EVA B777 close call departing LAX
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The data revealed that the system generated two sets of caution warnings to the pilots, and then a seven-second pull up alert that began at 0124:49, as the aircraft was turning just south of Mt. Wilson.
That's significantly different from the proposal to facilitate publication and electronic depiction of MVAs.
MVAs have been evaluated per criteria similar to those embodied in MEA/MOCAs -- specific vertical and horizontal margins are guaranteeing minimum obstacle clearance values. Those MEA/MOCA margins are not "emergency" EGPWS algorithms.
Many envision the cockpit display of MVA sectors as more akin to depiction of MEAs on airways rather than waiting for EGPWS to turn red or issue audible "last chance" alarms.
Saying that "we have EGPWS so we don't need MVA moving maps" is a bit like saying "we have TCAS so we don't need ATC". (And I realize that no one on here has said that.)
Would pilots prefer to have MVA information in the cockpit presented on a scalable moving map vs delaying action until the EGPWS to turn red and hollers "PULL UP" "PULL UP"?
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https://dms.ntsb.gov/public/62000-62...361/624523.pdf
- one second after the pull up warning started the autopilot has disengaged.
- two seconds later the auto-throttles went from MODE (5) to THR HOLD (4)
- three seconds later the auto-throttles went from THR HOLD (4) to SPEED (1)
- until the pull up warnings the engines have been at around 79% N1. After those 7 seconds the engines reached 91% N1. 10 seconds later they reached 94% N1.
- until the pull up warnings they were climbing at around 1500 feet per minute. 7 seconds later they were climbing at about 3500 feet per minute. 3 seconds later they reached a vertical speed of about 4200 feet per minute.
- their pitch attitude was 7 degrees up when the warnings started. After 7 seconds it was 12 degrees up.
I doubt all that would have been possible if they "did nothing in the vertical direction".
I really don't understand the tendency on these forums to direct as much blame/responsibility as possible towards the pilots, even after the preliminary report clearly listed mistakes on the ATC's side, and didn't list any on the pilot side, not even recommendations. And the latest documents released by NTSB paint a similar picture. I noticed the same tendency in the discussions about the 737 MAX.
Yes, it's clear the EVA pilots lost situational awareness. But that ATC controller lost situational awareness much earlier and, like a human version of MCAS, repeatedly tried to kill them (of course, not intentionally). So it's not surprising the pilots became extremely confused.
It seems that controller was not trained for the northern area near the mountains so she didn't know the minimum altitudes in that area. So initially she kept telling them to stop climbing. The controller responsible for that northern area had to yell at her to watch the MVAs, when he realized the aircraft is too low and she's doing nothing about it.
Along with the GPWS, that's probably what saved the aircraft. Another controller paying attention.
Some quotes from her interview:
Ms. Hocutt said she was thinking about other duties, still scanning, still working with other aircraft, when she looked back at EVA015 and saw the aircraft was not turning south as instructed. She instructed the pilot of EVA015 to go southbound; she just wanted to get EVA015 out of the Burbank sectors airspace and back into her own airspace. She was not familiar with the MVAs in the Burbank sector because that was not her airspace. Even on an east flow, they are always topping Burbank’s traffic so the MVA did not cross her mind.
Ms. Hocutt did not know why she turned EVA015 left instead of right; she just wanted EVA015 to go southbound. [...] The Burbank controller had yelled over to her and said watch out for the MVAs with EVA015. She said that she knew she needed to be higher with EVA015 when she looked at the MVA map. Everybody in the TRACON heard what was going on because she was talking loudly and using expletives between transmissions.
Ms. Hocutt did not know why she turned EVA015 left instead of right; she just wanted EVA015 to go southbound. [...] The Burbank controller had yelled over to her and said watch out for the MVAs with EVA015. She said that she knew she needed to be higher with EVA015 when she looked at the MVA map. Everybody in the TRACON heard what was going on because she was talking loudly and using expletives between transmissions.
Her interview is at page 10.
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Non-pilot here, where did you get this information that they did nothing? I'm looking at the GPWS data and it seems to disagree with your claim:
https://dms.ntsb.gov/public/62000-62...361/624523.pdf
- one second after the pull up warning started the autopilot has disengaged.
