Air Carrier crew reported an unstable approach and CFIT/CFTT event along with a TCAS RA and low altitude alert from ATC while executing a visual approach to runway 28R at SFO. Crew performed a missed approach and returned for landing.
Synopsis
Air Carrier crew reported an unstable approach and CFIT/CFTT event along with a TCAS RA and low altitude alert from ATC while executing a visual approach to runway 28R at SFO. Crew performed a missed approach and returned for landing.
Narrative
I was PF and the Captain was the PM. We had completed one flight together the night before and I thought we worked well together. At the beginning of the event flight we both stated that we were very familiar with SFO. The weather was good VFR; and the flight was standard until we entered the SFO terminal area.We were on the BDEGA4 STAR and were expecting to fly the full STAR which overflies SFO and leaves you on a left downwind for 28L. Because of this we had briefed the visual 28L backed up by the ILS but acknowledged 28R was a possibility. When Oakland Center handed us off to NorCal approach we did not receive a runway assignment. We were then handed off to another Controller who did not give us a runway assignment. When we were approximately at the CORKK intersection ATC gave us heading 110; that put us on a right downwind for 28R; however we still did not receive a runway assignment. We decided not to change the box since we did not want to make multiple FMC changes if ATC ended up doing something unusual. The Captain said he would quickly load a new approach; as needed; once a runway assignment or approach clearance was given by ATC. We received at least one more frequency change; still with no runway assignment.Roughly abeam the CEPIN intersection (on the ILS 28R approach chart) we were given a base turn. We were at approximately 5000 ft; descending to 4000 ft; and CEPIN has a published altitude of 3000 ft. ATC asked if we had the field or the traffic on 28L in sight. We said we had the field in sight but not the traffic. Because of this ATC turned us in towards the final approach course but did not give us a lower altitude. At this point there was confusion as to what approach should be flown. The Captain wanted to load the straight in ILS to 28R. I was unsure if we should do that or the Bridge visual. I voiced my concern; and the Captain quickly convinced me to go with the ILS. Finally; we saw the traffic below us; and we informed ATC. ATC cleared us for the visual 28R. Maintain 160 knots to the bridge." At this point things became extremely hectic. I immediately saw that we were extremely high and at least 20 knots faster than the speed assignment. The Captain asked if I wanted a lower altitude. I quickly said 'Yes! Give me anything.' I rapidly configured the aircraft with flaps 3; gear down; and full speed brakes; in an OPEN DES (idle thrust) descent at 160 kts. We were descending at 2000-2500 FPM trying to catch the glideslope. The Captain told me to shallow the heading to intercept the localizer so we wouldn't have a problem with the parallel 28L traffic. I complied; and a little while later the autopilot grabbed the localizer. I remember the automated '2500' callout was made by the aircraft. Shortly after that we received a TCAS traffic alert from Aircraft Y parallel to us on 28L. A few seconds after the TCAS alert we received turned into a TCAS Resolution Advisory.[Then the next few events happened extremely rapidly]: The aircraft called out 'monitor vertical speed.' I disconnected the autopilot; left the auto throttles engaged; and turned both of the flight directors off. (The Captain was busy looking for the traffic and talking on the radio; and I did not want to overload him by asking for flight directors off.) I also decided to retract the speed brakes as I did not want to have so much drag out while flying a TCAS RA. However; the speed immediately shot up from our current speed of 160 kts to approximately 175 kts. (Flaps 3 limit speed is 185 kts.) I instinctively pulled the throttles to idle. (Not that it made any difference since the throttles were at idle the entire time.) I looked down at the VSI to see if I could reduce my rate of descent. Instead; I saw that I was doing 2000 fpm and the VSI number was red. The green portion of the VSI was below my VSI needle indicating a steeper descent was needed to get clear of the conflict.I immediately pulled full speed brakes and tried to gently pitch down. Airspeed was approximately 170 kts; and I did not want it to increase much more than that. I was extremely task saturated by hand flying a localizer course and an idle; high drag descent. I was simultaneously trying to comply with the TCAS RA without over speeding the flaps. While retracting the flaps might have helped; I did not think about that at time. (The thought of retracting flaps during a descending; low altitude; relatively low airspeed TCAS RA would not come naturally to most pilots.) I glanced at the radar altimeter and saw we were less than 2000 ft AGL. Up until this point the Captain had been extremely busy on the radio trying to tell ATC about the TCAS RA while meanwhile looking over his left shoulder trying to keep Aircraft Y in sight. In this moment of rapidly growing frustration I yelled something like 'this is [expletive] up' to bring the Captain into the loop and give me direction. I then looked down at the VSI and radar altimeter and saw we were still descending at 2000 rpm; the VSI was STILL red