WE KNOW THAT THE CAPTAIN, THE THIS WAS OPERATING IN THE CAPTAIN'S IN-FLIGHT CREW CIRCADIAN LOW AT 3:00 IN THE MORNING ON HIS BODY CLOCK. IT IS GENERALLY BETWEEN 2:00 AND 6:00 IN THE MORNING. AWAKENING WAS 19 HOURS. WAS THE CAPTAIN RUNNING A CUMULATIVE SLEEP DEBT?

HE DIDN'T INDICATE HE HAD A CUMULATIVE DEBT? CHAIRMAN SUMWALT: DID HE HAVE SLEEP DISORDERS?

NO. TWO OF THE ISSUES WE USUALLY LOOK AT, THE BOXES WERE CHECKED. I DON'T HAVE ANY DOUBT HE WAS FATIGUED. WE BELIEVE THAT MAY HAVE LIKELY AFFECTED HIS PERFORMANCE. EXPLAIN TO WAS. YOU SAID EARLIER SOMETHING ABOUT THE CANADIAN TIME LIMITS. THE CAPTAIN COULD HAVE LEGALLY REMAINED ON DUTY ANOTHER NINE HOURS. HE COULD HAVE BEEN ON DUTY LEGALLY ANOTHER NINE HOURS. CAN YOU EXPLAIN THAT?

ACCORDING TO CANADIAN REGULATIONS, THAT WOULD HAVE BEEN PERMISSIBLE. CHAIRMAN SUMWALT: WHAT THAT HAVE BEEN PERMISSIBLE UNDER THE U.S. REGULATIONS THAT WERE REVISED COMING OUT OF THE AIRCRAFT?

IT WOULD NOT HAVE. CHAIRMAN SUMWALT: IT WOULD NOT HAVE BEEN ALLOWED. WE HAVE RECOMMENDATIONS TO TRANSPORT CANADA PROPOSED TO THEM. THANK YOU. DO WE HAVE ANY CONCERNS THERE WAS ONLY ONE AIR TRAFFIC CONTROLLER THIS EVENING?

NO SIR. CHAIRMAN SUMWALT: MAYBE STAFF DOESN'T BUT I DO. I KNOW THIS IS ALLOWED THAT WHERE IS THE REDUNDANCY IF YOU DON'T HAVE -- IF YOU ONLY HAVE ONE PERSON IN THE TOWER. I'M IN FAVOR OF PEOPLE TAKING RESTS. BUT IT DEFEATS THE PURPOSE OF HAVING TWO PEOPLE ON DUTY IF ONE IS GOING TO BE TAKING A REST FOR THREE HOURS. IT DOES APPEAR THIS CONTROLLER WAS AWFULLY BUSY. WHAT THINGS HAS THE TOWER PUT IN PLACE AS A RESULT OF THIS, THAT THEY ARE NOT GOING TO GO TO A SINGLE TOWER OPERATION UNTIL LATER IN THE EVENING.

YES. THEY HAVE EXTENDED THAT TIME AND PUT IN A STANDARD OPERATING PROCEDURE THEY WOULD NOT BREAK DOWN TO ONE CONTROLLER UNTIL 12:15. CHAIRMAN SUMWALT: I HAVE A QUESTION. WE HAVE DRAFT RECOMMENDATIONS. DRAFT RECOMMENDATIONS TO INCREASE THE CDR TIME TO 25 HOURS. I INTEND TO SUPPORT THAT. WHY DID WE NOT REITERATE RECOMMENDATIONS FOR COCKPIT IMAGE RECORDERS? HAVEN'T WE RECOMMENDED THAT FOR A WHILE? OK. SO, YOU THOUGHT YOU WERE GOING TO GET OFF.

A GOOD QUESTION. AS FAR AS THE VOICE RECORDER, ONE OF THE REASONS THAT IS DRAFTED AS A SEPARATE RECOMMENDATION TO THE BOARD IS IN THIS CASE, 25 HOURS WOULD NOT HAVE CAPTURED THE EVENT. SO IMAGE RECORDER WOULD REQUIRE MORE MEMORY. OBVIOUSLY WE HAVE NOT HAD MUCH LUCK WITH OUR IMAGE RECORDER RECOMMENDATIONS. THEY HAVE BEEN IN PLACE SINCE ROUGHLY 2000. THEY WERE NOT PUT IN THE REPORT. CHAIRMAN SUMWALT: IT WOULD BE AN EASIER LIVE FROM THE 25 HOUR BECAUSE I KO HAS ADOPTED REQUIREMENT FOR AIRCRAFT MANUFACTURED AFTER THE 2021 TRANSPORT CATEGORY AIRPLANES TO HAVE 25 HOURS CVR.

YES. THAT IS CORRECT.

WE WOULD JUST BE ALIGNING WITH THAT. THANKS. WE HAVE MORE QUESTIONS FROM THE BOARD. WOULD YOU LIKE TO CONTINUE THE ROUND OR TAKE A BREAK? OK. WHO HAS ADDITIONAL QUESTIONS?

I HAVE AN OBSERVATION.

THAT COUNTS.

RELATIVE TO MEMORY, I BELIEVE YOU CAN BUY MULTIPLE TERABYTE DRIVES THESE DAYS FOR UNDER $100. SO I GUESS I AM CURIOUS AS TO WHY THIS SEEMS TO BE A TECHNICAL PROBLEM. I SUSPECT IT IS SOMETHING OTHER THAN A TECHNICAL PROBLEM. RELATIVE TO AIR TRAFFIC AND THE SINGLE CONTROLLER IN THE TOWER, THIS SOUNDS A LOT LIKE THE PROBLEM WE HAD IN LEXINGTON WITH THE COMAIR FLIGHT TAKING OFF ON THE WRONG RUNWAY, WHETHER THAT WAS NECESSARILY THE CASE HERE, THERE IS A LOT OF SIMILARITIES. I WAS HOPING WE WOULD HAVE HAD THAT PLUGGED BY NOW. WHEN CONTROLLERS GET DIZZY. WE HAVE FRIENDS WHO ARE CONTROLLERS AND BY THEIR MINDSET THEY ARE TYPE A PERSONALITIES AND THEY SAY BRING IT, I CAN HANDLE IT, I CAN HANDLE IT, UNTIL I CAN'T. I THINK THERE WAS A SIGNIFICANT TIME LAG FROM THE TIME THERE WAS A QUESTION VOICED UNTIL A RESPONSE CAME BACK WHICH COULD HAVE BEEN CRITICAL. ANY OBSERVATIONS ON THAT?

AS MENTIONED EARLIER WE HAD A CREW THAT QUESTIONED ATC AND THAT TRANSMISSION TOOK SIX SECONDS. THE CONTROLLER RESPONDED WITHIN ONE SECOND. THAT IS ACCEPTABLE.

THERE WAS SOMETHING IN THE REPORT ABOUT SOMETHING THAT CAME UP, THAT WAS A 32ND DELAY. WHEN YOU ARE MOVING AT 160 KNOTS ON FINAL APPROACH, YOUR COMMENT -- COVERING A LOT OF GROUND. THAT IS WHAT I'M CURIOUS ABOUT. I WILL FIND IT.

THE DELAY THAT WE MENTIONED IN THE REPORT WHICH IS RELEVANT TO OUR FINDING, SPECIFICALLY ABOUT FREQUENCY CONGESTION, THIS IS A PERCEIVED FREQUENCY CONGESTION. WE DEALT NO WIN THE CAPTAIN NOTICE LIGHTS ON THE RUNWAY. IF WE HAD CVR IT IS POSSIBLE HE WOULD HAVE MORE CERTAINTY. WE HAD A RANGE AND CALCULATED THE TIME IT TOOK FROM THE CREW , THE FIRST OFFICER SAID HE BELIEVED IT HAPPENED BEFORE 600 FEET. THEY LOOKED AT AIR TRAFFIC CONTROL RECORDINGS FROM THAT POINT ON. WE DO NOT HAVE A RECORDING OF WHAT WAS TRANSMITTED ON TOWER FREQUENCY. WE ONLY HAVE WHAT THE CONTROLLER HEARD. IT WOULD HAVE BEEN OCCURRING ON TOWER FREQUENCY IS THE RESPONSE THAT THE AIR TRAFFIC CONTROLLER MADE. IN THIS CASE, WE REFER TO IT AS A PERCEIVED FREQUENCY CONGESTION BECAUSE PEOPLE CAN ONLY HEAR HALF OF A CONVERSATION. THAT SPECIFICITY IS WHAT THE CREW MENTIONED DELAYED THEIR RESPONSE.

