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TimeTimeAircraft 1Aircraft 1Aircraft 2Aircraft 2AssessmentsAssessmentsEventsEventsPerson 1PlacePlaceSynopsis
DateLocal Time Of DayFlight PhaseMake Model NameFlight PhaseMake Model NameContributing Factors / SituationsPrimary ProblemAnomaly.ConflictResult.Flight CrewHuman FactorsLocale Reference.AirportLocale Reference.ATC FacilitySynopsis
2011111201-1800CruiseCessna Aircraft Undifferentiated or Other ModelChampion Citabria UndifferentiatedHuman FactorsHuman FactorsNMACCommunication Breakdown, Situational AwarenessOAK.AirportA C162 pilot experienced an NMAC inbound to PAO when he mis-identified ATC issued traffic.
2011110601-1200TaxiB757-200Airport, Chart Or Publication, ProcedureAmbiguousRequested ATC Assistance / ClarificationConfusion, Situational AwarenessSFO.AirportA B757-200 Captain reported a discrepancy between the airport signage and the commercially provided airport page for Taxiways S at SFO. Noting, specifically, that two independent taxiway entrances to Runway 10L are identified as S.
2011110601-1200TakeoffB757-200Commercial Fixed WingHuman FactorsHuman FactorsCommunication Breakdown, Situational AwarenessSFO.AirportAir Carrier departing from SFO on an assigned 040 heading reported confusion regarding ATC's instructions involving them and and a missed approach aircraft.
2011110001-0600LandingB747-400LandingDassault-Breguet Undifferentiated or Other ModelProcedureProcedureOther / UnknownSFO.TowerAir Carrier landing SFO Runway 28L during side-by simultaneous approaches suggested that ATC provide more speed information on parallel traffic when issuing a "do not pass" clearance.
2011110601-1200DescentA320Aircraft, Human Factors, ProcedureHuman FactorsCommunication Breakdown, Situational AwarenessNCT.TRACONNCT Controller described a loss of separation event during SOIA operations when a participating aircraft entered the NTZ and failed to respond to ATC instructions to turn.
2011110601-1200TaxiLight TransportProcedureProcedureCommunication Breakdown, Situational AwarenessSFO.AirportAir Carrier departing SFO being handled by company Ramp Control was questioned by Ground Control regarding ATC communications contact point.
2011111801-2400Final ApproachB757-200Final ApproachLight Transport, Low Wing, 2 Turbojet EngProcedureProcedureAirborne ConflictCommunication BreakdownSFO.TowerSFO Controller voiced concern regarding alleged ambiguous visual separation procedures applied by NCT Controller during simultaneous approaches, listing aircraft passing one another as an example.
2011110601-1200ParkedA321Company Policy, Human Factors, WeatherHuman FactorsCommunication Breakdown, Situational AwarenessSFO.AirportAn A320 Captain refused a flight Release from his Dispatcher that routed them through an area of forecast and reported severe turbulence. The Dispatcher had advocated the original route because it was shorter and burned less fuel.
2011111201-1800Final ApproachB737-800Human Factors, Procedure, WeatherProcedureCommunication Breakdown, Other / Unknown, Situational AwarenessSFO.TowerSFO Tower Controller voiced concern regarding NCT's handling of a simultaneous arrivals to Runways 28L/R during rapidly changing weather conditions, suggesting NCT should have sent the second aircraft around earlier.
2011111201-1800ClimbA320ClimbGulfstream IV/G350/G450Human Factors, ProcedureHuman FactorsSFO.AirportLoss of separation between traffic departing Runway 1 and Runway 28 at SFO when the Runway 1 departure turned early on the OFFSH5 departure.
2011111201-1800Final ApproachLearjet 40Initial ApproachLearjet 60ATC Equipment / Nav Facility / Buildings, Human Factors, ProcedureAmbiguousNMACTook Evasive ActionCommunication BreakdownSFO.TowerLJ40 Captain on approach to Runway 28L at SFO reports a TCAS RA with a LR60 on approach to Runway 28R. Both aircraft were in VMC and the LR60 crew had the LR40 in sight and turned away.
2011110601-1200DescentA320Human Factors, WeatherWeatherTook Evasive ActionSFO.AirportA320 flight crew reports encountering turbulence, which is the subject of a SIGMET. The seatbelt sign is turned on and the flight attendants are asked to be seated prior to encountering moderate turbulence. On a subsequent leg, a Flight Attendant reports that he was injured by this turbulence.
