EVA B777 close call departing LAX

[MajorLemond]

After reading through this as pilot, I'm stunned at how much flak ATC is copping for this. Almost entirely flight crew error and frustrating to listen to.

Firstly, yes, Atc made the initial error of issuing a left turn, however any pilot with even a moderate shred of situational awareness would query this as it is not logical. Even if you are half asleep when you start winding the heading bug looking for a Hdg of 180 it's immediately obvious that something isn't right as the digits in the FCU window start winding back from an easterly HDG. It was never queried by EVA, just blindly followed.

Secondly, the error was corrected by ATC soon after and acknowledged by The crew who proceeded to then carry on North (Towards high terrain) after repeated instructions to turn south. I'm with ATC wholeheartedly she says "What are you doing!?"

Yes, What the actual are you doing?

Thirdly, in the process of ignoring / not complying with repeated ATC instructions these guys completely screwed up the traffic situation that the controller had to manage. Her workload increased 10-fold in a busy traffic situation and I feel she managed it quite well - considering she had to deal with what became essentially a rogue aircraft in her airspace.

I hear a lot of these particular guys on the airwaves with varying degrees of spoken English. The guy responding to to ATC seemed to have excellent english so I doubt that it was a factor in this incident.

I would imagine that that these guys did some sort of pre-departure brief, surely the threat of high terrain to the North would be the sticking point of this, but who knows... maybe their pre departure brief consisted of a dart in the cockpit.

Sorry, but both of the crew need a massive boot up the ass for this. Huge lack of situational awareness and basic airmanship.

[ussatlantis]

There are plenty of incompetent captains and non-assertive FOs in Asia.

[RubberDogPoop]

Sergeant Lemon, I know it's a lot, but please go back and read the thread - it's been done to death that the crew didn't just fly a heading of 360 when they meant 180. Language or no, we all use the same numbers - are you seriously contending that the crew "just" flew 360 in error?
1. Give a heavy jet multiple, rapid reversals of turn and pretty soon they'll appear on your scope to be "maintaining a heading".
Should some query have taken place? Absolutely. Though, not having your read-back of the instruction corrected would go some way to alleviate any doubt.

2. No. They did not "proceed(ed) to then carry on North"

3. Her traffic situation should not be a concern of theirs.

4. Speaking English, and translating it in your head to native language is not the same thing.

Yes. Yes they do, more for the loss of SA on terrain than for anything else...
As always, multiple factors, and players involved.

[Zeffy]

Two Years (!) Later

Originally Posted by aterpster

...Hope we get to see a final report, complete with ATC transcripts and TRACON radar readouts.

NTSB -- nearly two years have passed and we are still waiting to see the report.

[Gipsy Queen]

Originally Posted by Airbubba

And never get between a Canadian and a Walmart in the lower 48. .

Having spent 15 years in the Florida boat business, I really understand this comment!

[Zeffy]

NTSB Accident ID OPS17IA010

NTSB Docket

[AerocatS2A]

Wow. If I'm reading correctly, while all this was happening, another aircraft in a missed approach was vectored below the MVA.

[Zeffy]

https://www.ntsb.gov/_layouts/ntsb.a...17IA010&akey=1

NTSB Identification: OPS17IA010
Incident occurred Friday, December 16, 2016 in Mt. Wilson, CA
Probable Cause Approval Date: 05/07/2019
Aircraft: BOEING 777, registration:
Injuries: Unavailable
NTSB investigators used data provided by various sources and may have traveled in support of this investigation to prepare this aircraft incident report.

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.

The National Transportation Safety Board determines the probable cause(s) of this incident as follows:

• 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.

Full narrative available

[aterpster]

I recommend downloading the entire docket and, if the audio is still available on the Internet, to give it a good listen once you have read the docket materials.

[bill fly]

The Profession

What an interesting thread... We are all in the same profession - have the same aims and try to be professional in our work.
We rely on each other and communicate together every day.

Yet pilots and ATC both use almost slanderous terms here to describe each other, US and non-US pilots pontificate at each other,
everybody is certain to be "in the right".

If that can happen here, in our prestigious club, no wonder that the World is falling apart in other respects.