- two seconds later the auto-throttles went from MODE (5) to THR HOLD (4)
- three seconds later the auto-throttles went from THR HOLD (4) to SPEED (1)
- until the pull up warnings the engines have been at around 79% N1. After those 7 seconds the engines reached 91% N1. 10 seconds later they reached 94% N1.
- until the pull up warnings they were climbing at around 1500 feet per minute. 7 seconds later they were climbing at about 3500 feet per minute. 3 seconds later they reached a vertical speed of about 4200 feet per minute.
- their pitch attitude was 7 degrees up when the warnings started. After 7 seconds it was 12 degrees up.
I doubt all that would have been possible if they "did nothing in the vertical direction"..
https://dms.ntsb.gov/public/62000-62...361/624523.pdf
- one second after the pull up warning started the autopilot has disengaged.
- two seconds later the auto-throttles went from MODE (5) to THR HOLD (4)
- three seconds later the auto-throttles went from THR HOLD (4) to SPEED (1)
- until the pull up warnings the engines have been at around 79% N1. After those 7 seconds the engines reached 91% N1. 10 seconds later they reached 94% N1.
- until the pull up warnings they were climbing at around 1500 feet per minute. 7 seconds later they were climbing at about 3500 feet per minute. 3 seconds later they reached a vertical speed of about 4200 feet per minute.
- their pitch attitude was 7 degrees up when the warnings started. After 7 seconds it was 12 degrees up.
I doubt all that would have been possible if they "did nothing in the vertical direction"..
I really don't understand the tendency on these forums to direct as much blame/responsibility as possible towards the pilots, even after the preliminary report clearly listed mistakes on the ATC's side, and didn't list any on the pilot side, not even recommendations. And the latest documents released by NTSB paint a similar picture. I noticed the same tendency in the discussions about the 737 MAX.
https://dms.ntsb.gov/public/62000-62...361/624519.pdf
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It seems that controller was not trained for the northern area near the mountains so she didn't know the minimum altitudes in that area. So initially she kept telling them to stop climbing. The controller responsible for that northern area had to yell at her to watch the MVAs, when he realized the aircraft is too low and she's doing nothing about it.
Along with the GPWS, that's probably what saved the aircraft.
.
Along with the GPWS, that's probably what saved the aircraft.
.
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Thanks for that -- I stand corrected. My eyes had glazed over after the first few pages of "not pull up" status.
Oh, without a doubt, the ATC owns this one. Also noteworthy were her failure to file an ATSAP within 24 hours and the decisions by her managers in evaluating the magnitude of the near disaster.
Oh, without a doubt, the ATC owns this one. Also noteworthy were her failure to file an ATSAP within 24 hours and the decisions by her managers in evaluating the magnitude of the near disaster.
What really bothers me is the FAA ATC policy to place aircraft separation ahead of assuring separation from terrain. The controller should have climb EVA to prevent it from going below an area where MVAs became higher than EVA's assign altitude.
I find that absolutely appalling.
I find that absolutely appalling.
That’s quite a policy the FAA have implemented there, can you point me in the direction where this FAA policy is published?
Rumour has it their union doesn’t want pilots “looking over the controller’s shoulders”
Any source to this rumour?
It appears the flight crew saved the day in spite of ATC
I haven’t read the full report, was that the published conclusion?
Sorry, I don’t want to dig you out on every post Aterpster but I wonder if cheap shots and ?made up? rumours really advance the exchange of information here and flight safety in general.
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Read the NTSB report.
Any source to this rumour?
I haven’t read the full report, was that the published conclusion?
Sorry, I don’t want to dig you out on every post Aterpster but I wonder if cheap shots and ?made up? rumours really advance the exchange of information here and flight safety in general.
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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.
Personnel issues:
Incorrect action selection - ATC personnel (Cause)
Interpretation/understanding - ATC personnel (Factor)
Total instruct/training recvd - ATC personnel
Lack of action - ATC personnel
Experience/qualifications - ATC personnel
Incorrect action selection - ATC personnel (Cause)
Interpretation/understanding - ATC personnel (Factor)
Total instruct/training recvd - ATC personnel
Lack of action - ATC personnel
Experience/qualifications - ATC personnel
If you want a clearer picture you should really read the entire report:
https://app.ntsb.gov/pdfgenerator/Re...Final&IType=IA
And the associated documents:
https://dms.ntsb.gov/pubdms/search/d...361&mkey=94560
And then maybe draw your own conclusion, if you don't trust NTSB's conclusion.
