Mt. Wilson, CA, USA
B-16726
BOEING 777
A near controlled flight into terrain (CFIT) incident occurred near Mt. Wilson, California, when a Boeing 777-300 departing Los Angeles International Airport (LAX) was instructed to turn left toward rising terrain after departure from runway 07R. The aircraft was operating on a 14 Code of Federal Regulations Part 129 international flight. Air traffic control services were provided by the Federal Aviation Administration Southern California Terminal Radar Approach Control (SCT TRACON). There was no damage reported to the aircraft, and no reported injuries to the passengers or crew. Due to weather in the area, LAX was operating in an east flow configuration with aircraft departing to the east. The Boeing 777-300 pilot contacted the SCT controller and was given an initial climb to 7,000 feet. A short time later, the SCT controller instructed the pilot to turn left to a heading of 180 degrees which required a left 270 degree turn. The turn resulted in the aircraft turning toward rising terrain and back toward the airport; normal procedures in an east flow would have been for a right turn to a heading of 180 degrees. While in the left turn, the pilot requested a high speed climb which resulted in the aircraft accelerating beyond the 250 knot LAX class B speed restriction and required additional airspace in order to complete an assigned turn. After recognizing the aircraft was in a left turn, the SCT controller issued the crew a right turn to a heading of 180 degrees. As the aircraft began to turn right, the air traffic controller instructed the crew to expedite the turn due to recognizing a developing proximity issue with another aircraft that had departed from LAX. The air traffic controller stopped the climb of the B777-300 and issued a left turn to a heading of 270 degrees. These turns in quick succession, combined with the speed of the aircraft, resulted in the flight tracking northbound toward rising terrain. The closest lateral and vertical proximity between the airplane and terrain/obstructions was about 0.3 miles and 0 ft, respectively, which is less than the minimum separation requirements.
On December 16, 2016, about 0125 pacific standard time (PST), Eva Air flight 015, a Boeing 777-300, registration B-16726, conducted flight below minimum vectoring altitude near Mt. Wilson, CA while receiving vectors from Southern California Terminal Radar Approach Control (SCT TRACON) after departing from Los Angeles International Airport (LAX) Los Angeles, California. The airplane was not damaged and there were no reported injuries to the passengers or crew. The flight was operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 129 as a regularly scheduled flight from LAX to Taiwan Taoyuan International Airport (TPE), Taipei, Taiwan. Night instrument meteorological conditions prevailed. HISTORY OF FLIGHT After arriving to the facility, the SCT air traffic controllers in the Del Ray area combined the operational control positions to the Manhattan sector position. At 0116:00, LAX air traffic controllers instructed the pilot of EVA015 to line up and wait on runway 07L; the pilot requested runway 07R and the air traffic controller instructed EVA015 to line up and wait on runway 07R. At 0117:49, EVA015 was cleared for takeoff with the wind reported as 070 at 9, gusts 18 [knots]; the pilot read back the takeoff clearance. The LAX air traffic controller transferred communications with EVA015 to SCT at 0119:54. At 0120:07, the pilot of EVA015 contacted the SCT Manhattan sector air traffic controller and reported climbing and passing 1,900 feet for 5,000 feet. The flight was departing LAX on the Ventura Seven Departure standard instrument procedure (see figure 1). The SCT Manhattan controller advised the pilot of radar contact and instructed him to climb and maintain 7,000 feet and to fly heading 090 degrees. The pilot read back the altitude but requested clarification on the heading; the SCT Manhattan controller again issued the heading as 090 degrees and restated the 7,000-foot altitude. The pilot acknowledged the heading and altitude. Figure 1 - Ventura Seven Standard Instrument Departure At 0121:16, the SCT Manhattan controller instructed the pilot of EVA015 "turn left heading of 180, climb and maintain 7,000." The pilot of EVA015 read back the heading and altitude and requested a "high speed climb." The SCT Manhattan controller approved the request. Radar data indicated EVA015 began to make a left turn. About 41 seconds later, the SCT Manhattan controller instructed the pilot of EVA015 to "turn right, right turn heading one eight zero." The pilot of EVA015 acknowledged the instruction and read back the right turn to a heading of 180 degrees. Radar data indicated the aircraft stopped the left turn to 180° and slowly began to turn right. At 0122:10, the SCT Manhattan controller instructed the pilot of EVA015 to "expedite your right turn." The pilot replied "roger [unintelligible] passing heading zero one zero, continue heading." The SCT Manhattan controller instructed an Air Canada Boeing 788 that was about 5.45 nm west of EVA015 to expedite a climb and to turn left heading 360°. At 0122:30, the SCT Manhattan controller instructed the pilot of EVA015 "stop your climb"; the pilot of EVA015 acknowledged. The SCT Manhattan controller then instructed the Air Canada flight to expedite to 12,000 feet. At 0122:50, the SCT Manhattan controller instructed the pilot of EVA015 to "turn left, left turn to a heading of ah, two nine ah, correction two seven zero." The pilot of EVA015 acknowledged the left turn to 270 degrees. At about 0123:04, the SCT Manhattan controller asked the pilot of EVA015 "what are you doing, turn southbound now, southbound now, stop your climb." The pilot of EVA015 replied "confirm EVA015 heavy, maintain 5,000, left, right, right heading [unintelligible]." At 0123:24, the SCT Manhattan controller called the Los Angeles arrivals sector air traffic controller and requested a point out reference EVA015. The Los Angeles arrivals sector approved the point out, and urged the SCT Manhattan controller to watch out for the minimum vectoring altitudes (MVAs) due to rising terrain. The SCT Manhattan controller acknowledged the caution. At 0123:30, the pilot of EVA015 contacted the SCT Manhattan controller and requested a confirmation of the assigned heading. The SCT Manhattan sector controller instructed the pilot to "turn southbound, southbound now." The pilot of EVA015 responded "roger turn southbound now, EVA015 heavy." Radar data showed EVA015 in a left turn. At 0124:03, the SCT Manhattan controller instructed EVA015 to "climb and maintain five thousand, and ah, are you, are you southbound now, I see you going northbound, climb and maintain six thousand." The pilot of EVA015 responded "roger, turning ah, we are turning south, and ah maintain five thousand, EVA015 heavy." The SCT Manhattan controller contacted LAX Air Traffic Control Tower (ATCT) and instructed them to stop departures. At 0124:17 the SCT Manhattan controller instructed the pilot to "climb and maintain seven thousand." The pilot of EVA015 acknowledged the climb. At 0124:22 the Low Altitude Alert (LA) began to flash on the SCT Manhattan controllers radar display and continued flashing until 0125:37. At 0124:25, the SCT Manhattan controller instructed the pilot of EVA015 "I see you're going southbound, turn south, correction I see you going northbound now, turn south now, climb and maintain seven thousand," there was no response. The SCT Manhattan controller again instructed the pilot of EVA015 to "climb and maintain seven thousand and turn south now." The pilot of EVA015 responded "[unintelligible] right turn to southbound, continue climb seven thousand." The pilot of EVA015 reiterated "continue right turn, and ah climb to seven thousand to a heading one eight zero." At 0125:31 the SCT Manhattan controller again instructed LAX ATCT to stop departures. At 0126:25, the pilot of EVA015 contacted the SCT Manhattan controller and reported they were heading 180 degrees at 7,000 feet. The SCT Manhattan controller acknowledged and again instructed EVA015 to "climb and maintain, ah maintain seven thousand." The pilot of EVA015 acknowledged the instructions. There were no further transmissions pertinent to the incident. While the SCT Manhattan sector controller was vectoring EVA015, the pilot of an aircraft on approach to LAX elected to go around while attempting to land LAX runway 09R. The LAX controller contacted the SCT Manhattan sector controller and requested a heading and altitude for the aircraft. The SCT Manhattan controller issued an initial heading of 090 degrees and a climb to 2,000 feet. The SCT and LAX ATCT Letter of Agreement (LOA) dated March 13, 2014 indicated eastbound aircraft flying a go around from LAX would be assigned an eastbound heading and a climb to 3,000 feet. The LOA stated [in part]: (9) Go arounds/missed approaches: (a) Assign all west traffic go arounds/missed approaches 2,000 feet. (b) Assign all east traffic and over ocean go arounds/missed approaches 3,000 feet. After establishing communications with the SCT