2011101801-2400B757-200Aircraft, ProcedureProcedureAirborne ConflictOther / UnknownSFO.TowerAir Carrier on Visual Approach to SFO Runway 28L experienced a TCAS RA after maneuvering slightly to adjust position with parallel traffic as per Tower instructions.
2011101201-1800Initial ClimbShorts SD-360Initial ClimbB737 Undifferentiated or Other ModelHuman Factors, ProcedureProcedureSituational AwarenessNCT.TRACONNCT Controller described a conflict situation caused by SFO Tower's reported inappropriate utilization of successive departure separation criteria.
2011090601-1200Final ApproachLarge Transport, Low Wing, 2 Turbojet EngEnvironment - Non Weather Related, ProcedureAmbiguousExecuted Go Around / Missed Approach, Returned To ClearanceCommunication Breakdown, Confusion, Distraction, Situational Awareness, WorkloadSFO.AirportAn air carrier pilot reported an unstabilized approach to SFO Runway 28L after getting high on approach, then executing a non-startard Tip Toe approach go-around.
2011091801-2400Final ApproachB737-800Human FactorsHuman FactorsBecame Reoriented, Returned To ClearanceConfusion, Human-Machine InterfaceSFO.AirportA B737-800 flight crew reported confusion on how to properly set up the autoflight system for a visual approach (ILS out of service) to SFO at night. They improperly armed VOR/LOC mode and a track deviation resulted.
2011090601-1200TaxiB757-200Human FactorsHuman FactorsGround Conflict, Less SevereBecame ReorientedCommunication BreakdownSFO.AirportB757 Flight Crew reports being cleared for push back by Ramp Control, only to be countermanded by the maintenance taxi crew of the aircraft passing behind them. Non standard phraseology is used causing some confusion for the reporters.
2011090601-1200Initial ApproachWidebody, Low Wing, 4 Turbojet EngClimbSmall AircraftAirspace Structure, Human Factors, WeatherAmbiguousAirborne ConflictTook Evasive ActionDistraction, Situational AwarenessNCT.TRACONAir Carrier aircraft in IMC on the SFO ILS PRM Runway 28L stopped its descent at 3,000 FT because an unknown aircraft was climbing to 2,300 FT inside the No Transgression Zone and TCAS alerted two TA's.
2011091801-2400Initial ApproachWidebody, Low Wing, 2 Turbojet EngWeatherWeatherRegained Aircraft Control, Took Evasive ActionPhysiological - Other, Situational Awareness, WorkloadNCT.TRACONA heavy jet on the SFO FMS Bridge Visual encountered severe turbulence, a 30 KT speed decrease and a 2,000 FT altitude loss passing the ARCHI waypoint at 8,000 FT.
2011091801-2400Final ApproachB737 Undifferentiated or Other ModelFinal ApproachLearjet 60Human Factors, ProcedureProcedureAirborne ConflictCommunication Breakdown, Situational AwarenessOAK.AirportOAK Tower Controller described a developing conflict between air carrier arrival traffic assigned Runway 29 and an FAA flight check operation to Runway 11, noting lack of internal coordination between positions at NCT.
2011081201-1800Initial ClimbCessna Citation Undifferentiated or Other ModelChart Or Publication, Human Factors, ProcedureHuman FactorsAirborne ConflictBecame ReorientedCommunication Breakdown, Confusion, Human-Machine InterfaceNCT.TRACONA CE-750 flight crew failed to comply with the 2,000 MSL at 4.0 DME restriction on the SKYLINE SID off Runway 29 at OAK. Inappropriate FMS route alterations and distractions from a TA shortly after takeoff may have contributed.
2011080001-0600Final ApproachB767 Undifferentiated or Other ModelFinal ApproachB757 Undifferentiated or Other ModelHuman FactorsHuman FactorsSituational AwarenessNCT.TRACONNCT Controller described a loss of wake separation event on the SFO final when after issuing a go around, radar data indicated the separation was less than required prior to the go around instruction, contrary to PRM Data.
2011080001-0600DescentA340Human Factors, ProcedureProcedureCommunication BreakdownSFO.AirportNCT Controller described a communications failure involving a visual approach clearance, the SFO landing flight crew failing to respond with their "call sign."
2011081201-1800Final ApproachRegional Jet 200 ER/LR (CRJ200)Final ApproachA320Human Factors, ProcedureHuman FactorsAirborne ConflictSituational AwarenessSFO.AirportNCT Controller described a conflict event on the SFO final when traffic assigned a Visual Approach to Runway 28R over flew sighted traffic inbound for Runway 28L, citing pressure to establish side-by's as a causal factor.