I AM A LITTLE CONFUSED. IF THE CONTROLLER IS HANDLING ALL FREQUENCIES, HE WAS THE SOLE PERSON IN THE TOWER, HANDLING GROUND, LOCAL CONTROL, WHILE DEALING WITH THAT, HE IS GOING TO HAVE ALL OF THOSE FREE SEAS, THE AIRCRAFT ON THE TOWER, THEY ARE ONLY GOING TO HEAR WHAT IS ON THE TOWER FREQUENCY. THEY ARE GOING TO HAVE SILENT WHERE OTHER STUFF IS GOING ON, BUT THEY ARE NOT GETTING A RESPONSE. IT IS ALMOST A DISTINCTION WITHOUT A DIFFERENCE. I AM NOT ARTICULATING THIS WELL. I HAVE SEEN THIS BEFORE WHERE YOU ARE TRYING TO GET A RESPONSE , AND YOU CAN'T GET A WORD IN EDGEWISE FOR THE CONTROLLER IS DISTRACTED ON ANOTHER FREQUENCY YOU CAN'T HEAR. MEMBER WEENER: I WOULD LIKE TO CIRCLE BACK TO THE QUESTION ABOUT WHEN WAS IT RECOGNIZED, WHO RECOGNIZED THE SERIOUSNESS OF THE INCIDENT? WHEN DID THEY KNOW IT AND WHO KNEW IT?



WHEN THE TRANSMISSIONS WERE MADE BY THE UNITED CREW, CERTAINLY THAT CAUGHT THE ATTENTION OF THE CONTROLLER AND ALSO SUBSEQUENT TO THAT, I BELIEVE THAT IS WHAT MADE IT SAME MORE URGENT OR CRITICAL. I THINK THE CREW SAYING THAT HE IS BASICALLY LINED UP ON THE TAXIWAY AND THEN THAT HE FLEW OVER BROUGHT ABOUT THE SERIOUSNESS OF THAT AND THEN THAT CAUGHT THE CONTROLLER'S ATTENTION, AND THAT BROUGHT ABOUT FURTHER ACTIVITY IN TERMS OF SPEAKING TO THE CREW AFTERWARDS. I BELIEVE WHAT REALLY CAUGHT THE ATTENTION AND BROUGHT IT TO THE FOREFRONT WAS THE STATEMENTS FROM THE CREW THAT WERE SITTING ON THE GROUND. MEMBER WEENER: SO AFTER THAT RECOMMENDED -- RECOGNITION, WAS THE AIR CANADA THE NEXT ORGANIZATION NOTIFIED OF THE SERIOUSNESS OF IT?

I AM NOT SURE WE UNDERSTAND YOUR QUESTION. MEMBER WEENER: IT LOOKS LIKE AIR CANADA WAS NOTIFIED BY THE FAA. THEY NOTIFIED TRANSPORTATION SAFETY BOARD OF CANADA, WHICH NOTIFIED NTSB AND THE FAA. IS THAT THE CHAIN OF NOTIFICATION?

THE CHAIN OF NOTIFICATION WAS THE CONTROLLER SPOKE WITH THE CREW, THEN THE CREW SPOKE WITH THEIR COMPANY. WE WERE NOTIFIED ON THE NINTH OF BY THE FAA AFTER THEY REVIEWED THE TAPE AND INFORMED US OF THE EVENT. DOES THAT ANSWER YOUR QUESTION?

I THINK THAT IS FINE. THANK YOU. CHAIRMAN SUMWALT: I'M CONFUSED ABOUT THIS TIME. DR. SILVA. BOTTOM OF PAGE 109, ONTO PAGE 110, IT SAYS, TALKING ABOUT THE TIME, I WILL JUST READ IT. ACCORDING TO THE POST AT INCIDENT INTERVIEWS THE CAPTAIN'S REQUEST FOR THE FIRST OFFICER TO VERIFY WITH THE TOWER CONTROLLER THAT RUNWAY TO A RIGHT WAS CLEAR OCCURRED BETWEEN THE TIME THE AIRPLANE PAST FD OR F 101 D, AND THE TIME THE AIRPLANE REACHED AN ALTITUDE OF 600 FEET. AIRPLANE DESCENDED AT SUCH AND SUCH TIME. THE FLIGHT CREW DID NOT BREAK INTO THE CONVERSATION UNTIL 38 SECONDS LATER. I AM NOT CLEAR ON THIS. IF YOU COULD CLEAR IT UP FOR ME. DR. SILVA: AS WAS WRITTEN IN THE REPORT, WE LOOK AT THE TIME THIS OF THE CREW, THE LATEST TIME THE CREW COULD HAVE NOTICE THAT, 600 FEET, WE TOOK THAT TIME AND COMPARED IT TO THE TIME THEY BROKE IN. THAT IS WHERE THAT 38 SECONDS COMES FROM. WE EVALUATED THE ATC TRANSCRIPT IN THAT TIMEFRAME TO SEE WHAT FREQUENCY CONGESTION EXISTED. IN THAT CASE, THAT SPECIFICALLY IS WHAT WE DISCUSSED IN OUR CONCLUSION. CHAIRMAN SUMWALT: WAS THERE FREQUENCY CONGESTION DURING THAT. 'S -- DURING THAT PERIOD? DR. SILVA: THERE IS PERCEIVED CONGESTION BECAUSE THE AIR CANADA CREW WOULD ONLY HAVE HEARD PARTIAL CONVERSATION ON THE FREQUENCY. CHAIRMAN SUMWALT: WE HAVE THE ATC TRANSCRIPT. WHY AREN'T WE -- SHOULD WE LISTEN TO THE TAPE? WE DID. BASED ON YOUR EXPERIENCE, WAS THERE CONGESTION THE YES OR NO?

