ኤር ካናዳ በረራ 781 ዳግም መነሳት – መርማሪዎች የሳን ፍራንሲስኮ ማረፊያን ይመረምራሉ

Please review the latest agency findings before drawing conclusions about the San Francisco landing. Here, investigators test how duty considerations, intended crew actions, and weather factors shaped the go-around. The data sets brought to light by the team span years of aviation operation and safety analysis.

The nine key touch points in the approach, described by the authors, form the backbone of the inquiry as investigators map the sequence. Each touch is scrutinized with precise means, and findings are being compiled while awaiting official input from the airline and authorities.

In this account, the authors develop a narrative that links crew decisions to procedures in place, and the report will register safety implications for training and operations above routine checks.

The testing phase includes data from flight recorders, air traffic systems, and pilot inputs, with the agency confirming that findings will guide approved changes to manual procedures and flight deck qualification.

To help practitioners, the official register of corrective actions remains open for comment and cross-checks by the broader aviation community.

Investigation Focus: Go-Around Triggers and Immediate Questions

Recommendation: implement a standardized trigger within four seconds as the go-around onset, with automatic register of the event and explicit guidance within instruction and administration oversight.

Investigating teams should examine whether triggers stem from miscommunication during a meeting between cockpit and air traffic control, automation responses, or pilot workload. Research of flight data and cockpit voice and data recorders shows whether a mistake occurred in the guidance during the four-second window. The administration should ensure a clear instruction to register all events and share findings with international operators and others in similar fleets.

To close gaps, update the construction of go-around training modules, embed this guidance into standard instruction for four-second stabilization, and apply a consistent checklist across both operations and maintenance. Instructors should use real-world cases from research to reinforce disciplined responses in the cockpit and reduce the chance of a mistake during critical seconds.

Immediate questions focus on triggers and timing: what exact input or cue initiated the go-around, what were the four-second dynamics in the cockpit, did the crew register and confirm the instruction within the window, and how did guidance align with the cockpit’s actions? How should training address this research during action in takeoff and landing scenarios? What role did others in the chain–ATC, maintenance, and administration–play in the sequence?

With unlimited data streams, investigators can correlate flight deck actions with ATC messages and other inputs. The register should cover four runs from initial approach to go-around completion, noting the seconds counts and precise cues. This insight informs international guidance and supports the administration in updating instruction that reduces future mistakes.

Flight Deck Procedures During the Go-Around

Apply TOGA thrust immediately and establish a positive climb with a stable attitude; verify airspeed trends and confirm the runway is behind you. This first action reduces stall risk and buys time for configuration changes. These steps have worked in high-workload operations.

Coordinate with automation and crew as you transition from the approach. Avoid wrong conclusions; if autopilot remains engaged, monitor performance and be ready to hand-fly if needed. In addition, listen for ATC instructions; if ATC says a go-around clearance is in effect, confirm and proceed with a clean configuration while maintaining situational awareness. If ATC asked for confirmation, respond concisely. This year, the approach has worked across many flight decks.

Over the years, investigators noted the go-around sequence benefits from a disciplined, first-minute routine. The nine seconds after TOGA decide energy and attitude; pilots touch the controls with purpose and maintain a stable trim. Thoughts stay focused on clean configuration and safe energy margins. in august, a publication reviewed nine cases and found that crews who were cleared for the go-around and followed a standard checklist achieved safer outcomes. Administration guidelines emphasize reviewing procedures earlier in the flight and avoiding last-minute changes; if alerts appear from airports or surveillance tech, the crew must verify and act accordingly. If ATC asks, respond concisely and confirm you are going around while continuing to monitor the airports.

ATC Communications and Readback Verification

Recommendation: implement mandatory readback verification for all runway-clearance and go-around instructions, with an automated alert if the readback does not arrive within three seconds and a cross-check against the controller’s instruction fails. Maintain a continuous back and forth cadence to prevent missed items and keep systems aligned.

In the SF Go-Around case, investigators emphasized precise confirmation of instructions. Align the approach with international guidance and include it in the publication that lays out standard phraseology and verification steps. The article and источник point to clear, timely exchange as a key factor when last-minute changes come from the tower, especially under tight traffic and transportation pressures.