2011080001-0600ClimbA320ClimbRegional Jet 200 ER/LR (CRJ200)Human Factors, ProcedureHuman FactorsConfusionSFO.TowerSFO Controller described a near conflict event when traffic departing Runway 1R started a wrong turn toward a Runway 1L aircraft, allegedly due to mis-reading the PDC clearance.
2011081201-1800ClimbPA-28 Cherokee/Archer/Dakota/WarriorChart Or Publication, Human FactorsHuman FactorsConfusionOAK.TowerA PA-28 pilot cleared via the OAK NUEVO 5 Departure, mistakenly flew the "LOST COMMUNICATIONS PROCEDURE ONLY" track instead.
2011081801-2400LandingSkyhawk 172/Cutlass 172Human Factors, ProcedureHuman FactorsCommunication Breakdown, Confusion, Situational AwarenessOAK.TowerOAK Controller described a near loss of separation event between an airport vehicle and a Cessna in the pattern resulting unclear communications between the Tower and the airport vehicle.
2011071201-1800Initial ApproachA320Human FactorsHuman FactorsAirborne ConflictNCT.TRACONAir Carrier being vectored by NCT was not given instructions to turn and intercept the final for Runway 28R causing a conflict with traffic intercepting the Runway 28L final, ATC acknowledged an error on their part.
2011071801-2400TaxiSkyhawk 172/Cutlass 172AirportAirportOther / UnknownSJC.TowerSJC Controller described an unauthorized Runway 29 crossing at Taxiway D, claiming additional signs are necessary to prevent similar events in the future.
2011071801-2400Initial ClimbA320Initial ClimbRegional Jet 200 ER/LR (CRJ200)Human Factors, ProcedureHuman FactorsCommunication Breakdown, Situational AwarenessSFO.TowerSFO Controller described a confused departure event involving two Air Carrier aircraft on parallel tracks of Runways 1L/R, the reporter noting wrong strips were present at the position prompting the confusion.
2011071801-2400TakeoffA320TakeoffAny Unknown or Unlisted Aircraft ManufacturerProcedureProcedureAirborne ConflictOther / UnknownSFO.TowerAir Carrier departure from SFO voiced concern regarding the simultaneous departures from Runway 1L/R, suggesting Tower momentarily delay one of the two departing aircraft.
2011070601-1200ClimbBonanza 33Chart Or Publication, Human FactorsHuman FactorsBecame ReorientedConfusion, Situational AwarenessOAK.AirportA Bonanza pilot, unfamiliar with the government published version of the NUEVO DP from OAK, misinterpreted the Lost Com procedure on the graphic depiction as the initial departure procedure and turned prior to receiving a clearance to do so.
2011061801-2400TaxiA380TakeoffA380Human Factors, ProcedureProcedureDistraction, Situational Awareness, Training / QualificationSFO.TowerSFO Controller reported a possible procedural violation regarding A380 operations on the airport.
2011060001-0600DescentB757 Undifferentiated or Other ModelDescentHeavy TransportATC Equipment / Nav Facility / Buildings, Human Factors, ProcedureProcedureSituational AwarenessSFO.AirportNCT CIC described a loss of separation behind a heavy jet, noting the difficulty of controllers trying to discern 100ths of a mile distinctions when working with the current equipment.
2011060601-1200Initial ApproachB737-700Airspace Structure, Chart Or Publication, Human Factors, ProcedureProcedureCommunication Breakdown, Human-Machine Interface, Training / QualificationOAK.AirportAfter being cleared for the RNAV (RNP) Z Runway 11 approach to OAK, a B737-700 flight crew was unable to comply with a subsequent clearance to cross the IF (HIRMO) at 3,000 MSL but failed to advise Approach Control. A separation issue may have ensued although ATC did not pursue the issue short of bringing it to the the attention of the flight crew.
2011051801-2400DescentMedium Transport, Low Wing, 2 Turbojet EngClimbSmall Transport, Low Wing, 2 Turboprop EngEnvironment - Non Weather Related, ProcedureProcedureNMACBecame Reoriented, Returned To Clearance, Took Evasive ActionCommunication Breakdown, Distraction, Situational Awareness, WorkloadOAK.AirportA chartered jet on a NCT vector for OAK at 11,000 FT responded to a TCAS RA with an aircraft whose crew had reported them insight yet still passed 200 FT horizontally and 50 FT vertically.
