37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 85583 |
Time | |
Date | 198804 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : smo airport : lax |
State Reference | CA |
Altitude | msl bound lower : 9000 msl bound upper : 9700 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid enroute airway : lax |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other descent other |
Route In Use | arrival : profile descent arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 237 flight time total : 11732 flight time type : 8532 |
ASRS Report | 85583 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 180 flight time total : 3400 |
ASRS Report | 86032 |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Miss Distance | horizontal : 1500 vertical : 350 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Intra Facility Coordination Failure |
Narrative:
We had just departed lax on the gorman 7 SID. We were being radar vectored by lax departure control. WX was scattered to broken clouds with multiple layers. The controller cleared us to 9000', heading 360 degrees. Shortly after we reached 9000', the controller cleared us to 13000'. Passing 9700', I caught sight of an medium large transport Y at my 11:30, traveling from my left to my right, level in altitude with us, 2000' away and closing. (I later found out it was inbound to lax on the fim 4 profile descent.) I initiated an immediate left turn, 45 degrees of bank, stopped my climb and started descending. The controller came on and told us to return to 9000'. My first officer said, 'please confirm for medium large transport Y.' the controller told us to descend to 9000' 'immediately.' the turn I made changed our heading 40-50 degrees. I rolled wings level and watched the medium large transport Y travel on away from us. Although this was not a near miss, it was a potential near miss! My turn prevented a potential disaster. 'The controller messed up,' the lax approach area manager told me on the telephone he told me that both the approach and departure controllers were in training. He said that the departure controller didn't see the inbound medium large transport Y. It was obvious, but he didn't say it, that the approach controller didn't talk with the departure controller. The supervisor said that he was instituting corrective action with them. The departure controller should have kept us at 9000' until we had passed the 261 degree right smo VORTAC, then cleared us to climb. He should also coordinate with the approach controller before issuing climb clearance. His reaction to the conflict was wrong. A straight ahead descent would have put us into a collision with the medium large transport Y! An order for us to make an immediate turn and a maximum climb would have been appropriate. I would suggest more training is needed for both controllers. The question remains: what would hav happened if we had been in solid IMC and not seen the medium large transport Y? Supplemental information from acn 86032: at the same time, our captain had spotted an oncoming aircraft at our altitude and to the left of us. He made an immediate turn towards the other aircraft rear, taking us behind that aircraft flight path. Supplemental information from acn 85651: while executing the published (fim fim 4) profile descent 24/25 to lax near bayst, we saw an large transport X coming towards us from the right and lower than we were but climbing. We were level at 10000' MSL and the large transport X appeared to level off at 9000' MSL. A very short time later the large transport X started a climb. From my perspective the large transport X was going to strike our aircraft on the right side if we both continued as we were going. I then turned the autoplt off and commenced a descent and turn to the left away from the oncoming large transport X. We passed through the large transport X altitude at approximately 9700', 35 degree bank, 8 degree nose down. At the moment when we went through the large transport X altitude, we saw that aircraft roll left at a very steep bank angle and pitch up higher than normal. Obviously, the other crew had seen us. The large transport X passed behind us and higher than we were as now we were down to approximately 9550' MSL. We then climbed back to 10000' MSL and got back over to the 261 degree right of smo and continued in to lax. Shortly after we pitched down and turned left, the approach controller started telling us to make an immediate left turn. If we had waited for his command, we would not have cleared the large transport X. The moves made by either aircraft avoided the impact. The moves made by both afforded us approximately 1500-2000' horizontal sep, no vertical sep, as we passed through each others' altitude. If the conditions had been IMC at the time, there would have been a midair collision. Lax approach admitted this near midair collision was caused by controller error. The departure controller cleared the large transport X from 9000 to 11000', through our altitude. 1) do not clear aircraft on the gorman 7 departure (GMN7.gmn) to above 9000' MSL until north of the smo 261 degree right. 2) make all acfr on GMN7.gmn track northbound west of bayst intersection. Normally at bayst a clearance to descend to cross smo VOR at 7000' is issued by approach (fim.FIM4) arrival. This arrival procedure generally uses the airspace from 7000 to 10000' on the 261 degree right smo from the VOR to 10 west of the VOR, so if aircraft departing could stay west of bayst at 9000' or below this may not happen again.
Original NASA ASRS Text
Title: DEPARTURE CTLR IN TRAINING CLIMBED AN LGT WITHOUT COORD WITH APCH CTLR. ACFT TOOK EVASIVE ACTION TO MISS.