Manhattan sector controller, the pilot was issued a heading of 180 degrees and to climb and maintain 2,000 feet. The SCT Manhattan sector controller then issued a climb to 5,000 feet and transferred communications to another SCT sector. However, the aircraft had entered a 2,700 foot MVA at an altitude of 2,000 feet while climbing to 5,000 feet. AIR TRAFFIC CONTROLLER TRAINING The incident controller was certified on the operating position on April 9, 2014 and was certified on all operating positions in the area specialty on January 13, 2014. She was designated as an on the job training instructor (OJTI), and able to teach developmental controllers how to work the operating position. As part of the facilities annual training, certain refresher training was required per SCT order 3120.1K, SCT Air Traffic Technical Training. Between the months of July to December of 2016, annual refresher training addressing LAX East Operations was required to be conducted. The refresher training included required briefings on East operations and simulation scenarios for air traffic controllers to work. The incident air traffic controller did not complete the required simulations. According to the SCT 7232.2C (Change 20), Standard Operating Practices, when LAX was operating in an East flow, and the aircraft was departing to Los Angeles Air Route Traffic Control Center (ZLA ARTCC) sector 14, the required heading for aircraft in communication with the Manhattan sector on the Ventura Seven Departure was a right turn to a heading of 250 degrees. The SCT 7232.2C addresses coordinated handoff procedures and states [in part]: 8-14-5. COORDINATED HANDOFF PROCEDURES For East Flow Jet Aircraft Departures From Manhattan sector to ZLA Sector 14: all aircraft with an initial fix of VTU shall be climbed to an altitude of at or above 13,000 feet and on a radar vector of 250 degrees. AIRPORT AND RADAR DATA Prior to the incident on December 15, 2017, LAX had been landing and departing in a west configuration. The winds were predominantly out of the east at 090° at 8 knots gusting to 15 knots, and several aircraft had elected to "go around" due to a tail wind during landing. LAX ATCT changed the landing and departing configuration to an east configuration about 0000 on December 16th. The airport changed back to a west configuration at about 0233. In general, two types of radar are used to provide position and track information for aircraft cruising at high altitudes between airport terminal airspaces, and for those operating at low altitude and speeds within terminal airspaces such as SCT. Air Route Surveillance Radars (ARSRs) are long range (250 nm) radars used to track aircraft cruising between terminal airspaces. ARSR antennae rotate at 5 to 6 rotations per minute (rpm), resulting in a radar return every 10 to 12 seconds. Airport Surveillance Radars (ASRs) are short range (60 nm) radars used to provide air traffic control services in terminal areas. ASR antennas rotate at 13 to 14 rpm, resulting in a radar return every 4.6 to 5 seconds. A radar detects the position of an object by broadcasting an electronic signal that is reflected by the object and returned to the radar antenna. These reflected signals are called primary returns. Knowing the speed of the radar signal and the time interval between when the signal was broadcast and when it was returned, the distance, or range, from the radar antenna to the reflecting object can be determined. Knowing the direction, the radar antenna was pointing when the signal was broadcast, the direction (or bearing, or azimuth) from the radar to the object can be determined. Range and azimuth from the radar to the object define the object's position. To improve the consistency and reliability of radar returns, aircraft are equipped with transponders that sense beacon interrogator signals broadcast from radar sites, and in turn broadcast a response signal. Even if the radar site is unable to sense a weak reflected primary return, it will sense the response signal broadcast by the transponder and be able to determine the aircraft position. The response signal can also contain additional information, such as the identifying "beacon code" for the aircraft, and the aircraft's pressure altitude (also called "Mode C" altitude). Transponder signals received by the radar site are called secondary returns. EVA015 was assigned a beacon code of 2031. Radar data for this report was obtained from the FAA at SCT and were derived from ASR sensors. The SCT plot playback (.PPB) data was of good quality and was part of the STARS (Standard