2011051201-1800Final ApproachB747 Undifferentiated or Other ModelFinal ApproachA319Human Factors, ProcedureHuman FactorsOther / UnknownSFO.AirportSFO Controller voiced concern regarding the Local Controller and Supervisors non-action during a heavy over take situation on the final for Runway 28, adding the heavy aircraft elected to go around when ATC should have initiated the action.
2011051801-2400ClimbB737-800CruiseSkyhawk 172/Cutlass 172Human Factors, ProcedureProcedureAirborne ConflictSituational AwarenessNCT.TRACONSFO Departure Controller experienced a loss of separation event involving SFO and OAK departure traffic complicated because of SFO's refusal to allow a VFR overflight to transverse their airspace.
2011050001-0600A319Human Factors, ProcedureHuman FactorsSFO.AirportAir Carrier landing SFO expressed concern regarding ATC's instructions to turn off the runway, noting the clearance was unreasonable due to location and speed.
2011051201-1800TaxiA320Airport, Chart Or Publication, Human FactorsAmbiguousBecame Reoriented, Returned To ClearanceConfusionSFO.AirportA320 Captain reports deviation from the taxi clearance due to confusion over the location of Taxiway F as depicted inside HS1 at SFO.
2011040001-0600Initial ClimbEMB ERJ 190/195 ER&LRChart Or Publication, Human Factors, ProcedureHuman FactorsConfusionSFO.TowerSFO Controller described a wrong turn initiated by a SFO8 departure aircraft, noting a further turn was issued to simulate the Shoreline SID given the obstruction northwest of the airport.
2011040001-0600DescentB767 Undifferentiated or Other ModelDescentB757 Undifferentiated or Other ModelProcedureProcedureCommunication Breakdown, ConfusionNCT.TRACONNCT Controller described an ATC initiated go around event when traffic conducting side-by visual approaches to Runways 28L/R were reluctant to acknowledge visual separation directions.
2011041801-2400ClimbBonanza 33Human FactorsHuman FactorsAirborne ConflictSituational AwarenessSFO.AirportSFO Controller described a developing conflict when NCT Controller/s permitted an aircraft to fly directly toward the SFO Runway 1 departure path, noting the situation allowed only minimum time to achieve separation.
2011031801-2400Initial ClimbB737-800CruisePA-23-250 AztecProcedureProcedureAirborne ConflictConfusionSFO.AirportSFO Controller described an event when 3 VFR transition aircraft, a VFR photo mission aircraft and an Air Carrier departure presented a potential conflict.
2011031201-1800CruiseSkyhawk 172/Cutlass 172Human FactorsHuman FactorsOvercame Equipment ProblemOAK.AirportA private pilot and his instructor failed to recognize inappropriate com radio settings during a training flight. As a result they transmitted numerous transmissions to unintended recipients, disrupting air traffic control and operating touch and go landings at an uncontrolled airport without position and intention reports to other traffic.
2011030001-0600DescentA319Environment - Non Weather Related, ProcedureAmbiguousBecame Reoriented, Requested ATC Assistance / Clarification, Returned To Clearance, Took Evasive ActionCommunication Breakdown, Distraction, Situational AwarenessNCT.TRACONAn A319 received a TCAS TERRAIN alert at 5,000 FT on the downwind for OAK Runway 11 in the vicinity of Mount Diablo and responded by climbing above 7,000 FT where the TERRAIN alert ceased.
2011031801-2400DescentB737-300Environment - Non Weather Related, Human FactorsHuman FactorsFLC complied w / Automation / Advisory, Returned To ClearanceCommunication Breakdown, Confusion, Human-Machine InterfaceOAK.AirportAlthough questioning their altitude clearance on vectors for Runway 11 at OAK, the flight crew of a B737-300 continued their descent until receiving a GPWS terrain warning at which time they confirmed their cleared altitude as 3,100 FT not 2,100 FT as they had read back and entered in the altitude alert window.
2011030001-0600DescentHS 125 SeriesHuman FactorsHuman FactorsCommunication BreakdownNCT.TRACONNCT Controller described a MVA infraction when a SJC inbound Corporate Aircraft failed to comply with issued altitude assignments.
2011030001-0600LandingSmall Aircraft, High Wing, 1 Eng, Fixed GearAirport, Human FactorsHuman FactorsConfusion, Distraction, Situational AwarenessSJC.AirportA Part 135 Cargo pilot landed on SJC Runway 30R after being cleared to land on Runway 30L. He mistook the taxiway east of 30R as Runway 30R, And because the R in 30R was faded thought he was landing on 30L.