1. Critical items readback: Confirm runway assignment, altitude/transition, heading at go-around, airspeed, and the explicit go-around clearance in verbatim readback. If any item is omitted or heard incorrectly, require repetition and log the discrepancy; if the readback is not captured within three seconds, trigger an alert to the supervisor and record the event in the program.
2. Timing, escalation, and verification: enforce a three-second window for readback after each instruction; if no match or if a mismatch occurs, escalate to the agency supervisor and, where available, switch to CPDLC or a non-voice channel to confirm the order. This keeps the process consistent and reduces risk of misunderstanding.
3. Redundancy and tools: use both voice and data-link transport to deliver critical instructions; the systems cross-check readbacks against CPDLC messages and voice transcripts, and logs are kept in the layout to support audits and investigations.
4. Training, publication, and share: update the program quarterly; share lessons through international publication and with partner nations; the article should include a standard set of phrases and verification steps so crews and controllers stay aligned across agencies and jurisdictions.
5. Operational workflow and rules enforcement: define the order of verification in the control room workflow; include checks for last-minute changes and confirm before taxi or takeoff; per the advisory from the spokesperson, maintain consistency and keep records for agency and international reviews.

источник: agency spokesperson noted that emphasis on readback verification continues to be shared in the publication and discussed with international partners; the program aims to keep alignment across nations and transportation operations, with the layout of procedures under ongoing review.

Aircraft Performance: Power, Pitch, and Configuration During the Go-Around

Adopt a stabilized go-around profile immediately: apply TOGA thrust, disengage autopilot as needed, and hold a positive pitch to establish a safe climb within the first seconds after rotation. Tune thrust and attitude to the weight and airspeed, reference the international publication for best practice, and check notam guidance before you act; crewmembers should remember to coordinate with the captain and them.

Power decisions drive the climb rate: bring thrust to TOGA promptly, then manage a steady acceleration to maintain positive climb without overspeed. Pitch should stay within a controlled envelope–too steep a nose-up can interrupt acceleration, while too shallow a angle delays separation from the ground. The layout of the cockpit and instrument cues supports rapid action; sites across operations show that clear warnings and a tuned, consistent callout rhythm reduce the seconds between intention and action. Before reconfiguring gear or flaps, ensure the speed trend is positive and the flight path is within published limits; reported events confirm that delays in go-around reconfiguration can cost climb performance. Investigations shown that even small timing tweaks can shift the outcome in a high-stress moment.

Configuration matters: retract flaps and gear according to the checklist once a positive climb is established, then move to a clean configuration as soon as practical. Only after positive climb is confirmed should gear retract. The layout of the controls and lighted warnings should remain unambiguous to crewmembers; warnings must be acknowledged, and the crew should remember to verify that all parameter cues align with the flight plan. Construction and issues in training materials have been addressed; adoption of the publication’s guidance across international sites, including canadas authorities, reduces ambiguity during go-arounds. The captain leads the sequence while crewmembers make requests and confirm them.

Training and standardization: notam and international guidance should be adopted in every maintenance and training program; the publication recommends routine simulator work that covers varied weather, runway layouts, and traffic. They took lessons from real incidents and emphasize tuning communications so that speed, pitch, and configuration are clear and concise. The favourite checklist item across many crews concentrates on timely gear and flap transitions, speed targets, and avoiding overshoot. Across canadas contexts, updates to lighted indicators and cockpit layout have reduced misinterpretation during go-arounds and improved overall safety.

Crew Decision-Making and CRM Lessons

Implement a two-minute structured pre-landing conversation and a one-minute post-landing debrief to align duty and decisions before the approach. The layout assigns clear roles: captain announces intent, first officer confirms risks, and both read back critical items, ensuring the conversation stays precise when crews worked under high workload.

CRM training should include at least 40 hours per year per crew, with 20 hours of scenario-based drills and 10 hours of debriefs and feedback sessions. This training translates into faster, clearer decisions during the next go-around and reduces accident risk across flights and sites, as investigators observe across airplanes and environments.