YES. CHAIRMAN SUMWALT: THANKS. THAT IS ALL WE WANTED TO KNOW. THAT IS PART OF THE REASON I'M CONCERNED ABOUT ONE CONTROLLER BEING IN THE TOWER. THE TOWER WOULD BE DEALING WITH LOCAL ISSUES. OK. SO REALLY, WHAT I BELIEVE WE ARE DOING HERE IS TAKING -- LOOKING AT MULTIPLE LEVELS OF DEFENSE. MULTIPLE LAYERS OF DEFENSE. IF WE DO WHAT THIS REPORT CALLS FOR WE WILL HAVE NO TAMS PRESENTED IN A MORE SALIENT MANNER. WE WANT PILOTS TO ALWAYS BACK UP PRECISION NAVIGATION AIDS. THE COMPANY SHOULD DO A BETTER JOB WITH PRESENTING THAT INFORMATION AND NOT JUST BEARING IT IN WITH OTHER TEXT. WE WOULD HAVE ONBOARD SYSTEMS, LIKE THE COCKPIT TO ALERT CREWS ON NON-RUNWAY LANDINGS. THE ATC TOWER WOULD HAVE A SYSTEM LIKE IN SDX TO ALERT CONTROLLERS OF SOMETHING LIKE THIS. CONTROLLERS WOULD NOT BE SHORT STAFF TO PREVENT OVERSATURATED CONTROLLERS AND WE WOULD HAVE THAT ARE CONSPICUOUS MARKING TO DENOTE WHEN A RUNWAY IS CLOSED. SO WE WILL TAKE A BREAK. WE WILL BE BACK AT 3:00 -- 3:40. WE ARE IN RECESS. CHAIRMAN SUMWALT: GOOD AFTERNOON. WE WILL GET STARTED HERE IN ONE MINUTE. GOOD AFTERNOON. WE WILL GET STARTED HERE IN ONE MINUTES. CHAIRMAN SUMWALT: WE ARE BACK IN SESSION. IS THERE ANYTHING ELSE COME ANY FURTHER QUESTIONS OR DISCUSSION BEFORE WE MOVE ON TO THE FINDINGS? MR. JONES, IF YOU WOULD READ THE FINDINGS. MR. JONES: THANK YOU. THE RESULT OF THE INVESTIGATION THAT PROPOSES -- STAFF PROPOSES 19 FINDINGS. 1, NONE OF THE FOLLOWING WERE FACTORS, FLIGHT CREW QUALIFICATIONS WHICH WERE IN ACCORDANCE WITH REGULATIONS,, TWO, FLIGHT CREW MEDICAL CONDITIONS, THREE, AIRPLANE MECHANICAL CONDITIONS, LIGHTING, WHICH MET CONDITIONS. RECOMMENDATION TWO, THE INSTRUMENT LANDING PREGNANCY WAS NOT TUNED COME AND CAP DID NOT COMPLY WITH COMPANY PROCEDURES TO VERIFY THE ILS FREQUENCY AND IDENTIFIER FOR THE APPROACH, SO CREW MEMBERS COULD NOT TAKE ADVANTAGE OF THE ILS TO HELP ENSURE PROPER SURFACE ALIGNMENT. THREE, THE CREW'S FAILURE TO MANUALLY TUNE THE ILS FREQUENCY FOR THE PURCHASE OCCURRED BECAUSE THEM FLIGHT INSTANCES THE BRIDGE VISUAL APPROACH WAS THE ONLY APPROACH IN THE A3 20 DATABASE, SO THE MANUAL TUNING WAS NOT A USUAL PROCEDURE FOR THE CREW, AND, TWO, INSTRUCTIONS ON THE APPROACH CHART TO MANUALLY TUNE THE FREQUENCY WAS NOT CONSPICUOUS DURING THE CREW'S REVIEW OF THE CHART. FOUR, THE FIRST OFFICER'S FOCUS ON TASK INSIDE THE COCKPIT AFTER THE AIRPLANE PASSED THE FINAL WEIGHT POINT REDUCE HIS OPPORTUNITY TO MONITOR THE APPROACH AND RECOGNIZE THAT THE AIRPLANE WAS NOT ALIGNED WITH THE INTENDED LANDING RUNWAY. FIVE, THE FLIGHT CREW INITIATED LOW OUT TO GO AROUND OVER THE TAXIWAY PREVENTED A COLLISION BETWEEN THE AIR CANADA AIRPLANE AND ONE OR MORE AIRPLANES ON THE TAXIWAY. SIX, THE CONTROLLER RESPONDED APPROPRIATELY ONCE HE BECAME AWARE OF THE POTENTIAL CONFLICT. SEVEN, ERRORS THAT THE FLIGHT CREW MADE THEM INADEQUATE PREPARATIONS FOR THE APPROACH, AND DELAYED RECOGNITION THAT THE AIRPLANE WAS NOT LINED UP WITH RUNWAY 28 RIGHT REFLECTED BREAKDOWNS INCLUDE -- CREW RESOURCE MANAGEMENT AND LED TO MINIMAL SAFETY MARGINS AS THE OVER -- AS THE AIRPLANE OVERFLEW THE TAXIWAY. 8, THE CREW MEMBERS' PREVIOUS EXPRESS OF SEEING TWO PARALLEL RUNWAYS AT SAN FRANCISCO LED TO THEIR EXPECTATION TO IDENTIFY TWO RUNWAY SURFACES DURING APPROACH AND RESULTED IN THEIR INCORRECT ACTIVATION OF TAXIWAY CHARLIE AS THE INTENDED LANDING RUNWAY. NINE, ALTHOUGH THE NOTICE TO AIRMEN ABOUT THE RUNWAY 28 LEFT CLOSURE APPEARED IN THE FLIGHT RELEASE, THE AIRCRAFT CAN VACATION REPORTING THAT WAS PROVIDED TO THE FLIGHT CREW COME THE PRESENTATION OF THE INFORMATION DID NOT EFFECTIVELY CONVEY THE IMPORTANCE OF THE RUNWAY CLOSURE INFORMATION AND PROMOTE FLIGHT CREW REVIEW AND RETENTION. 10, THE CUES AVAILABLE TO THE MEMBERS TO INDICATE THAT THE AIRPLANE WAS ALIGNED WITH THE TAXIWAY WERE NOT SUFFICIENT TO OVERCOME THEIR BELIEF AS A RESULT OF EXPECTATION BIAS THE TAXIWAY WAS THE INTENDED LANDING RUNWAY. 11, MULTIPLE SALIENT CUES OF THE SURFACE MISALIGNMENT OR PRESENT AS THE AIRPLANE APPROACHED THE AIRPORT SEWALL AND ONE OR MORE OF THESE CUES TRIGGERED THE CAPTAIN'S INITIATION OF A GO AROUND, WHICH REPORTEDLY OCCURRED SIMULTANEOUSLY WITH THE FIRST OFFICER'S CALL FOR A GO AROUND. 12, THE CAPTAIN IN THE FIRST OFFICER WERE FATIGUED DURING THE INCIDENT FLIGHT DUE TO THE NUMBER OF HOURS THAT THEY HAD BEEN CONTINUOUSLY AWAKE, WHICH LIGHTLY CONTRIBUTED TO CREW MEMBERS' MISIDENTIFICATION OF THE LATE INTENDED LANDING SURFACE, THERE ONGOING EXPECTATION BIAS, AND THE DELAY DECISION TO GO AROUND. 13, CURRENT CANADIAN REGULATIONS DO NOT IN SOME CIRCUMSTANCES ALLOW FOR SUFFICIENT REST FOR RESERVED PILOTS, WHICH CAN RESULT IN THESE PILOTS FLYING IN A 15TH STATE DURING THEIR WINDOW OF -- 14, FLIGHT SAFETY WOULD BE ENHANCED IF AIRPLANES LANDING AT PRIMARY AIRPORTS WITHIN CLASS B AND CLASS C AIRSPACE WERE EQUIPPED WITH A SYSTEM THAT PROVIDED FLIGHT CREWS WITH POSITIONAL AWARENESS INFORMATION THAT IS INDEPENDENT OF AND DISSIMILAR FROM THE CURRENT INSTRUMENT LANDING SYSTEM BACKUP CAPABILITIES FOR NAVIGATING TO A RUNWAY. 15 ALTHOUGH THE INVESTIGATION INTO INCIDENT IDENTIFY SIGNIFICANT SAFETY ISSUES, COCKPIT RECORDER INFORMATION, HAD IT BEEN AVAILABLE, COULD HAVE PROVIDED DIRECT EVIDENCE REGARDING THE FLIGHT CREW'S APPROACH PREPARATION, PAINT COORDINATION, RECEPTION OF THE AIRPORT ENVIRONMENT, AND DECISION-MAKING. 16, ONCE THE MEMBERS PERCEIVE LIGHTS ON THE RUNWAY, A CONTACTED THE CONTROLLERS ASK ABOUT THE LIGHTS. HOWEVER, THIS WAS DELAYED BECAUSE OF CONGESTION ON THE TOWER FREQUENCY, WHICH REDUCED THE TIME AVAILABLE FOR THE CREWMEMBERS TO RECONCILE THEIR CONFUSION ABOUT THE LIGHTS OR THE CONTROLLERS CONFIRMATION THAT THE RUNWAY WAS CLEAR. 17, ALTHOUGH THE USE OF LINE UP AND WAIT PROCEDURES DURING SINGLE PERSON AIR TRAFFIC CONTROL OPERATION WAS NOT A FACTOR IN THIS INCIDENT, THE TOWER CONTROLLERS SHOULD HAVE DELAYED CONSOLIDATING LOCAL AND NONLOCAL CONTROL POSITIONS UNTIL THE LINE OF AND WAIT PROCEDURES ARE NO LONGER NEEDED. 18, IF AN AIRPLANE OR TO ALIGN FOR A TAXIWAY, AN AUTOMATED AIRPORT SERVICE DETECTION ALERT WOULD ASSIST CONTROLLERS IN IDENTIFYING AND PREVENTING A POTENTIAL TAXIWAY LANDING AS WELL AS THE POTENTIAL COLLISION WITH AIRCRAFT, VEHICLES, OR OBJECTS POSITION ALONG TAXIWAYS. 19, INCREASED CONSPICUITY OF MARKERS, ESPECIALLY THOSE USING PARALLEL RUNWAY CONFIGURATIONS, WOULD HELP PREVENT RUNWAY MISIDENTIFICATION BY FLIGHT CREWS FOLLOWING APPROACH TO AIRPORT. CHAIRMAN SUMWALT: THANK YOU, MR. DRONES. ARE THERE ANY AMENDMENT S? I THINK THE VICE CHAIRMAN HE HAVE AN AMENDMENT. VICE CHAIR LANDSBERG: NUMBER 14, I'M CONCERNED A LITTLE BIT ABOUT -- CHAIRMAN SUMWALT: IF YOU HAVE A MOMENT, PLEASE MAKE A MOTION. VICE CHAIR LANDSBERG: OK I WOULD PROPOSE THAT IT BE REVISED TO READ AS FOLLOWS -- FIGHT SAFETY WOULD BE ENHANCED IF AIRPLANE WEIGHING MORE THAN 12,500 POUNDS WERE EQUIPPED WITH A COPY SYSTEM THAT COPYRIGHTED CREWS WITH VISUAL AWARENESS INFORMATION THAT IS INDEPENDENT FROM AN DISSIMILAR FROM THE CURRENT BACKUP CAPABILITY FOR NAVIGATING TO A RUNWAY. THAT IS MY MOTION. CHAIRMAN SUMWALT: IT HAS BEEN MOVED IS THERE A SECOND -- IT HAS BEEN MOVED. IS THERE A SECOND QUESTION MARK -- IS THERE A SECOND? DISCUSSION. VICE CHAIR LANDSBERG: THE REASON I AM MAKING THIS, IT SEEMS BROUGHT THAT ALL PLANES LANDING AT CLASS B AND C AIRPORTS, THAT IS A BROAD REQUIREMENT, AND WE HAVE DATA TO SUPPORT THAT? I HAVE NOT SEEN ANY, AND I KNOW IN DISCUSSIONS WITH STAFF, THERE WAS AN ALLUSION TO THE FACT THAT FAA HAD SNEDDON -- HAD MAKE REGULATIONS, BUT I HAD NOT SEEN RON DATA THAT WOULD SUPPORT THIS -- RAW DATA THAT WOULD HAVE SUPPORTED THIS FINDING.