2011030001-0600TakeoffB767-300 and 300 ERTakeoffAircraft, Human Factors, ProcedureProcedureSituational AwarenessSFO.AirportSFO Controller described a possible loss of separation event when departure traffic crossing at the runway intersections may have been technically airborne bring into play additional wake separation criteria.
2011031201-1800Final ApproachA310Human Factors, ProcedureProcedureAirborne ConflictSituational AwarenessSFO.AirportAir Carrier flight crew described a wingtip to wingtip operations while landing at SFO that resulted in a go around by the adjacent traffic, the reporter's questioning ATC's simultaneous procedures.
2011020601-1200ClimbB737 Undifferentiated or Other ModelCommercial Fixed WingHuman Factors, ProcedureHuman FactorsBecame Reoriented, Returned To ClearanceCommunication Breakdown, Confusion, Situational AwarenessSJC.AirportTwo air carrier aircraft with similar call signs confused both the flight crews and ATC when clearances intended for one were accepted and read back by the other.
2011021801-2400ClimbB737-300CruiseDA40 Diamond StarAirspace Structure, Human Factors, Procedure, WeatherHuman FactorsAirborne ConflictCommunication Breakdown, Situational AwarenessOAK.AirportAir Carrier flight crew departing Runway 11 at OAK described a TCAS RA event with unreported traffic between 600 and 1,000 FT, the reporter questioning ATC clearance for departure.
2011020001-0600Initial ClimbB747-400ProcedureProcedureOther / UnknownSFO.AirportSFO Air Carrier departure questioned NCT's request for 300 KT speed restriction after crossing ocean shoreline.
2011021201-1800Initial ApproachB737-700Initial ApproachWidebody, Low Wing, 2 Turbojet EngHuman FactorsHuman FactorsAirborne ConflictRequested ATC Assistance / ClarificationConfusionSFO.AirportB737 flight crew describes a conflict with a heavy Airbus on short final during simultaneous visual approaches to Runways 28L and R. The Airbus crew either mistook or misunderstood the clearance to Runway 28L and attempted to line up on Runway 28R, before going around when the error is discovered.
2011011801-2400Initial ApproachGulfstream V/G500/G550Initial ApproachA319Human Factors, ProcedureHuman FactorsAirborne ConflictTook Evasive ActionCommunication Breakdown, Distraction, Other / Unknown, Physiological - Other, Situational Awareness, WorkloadSFO.AirportThe flight crew of a G-V suffered an RA while on side by side visual to Runways 28 at SFO. Poor CRM throughout the flight and the invited cockpit presence of the non-pilot passenger were contributing factors.
2011011801-2400LandingA319Human FactorsHuman FactorsPhysiological - OtherSFO.AirportA319 First Officer reports being illuminated by a blue laser near MENLO during a night visual approach to SFO.
2011010601-1200Initial ClimbB757 Undifferentiated or Other ModelCompany Policy, Human Factors, ProcedureHuman FactorsCommunication Breakdown, ConfusionNCT.TRACONA near conflict occurred when traffic departing from Runway 28 and Runway 1 at SFO turned toward one another because the clearance issued to the Runway 28 traffic was confused and/or not updated.
2011010601-1200Final ApproachB747-400ProcedureProcedureSituational AwarenessSFO.AirportAir Carrier B747 pilot expressed concern regarding NCT's handling of parallel approach procedures into SFO, claiming NCT frequently sequences faster aircraft behind slower/smaller aircraft complicating speed adjustments.
2011010601-1200TaxiCommercial Fixed WingChart Or Publication, ProcedureChart Or PublicationCommunication Breakdown, Confusion, Situational Awareness, WorkloadSFO.AirportAn SFO Ground Controller directed a crew to taxi on Taxiway A to Taxiway Q, but the airport diagrams allegedly do not indicate a Taxiway A and Taxiway Q Intersection.
2010121801-2400DescentA319Airspace Structure, Environment - Non Weather Related, ProcedureAmbiguousTook Evasive ActionCommunication Breakdown, Distraction, Situational Awareness, Training / QualificationOAK.AirportAn A319 crew executed an escape maneuver after the TERRAIN warning alerted while flying the OAK COMMO1 arrival to Runway 11.
