NTSB Issues Safety Alert On Midairs

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The NTSB this week completed its investigation of two fatal midair crashes that occurred in 2015, and on Wednesday they issued a Safety Alert (PDF) urging pilots to make use of cockpit technologies that can help them to see and avoid other aircraft. The alert reviews the two recent crashes as well as two earlier ones, and notes that in each case, the pilot had access to technology in the cockpit that may have helped avert the crash if it had been utilized. The traditional “see and avoid” practice has “inherent limitations,” the NTSB said, including aircraft blind spots, operational distractions and human error, which “leave even the most diligent pilot vulnerable to the threat of a midair collision with an unseen aircraft.” In both midair accidents last year, the pilots were talking to ATC.

On July 7, 2015, a Cessna 150 that had just departed from Moncks Corner, South Carolina, and an F-16 Air Force fighter jet on a training mission collided. An air traffic controller advised the F-16 pilot that the Cessna was a potential traffic conflict. The F-16 pilot was not able to locate the Cessna until it was too late to avoid the collision. The two occupants of the Cessna were killed; the F-16 pilot ejected and survived. In its probable-cause report issued this week, the NTSB determined that the probable cause of the crash was the air traffic controller’s failure to provide an appropriate resolution to the traffic conflict.

On August 16, 2015, a North American Rockwell Sabreliner inbound for landing at Brown Field Municipal Airport in San Diego and a Cessna 172 that was practicing landings at the same airport collided. The four occupants of the Sabreliner and the sole occupant of the Cessna were killed. A cockpit visibility study revealed the fields of view of both pilots were limited and partially obscured at times. The NTSB determined that the probable cause of the accident was the air traffic controller’s failure to properly identify the aircraft in the pattern and to ensure control instructions were being performed.

The Safety Alert to pilots — Prevent Midair Collisions: Don’t Depend on Vision Alone — is available online (PDF). The NTSB also has posted its report, its safety recommendation report and the accident reports. A series of video animations of the two accidents, which includes several besides the two posted here, are posted online.

San Diego

view on YouTube

Moncks Corner

view on YouTube

Comments (4)

So both these accidents are essentially the fault of ATC. In the Moncks corner incident the controller had the F-16 turn into the Cessna and in the Brown field incident they allowed the planes to conflict. So what would have happened if the F-16 driver had ignored the ATC instructions? Or if the Cessna had deviated from the ATC instructions? They would be alive but in trouble with the FAA. What would you have done in this circumstance? ATC says conflicting traffic but you do not see them. ATC tells you to turn so you do, right into the conflicting traffic. Perhaps ATC and the FAA should be the ones getting sued in this instance although I know it will be the pilots insurance company and the DOD. The pilots did what they were trained to do, rely on ATC and follow instructions. ATC killed them.

Posted by: RODNEY HALL | November 17, 2016 7:02 AM    Report this comment

You have to pay attention to your surroundings. Just because you are under direct ATC control does not relieve the PIC to take action to avoid possible ATC errors. I have seen my share of ATC mistakes over the years and have taken action to avoid conflicts on my own. ATC does a wonderful job of keeping planes separated but no one is perfect, otherwise there would be no need for TCAS. The airport where I learned to fly used to have the most TO and Lnd in my home state of any other airport and it is an uncontrolled VFR field. In the thirty or so years I can remember there has never been a mid-air collision there.

Posted by: matthew wagner | November 17, 2016 9:04 AM    Report this comment

I have had ADS-B for three years. I also have TCAS. But these things won't help you if the object you are trying to see and avoid is going 250 plus kts. The combat jet should not be going that fast below 10k feet...so it's odd NTSB would simply blame ATC and encourage the Cessna drivers to get ADS-B.

Posted by: GBigs Angle | November 17, 2016 11:42 AM    Report this comment

In the SanDiego example, the controller has e relatively high workload. The Sabreliner previously reported traffic in sight but later flew into that traffic. The controller seems to have missed the Sabreliner call concerning traffic in sight which could have triggered him to be aware of the conflicting traffic on downwind.
This is a complicated scenario involving several people operating in their own complicated 'bubble' and then having to anticipate, react and adjust to each other's continuously changing environment...this is a challenge for anybody's mental capacity - that is the factor overlooked by all parties involved.
Just my opinion after 35 years in the air.

Posted by: Mauro Hernandez | November 20, 2016 3:34 AM    Report this comment

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