AS I MENTIONED, THIS DISCUSSION ABOUT IS ABOUT RECOMMENDATIONS THREE AND FOUR, SO WE'RE HAVING THAT SAME DISCUSSION. IN RECOMMENDATIONS THREE AND FOUR, STAFF DRAFTED A RECOMMENDATION APPLICABLE TO ALL AIRCRAFT. IT WAS DISCUSSED, AND THE FEEDBACK WE GOT ON THE REPORT WAS THAT WAS AN OVERREACH AND WE NEEDED TO SCOPE THIS TO A MORE APPROPRIATE RELATION THAT DID NOT INCLUDE A PILOT FOR FROM A CESSNA 152 FROM A GRASS STRIP IN KANSAS. OUR EFFORT HAD US WE IDENTIFIED THAT THE RISK WE WERE TRYING TO MITIGATE WAS THAT OF PASSENGERS SITTING IN AIRLINERS ON TAXIWAYS, AND THAT OCCURS AT AIRPORTS WITHIN CLASS B AND C AIRSPACE. SO IF YOU ARE GOING TO BE IN THAT ENVIRONMENT WHERE YOUR MISALIGNED APPROACH COULD POSE A RISK TO PASTOR SITTING ON A TAXIWAY, YOU SHOULD TAKE ADVANTAGE OF THIS NEW TECHNOLOGY. VICE CHAIR LANDSBERG: DON'T AIRLINERS GO TO OTHER AIRPORTS AS WELL TO ME, THAT IS EXPANDING IT VERY BROADLY. THE 152 IN KANSAS IS A BIT OF AN EXTREME CASE. WE HAVE A LOT OF AIRPLANES THAT FLY INTO CLASS B AND C AIRPORTS THAT ARE NOT 152'S AND SO FORTH. I HAPPEN TO KNOW ONE OF THE PILOTS VERY WELL, WHO FLIES INTO BNC AIRPORTS REGULARLY -- B AND C AIRPORTS REGULARLY. I'M LOOKING FOR THE DAY THIS IS A PART OF THIS, WHERE THE REAL MEAT THIS COMES IN IS IN RECOMMENDATIONS THREE AND FOUR. WE WOULD BE GETTING OUT OF SEQUENCE WE JUMPED INTO DISCUSSING THE RECOMMENDATION BEFORE WE GOT TO THE FINDING. CHAIRMAN SUMWALT: MEMBER HOMENDY ? MEMBER HOMENDY: AND I HAVE A COMMENT. FIRST, I WANT TO ASK FOR STAFF'S OPINION ON THIS AMENDMENT. CAN I DO THAT? CHAIRMAN SUMWALT: WE CAN DO THAT. WE WILL DO, SO PLEASE GO AHEAD. MEMBER HOMENDY: I HAVE A CONCERN THAT I SLIPPED THROUGH A VERY LONG 131-PAGE REPORT AND HAVE NOT SEEN IT UP REFERENCE TO 12,500 POUNDS. I DO NOT SEE THE DATA IS ON 12,500 POUNDS, BUT I DO NOT SEE HOW WE CAN MAKE A RECOMMENDATION IS ON 12,500 POUNDS ON THE WEIGHT OF AN AIRPLANE. WHAT I SEE IS THIS INCIDENCE OCCURRED ATSFO, A CLASS B AIRSPACE. CLASS C ALSO HAS THE AIRCRAFT LINED UP, AT IN THIS SITUATION, AND I WANT TO REITERATE YOU HAVE THE POTENTIAL, IF THE CREW DID NOT EXECUTE A GO AROUND OF OVER 1100 AIRPLANE OCCUPANTS COULD HAVE BEEN AFFECTED, GIVEN THE LINEUP ON THE TAXIWAY. SO IT WAS A SERIOUS SITUATION, AND SO WHAT YOU WERE TRYING TO DO WAS TRY TO ADDRESS SOME OF THE BOARD'S CONCERNS ABOUT BEING OVERLY BROAD, BUT FOCUSING ON ONLY ON THESE TYPES OF AIRPORTS. SO AND JUST TO GIVE YOU A SENSE WE ARE NOT TALKING STAFFORD REGIONAL AIRPORT, WHICH IS CLOSE TO ME, BUT WE ARE TALKING CLASS B, SAN FRANCISCO, PHOENIX, RALEIGH-DURHAM, RICHMOND, PORTLAND, WHICH I FLY OUT OF. SO THE RISK HERE IS YOU HAVE SIGNIFICANT AIRPORT OPERATIONS, AT IT SHOULD NOT MATTER THE WEIGHT OF THE AIRCRAFT. THE RISK IS WHAT COULD OCCUR. COULD THIS INCIDENT OCCUR IN ANY OTHER SITUATION, AND IT SHOULD NOT MATTER IF IT IS 12,500 POUNDS, IS IT LESS THAN THAT? I THINK IT IS OUR DUTY TO DETERMINE WHAT HAPPENED, WHY IT HAPPENED, AND PREVENT IT FROM HAPPENING AGAIN REGARDLESS OF THE SIZE OF THE AIRCRAFT. AND SO I HAVE A LOT OF CONCERNS ABOUT THIS AMENDMENT AND THE OTHERS, AND I WOULD JUST ASK, DID YOU ALL LOOK AT, AND I'M SURE HE DID NOT, BECAUSE IT IS NOT IN THE REPORT, ISSUE OF 12,500 POUNDS?