2010121801-2400TaxiA319Human FactorsHuman FactorsBecame Reoriented, Requested ATC Assistance / ClarificationCommunication Breakdown, Distraction, Situational Awareness, WorkloadSFO.AirportAn A319 crew taxiing to SFO Runway 1R for takeoff advised ATC they were not ready because the cabin was not ready. ATC replied, "Advise, line up and wait 1R." The crew verified the clearance because of task saturation and the extended delay.
2010121801-2400TakeoffLarge Transport, Low Wing, 2 Turbojet EngAirport, Environment - Non Weather RelatedEnvironment - Non Weather RelatedLanded As Precaution, Returned To Departure AirportSituational Awareness, Training / Qualification, Troubleshooting, WorkloadSFO.AirportAn Air Carrier aircraft departed SFO Runway 1R and struck a flock of birds at about 700 FT damaging the left engine. The crew returned to land and found 6-8 blades with significant damage.
2010121801-2400TaxiRegional Jet 700 ER/LR (CRJ700)TaxiMedium Large Transport, Low Wing, 2 Turbojet EngHuman Factors, ProcedureHuman FactorsGround Conflict, Less SevereSituational AwarenessSJC.TowerSJC Controller described a taxi conflict event resulting in an abrupt stop by one of the aircraft, the reporter acknowledging more positive sequencing instructions should have been issued prior to the aircraft taxiing.
2010111801-2400TaxiSkyhawk 172/Cutlass 172Airport, Chart Or Publication, Human FactorsHuman FactorsBecame Reoriented, Returned To ClearanceConfusion, Situational Awareness, Training / QualificationOAK.AirportC172 pilot experiences confusion while taxiing to Runway 27R at OAK via C Taxiway during night time conditions. Alpha Taxiway is inadvertently entered which has no connection to Runway 27R.
2010121201-1800DescentB737-800ATC Equipment / Nav Facility / Buildings, Human FactorsHuman FactorsConfusion, Distraction, Situational AwarenessSFO.AirportNCT Controller described a possible MVA infraction during SOIA procedures when distracted by a sudden PRM failure requiring an immediate change to conventional approach procedures.
2010111801-2400DescentCommercial Fixed WingAircraft, Company Policy, Human Factors, Procedure, WeatherWeatherCommunication Breakdown, ConfusionSFO.AirportAn Air Carrier arrival into SFO received confused holding instructions issued by ATC followed by an unexpected routing and runway change. The absence of automated ATIS updating reportedly added to the confusion experienced.
2010110001-0600Initial ApproachGlobal Express (BD700)Final ApproachCommercial Fixed WingHuman Factors, Procedure, WeatherHuman FactorsCommunication Breakdown, Situational AwarenessSJC.AirportSJC Controller described a go around event caused by a strong tail wind, the reporter noting NCT's reluctance to change runway configurations.
2010110601-1200DescentB757-200Airspace Structure, Human Factors, ProcedureProcedureCommunication Breakdown, Situational AwarenessSFO.AirportAir carrier landing at SFO and kept high on the landing profile voiced concern regarding the handling by NCT as compared to other ATC facilities.
2010110001-0600Final ApproachB757-200Human Factors, ProcedureHuman FactorsSituational AwarenessSFO.AirportAir Carrier landing SFO was issued a go around by ATC because traffic and speed assignments could not be achieved, the reporter voicing concern regarding the NCT Controller's technique and speed/visual separation requests.
2010111801-2400LandingB757-200Human FactorsHuman FactorsDistraction, Other / UnknownSJC.AirportB757 First Officer reports another Green Laser incident approaching SJC from the south. Local police show up to take a statement and report that one perpetrator has already been arrested during a previous incident.
2010111201-1800Final ApproachCommercial Fixed WingHuman Factors, ProcedureHuman FactorsBecame Reoriented, Regained Aircraft ControlCommunication Breakdown, Confusion, Human-Machine Interface, Situational Awareness, Training / Qualification, WorkloadSFO.AirportAn air carrier First Officer described her first experience with an unstabilized approach flown by the other pilot and the mental gymnastics involved with interpreting, reacting, and safely resolving the events that followed.
2010110001-0600Initial ApproachLarge Transport, Low Wing, 2 Turbojet EngEnvironment - Non Weather RelatedEnvironment - Non Weather RelatedDistraction, Physiological - OtherSJC.AirportAn Air Carrier Captain reported that while over West Santa Clara Valley on the SJC Runway 30 Fairgrounds Visual he and the First Officer were hit by an intense green laser which originated somewhere west of the airport. Both pilots reported visual impairment requiring medical attention.