indicating a steeper descent was STILL needed for the TCAS RA; and the radar altimeter was now 1000 ft. At that point I 'snapped out of it' and realized the TCAS RA was the least of our problems. I stowed the speed brakes; slammed the throttles to TOGA and began gently pitching to 10 degrees nose up. As the aircraft started to climb I called out 'Going around. Gimme gear up.' I began a shallow turn to the right to get away from the traffic on 28L. ATC gave us a climb to 3100 ft and runway heading (284). About this time; I got the autopilot and autothrottles engaged. A short time later we were given a small left turn to 260. The Captain grabbed the heading knob and started quickly turning it to the left; well past 260; and he kept turning it to the left. I disconnected the A/P and flew approximately a 260 heading. I loudly said; 'stop that's the wrong way.' He loudly said; 'it's a left turn.' And I said; 'to 260' and I pointed right in front of the aircraft to indicate where heading 260 was. At that point he also 'snapped out of it' and returned the heading bug to 260. I tried to reengage the A/P; but it kept trying to turn left in the direction the heading bug had been initially turned. I disconnected the A/P again and hand flew for a few seconds before the airplane seemed to 'snap out of it' and the A/P began working correctly. The rest of the flight was uneventful. Contributing Factors:--Multiple NorCal Controllers failed to give us a runway assignment. This left us unsure what approach to have loaded in the FMGC and required a last-minute heads down input at the worst possible moment. When the last Approach Controller cleared us for the visual 28R; he did not specify whether we should join a straight in or the Bridge visual. I think all 28R visuals should be flown on the Bridge visual; but ATC needs to specify that in the clearance.ATC's vectors were also too tight and too high. We can't be left high and then given a last-minute approach clearance with a simultaneous speed reduction. Not only do aircraft descend faster at higher airspeeds; but we need to stay level to bleed off speed resulting in being even higher on the approach profile. My former company had a policy that ALL RAs may be ignored if the pilots have the RA traffic in sight. I have a theory that that is exactly what happened on this day. I think our TCAS gave us a descending RA and gave Aircraft Y a climbing RA; but the pilots chose to ignore it (because they had us in sight) which led to our TCAS to almost drive us into the water. If the pilots had followed their RA maybe we would have received a clear of conflict sooner and not flown so close to the water."
Second reporter narrative
During our arrival to SFO we were given a visual approach to runway 28R. During that approach we were held high and vectored too close to the aircraft on runway 28L resulting in an RA and a go around. It was a clear and sunny approach into SFO. We flew directly over the field from the BEDGA4 RNAV arrival. We then received vectors to the east of the field and were told to expect a visual. We had runway 28L in the FMGC as it was our best estimate and not specified by approach nor the chart. We received a descent to 4000 and a turn to the south with instructions from ATC to call traffic and the airport in sight. At this point we clarified which runway we could expect and changed the FMGC appropriately. While looking for the traffic; we received another turn towards the final approach course. At that point the traffic and the airport were in sight. We called them as such and received a clearance for a 'visual approach to 28R'. Approach then asked us to fly a shallower intercept heading. Our best guess is that the original heading was too close to the other A/C. We were high so the PF started to configure and descend. While I did my best to keep the traffic in sight and monitor the approach; the traffic for 28L slid behind our wing. At this point we were shallowing our descent to stabilize our approach. I would estimate it was roughly 1500'. At this time we received a descending RA of approximately 2000 FPM. While digesting the situation the PF retracted the speed brakes and now we were accelerating towards a flap over speed and attempting to respond to the RA. It became clear that this was unstable and a GA was necessary. At 1000' the PF made the correct decision to GA and started the GA sequence. At this time we received an altitude alert from the Tower Controller. I responded saying that we were responding to an RA and also going around. At this point we had TOGA power set and were cleaning the A/C up while getting heading and ALT instructions from Tower. Our initial instructions were to fly runway heading and climb to 3100'. While I was attempting to set 3100; we received instructions to make a 'Left turn 260; Left turn; Left turn 260.' This urgency combined with the 3100' altitude caused me to momentarily lose SA. I sternly told the FO to turn left as I was spinning the heading selector. He correctly stated that he was flying 260 and I was spinning the heading selector incorrectly. I regained my SA and we cleaned the A/C up. After receiving higher altitude instructions we were cleared back around for a visual to 28L. An uneventful landing was accomplished. We parked at the gate and had a very good debrief on the event. Credit to the PF for concentrating on flying the A/C and maintaining SA and safety at all times.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.