The internet has a lot to answer for if this is the best we can do.

[Airbubba]

It was the controller's second loss of separation incident in less than two years and she was traumatized by the event.

As she says in her NTSB interview:

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.

Looks like our early analysis on this thread of the close encounter with the Mount Wilson antenna farm was pretty accurate.

Originally Posted by aterpster

I recommend downloading the entire docket and, if the audio is still available on the Internet, to give it a good listen once you have read the docket materials.

The audio is still online here:

You Tube

Because the controller submitted an Air Traffic Safety Action Program report, the NTSB was not able to determine if she again received additional remedial training (Skill Enhancement Training) due to confidentiality rules.

Because of the significant MOR for this incident, the incident controller was recommended for SET by the SCT Local Safety Council and the ATM. However, because the controller submitted an ATSAP report, the SET request was submitted to the WSA ERC for consideration. According to FAA JO 7200.20, Voluntary Safety Reporting Programs (VSRP), “Keep confidential, to the extent feasible, information requested by, and all skill enhancement training recommended by the ERC.” Accordingly, there is no record of the approved SET by the ERC.

Before this incident, the SCT Manhattan sector controller had received SET on March 16, 2015 because of a loss of separation event between two aircraft. On February 27, 2015, she was working the SCT Malibu radar sector in the DEL area separation was lost between two aircraft that she was responsible to provide separation between. The SET was recommended by the OM for the Del Ray area and concurred with by the WSA ERC. The SET noted that its purpose was to assist the controller with an “opportunity to improve your knowledge, skills, abilities, and performance in the radar environment.”

Also, the FAA would not reveal whether the ATSAP report was accepted late after the 24 hour reporting deadline:

An interview with the incident controller revealed that she submitted her ATSAP report on December 17, 2016 and acknowledged it was more than 24 hours after being notified of the incident. The NTSB made efforts to determine if the ATSAP report was accepted by the ERC, however, FAA ATO declined to provide that information.

[Zeffy]

Why can't FAA provide MVA data for display in cockpits?

And it remains doubtful that any disaster or near-disaster will ever persuade FAA's Air Traffic Organization to support cockpit displays of MVAs.


https://flightsafety.org/fsd/fsd_sept04.pdf

[cactusbusdrvr]

Whoa. What a sh** show.

It all works great..... until it doesn’t. I have no idea why the controller did not give the corrected headings to Eva in degrees instead of directions in such a stressful situation. Those guys fly by rote, they will execute instructions but it can’t be in nonstandard form.

I have had London Control give me headings referenced to compass directions, I.e. “American 135 heavy turn left heading North” but that’s not usual, and it makes perfect sense to us when it happens.

Longtime ago I was working for a cargo carrier in Detroit. We were out doing practice approaches when we heard Detroit Approach working a small Cessna who was obviously lost. They poor guy was trying to identify landmarks and was having trouble getting his transponder to work. The controller was trying to identify him by giving vectors. The guy kept screwing that up as well. Finally the controller said “turn towards the big E on your compass and look for the river”.

And I would fault the EVA crew for not recognizing the situation and speaking up sooner. According to the NTSB they got multiple alerts then the final terrain warning, yet they never said a word???

[Zeffy]

https://aviationweek.com/commercial-...ain-ntsb-finds

ATC Mistakes Sent 777 Towards California Mountain, NTSB Finds
May 14, 2019 Sean Broderick | Aviation Daily


WASHINGTON—An air traffic controller’s errant instruction to turn left instead of right towards an assigned heading during a rare departure pattern out of Los Angeles International Airport (LAX) led an EVA Air Boeing 777 to within hundreds of feet of a mountain peak topped with large antennas, an NTSB investigation found.

The incident took place Dec. 16, 2016. Weather at the time was overcast with steady rain and visibility of about 1,000 ft. The weather and winds had the airport operating in a rare “east flow” departure configuration starting at about midnight Dec. 15, NTSB said. Prevailing winds usually have LAX operating a west flow, with departures heading directly out over the Pacific Ocean.

The crew of the 777-300ER, Flight 015 (EVA015) headed for Taipei, requested Runway 07 Right for departure, and was granted the request.