2010100601-1200LandingB747-400Human Factors, ProcedureHuman FactorsOther / UnknownNCT.TRACONAir Carrier inbound to SFO Runway 28L failed to comply with go around instructions issued by the PRM Monitor Controller because the crew believed they were issued a standard ILS procedure and changed to the Tower frequency.
2010101801-2400TaxiHS 125 SeriesProcedureProcedureCommunication BreakdownSFO.TowerSFO Controller described a confused "Line Up And Wait" event noting the new phraseology is flawed because it is limited to one action, when other ATC instructions/advisories involve entering/holding on the runway.
2010101801-2400ClimbA320Human Factors, ProcedureHuman FactorsSituational AwarenessSFO.AirportNCT Controller witnessed an unauthorized airspace entry event where the Controller in question had a poor understanding of point outs and airspace restrictions.
2010101201-1800DescentCommercial Fixed WingHuman Factors, ProcedureHuman FactorsCommunication BreakdownSFO.AirportB777 on final for SFO Runway 28L described a go around event involving a B757 on final for Runway 28R claiming the instructions from the Approach Controller were reversed by the Tower Controller causing the event.
2010101201-1800DescentFalcon 2000Any Unknown or Unlisted Aircraft ManufacturerHuman FactorsHuman FactorsAirborne ConflictTook Evasive ActionSituational Awareness, Time PressureNCT.TRACONDA2000 First Officer reports declining a descent clearance from ATC at the Captains request, due to traffic on the TCAS display. This results in a TCAS TA then RA to climb, to which the crew responds.
2010091201-1800DescentB757-200Human FactorsHuman FactorsAirborne ConflictTook Evasive ActionOther / UnknownNCT.TRACONAir Carrier descending on the FMS Bridge arrival into SFO was issued conflicting VFR traffic by ATC and issued an avoidance turn, TCAS TA/RA was received, the reporter noting ATC should have issued a level off altitude.
2010091201-1800LandingB737 Undifferentiated or Other ModelHuman FactorsHuman FactorsAirborne ConflictExecuted Go Around / Missed ApproachCommunication BreakdownSFO.AirportSFO Controller described a conflict event involving an Runway 28R go-around and a Runway 1R departure, the Controller alleged landing traffic did not advise ATC, and appeared to be using the IFR published missed approach.
2010090001-0600ClimbB737-800CruiseCessna Aircraft Undifferentiated or Other ModelHuman Factors, ProcedureHuman FactorsAirborne ConflictTook Evasive ActionSituational AwarenessSFO.AirportAir Carrier departure from SFO described a TCAS RA event shortly after take off on the SHOR1 SID, noting ATC had re-assigned an interim altitude (3000 FT) just prior to the event.
2010091201-1800Final ApproachB737 Undifferentiated or Other ModelCruiseSkyhawk 172/Cutlass 172Human FactorsHuman FactorsAirborne ConflictSituational AwarenessSJC.AirportSJC Controller described a TCAS RA event when an Air Carrier on final for Runway 30R conflicted with a traffic watch aircraft on the Tower frequency, the reporter indicating the traffic watch aircraft should have been transferred to the Approach Control.
2010091201-1800Final ApproachB737 Undifferentiated or Other ModelLandingB757 Undifferentiated or Other ModelATC Equipment / Nav Facility / Buildings, Human Factors, ProcedureHuman FactorsNCT.TRACONNCT Controller described a loss of B757 separation event on final to SFO when he/she failed to note the "BAT", (an electronic RADAR display separation device), was set at 3 miles instead of the required 4 miles in this instance.
2010091201-1800TaxiMedium Transport, High Wing, 2 Turboprop EngAirportAirportDistraction, Situational AwarenessOAK.AirportAn air carrier Captain reported the designated parking location for an in ground fueling cart was too close for comfort when being marshalled into the gate.
2010090001-0600Initial ApproachB757-200ATC Equipment / Nav Facility / Buildings, Human Factors, ProcedureATC Equipment / Nav Facility / BuildingsHuman-Machine Interface, Other / UnknownSFO.AirportSFO Controller described an overtake event on short final during parallel operations to Runways 28L/R, the reporter noting available RADAR equipment makes it difficult for controllers to identify overtake events.