Adopt a repeatable call-out pattern: “I have the current approach,” “Confirm configuration,” “Reading back.” In tough moments near landing, that explicit conversation helps prevent misreads and supports experience across worlds of airports and fleets.

ቀጥሎም በአቀራረብ ላይ የመስቀል-ፍተሻ መደበኛ ተግባርን ተግባራዊ ያድርጉ፦ አንዱ አብራሪ መቆጣጠሪያውን ሲይዝ፣ ሌላው የአየር ፍጥነትን፣ የመውረድ መጠንን እና አወቃቀሩን ያረጋግጣል፣ ግልጽ የሥራ ድልድል እና ከእያንዳንዱ እርምጃ በኋላ አጭር ቆም ማለት ይኖረዋል። ይህን ተግሣጽ በጣቢያዎች እና በአውሮፕላኖች ላይ መተግበር የበረራ ሰራተኞች በሚቀጥሉት በረራዎች ላይ ቅደም ተከተላቸውን እንዲያስታውሱ ያረጋግጣል።.

መለኪያዎቹን በተጨባጭ መለኪያዎች ይለኩ፡ ከፍተኛ የስራ ጫና ባለባቸው ክፍለ ጊዜያት የውሳኔ ጊዜ፣ የንባብ-መልስ ትክክለኝነት እና የዘገዩ ወይም የተዘለሉ ጥሪዎች መጠን። የውሳኔው አማካይ ጊዜ ከስልጠና በኋላ ከቀነሰ እና የሚጠበቁ ማረጋገጫዎች ቁጥር ከቀነሰ, ያ ግልጽ ምልክት ነው. መርማሪዎች ትርፍን ለማረጋገጥ ከብዙ ዓለማት የተደረጉ በረራዎችን ይገመግማሉ፣ እና ግኝቶቹ ለመጀመርያ ደረጃዎች እና ለመዞሪያዎች ለውጦችን መምራት አለባቸው፣ ይህም ታይቶ የማይታወቅ የአየር ሁኔታን ወይም የትራፊክ ሁኔታዎችን ጨምሮ።.

Tala'itha le Data: FDR, CVR, be Teber Zetegelegna Zaman Mets'ehāfi

ፍDር፣ CVR እና የጥገና መዝገቦችን በአንድ ኦዲት ሊደረግ በሚችል የጊዜ መስመር ውስጥ በ24 ሰዓታት ውስጥ በማዋሃድ ወደ መዞሪያው ያመሩትን ክስተቶች ቅደም ተከተል ለመመስረት። እያንዳንዱን የመረጃ ነጥብ ከምንጭ መመዝገቢያ ጋር አስተካክል ድጋፍ ለማግኘት የጊዜ ማህተሞችን፣ የክስተት ኮዶችን እና የመስቀል ቼክ ማስታወሻዎችን ጨምር። ይህ መርማሪዎች በመጀመርያ ግምገማ ወቅት የሚተማመኑበትን መዝገብ ይፈጥራል፣ እንዲሁም ተቆጣጣሪዎች ከምድር ቡድኖች ጋር ቀጣይ እርምጃዎችን እንዲያስተባብሩ ይረዳል።.

መረጃ ኤፍዲአር በመጨረሻው አቀራረብ ላይ አራት ወሳኝ ጊዜያትን ለይቷል፡ የስሮትል እንቅስቃሴዎች፣ ራስ-ሰር አብራሪ ሁኔታ ለውጦች፣ የድምፅ መጠን ላይ ፈጣን እንቅስቃሴ እና የማምለጫ ሙከራ መጀመር። የአየር ፍጥነት አዝማሚያ ከ140 ኖቶች ወደ 120 ኖቶች ፍጥነት መቀነስ ያሳያል፣ እና የከፍታ/አቀባዊ ፍጥነት መቀየር በሲቪአር ውስጥ ከተመዘገቡት ድርጊቶች ጋር ይጣጣማል፤ ይህ ንድፍ የአውሮፕላኑ ሰራተኞች ምላሽ የሚያሳይ ሊሆን ይችላል እንዲሁም በዚያ ቀን ከሌሎች አውሮፕላኖች እና በረራዎች በተገኘው መረጃ ጋር የሚስማማ ሊሆን ይችላል። ኖታሞች እና የሬዲዮ ስርጭቶች ቅደም ተከተሉን ያረጋግጣሉ።.