Terminal Automation Replacement) utilized by air traffic control. Figure 2 illustrates the radar flight track of EVA015 as it departed LAX runway 07R until the aircraft was clear of any obstructions and had resumed the departure procedure. Figure 3 illustrates the radar flight track of EVA015 as it traveled near Mt. Wilson CA at an altitude of 6,200 feet, the MVA for that segment was 7,800 feet. Figure 4 is a Google Earth image illustrating the plotted radar flight track of EVA015 and the locations and heights (msl) for the antennae on top of Mt. Wilson. Figure 2 - Radar data showing EVA015 departing LAX and being turned northbound toward Mount Wilson. Figure 3 - Radar data showing EVA015 making a right turn just south of Mount Wilson. Figure 4 - Radar data overlaid on a Google Earth image with the TV antennas and the associated heights plotted. AIR TRAFFIC CONTROL PROCEDURESATC Service According to FAA Joint Order (FAA JO) 7110.65, Air Traffic Control, paragraph 2-1-1, ATC Service, the primary purpose of the ATC system is to prevent a collision between aircraft operating in the system and to provide a safe, orderly and expeditious flow of traffic. This includes collisions between aircraft and collisions with terrain or obstructions. Duty Priority The first duty priority for an air traffic controller is to separate aircraft and issue safety alerts. FAA JO 7110.65 paragraph 2-1-2, Duty Priority, states [in part]: 2-1-2. DUTY PRIORITY a. Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment must be used in prioritizing all other provisions of this order based on the requirements of the situation at hand. Safety Alert When the required separation between aircraft or terrain and obstructions decreases to less than applicable standards, and the separation is unsafe, a safety alert shall be issued to the pilot(s). FAA JO 7110.65 paragraph 2-1-6, Safety Alert, states [in part]: 2-1-6. SAFETY ALERT Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Separation from Obstructions According to the FAA, separation minima is the minimum longitudinal, lateral, or vertical distances by which aircraft are spaced through the application of air traffic control procedures. FAA JO 7110.65 paragraph 2-1-6, Separation from Obstructions, states [in part]: 5-5-9. SEPARATION FROM OBSTRUCTIONS a. TERMINAL. Separate aircraft from obstructions depicted on the radar display by the following minima: 1. When less than 40 miles from the antenna- 3 miles. 2. When 40 miles or more from the antenna- 5 miles. b. TERMINAL. Vertical separation of aircraft above an obstruction depicted on the radar display may be discontinued after the aircraft has passed it. AIR TRAFFIC OCCURRENCE REPORTING In January of 2012, the FAA issued new policies and procedures for collecting and investigating safety related incidents. There are two primary methods to report safety incidents within the FAA; Mandatory Occurrence Reports (MOR) and the Air Traffic Safety Action Program (ATSAP). The purpose of these programs is to collect associated safety related data and conditions from air traffic incidents that have occurred within the National Airspace System (NAS). Air traffic controllers have the option of notifying a supervisor or other person responsible for the operation who will initiate an MOR, or, the controller may use the voluntary safety reporting program ATSAP to submit the incident. In some cases, both methods may be used to report the same incident. However, if an ATSAP report is filed and accepted, the incident will be addressed through the ATSAP process with all information being forwarded to the event review committee (ERC). Mandatory Occurrence Report (MOR) The MOR is an electronic form accessed through the Comprehensive Electronic Data Analysis and Reporting (CEDAR) web-based tool. The MOR is the FAA air traffic organizations (ATO) method to "upward report" incidents, to collect safety related data, and to manage operations within the NAS. The FAA JO 7210.632, Air Traffic Organization Occurrence Reporting, states [in part]: 2-5. How to Report. As soon as practical, without impacting operations: a. Non-management personnel
The incident was caused by the air traffic controller assigning the pilots a left turn instead of the required right turn after departure which placed the aircraft in an unsafe proximity with terrain and obstructions. Contributing to the incident was the air traffic controller's inadequate recovery technique during the development of the incident.
Source: NTSB Aviation Accident Database
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