2010090601-1200TakeoffCommercial Fixed WingEnvironment - Non Weather Related, ProcedureProcedureGround Conflict, Less SevereRejected Takeoff, Took Evasive ActionCommunication Breakdown, Situational AwarenessSFO.AirportAn air carrier Captain reported rejecting a SFO Runway 1L takeoff after ATC alerted the takeoff clearance cancellation. Traffic was on short final for Runway 28 but the crew could not see the aircraft in the sun over the bay.
2010090601-1200Final ApproachCommercial Fixed WingFinal ApproachCommercial Fixed WingAirport, Airspace Structure, ProcedureAmbiguousReturned To Clearance, Took Evasive ActionDistraction, Human-Machine Interface, Situational Awareness, Training / QualificationSFO.AirportAn air carrier crew reported a TCAS RA warning on short final to SFO Runway 28R behind a B767 on final for Runway 28L. The crew adjusted the profile slightly to increase clearance with the traffic in sight, and feeling in control continued the approach normally.
2010080601-1200TaxiA318Environment - Non Weather Related, ProcedureProcedureTook Evasive ActionCommunication Breakdown, DistractionSFO.AirportAirbus flight crew preparing for taxi had to abruptly stop when a tug approached the front of their aircraft to inquire about an on board passenger.
2010081201-1800TaxiSmall Transport, Low Wing, 2 Turbojet EngHuman Factors, ProcedureHuman FactorsCommunication Breakdown, Confusion, Situational AwarenessSFO.AirportSmall turbojet First Officer reports crossing runways 1L and 1R inadvertently after being cleared to taxi via Taxiway A to Runway 1R behind a B757. The B757 had been cleared to Runway 28L.
2010080601-1200Final ApproachB777-200Final ApproachCessna Citation Undifferentiated or Other ModelHuman Factors, ProcedureProcedureAirborne ConflictOther / UnknownSFO.AirportB777 at 800 FT and assigned Runway 28R SFO described a conflict event with a light jet when ATC initiated a last minute runway change resulting in the light jet directly overhead, the reporter noting this was becoming standard at SFO.
2010081201-1800DescentCommercial Fixed WingAirport, Human Factors, ProcedureHuman FactorsBecame ReorientedCommunication Breakdown, Confusion, Situational Awareness, WorkloadNCT.TRACONA320 flight crew cleared for the visual to Runway 28R at SFO from a right base reports conflict with another aircraft landing Runway 28L. After switching to Tower it was discovered that both aircraft were trying to land on Runway 28R.
2010080601-1200Initial ClimbLearjet 60Chart Or Publication, Human FactorsHuman FactorsTook Evasive ActionConfusion, Training / QualificationOAK.AirportLJ60 Captain departing OAK reports mistaking the lost comm procedure for the normal departure procedure. Reporter turned to 200 degree heading at 3000 FT much to the chagrin of an NCT Controller.
2010080001-0600Final Approach, Initial ApproachA319ATC Equipment / Nav Facility / Buildings, Human FactorsHuman FactorsExecuted Go Around / Missed ApproachSituational AwarenessSFO.AirportNCT Controller working the final position for SFO described a loss of wake turbulence separation.
2010081801-2400Initial ApproachP180 AvantiInitial ApproachSkylane 182/RG Turbo Skylane/RGHuman FactorsHuman FactorsAirborne ConflictSituational AwarenessOAK.AirportOAK Local Controller described a conflict between a VFR arrival to HWD and an aircraft inbound to OAK Runway 27R on a visual approach, the reporter listing several actions which would have prevented the event.
2010071201-1800TaxiHeavy TransportAirport, Chart Or Publication, ProcedureProcedureReturned To ClearanceCommunication Breakdown, ConfusionSFO.AirportA clearance from Spot 10 at SFO was incompatible with Ground Control's clearance to taxi via taxiway B and F to the departure runway.
2010071801-2400LandingCommercial Fixed WingHuman FactorsHuman FactorsDistraction, Physiological - OtherOAK.AirportAir Carrier Captain reports being illuminated by a green laser on a four mile final to Runway 29 at OAK.
2010070001-0600Initial ClimbCommercial Fixed WingHuman FactorsHuman FactorsBecame ReorientedConfusion, Situational AwarenessSJC.AirportAn air carrier Captain reported exceeding FAR speed limit below Class B on the SJC Loupe 1 SID.
2010070001-0600TakeoffB757-300Company Policy, Environment - Non Weather Related, Human FactorsHuman FactorsConfusion, Human-Machine Interface, Time Pressure, Training / Qualification, WorkloadSFO.AirportB757-300 flight crew mistakenly departed with derated power after misreading their company provided performance information.