In my opinion, after I reviewed the GPWS data, the pilots initially followed the controller instructions to the letter. She told them to go left, they went left. She told them to go right, they went right. She told them to stop climbing, they stopped climbing. She told them to go left again, they went left again. She told them to climb, they climbed.
Unfortunately the controller assumed they were not following her instructions and/or not understanding her, and lost her temper. They only stopped following her instructions when they became extremely confusing, like telling them to go southbound when they were heading north, without specifying a left or right turn. They even asked her to clarify if she meant left or right. She seems to have missed that, didn't answer, and kept telling them to go southbound, still without specifying a turn direction, left of right.
Towards the end of the incident she finally started telling them to climb, after another controller yelled at her to watch the MVAs, but at no point there was a "expedite climb" from her. And she only asked them to climb to 7000, when the MVA for that mountain was 7800. It seems she didn't realize how close they were to terrain.
At some point the pilots realized they would have to do something themselves, and they chose a random turn direction, to the right, without waiting further confirmation. The only problem is that they were already very close to the terrain when they did that. The final piece that saved the day was the GPWS system telling them to pull up during that right turn, to which the pilots reacted immediately.
Also, there is no evidence the pilots had any issues understanding English as it was initially discussed here. I was doubting that was a factor in this incident, as their readbacks didn't have any errors and were very prompt, and to me their English sounded quite good, but I'm not a native English speaker.
Now, maybe there are things that the pilots could have done better, for example questioning the controller more, and having a better awareness of the terrain around them, but I think overall they didn't make any major mistakes.
As to the controller, not sure what to say. Anyone can make mistakes. Her losing her temper and using "expletives" was probably not ideal, but we all have bad days. It was an unusual situation, with traffic departing in the opposite direction that night due to weather, which happens very rarely. From her interview, she felt overloaded. And the aircraft entered an area she wasn't trained for.
She was alone at that point, her colleague was on a break and asked her to call him back if the departures change direction, which would things more challenging, but for some reason she didn't call him back to help.
What really surprised me was her work schedule. From her interview:
On the day of the incident, she had worked a 0545 to 1345 shift followed by an overtime mid-shift starting 8 hours later at 2200 to 0600 the following morning. Ms. Hocutt left work the afternoon prior to the incident; she could not recall exactly what she did, but, said she would normally eat and go to sleep around 1800 and wake up around 2100 to 2110. She lived within 20 minutes of the facility.
In any case, this is one of the limits for truck drivers:
14-Hour Driving Window This window is usually thought of as a “daily” limit even though it is not based on a 24-hour period. You are allowed a period of 14 consecutive hours in which to drive up to 11 hours after being off duty for 10 or more consecutive hours. The 14-consecutive-hour driving window begins when you start any kind of work. Once you have reached the end of this 14-consecutive-hour period, you cannot drive again until you have been off duty for another 10 consecutive hours, or the equivalent of at least 10 consecutive hours off duty.
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What happened to the controller?
It is rather concerning, given the results of the NTSB investigation, that the FAA refuses to provide information on what happened to this controller, even to the NTSB. Her actions nearly cost hundreds of lives. Surely the public's safety and confidence in the air traffic control system should outweigh privacy concerns in this instance.
Furthermore, given the apparent level of competence demonstrated by the controller, it is worth asking whether this controller was hired as part of the FAA's revamped ATC hiring policy, which substantially reduces the weight of AT-SAT scores and aviation background. That change was widely suggested to put other factors "ahead of airline safety.” Did it nearly lead to a major aviation disaster, and is it likely to lead to one in the future?
Furthermore, given the apparent level of competence demonstrated by the controller, it is worth asking whether this controller was hired as part of the FAA's revamped ATC hiring policy, which substantially reduces the weight of AT-SAT scores and aviation background. That change was widely suggested to put other factors "ahead of airline safety.” Did it nearly lead to a major aviation disaster, and is it likely to lead to one in the future?
