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|
Attributes | |
ACN | 418332 |
Time | |
Date | 199810 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : sac airport : sac |
State Reference | CA |
Altitude | msl bound lower : 1300 msl bound upper : 1300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sac |
Operator | general aviation : corporate |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : intermediate altitude landing : go around landing : missed approach |
Route In Use | enroute : on vectors |
Flight Plan | None |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, Low Wing, 1 Eng, Retractable Gear |
Flight Phase | climbout : intermediate altitude |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain instruction : instructor oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 60 flight time total : 5500 flight time type : 800 |
ASRS Report | 418332 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer instruction : trainee |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | conflict : nmac non adherence : required legal separation other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew Other |
Miss Distance | horizontal : 300 vertical : 0 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
On oct/xa/98 at approximately XA15, I was training an experienced pilot for first officer duties in a beechcraft 1900. It was a VFR day and we were in the process of shooting an ILS 2 approach into sac. My first officer student was flying and was 'on the gauges.' we were advised by approach control that our missed approach procedure would be a left turn to 250 degrees and climb to 1500 ft. As we crossed the OM we were told by approach to contact sac tower. After contacting the tower, the tower operator told us to start our missed approach when reaching the golf course, which is short of the runway. The tower also changed our missed approach to a right turn to 150 degrees with no change in the altitude. As we approached the airport, a beechcraft bonanza was cleared for takeoff on runway 20. The bonanza was not in sight. We went missed approach at the golf course and turned to a heading of 150 degrees and started our climb to 1500 ft. As we reached 1300 ft the tower instructed us to maintain 1000 ft. At this moment we were still in our right turn when I saw the bonanza out of the first officer's window. He was going approximately the same direction as we were. We were very quickly overrunning him as he started to turn into us and we were turning into him. I grabbed the controls and made a steep left turn to avoid the bonanza. I only got a glimpse of the bonanza but feel that we were within 300 ft laterally and on the same altitude when I first saw him. We were climbing out at approximately 160 KTS and the bonanza was probably climbing out at 100 KTS. The tower then instructed us to continue our left turn and to fly over the airport and then to contact approach control. I later telephoned the tower to ask what went wrong. I was told that the bonanza pilot had reported me in sight and that the tower operator had both the bonanza and myself in sight and since VFR conditions existed, the rules of see and avoid were applicable. I agree that the conditions were VFR and that it was the responsibility of each pilot to see and avoid the other aircraft, however, when the tower changed my missed approach instructions from turning left to turning right, the same directions as the bonanza pilot, this set up a recipe for disaster with both aircraft converging and turning to the same side of the airport. It is my personal feeling that the tower operator erred in that I did not see the bonanza and that I did not report it in sight when queried by the tower operator prior to the incident. I had reported that we were 'looking.' the tower operator also should not have turned the 2 converging airplanes into each other. After all, the bonanza had turned away from us and could no longer see us. I was turning to the right with the first officer 'on the gauges' and also could not see the bonanza. The beechcraft 1900 is a twin turboprop and is much faster than the bonanza and as a result we overtook the bonanza in short order. The bonanza was in our blind area until it became visible as he turned into us.
Original NASA ASRS Text
Title: BE02 AND BE35 HAD NMAC WHEN BOTH ACFT WERE FOLLOWING TWR LCL CTLR DEP INSTRUCTIONS.