After receiving their takeoff clearance at 0117:49 a.m. local time, the pilots lifted off, flying the Ventura Seven Departure standard instrument procedure, and were transferred to Southern California Terminal Radar Approach Control (SCT). Soon after departure, the controller working SCT’s Manhattan sector told EVA015 to climb and maintain 7,000 ft. and fly heading 090 deg. The pilot confirmed the instruction and proceeded.

About one minute later, the controller instructed EVA015 to “turn left heading of 180 [deg.], climb and maintain 7,000 [ft.],” the report said. A pilot confirmed the heading and altitude and requested a high-speed climb, which the controller approved.

The aircraft began a slow turn and was soon headed northwest towards the San Gabriel Mountains north of Los Angeles. About 41 sec. after the turn began, the controller ordered EVA015 to “turn right, right turn heading 180 [deg.].” The pilot read back the instructions and confirmed them.

“Radar data indicated the aircraft stopped the left turn to 180 deg, and slowly began to turn right,” the report said.

At 0122:10, the controller asked EVA015 to “expedite its right turn.” The controller also ordered an Air Canada Boeing 787-8 that was 5.5 nm west of EVA015 and heading towards the 777 to expedite a climb and turn left, and asked EVA015 to “stop your climb.” One of the EVA015 pilots confirmed the instruction and said it would hold at 5,000 ft.

At 0122:50, the controller instructed EVA015 to “turn left, left turn to a heading of ah, two nine ah, correction two seven zero,” the report said. The pilot of EVA015 acknowledged the left turn to 270 deg. and began a slow turn. Seconds later, the controller asked EVA015, “What are you doing? Turn southbound, southbound now. Stop your climb.” The crew responded with a partially unintelligible message that included “maintain 5,000.”

About a minute after ordering the left turn, the SCT controller cleared EVA015 to 6,000 ft., and asked if the aircraft was going south. “I see you going northbound,” the controller said.

EVA015 replied that was “turning south” and would maintain 5,000 ft.

The SCT controller then contacted Los Angeles arrivals sector controllers and asked them to stop departures out of LAX.

At 0124:17, the SCT controlled ordered EVA015 to “climb and maintain 7,000 ft.” The pilot of EVA015 acknowledged the climb. At 0124:22 the Low Altitude Alert (LA) began to flash on the SCT controllers’ radar display and continued until 0125:37.

At 0124:25, the SCT controller told EVA015, “I see you’re going southbound, turn south, correction I see you going northbound now, turn south now, climb and maintain 7,000,” The pilots did not respond.

The controller repeated the instruction to climb and maintain 7,000 ft. and “turn south now.” EVA015 confirmed, and began a right turn to 180 deg.

As the aircraft turned, it was climbing through an altitude of 6,200 ft. above ground level, and passed about 1,600 ft. south of Mt. Wilson, investigators determined. The minimum vectoring altitude for the segment was 7,800 ft., NTSB said. Mt. Wilson’s peak is 5,700 ft., and its summit hosts a number of telecommunications antennas—the tallest of which is 970 ft.

At 0126:25, EVA015 contacted the controller and reported it was heading 180 deg. at an altitude of 7,000 ft. There were no other transmissions relevant to the incident.

NTSB, working through the Taiwanese Aviation Safety Council, obtained enhanced ground proximity warning system data from the aircraft. 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.

NTSB determined that the SCT controller’s erroneous instruction to turn left to the assigned heading instead of right began the incident. The issue was exacerbated when EV015 was given permission to conduct a high-speed climb while making the left turn. This “resulted in the aircraft accelerating beyond the 250 kt LAX class B speed restriction and required additional airspace in order to complete an assigned turn,” NTSB found.

Once the controller realized the problem, the 777 was vectored back around to the right, which created a separation issue with the Air Canada 787 that had departed LAX, leading to a command to EV015 to stop its climb and turn left.

“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 obstruction,” NTSB found. “Contributing to the incident was the air traffic controller’s inadequate recovery technique during the development of the incident.”