NO, WE DID NOT. MEMBER HOMENDY: THAT CONCLUDES MY CONCERNS THERE. CHAIRMAN SUMWALT: WHAT OTHER CONCERNS TO WE HAVE, OR COMMENTS? MEMBER DINH-ZARR: I WOULD LIKE TO ASK THE VICE CHAIRMAN HIS REASONS FOR PROPOSING THIS AMENDMENT. AND WHY 12,500 POUNDS, SPECIFICALLY VICE CHAIR LANDSBERG: IT IS A CONVOLUTED PATH TO GET HERE, BUT THE POINT I AM TRYING TO MAKE, AND I THINK WE HAVE HAD CONSIDERABLE DISCUSSION ON THIS IS WE HAD VERY LIMITED DATA TO SUPPORT A BROAD-REACHING RECOMMENDATION TO REQUIRE ADDITIONAL EQUIPMENT SEPARATE FROM THE PRIMARY NAV EQUIPMENT THAT IS ALREADY INSTALLED ON VIRTUALLY EVERY AIRPLANE THAT FLIES TODAY AND SO FORTH. I CAN SEE CONSIDERABLE COMPLEXITY OF EXPENSE BEING LEVIED AND RESTRICTIONS ON ALL KINDS OF AIRCRAFT GOING INTO THESE KINDS OF AIR SPACES. THERE IS NO DATA TO SUPPORT THE BASIS THAT THIS IS A PROBLEM. WHATEVER DATA THAT THE FAA HAS GENERATED, AND THERE WAS SOME REFERENCE IN THE REPORT HERE, THAT GENERAL AVIATION WAS RESPONSIBLE FOR 80% OF THE WRONG SURFACE ALIGNMENTS. WHAT THEY FOUND WAS, HOWEVER, WAS THAT THE HIGH RISK ALIGNMENTS, THE ONES WHERE YOU ARE GOING TO HAVE A PROBLEM, ALL HAPPENED WITH LARGER AIRCRAFT. THE SMALL AIRCRAFT WERE NOT IMPLICATED. THAT IS A FACT. AND FAA HAD THAT IN THEIR FINDINGS, AT LEAST IN THE DOCUMENT THAT I WAS ABLE TO FIND, WHICH STAFF, BY THE WAY, WAS IN ABLE -- UNABLE TO BUY. SO I AM LOOKING AT A MEMORANDUM FROM FLIGHT STANDARD SERVICE, SRM REPORT, LANDING SAFETY RISK ASSESSMENTS, AND THEY SAY LIGHT AIRPLANES HAVE A VERY LOW RISK, BECAUSE THE PROBLEMS THAT THEY INCUR ARE IN DAY CONDITIONS, NOT AT LIGHT. THE TWO EXAMPLES WE HAVE HAD MOST EASILY HAVE BEEN LARGE AIRCRAFT, AN AIRBUS, AND THE MOST RECENT ONE WAS A GULFSTREAM 4, 135, AND IN OUR DISCUSSIONS WE HAD A DISCUSSION OF, OK, REQUIRING THIS FOR ALL -- I WOULD ADVISE MEMBER HOMENDY, THAT ALL SIZES FLY INTO CLASS B AND C AIRSPACE IS. IF YOU LEVY THIS REQUIREMENT ACROSS THE BOARD, YOU ARE CREATING A POTENTIALLY SIGNIFICANT PROBLEM WHERE WE HAVE NO DATA TO SUPPORT THAT THERE IS A PROBLEM. MEMBER HOMENDY: THE DOCUMENT YOU REFERENCE SAYS IT IS MEDIUM RISK, AND IT ALSO SAYS IF FAA IMPLEMENTS OTHER SAFETY RECOMMENDATIONS OR INITIATIVES, THAT THEY REVIEW A 7% DECREASE IN WRONG ALIGNMENT LANDINGS. THE FAA PUBLISHED A VIDEO CALLED PILOTS LEARN HOW TO AVOID WRONG SURFACE LANDING, AND DATA SHOWS THAT 85% OF WRONG SERVICE LANDINGS INVOLVE GENERAL 80 AVIATION AND 89% OF THOSE OCCUR IN DAYTIME HOURS. VICE CHAIR LANDSBERG: DO WE KNOW OTHER AIRCRAFT INVOLVED? THAT IS THE POINT. CHAIRMAN SUMWALT: YOU'RE OUT OF ORDER. MEMBER HOMENDY: THE RISK HERE IS NOT -- IT IS NOT THE TYPE OF AIRCRAFT. IT IS THE INCIDENTS THAT COULD OCCUR, AND IN THIS SITUATION, IT WAS A CLASS B AIRSPACE. YOU HAVE THE SAME SITUATION IN CLASS C AIRSPACE. YOU ARE TRYING TO PREVENT A SIMILAR SITUATION, AND THAT IS WHAT WE SHOULD BE ADDRESSING. IT SHOULD NOT BE THE WAY TO THE PLANE, EVEN IF IT IS LESS DATA, BECAUSE IT IS NOT ADDRESSED IN THIS INCIDENT REPORT. SO THANK YOU. CHAIRMAN SUMWALT: YOU KNOW, WE ARE USED TO PLAY THE DEVIL'S ADVOCATE. THERE'S LITTLE DATA TO SUPPORT WHAT STAFF SAID, BUT THERE IS LITTLE DATA TO SUPPORT THE 12,000 POUND THING. I DO NOT BELIEVE THAT THIS AGENCY SHOULD BE CONCERNED WITH A BURDEN TO THE INDUSTRY. THAT SHOULD NOT THE OUR CONCERN. OUR CONCERN SHOULD BE WHAT ARE THE FACTORS IN THIS EVENT, AND WHAT DO WE RECOMMEND TO PREVENT IT. THE FAA HAS THE BURDEN TO DO THE COST-BENEFIT ANALYSIS. THAT IS NOT TO MEAN I DO NOT WANT TO MAKE RECOMMENDATIONS. OUR RECOMMENDATIONS HAVE TO BE PRACTICAL, BUT THE NTSB SHOULD NOT WORRY ABOUT THAT. THE PROBLEM WITH RESTRICTING IT TO B AND C , IS HER NUMBER ON DECEMBER 29, WE HAD A RUNWAY TAXIWAY LANDING AT PULLMAN WASHINGTON, A Q 400. PULLMAN, WASHINGTON, IS NOT A CLASS A AIRPORT. IT IS CLASS C AIRSPACE? I DO NOT THINK IT IS.

WE DO NOT THINK COLEMAN -- PU LLMAN IS, BUT THAT ROUTE SERVICES AIRPORTS WITHIN CLASS B AND C. CHAIRMAN SUMWALT: THE AIRPLANE WOULD HAVE COME FROM SEATTLE OR PORTLAND GOING TO PULLMAN AND BACK, BUT IT LANDED ON A TAXIWAY. AT LEAST THE 12,500 REQUIREMENT WOULD HAVE CAPTURED THAT AIRPLANE, WHEREAS YOU COULD -- WHEREAS IT WOULD NOT -- SO A NON-CLASS B AIRPORT HAS AIR CARRIER TRAFFIC GOING IN AND OUT OF IT. ANYWAY, I THINK YOU WERE PERPLEXED WITH THE POINT I WAS TRYING TO MAKE. THAT IS OK. [INDISCERNIBLE] CHAIRMAN SUMWALT: YES, ABSOLUTELY. WOULD YOU LIKE TO MAKE A STATEMENT?