Narrative: ON OCT/XA/98 AT APPROX XA15, I WAS TRAINING AN EXPERIENCED PLT FOR FO DUTIES IN A BEECHCRAFT 1900. IT WAS A VFR DAY AND WE WERE IN THE PROCESS OF SHOOTING AN ILS 2 APCH INTO SAC. MY FO STUDENT WAS FLYING AND WAS 'ON THE GAUGES.' WE WERE ADVISED BY APCH CTL THAT OUR MISSED APCH PROC WOULD BE A L TURN TO 250 DEGS AND CLB TO 1500 FT. AS WE CROSSED THE OM WE WERE TOLD BY APCH TO CONTACT SAC TWR. AFTER CONTACTING THE TWR, THE TWR OPERATOR TOLD US TO START OUR MISSED APCH WHEN REACHING THE GOLF COURSE, WHICH IS SHORT OF THE RWY. THE TWR ALSO CHANGED OUR MISSED APCH TO A R TURN TO 150 DEGS WITH NO CHANGE IN THE ALT. AS WE APCHED THE ARPT, A BEECHCRAFT BONANZA WAS CLRED FOR TKOF ON RWY 20. THE BONANZA WAS NOT IN SIGHT. WE WENT MISSED APCH AT THE GOLF COURSE AND TURNED TO A HDG OF 150 DEGS AND STARTED OUR CLB TO 1500 FT. AS WE REACHED 1300 FT THE TWR INSTRUCTED US TO MAINTAIN 1000 FT. AT THIS MOMENT WE WERE STILL IN OUR R TURN WHEN I SAW THE BONANZA OUT OF THE FO'S WINDOW. HE WAS GOING APPROX THE SAME DIRECTION AS WE WERE. WE WERE VERY QUICKLY OVERRUNNING HIM AS HE STARTED TO TURN INTO US AND WE WERE TURNING INTO HIM. I GRABBED THE CTLS AND MADE A STEEP L TURN TO AVOID THE BONANZA. I ONLY GOT A GLIMPSE OF THE BONANZA BUT FEEL THAT WE WERE WITHIN 300 FT LATERALLY AND ON THE SAME ALT WHEN I FIRST SAW HIM. WE WERE CLBING OUT AT APPROX 160 KTS AND THE BONANZA WAS PROBABLY CLBING OUT AT 100 KTS. THE TWR THEN INSTRUCTED US TO CONTINUE OUR L TURN AND TO FLY OVER THE ARPT AND THEN TO CONTACT APCH CTL. I LATER TELEPHONED THE TWR TO ASK WHAT WENT WRONG. I WAS TOLD THAT THE BONANZA PLT HAD RPTED ME IN SIGHT AND THAT THE TWR OPERATOR HAD BOTH THE BONANZA AND MYSELF IN SIGHT AND SINCE VFR CONDITIONS EXISTED, THE RULES OF SEE AND AVOID WERE APPLICABLE. I AGREE THAT THE CONDITIONS WERE VFR AND THAT IT WAS THE RESPONSIBILITY OF EACH PLT TO SEE AND AVOID THE OTHER ACFT, HOWEVER, WHEN THE TWR CHANGED MY MISSED APCH INSTRUCTIONS FROM TURNING L TO TURNING R, THE SAME DIRECTIONS AS THE BONANZA PLT, THIS SET UP A RECIPE FOR DISASTER WITH BOTH ACFT CONVERGING AND TURNING TO THE SAME SIDE OF THE ARPT. IT IS MY PERSONAL FEELING THAT THE TWR OPERATOR ERRED IN THAT I DID NOT SEE THE BONANZA AND THAT I DID NOT RPT IT IN SIGHT WHEN QUERIED BY THE TWR OPERATOR PRIOR TO THE INCIDENT. I HAD RPTED THAT WE WERE 'LOOKING.' THE TWR OPERATOR ALSO SHOULD NOT HAVE TURNED THE 2 CONVERGING AIRPLANES INTO EACH OTHER. AFTER ALL, THE BONANZA HAD TURNED AWAY FROM US AND COULD NO LONGER SEE US. I WAS TURNING TO THE R WITH THE FO 'ON THE GAUGES' AND ALSO COULD NOT SEE THE BONANZA. THE BEECHCRAFT 1900 IS A TWIN TURBOPROP AND IS MUCH FASTER THAN THE BONANZA AND AS A RESULT WE OVERTOOK THE BONANZA IN SHORT ORDER. THE BONANZA WAS IN OUR BLIND AREA UNTIL IT BECAME VISIBLE AS HE TURNED INTO US.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.