Activity for the time period was considered normal, NTSB said, although there were a few go-arounds linked to the shifting winds that led to the change to east flow. The STC controller believed that the initial command given to EVA015 included a right turn. “By the time [the controller noticed EVA015 turning left, [the controller] realized the conflict with the Air Canada flight and just needed somebody stop their climb.

In a post-incident interview, the EVA015 crew reported significant confusion over receiving three different, conflicting turn instructions within such a short period of time, NTSB said. A fourth instruction to turn south with no heading provided compounded their confusion.

The board did not determine why the controller made the initial error, but details in the investigation’s docket suggest the east-flow configuration’s rarity likely played a role. When operating west, terrain is not an issue. But the east flow means that MVAs must be factored in.

“SCT operated ‘west traffic’ or ‘over water’ 99% of the time, and when LAX switched to east traffic no one considered the minimum vectoring altitudes,” an NTSB summary of one controller’s interview said. This controller “felt that facility training was not good for east traffic operations, and that there was a reluctance to switch to east traffic, usually waiting until the last minute to do so,” the summary added.

NTSB’s report does not include any recommendations or reported safety actions.

[Lonewolf_50]

Originally Posted by cactusbusdrvr

Those guys fly by rote, they will execute instructions but it can’t be in nonstandard form.

And there's a company/corporate cultural root cause that will likely be whitewashed or glossed over, right?

NTSB determined that the SCT controller’s erroneous instruction to turn left to the assigned heading instead of right began the incident.

Disorientation can happen both inside and outside of a cockpit.

Originally Posted by MajorLemond

Firstly, yes, Atc made the initial error of issuing a left turn, however any pilot with even a moderate shred of situational awareness would query this as it is not logical. Even if you are half asleep when you start winding the heading bug looking for a Hdg of 180 it's immediately obvious that something isn't right as the digits in the FCU window start winding back from an easterly HDG. It was never queried by EVA, just blindly followed.

Back to the cultural point cactusbusdrvr raised.

This takes us back to the old joke/teaching point on making sure to be aware and proactive in communicating with controllers:
What happens when the pilot screws up? The pilot dies.
What happens when the controller screws up? The pilot dies.

As someone pionted out a few posts back, it works best when it's a cooperative/team effort between the flight deck and ATC.

[aterpster]

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.

[Yaw String]

At the high risk of stating what has already been stated here,..we brief MSA and MORA to avoid terra firma..
At what point during the departure do we ignore what we have briefed.Part of our responsibility is to pick up each other's mistakes made by our colleagues in the air,and on the ground,
Why would you not query a turn instruction that was going to severely infringe your terrain separation,as briefed!

[Zeffy]

call me cynical

Originally Posted by Yaw String

At the high risk of stating what has already been stated here,..we brief MSA and MORA to avoid terra firma..
At what point during the departure do we ignore what we have briefed.Part of our responsibility is to pick up each other's mistakes made by our colleagues in the air,and on the ground,
Why would you not query a turn instruction that was going to severely infringe your terrain separation,as briefed!

Yet the tools available for such a departure briefing are poorly suited to the task... these instruments are far too blunt:

VTU7 chart:

No MSA information whatsoever


ILS 7R approach chart:

MSA information is entirely too coarse to be useable on any practical basis.


As mentioned above, the tool best suited to the task would be a scalable MVA sector map in the cockpit.

Pilot groups and FSF have advocated... heck, they've begged... FAA to provide MVA sector information in a format suitable for cockpit display.

FAA ATO simply isn't interested... in fact, their uninterest goes beyond that... they've been worse than unresponsive... FAA ATO continues to stubbornly resist the concept entirely.

[aterpster]

Originally Posted by Zeffy

FAA ATO simply isn't interested... in fact, their uninterest goes beyond that... they've been worse than unresponsive... FAA ATO continues to stubbornly resist the concept entirely.

Rumor has it their union doesn't want pilots "looking over the controller's shoulders."

[Airbubba]

Originally Posted by aterpster

Rumor has it their union doesn't want pilots "looking over the controller's shoulders."

And, most EGPWS depictions already have more granular and useful data for terrain avoidance as you head for those hills. A similar scenario out of LAX is a common sim setup for the required terrain avoidance escape maneuver training in my experience.