I THINK GETTING A SENSE OF THE BOARD HERE, AND THE ROOM, I WILL WITHDRAW THE CHANGE. CHAIRMAN SUMWALT: IT HAS BEEN WITHDRAWN. AND MEMBER DI NH-ZARR, YOU SECONDED THAT. ARE THERE ANY OTHER PROPOSED AMENDMENTS? IS THERE A MOTION TO ADOPT THE FINDINGS AS PROPOSED? MEMBER WEENER AND MEMBER DINH-ZARR JUMPED IN. ANY DISCUSSION? NO FURTHER DISCUSSION, ALL IN FAVOR OF ADOPTING THE FINDINGS AS PROPOSED, SIGNAL WITH A HAND AND SAY AYE. OPPOSED, THERE ARE NONE. THE FINDINGS HAVE PASSED UNANIMOUSLY. MR. JONES, WILL YOU PLEASE READ THE RECOMMENDATIONS. MR. JONES: PROBABLE CAUSE. CHAIRMAN SUMWALT: I'M SORRY. MR. JONES: STAFF PROPOSES THE FOLLOWING PROBABLE CAUSE. THE NTSB DETERMINE THE PROBABLE CAUSE OF THIS INCIDENT WAS THE FLIGHT CREW'S MISIDENTIFICATION OF TAXIWAY CHARLIE AS INTENDED LANDING RUNWAY THAT RESULTED FROM THE CREWMEMBERS LACK OF AWARENESS OF THE PARALLEL RUNWAY CLOSURE DUE TO THEIR IN EFFECT OF REVIEW OF NOTICE TO AIRMEN THAT IS NOTAM INFORMATION OVER THE FLIGHT AND DURING THE APPROACH BRIEFING. CONTRIBUTING TO THE INCIDENT WERE, ONE, THE FLIGHT CREW FAILURE TO TUNE THE INCIDENT LANDING SYSTEM FREQUENCY FOR BACKUP LATERAL GUIDANCE, EXPECTATION I.S., FATIGUE -- BIAS, FATIGUE COME AND BREAKDOWNS IN CREW RESOURCE MANAGEMENT, AND TWO, AIR CANADA'S INEFFECTIVE PRESENTATION OF APPROACH PROCEDURE AND NOTAM INFORMATION. CHAIRMAN SUMWALT: MR. JONES, THANK YOU VERY MUCH. ARE THERE ANY AMENDMENTS TO THE PROPOSED PROBABLE CAUSE? SEEING NONE, DO WE HAVE A MOTION? MEMBER HOMENDY MOVES TO ADOPT. IT HAS BEEN SECONDED BY THE VICE CHAIRMAN. ANY DISCUSSION? SEEING NONE, ALL IN FAVOR OF ADOPTING THE PROBABLE CAUSE AS PROPOSED SIGNAL WITH A HAND AND SAY AYE. OPPOSED, THERE ARE NONE. THE MOTION PASSES UNANIMOUSLY. NOW, MR. JONES, IF YOU WILL PLEASE READ THE RECOMMENDATIONS. MR. JONES: AS A RESULT OF THIS INVESTIGATION, STAFF PROPOSES SEVEN NEW RECOMMENDATIONS. SIX RECOMMENDATIONS TO THE FEDERAL AVIATION ADMINISTRATION, ONE, WORK WITH AIR CARRIERS CONDUCTING OPERATIONS UNDER TITLE 14 CODE OF FEDERAL REGULATIONS PART 121 TO ASSESS ALL CHARTED VISUAL PURGES WITH A RECORD BACKUP FREQUENCY TO DETERMINE THE FLIGHT MANAGEMENT SYSTEM OR TUNE IN CAPABILITY WITHIN AN AIR CARRIER'S FLEET. TWO, IDENTIFY THOSE APPROACHES THAT REQUIRE AN UNUSUAL OR ABNORMAL MANUAL FREQUENCY INPUT, AND, THREE, EITHER DEVELOP A SOLUTION OR ENSURE THAT THE MANUAL TO ENTRY HAS SUFFICIENT SALIENCE ON APPROACH CHARTS. TWO, ESTABLISH A GROUP OF EXPERTS TO REVIEW EXISTING METHODS FOR PRESENT FLIGHT OPERATIONS IN PERMISSION TO PILOTS, INCLUDING FLIGHT RELEASES AND GENERAL AVIATION FLIGHT PLANNING SERVICES, AND AIRCRAFT COMMUNICATIONS ADDRESSING AND REPORTING SYSTEM MESSAGES AND OTHER IN-FLIGHT INFORMATION, CREATE AND PUBLISH GUIDANCE ON BEST PRACTICES TO ORGANIZE, PRIORITIZE, AND PREVENT -- PRESENT THIS INFORMATION THAT -- RELEVANT INFORMATION AND WORK WITH AIR CARRIERS AND SERVICE PROVIDERS TO COMPONENT SOLUTIONS THAT ARE ALIGNED WITH THE GUIDANCE. CHAIRMAN SUMWALT: CAN I INTERRUPT FOR A SECOND? IS THAT WHAT EVERYONE ELSE HAS FOUR RECOMMENDATION TWO? THAT IS? OK, THANK YOU. THANK YOU, SORRY TO INTERRUPT. MY READING WAS FALLING BEHIND THERE. SO THANK YOU VERY MUCH. THESE PROCEED. MR. JONES: THREE, ESTABLISH REQUIREMENTS FOR AIRPLANES LANDING AT PRIMARY AIRPORTS WITH CLASS B AND CLASS C AIRPORTS WITH A SYSTEM THAT ALERTS PILOTS WHEN AN AIRPLANE DOES NOT ALIGN WITH A RUNWAY SURFACE. FOUR, COLLABORATE WITH MANUFACTURES TO DEVELOP THE TECHNOLOGY FOR A SYSTEM THAT PROVIDES AN ALERT THE PILOTS AND AIRPLANE IS NOT ALIGNED WITH THE INTENDED RUNWAY SURFACE, AND ONCE SUCH TECHNOLOGY IS AVAILABLE, ESTABLISH A REQUIREMENT FOR THE TECHNOLOGY TO BE INSTALLED ON AIRPLANES LANDING AT PRIMARY AIRPORTS WITHIN CLASS B AND CLASSY AIRSPACE -- CLASS C AIRSPACE. FIVE, MODIFY AIRPORT SERVICE DETECTION EQUIPMENT, ASDE, ASDE 3, AND ASDE -X, AT LOCATIONS WHERE THE SYSTEM COULD DETECT POTENTIAL TAXIWAY LADIES AND PROVIDE ALERTS TO CONTROL ABOUT POTENTIAL COLLISION RISK. SIX, CONDUCT RESEARCH TO DETERMINE HOW TO MAKE A CLOSED RUNWAY MORE CONSPICUOUS THE PILOTS WHEN AT LEAST ONE PARALLEL RUNWAY REMAINS IN USE AND IMPLEMENT A METHOD TO MORE EFFECTIVELY SIGNAL A RUNWAY CLOSURE TO PILOTS DURING GROUND AND FLIGHT OPERATIONS AT NIGHT. ONE RECOMMENDATION TO TRANSPORT CANADA, SEVEN , REVISE CURRENT REGULATIONS TO ADDRESS THE POTENTIAL FOR FATIGUE FOR PILOTS ON RESERVE DUTY WHO ARE CALLED TO OPERATE EVENING FLIGHTS THAT WOULD EXTEND INTO THE PILOT'S WINDOW OF CIRCADIAN LOW. CHAIRMAN SUMWALT: THANK YOU. ARE THERE PROPOSED RECOMMENDATIONS?

I HAVE ONE. CHAIRMAN SUMWALT: YES, SO THIS WILL BE HELPFUL FOR US TO IDENTIFY THAT ONE.

I HAVE AN AMENDMENT TO MY AMENDMENT. THIS WOULD BE FOR RECOMMENDATION NUMBER FOUR, TO INSERT THE WORDS AFTER COLLABORATE WITH MANUFACTURES, "AND SOFTWARE DEVELOPERS," SO WE BROADEN IT OUT A LITTLE BIT SO IT MIGHT NOT JUST BE HARDWARE, THAT COULD BEAT SOFTWARE TO EXISTING EQUIPMENT. WOULD YOU LIKE ME TO READ -- CHAIRMAN SUMWALT: YES, HANG ON JUST A SECOND. PLEASE. I BELIEVE YOU HAVE PASSED THIS ONE OUT, IS THAT CORRECT?