Narrative: WE HAD JUST DEPARTED LAX ON THE GORMAN 7 SID. WE WERE BEING RADAR VECTORED BY LAX DEP CTL. WX WAS SCATTERED TO BROKEN CLOUDS WITH MULTIPLE LAYERS. THE CTLR CLRED US TO 9000', HDG 360 DEGS. SHORTLY AFTER WE REACHED 9000', THE CTLR CLRED US TO 13000'. PASSING 9700', I CAUGHT SIGHT OF AN MLG Y AT MY 11:30, TRAVELING FROM MY LEFT TO MY RIGHT, LEVEL IN ALT WITH US, 2000' AWAY AND CLOSING. (I LATER FOUND OUT IT WAS INBOUND TO LAX ON THE FIM 4 PROFILE DSCNT.) I INITIATED AN IMMEDIATE LEFT TURN, 45 DEGS OF BANK, STOPPED MY CLB AND STARTED DSNDING. THE CTLR CAME ON AND TOLD US TO RETURN TO 9000'. MY F/O SAID, 'PLEASE CONFIRM FOR MLG Y.' THE CTLR TOLD US TO DSND TO 9000' 'IMMEDIATELY.' THE TURN I MADE CHANGED OUR HDG 40-50 DEGS. I ROLLED WINGS LEVEL AND WATCHED THE MLG Y TRAVEL ON AWAY FROM US. ALTHOUGH THIS WAS NOT A NEAR MISS, IT WAS A POTENTIAL NEAR MISS! MY TURN PREVENTED A POTENTIAL DISASTER. 'THE CTLR MESSED UP,' THE LAX APCH AREA MGR TOLD ME ON THE TELEPHONE HE TOLD ME THAT BOTH THE APCH AND DEP CTLRS WERE IN TRNING. HE SAID THAT THE DEP CTLR DIDN'T SEE THE INBOUND MLG Y. IT WAS OBVIOUS, BUT HE DIDN'T SAY IT, THAT THE APCH CTLR DIDN'T TALK WITH THE DEP CTLR. THE SUPVR SAID THAT HE WAS INSTITUTING CORRECTIVE ACTION WITH THEM. THE DEP CTLR SHOULD HAVE KEPT US AT 9000' UNTIL WE HAD PASSED THE 261 DEG R SMO VORTAC, THEN CLRED US TO CLB. HE SHOULD ALSO COORDINATE WITH THE APCH CTLR BEFORE ISSUING CLB CLRNC. HIS REACTION TO THE CONFLICT WAS WRONG. A STRAIGHT AHEAD DSCNT WOULD HAVE PUT US INTO A COLLISION WITH THE MLG Y! AN ORDER FOR US TO MAKE AN IMMEDIATE TURN AND A MAX CLB WOULD HAVE BEEN APPROPRIATE. I WOULD SUGGEST MORE TRNING IS NEEDED FOR BOTH CTLRS. THE QUESTION REMAINS: WHAT WOULD HAV HAPPENED IF WE HAD BEEN IN SOLID IMC AND NOT SEEN THE MLG Y? SUPPLEMENTAL INFO FROM ACN 86032: AT THE SAME TIME, OUR CAPT HAD SPOTTED AN ONCOMING ACFT AT OUR ALT AND TO THE LEFT OF US. HE MADE AN IMMEDIATE TURN TOWARDS THE OTHER ACFT REAR, TAKING US BEHIND THAT ACFT FLT PATH. SUPPLEMENTAL INFO FROM ACN 85651: WHILE EXECUTING THE PUBLISHED (FIM FIM 4) PROFILE DSCNT 24/25 TO LAX NEAR BAYST, WE SAW AN LGT X COMING TOWARDS US FROM THE RIGHT AND LOWER THAN WE WERE BUT CLBING. WE WERE LEVEL AT 10000' MSL AND THE LGT X APPEARED TO LEVEL OFF AT 9000' MSL. A VERY SHORT TIME LATER THE LGT X STARTED A CLB. FROM MY PERSPECTIVE THE LGT X WAS GOING TO STRIKE OUR ACFT ON THE RIGHT SIDE IF WE BOTH CONTINUED AS WE WERE GOING. I THEN TURNED THE AUTOPLT OFF AND COMMENCED A DSCNT AND TURN TO THE LEFT AWAY FROM THE ONCOMING LGT X. WE PASSED THROUGH THE LGT X ALT AT APPROX 9700', 35 DEG BANK, 8 DEG NOSE DOWN. AT THE MOMENT WHEN WE WENT THROUGH THE LGT X ALT, WE SAW THAT ACFT ROLL LEFT AT A VERY STEEP BANK ANGLE AND PITCH UP HIGHER THAN NORMAL. OBVIOUSLY, THE OTHER CREW HAD SEEN US. THE LGT X PASSED BEHIND US AND HIGHER THAN WE WERE AS NOW WE WERE DOWN TO APPROX 9550' MSL. WE THEN CLBED BACK TO 10000' MSL AND GOT BACK OVER TO THE 261 DEG R OF SMO AND CONTINUED IN TO LAX. SHORTLY AFTER WE PITCHED DOWN AND TURNED LEFT, THE APCH CTLR STARTED TELLING US TO MAKE AN IMMEDIATE LEFT TURN. IF WE HAD WAITED FOR HIS COMMAND, WE WOULD NOT HAVE CLRED THE LGT X. THE MOVES MADE BY EITHER ACFT AVOIDED THE IMPACT. THE MOVES MADE BY BOTH AFFORDED US APPROX 1500-2000' HORIZ SEP, NO VERT SEP, AS WE PASSED THROUGH EACH OTHERS' ALT. IF THE CONDITIONS HAD BEEN IMC AT THE TIME, THERE WOULD HAVE BEEN A MIDAIR COLLISION. LAX APCH ADMITTED THIS NMAC WAS CAUSED BY CTLR ERROR. THE DEP CTLR CLRED THE LGT X FROM 9000 TO 11000', THROUGH OUR ALT. 1) DO NOT CLR ACFT ON THE GORMAN 7 DEP (GMN7.GMN) TO ABOVE 9000' MSL UNTIL N OF THE SMO 261 DEG R. 2) MAKE ALL ACFR ON GMN7.GMN TRACK NBOUND W OF BAYST INTXN. NORMALLY AT BAYST A CLRNC TO DSND TO CROSS SMO VOR AT 7000' IS ISSUED BY APCH (FIM.FIM4) ARR. THIS ARR PROC GENERALLY USES THE AIRSPACE FROM 7000 TO 10000' ON THE 261 DEG R SMO FROM THE VOR TO 10 W OF THE VOR, SO IF ACFT DEPARTING COULD STAY W OF BAYST AT 9000' OR BELOW THIS MAY NOT HAPPEN AGAIN.
Data retrieved from NASA's ASRS site as of August 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.