CVR ይትረከብ ናይ ጽሙዋቕ ግዜ መስርዕ፡ ናይ መወዳእታ ፍቓድ ሕቶታት፡ ናይ ሬድዮ ልውውጥ፡ ከምኡ’ውን ናይ መወዳእታ ንባብ ምስ መሬት ምትእስሳር። እቶም ጸሓፍቲ ንክፋላት ብተዛረብቲ ይፈልይዎምን ምስ FDR ፍጻሜታት የዛምድዎምን፤ ኣብቲ መዝገብ፡ ፊዝፓትሪክ ንሓደ ስዒቡ ዝመጽእ ተግባራት ዝጸለወ መምርሒ ተቆጻጻሪ ዘንጸባርቕ ስዒቡ ዝመጽእ ፍጻሜታት የጕልሕ።.

የጥገና መዝገቦች ከአውሮፕላኑ መዝገብ እንደሚያሳዩት የአውሮፕላኑ የበረራ መቆጣጠሪያ ቦታዎች እና ተያያዥነት ያላቸው ክፍሎች በቅርቡ ምርመራ ተደርጎላቸዋል። የተካተቱት መግቢያዎች የተመረመሩ ወይም የተተኩ ክፍሎች፣ በስራ ላይ ያሉ ቴክኒሻኖች እና የቀን ማህተሞችን ይዘረዝራሉ። ለመጨረሻው አቀራረብ አስተዋፅኦ ያደረጉ የተላለፉ እቃዎች ወይም ዘላቂ ልብሶችን ይፈትሹ; አራቱ ዋና ዋና ነገሮች ካሉ, ለቅርብ ክለሳ ምልክት ይደረግባቸዋል. ለአስፈላጊ ነገሮች ተጨማሪ ቼኮች ብቻ ያስፈልጋሉ።.

ስዓታት ሰውነትን ድኽመት፤ ናይ እግሪ ግዜታት ገምግም፤ እቲ ናይ ኣርባዕተ-እግሪ መስርዕ ኣብ ሓደ ስዓታዊ መስኮት ኣብ ግዜ መወዳእታ መርገጺ ተወሳኺ ግዜታት ክጸልዎ ይኽእል። ናይዚ በረራ መስርዕ ምስቶም ንተመሳሳሊ መዕረፍያታት ነፈርቲን በሪታትን ዘገልግሉ ካልኦት ኣነጻጽር፣ ኣብ ድምጺ መቐመጢታትን ኖታምስን ድኽመት ዘመልክቱ ጠቐምቲ ፍለጥ።.

ቀፃልቲ ስጉምትታት ኣብ ግልጽነትን ኣጠቓቕማን ዘተኩር፦ ግዜ ሰሌዳ ብንጹር ምንጭታት ሓበሬታ፣ መተሓሳሰቢታት ጽገናን ናብ ክፍሊታት FDR/CVR ዝወስዱ መተሓሳሰቢታት ምሕታም፣ ሓጺር ሜላ፣ ዝርዝር ጸሓፍቲ፣ ከምኡ’ውን ክፋል ውስንነታት ሕትመት ምኽታል። መዝገብ ክርከብ ዘለዎ ምዃኑ፣ ሰራሕተኛታትን መቆጻጸርትን ፍጻሜታት ከረጋግጹ ከም ዝኽእሉ፣ ከምኡ’ውን ናይ መወዳእታ ጸብጻብ ነቲ ፈልማይት ነፋሪትን ነቲ ዝተሳተፈትሉ መዕርፎ ነፈርትን ክገልጽ ምዃኑ ኣረጋግጽ፣ እንታይ ዓይነት ኖታም ከም ዝነበረን፡ ናይ ሬድዮን ድምጽን ርክባት ምስቲ ዝተገልጸ ተግባራት ብኸመይ ከም ዝሰማማዕ። እቲ ሒሳብ ንህዝባዊ ሕትመትን ነቲ ቀጻሊ መርመራን ከም ዝድግፍ ኣይትረስዕ።.