ESSENTIALLY. I MADE A FEW CHANGES TO IT. CHAIRMAN SUMWALT: IF YOU WOULD READ YOUR AMENDMENT. VICE CHAIR LANDSBERG: THE AMENDMENT TO THE AMENDMENT IS COLLABORATING WITH MANUFACTURERS AND SOFTWARE DEVELOPERS TO DEVELOP THE TECHNOLOGY FOR A COCKPIT SYSTEM THAT PROVIDES AN ALERT PILOTS WHEN AN AIRPLANE IS NOT ALIGNED WITH THE INTENDED RUNWAY SERVICE, AND ONCE SUCH TECHNOLOGY IS AVAILABLE, ESTABLISH A REQUIREMENT FOR THE TECHNOLOGY TO BE INSTALLED FOR AIRPLANES AND AIRPORTS WITHIN CLASS B AND CLASS AIRSPACE. THE ONLY CHANGES ADDING SOFTWARE DEVELOPERS. CHAIRMAN SUMWALT: AS A POINT OF ORDER, I DO NOT BELIEVE I HEARD YOU SAY AVIONICS, BUT IT SHOULD SAY COLLABORATE WITH AVIONICS MANUFACTURERS? VICE CHAIR LANDSBERG: THAT IS CORRECT. I AM SORRY. CHAIRMAN SUMWALT: DO WE NEED TO RESTATE THE MOTION? WE DO NOT HAVE A SECOND YET. I WANT TO UNDERSTAND WHAT THE MOTION IS. MEMBER HOMENDY: I WANT TO UNDERSTAND I HAVE THE VERSION THAT SAYS WAITING 12,000 500 -- VICE CHAIR LANDSBERG: STRUCK THAT. MEMBER HOMENDY: IT IS A MOTION -- CHAIRMAN SUMWALT: SECONDED THE MOTION. IT HAS BEEN MADE AND SECONDED TO AMEND RECOMMENDATION 5 -- EXCUSE ME, RECOMMENDATION 4 AS A MOTION BY MEMBER VICE CHAIRMAN LANDSBERG AND SECONDED BY MEMBER DURING THAT MEMBER HOMENDY. -- MEMBER HOMENDY. IS THERE ANY DISCUSSION? IT IS YOUR MOTION, SO WOULD YOU LIKE TO COMMENT ON ANY OF THIS? VICE CHAIR LANDSBERG: THE PURPOSE OF PUTTING THIS IS TO RIDE WITHOUT A LITTLE BIT SO WE DO NOT JUST FOCUS ON THE AIRCRAFT MANUFACTURER, BUT TO THE PEOPLE WHO PROVIDE THE EQUIPMENT, SO THAT WOULD BE AVIONIC, AND BECAUSE WE HAVE A LOT OF EQUIPMENT IN COCKPITS, IT COULD ACTUALLY BE WHAT YOU WANT, COULD BE ACCOMPLISHED STRICTLY BY SOFTWARE, WHICH WOULD MAKE IT MORE AVAILABLE TO EVERYBODY. CHAIRMAN SUMWALT: I'M EXCITED ABOUT THIS, BECAUSE YESTERDAY YOU SAID EVERYBODY WANTS A 10,000 BOX IN AN AIRPLANE, AND NOBODY SAYS IT IS GOING TO BE A BOX. 10 YEARS AGO WE NEVER HEARD OF AN IPAD CAN LOOK AT WHAT WE HAVE NOW. WE HAVE ALL KINDS OF NEAT THINGS THERE. I AM OPTIMISTIC IF WE PUT THIS RECOGNITION OUT THERE, SOMEBODY'S GOING TO JUMP ON IT AND CREATE A VERY LOW COST SOLUTION. THAT CERTAINLY IS WHAT I BELIEVE AND WHAT I HOPE. ANY COMMENTS? WE CERTAINLY WANT TO HEAR FROM STAFF.

THANK YOU. THE ADDITIONAL SOFTWARE DEVELOPERS IS AN INTERESTING ADDITION THAT STAFF CONCURS WITH. THE DRAFT RECOMMENDATION JUST AS MANUFACTURES. THAT INCLUDES AIRPLANE AND AVIONICS MANUFACTURERS. TO JUST CALL UP AVIONICS MANUFACTURERS ILLUMINATES THAT THE AIR FRAMERS HAD A ROLE IN THAT,TOO. COLONIES LIKE BOEING AND AIRBUS ITERATE ALL KINDS OF TECHNOLOGY. ANOTHER SYSTEM IS A GREAT EXAMPLE WHERE A FRAME OR STARTED OUT WITH A CONCEPT OF PROTECTING THE RUNWAY LENGTH AND DEVELOPED WITH AVIONICS TO DEVELOP THOSE CUES. CHAIRMAN SUMWALT: WONDERFUL. VICE CHAIRMAN LANDSBERG I AM WONDERING IF YOU WOULD CONSIDER A FRIENDLY AMENDMENT BASED ON WHAT WE HEARD FROM MR. DELISI TO SAY ALONG THE LINES, AND THIS IS WHAT I'M GOING TO PROPOSE, A FRIENDLY AMENDMENT, COLLABORATE WITH AIRCRAFT AND AVIONICS AND YOU FRACTURES AND SOFTWARE DEVELOPERS -- AND YOU FRACTURES, AND SOFTWARE DEVELOPERS. VICE CHAIR LANDSBERG: THAT WOULD ABSOLUTELY BE ACCEPTED. CHAIRMAN SUMWALT: 10 MEMBER HOMENDY -- AND MEMBER HOMENDY THAT WOULD BE ACCEPTABLE TO YOU. SO ANY FURTHER DISCUSSION? OK, WOULD YOU KINDLY READ THE AMENDMENT AGAIN, AND THEN WE WILL VOTE ON IT. VICE CHAIR LANDSBERG: COLLABORATE WITH AIRFRAME AND AVIONICS MANUFACTURERS AND SOFTWARE DEVELOPERS TO DEVELOP THE TECHNOLOGY FOR A COPY SYSTEM THAT WILL PROVIDE LETTER TO PILOTS WHEN AN AIRPLANE IS NOT ALIGNED WITH A RUNWAY SURFACE, AND ONCE SUCH TECHNOLOGY IS AVAILABLE, ESTABLISHED THE REQUIREMENT FOR THE TECHNOLOGY TO BE REQUIRED HAVE OPERATING AIRPLANES WITHIN CLASS B AND CLASS C AIRSPACE. CHAIRMAN SUMWALT: GO AHEAD.

I THINK IT WAS -- VICE CHAIR LANDSBERG: I AM SORRY. CHAIRMAN SUMWALT: THAT IS THE WORD I INSERTED. I SAW YOU SHAKING YOUR HEADS. GO AHEAD, SIR. MR. DELISI: EITHER WAY IS FINE. AIRPLANE -- CHAIRMAN SUMWALT: MY PREFERENCE WOULD BE AIRCRAFT, BUT THAT MIGHT INCLUDE THAT EXCLUDE AIR HELICOPTERS. WHAT IS YOUR CHOICE OF WORDS? MR. DELISI: I HAVE NO STRONG FEELINGS ON THE TOP. CHAIRMAN SUMWALT: HOW ABOUT IF WE WENT WITH AIRCRAFT? WITH THAT WORK. WILL COLLABORATE WITH AIRCRAFT AND AVIONICS DEVELOPERS AND SOFTWARE DEVELOPERS. ANY FURTHER QUESTIONS NEEDING CLARIFICATION? IT HAS BEEN MOVED AND SECONDED NO FURTHER DISCUSSION, ON PAPER, SIGNAL WITH A HAND AND SAY AYE. OPPOSED? THE MOTION CARRIES UNANIMOUSLY. ARE THERE ANY FURTHER AMENDMENTS?