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OK. I took the 7,800 MVA from NTSB's final report, but they might have made a mistake. This quote is from page 8 of the final report:
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.
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It is rather concerning, given the results of the NTSB investigation, that the FAA refuses to provide information on what happened to this controller, even to the NTSB. Her actions nearly cost hundreds of lives. Surely the public's safety and confidence in the air traffic control system should outweigh privacy concerns in this instance.
Furthermore, given the apparent level of competence demonstrated by the controller, it is worth asking whether this controller was hired as part of the FAA's revamped ATC hiring policy, which substantially reduces the weight of AT-SAT scores and aviation background. That change was widely suggested to put other factors "ahead of airline safety.” Did it nearly lead to a major aviation disaster, and is it likely to lead to one in the future?
Furthermore, given the apparent level of competence demonstrated by the controller, it is worth asking whether this controller was hired as part of the FAA's revamped ATC hiring policy, which substantially reduces the weight of AT-SAT scores and aviation background. That change was widely suggested to put other factors "ahead of airline safety.” Did it nearly lead to a major aviation disaster, and is it likely to lead to one in the future?
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and just like the AC SFO near disaster, there was another ATCer around but they were on break again. Should the Unions be challenged on just how often ATC at night are being paid to do their jobs but bandbox sectors together and one creeps off for a snooze in the rest room? I am *not* referring here to the mandatory breaks controllers should rightfully take..
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It is rather concerning, given the results of the NTSB investigation, that the FAA refuses to provide information on what happened to this controller, even to the NTSB. Her actions nearly cost hundreds of lives. Surely the public's safety and confidence in the air traffic control system should outweigh privacy concerns in this instance.
Furthermore, given the apparent level of competence demonstrated by the controller, it is worth asking whether this controller was hired as part of the FAA's revamped ATC hiring policy, which substantially reduces the weight of AT-SAT scores and aviation background. That change was widely suggested to put other factors "ahead of airline safety.” Did it nearly lead to a major aviation disaster, and is it likely to lead to one in the future?
Furthermore, given the apparent level of competence demonstrated by the controller, it is worth asking whether this controller was hired as part of the FAA's revamped ATC hiring policy, which substantially reduces the weight of AT-SAT scores and aviation background. That change was widely suggested to put other factors "ahead of airline safety.” Did it nearly lead to a major aviation disaster, and is it likely to lead to one in the future?
She is a highly experienced controller with nearly 20 years on the job, including 5 years as a military controller (US Navy) before she joined the FAA.
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What really bothers me is the FAA ATC policy to place aircraft separation ahead of assuring separation from terrain. The controller should have climb EVA to prevent it from going below an area where MVAs became higher than EVA's assign altitude.
I find that absolutely appalling.
I find that absolutely appalling.
It is, however, the stated primary function of ATC to prevent aircraft-aircraft collisions. All innovations and "tombstone engineering" of the ATC system over many decades have been based on that proposition. Pilots are responsible for not hitting the ground, and ATC is responsible for pilots not hitting other aircraft.
And there is a certain logic to that: collide with another plane, and two planeloads of people die. Collide with a mountain, and we only lose one aircraft. Given that ATC is not exactly underworked and sitting around with free time on their hands, something has to give, and so the policy is "other aircraft first!"
Fortunately, pilots (some at least) are getting better tools to hold up their end (EGPWS, 3D cockpit maps, etc.). It may be more a question of better arranging when and how a PIC can depart from an ATC clearance that has them heading for terrain, and training on how important it is to do that, and not let "ATC Authority Gradient" put one at risk. "Unable maintain 6000, terrain - climbing to 8000 right now! Get 'em out of my way!"
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DPattern_is_full,
Concur 100%....Your comments should be emphasised in line training,not only bashing out SOP stuff...More of the "real world,save your butt stuff!
With the modern generation of aircraft,there is less and less excuse for lack of situational awareness.
My overriding ambition in my professional life,is to avoid appearing here!!!
Concur 100%....Your comments should be emphasised in line training,not only bashing out SOP stuff...More of the "real world,save your butt stuff!
With the modern generation of aircraft,there is less and less excuse for lack of situational awareness.
My overriding ambition in my professional life,is to avoid appearing here!!!
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Level 6 is supposed to be normal. It is not. Many are way below.
y