YES, MR. CHAIRMAN. AS A NEW RECOMMENDATION . I WOULD PROPOSE ESTABLISHING A REQUIREMENT FOR PILOTS OF AIRPLANE WEIGHING MORE THAN 12,500 POUNDS TO REFERENCE ELECTRONIC NAVIGATION GUIDANCE WHEN AVAILABLE, TO IDENTIFY THE CORRECT LANDING SURFACE DURING VISUAL APPROACHES. CHAIRMAN SUMWALT: OK, THERE IS A MOTION. IS THERE A SECOND? I WILL SECOND FOR DISCUSSION. GO AHEAD, SIR. VICE CHAIR LANDSBERG: I AM MAKING THIS MOTION BECAUSE IT IS SELF EVIDENT AFTER THIS INCIDENT THAT REFERENCING ELECTRONIC GUIDANCE WOULD HAVE ELIMINATED THIS PROBLEM IN THE FIRST PLACE. AND ALSO HAVE A PROBLEM WITH MANY PILOTS, WHERE THEY SELECT NOT ONLY THE ROCK SURFACE, BUT THE WRONG AIRPORT. WE HAVE HAD SEVERAL INCIDENTS OF THAT NATURE HERE OF LATE. THIS WOULD BE SIMILAR TO AN ADDITIVE TO THE EXISTING WORDING OF 14 CFR, WHICH IS A REQUIREMENT FOR LARGE AIRCRAFT AND TURBINE-POWERED AIRCRAFT TO COMPLY WITH BROAD SLOPE AND VISUAL GUIDANCE ALONG THE WAY, AND THIS WAS A REQUIREMENT IN AIR CANADA'S FLIGHT OPERATIONS MANUALS, BUT MAYBE THERE IS SOME ADDITIONAL INCENTIVE HERE, THAT IT IS A FEDERAL REGULATION THAT PEOPLE WOULD BE MORE INCLINED TO FOLLOW IT. SO THAT WAS THE LOGIC BEHIND IT. CHAIRMAN SUMWALT: WHEN YOU SAY THE WORD REGULATION, DO YOU MEAN A REGULATION, WHEN WE SAY REQUIREMENT? VICE CHAIR LANDSBERG: YES, SIR. IT MAY TAKE A WHILE TO GET THAT DONE, BUT IT IS A THOUGHT. CHAIRMAN SUMWALT: THERE ARE OTHER WAYS TO DO THAT. OK, ANY FURTHER DISCUSSION? MEMBER HOMENDY: ONCE AGAIN, I HAVE SIGNIFICANT CONCERNS REFERENCING WEIGHING MORE THAN 12,500 POUNDS, BECAUSE AGAIN, I CANNOT SEE ANY DISCUSSION OF THAT OR A VIOLATION OR ANALYSIS BY THE STAFF ON THAT. AND OUR RECOMMENDATIONS ARE WEIGHTED AND WEIGHED VERY CAREFULLY BY THE FAA, AND WHILE OUR MESSAGE THAT MISSION IS SAFETY, AND WE ALSO HAVE TO REALLY SEE WHAT OCCURRED IN A PARTICULAR ACCIDENT OR INCIDENT. AND IN THIS PARTICULAR ACCIDENT OR INCIDENT, THERE WAS NO EVALUATION OF 12,500 POUND AIRPLANES GOING INTO IN THIS CASE A CLASS B AIRSPACE. SO I HAVE CONCERNS ABOUT REFERENCING SOMETHING THAT IS NOT IN OUR REPORT. IN ADDITION, AND JUST A QUESTION, THIS WAS AN ISSUE -- AIR CANADA'S FLIGHT MANAGEMENT SYSTEM REQUIRED TUNING OF THE ILS FREQUENCY COME IS THAT CORRECT -- FREQUENCY, IS THAT CORRECT? AND THIS WAS A SITUATION WHERE THE CREW JUST DID NOT -- IS THAT CORRECT? FROM MY STANDPOINT IT IS A SITUATION THAT THE CREW DID NOT FOLLOW THROUGH WITH WHAT THEY WERE SUPPOSED TO DO TO ENSURE SAFETY, SO -- CHAIRMAN SUMWALT: I AGREE WITH YOU, IT WAS REQUIRED FOR AIR CANADA PILOTS TO DO THAT, AND THEY DID NOT DO THAT EVEN IF THERE WAS A REGULATION FOR THIS, IT WOULD NOT HAVE MADE A DIFFERENCE. THIS WAS A BEST PRACTICE. JUST GETTING EMAILS FROM THE DIRECTOR OF OPERATIONS FOR A MAJOR AIRLINE IN THIS COUNTRY. AND IT IS A BEST PRACTICE WITH ALL AIRLINE TO DO THIS. AND SO BASED ON WHAT MEMBER HOMENDY SAID, I DO NOT THINK THIS WOULD HAVE DONE ANYTHING TO PREVENT THIS EVENT BECAUSE IT WAS REQUIRED AND THE CREW SIMPLY MISSED IT. VICE CHAIR LANDSBERG: I WITHDRAW THE PROPOSED RECOMMENDATION. CHAIRMAN SUMWALT: DID YOU SAY YOU WOULD PROPOSE -- VICE CHAIR LANDSBERG: I PROPOSE TO WITHDRAW ITS, AND I SECONDED IT FOR A FRIENDLY -- WHATEVER -- FOR DISCUSSION, SO I ALSO WOULD ACCEPT THAT. VICE-CHAIRMAN LANDSBERG IS WITHDRAWING HIS MOTION. THANK YOU. AND YOU HAVE ONE MORE AMENDMENT? VICE CHAIR LANDSBERG: NOT AT THIS TIME, SIR. CHAIRMAN SUMWALT: THANK YOU. MAY WE HAVE A MOTION TO ADOPT THE RECOMMENDATIONS AS PROPOSED? IT HAS BEEN PROPOSED BY MEMBER WEENER AND SECONDED BY MEMBER HOMENDY. IT IS GETTING LATE. ARE THERE ANY DISCUSSIONS? SEEING NO DISCUSSION, ALL IN FAVOR OF ADOPTING THE RECOMMENDATIONS AS PROPOSED, PLEASE SIGNAL WITH YOUR HAND AND SAY AYE. THE RECOMMENDATIONS HAVE PASSED UNANIMOUSLY. DOES ANYONE HAVE ANY ADDITIONAL ISSUES FOR DISCUSSION? IS THERE A MOTION TO ADOPT THE REPORT AS PRESENTED?

SO MOVED. CHAIRMAN SUMWALT: IT HAS BEEN MOVED AND SECONDED. ANY DISCUSSION? OK, IT HAS BEEN MOVED AND SECONDED TO ADOPT THE REPORT AS PRESENTED. ALL IN FAVOR, PLEASE SIGNAL WITH A HAND AND SAY AYE. OPPOSED, THERE ARE NONE. THE PROPOSAL HAS BEEN ADOPTED UNANIMOUSLY BY THE NATIONAL TRANSPORTATION SAFETY BOARD. DO ANY NUMBERS WISH TO RESERVE THE RIGHT TO FILE A CONCURRING OR DISSENTING STATEMENT? MEMBER WEENER, MEMBER HOMENDY. ANY OTHERS? VICE CHAIR LANDSBERG: I WOULD LIKE TO AS WELL. CHAIRMAN SUMWALT: MR. VICE CHAIRMAN. WELL, IN CLOSING, I WANT TO THANK MY COLLEAGUES FOR THEIR PREPARATION GOING INTO THIS BOARD MEETING. THE BOARD MEMBERS HAVE MET INDIVIDUALLY WITH THE STAFF OVER THE LAST MONTH TO PRESENT THEIR FEELINGS ABOUT THE REPORT. STAFF REPLIED WITH A VERY LONG, LENGTHY LETTER MEMO TO SAY HOW THE REPORT WOULD WERE NOT BE REVISED. SO I THANK ALL OF MY COLLEAGUES FOR ALL OF YOUR GOOD WORK IT INTO THE MEETING, THE PROFESSION -- PREPARATION, DEBATE, DISCUSSION, AND ON BEHALF OF THE BOARD HIM A SINCERE THANK YOU, NOT ONLY TO THE INVESTIGATIVE STAFF, BUT ALSO TO THE SUPPORT STAFF AND THE PROGRAM STAFF AS WELL. I BELIEVE THE REGULATIONS WITH A DOCTOR DAY IF ACTED UPON WILL IMPROVE INSISTENTLY FOR FLIGHT CREWS AND THE METHODS USED TO AUTOTUNE OR MANUALLY SET LATERAL NAVIGATION DEVICE GUIDANCE IN FLIGHT MANAGEMENT SYSTEMS. THEY ALSO INCLUDE IDENTIFYING BETTER WAYS TO PRESENT PREFLIGHT AND IN FLIGHT INFORMATION ABOUT AIRPORT CONDITIONS AND OTHER RELEVANT DATA. AND THEY INCLUDE ACTIONS TO EXAMINE METHODS TO MORE EFFECTIVELY IDENTIFY CLOSED RUNWAYS. ADDITIONAL REGULATIONS, IF IMPLEMENTED, WOULD RESULT IN SYSTEMS ON AIRCRAFT AND AT AIRPORTS TO ALERT PILOTS AND AIR TRAFFIC CONTROLLERS WHEN AN AIRPLANE IS NOT LINED UP WITH THE RUNWAY. THE INCIDENT THAT WE DISCUSSED TODAY SHOULD DRIVE HOME THE POINT JUST HOW COSTLY A MISTAKE CAN BE. AND WE ALL MAKE MISTAKES. IF TODAY'S REGULATIONS ARE ACTED UPON, WE WILL HAVE TAKEN STEPS TO ENSURE THAT THE CIRCUMSTANCES OF THIS INCIDENT DO NOT HAPPEN AGAIN. WE URGE RECIPIENTS TO ACT ON THESE RECOMMENDATIONS TO FURTHER IMPROVE SAFETY SO THAT WE DO NOT HAVE TO RELEARN THE LESSONS OF THIS INCIDENT AT A FAR GREATER COST. WE STAND ADJOURNED.