Your other Left! (It doesn't happen only to me!)

[IAHM-COL]

Your other Left! (It doesn't happen only to me!)

http://www.dailymail.co.uk/news/article ... range.html

http://abc7.com/news/abc7-exclusive-err ... e/1664275/

https://www.youtube.com/watch?v=tFdXax7Zh_g

[IAHM-COL]

After watching the youtube video I just cant understand what EVA015 was doing.....

[KL-666]

Yes i have that impression too. The ATC may have made a little left right mistake, and corrected it. But the EVA never did anything and just kept flying north, even after reading back themselves to go south.

I suppose they were busy reprogramming the magenta line. That is endlessly slower than simply to get out of lnav and turn the heading knob.

Kind regards, Vincent

[IAHM-COL]

on the video at 2:40, the ATC says

SoCal : EVA015. what are you doin'?

I cant but agree that he have been sent Right 180, then to a left 270, then southbound NOW! and he kept looking for a Mountain ride straight at 360 @:

He knew it was 180 the ordered heading first. I wonder, was he looking at his compass? Was his PFD non-callibrated? did he know he was going north instead of the instructed South?

[Omega]

To put the blame solely on the pilots would be unfair in this situation. It is very clear that there were actually three parties at fault here: 1) the pilots, 2) the controller, 3) the FAA.

The root cause of this incident is that LAX was running east flow at the time (departing 6R, 7L and arriving 6L, 7R) which is unusual for this airport. 99% of the time, LAX will be in west flow due to the prevailing winds coming from the ocean.

Since the controllers work about 40 hours/week on west flow every time, their brain eventually gets used to these patterns, and mistakes are bound to happen after a switch to east flow.

Of course controllers have to go through re-familiarization simulation labs to keep up to date with east operations, however it is quite obvious that these re-familiarization sessions are not happening often enough, which is why the FAA is at fault.

The controller is also at fault for failing to see the problem early enough. After issuing the wrong instruction, she is given multiple opportunities to correct the error. First, the pilot reads back "Left heading 180." If the controller was paying attention to the readback, she could have corrected the situation almost instantly, this skill is referred to as "hearback awareness." A readback is not only used to verify that the transmission was received properly, it can also be used to verify that the instruction given was correct in the first place.

Second, after the instruction was issued, it takes her a complete 30 seconds to notice that the aircraft is turning towards the wrong direction. This indicates that the controller did not have a good, constant scan of each target, and was instead focused on a single area for too long. This is a direct result of feeling overwhelmed due to unfamiliarity with east operations.

Thirdly, after ACA788 comes into play, EVA015 is told to stop climb and maintain 5000. After taking too long to turn, the controller issues heading 270. After which the pilot again takes too long to turn and instead begins a climb due to the terrain ahead. The controller tells the aircraft again to stop climb and turn southbound. This is a very big mistake because the aircraft is about to be well below minimum vectoring altitude (MVA). At this point, EVA could actually climb higher because the ACA was already well above EVA, however the controller failed to notice this, again because she was overwhelmed with the situation now more than ever.

At around 3:52 in the video you can actually hear the MSAW (Minimum Safe Altitude Warning) in the background. After which she starts issuing a higher altitude. Of course at this point it's too late.

The biggest mistake by the pilot is failure to ask for clarification on the very first instruction. The instruction "turn left heading 180" would require him to complete a 270-degree turn which simply doesn't sound right. Other than that, the pilot fails to follow instructions and declare his intentions in a timely manner, causing more uncertainty for the controller. He should have explicitly declared that he is climbing due to terrain ahead.

I also see a lot of comments on the video pointing out that "turn southbound" is not correct. But the pilot was already given 2 instructions to turn to a heading, which he didn't execute, so the controller attempted to reword the instruction in the hope that the pilot could maybe understand it.

[IAHM-COL]

I concur with omega analysis. I'm glad the error was not a fatality ended one

[KL-666]

Omegas analysis looks balanced and correct to me. Personally i am most interested in the pilots performance in it's own right. Not to determine guilt in this case. But to learn and prevent such behaviour in the future.

In what state of mind were these guys to think they could take their time with reacting to ATC instructions? Did they have no situational awareness at all, specifically that they were flying near mountains?

What i expect of pilots specifically in mountainous terrain is to:
- read the charts before departure
- make a mental map of the area, knowing at what distances and minimum altitudes you want to be, to be able to warn ATC if they give instructions too close to terrain for comfort
- set the mind to be as sharp as an eagle to take immediate action on ATC instructions, specifically while still near mountains and low

Somehow these pilots give me the impression that they did not have any idea where they were. As if they just stepped into the plane, skipping the points above, in the believe that ATC will guide them fine enough.

I hope the report on this will have a substantial part on the pilots performance. And if there is any problem with their performance, action is taken to prevent other pilots to do the same.

Kind regards, Vincent

[Lydiot]

@Omega,

Nice analysis - good read!

[KB7]

I can agree with the idea that it seems like the controller missed something in the proper departure patterns. (eta: I disagree with the news report that said the controller steered them into the mountains. The controller tried to get them to AVOID the mountains.)

I wonder if EVA 015 on hearing the instruction to cancel the climb also decided that this should cancel the prior heading order (right 180) given before the cease climb order.

What I see is that the L.A. controller first tried to decided to turn EVA right to 180 to avoid ACA's path altogether and tries to get them both to hold altitude so EVA would stay under ACA. (Controller could/should have directed EVA to hold alitude but continue right 180 and continued ACA's climb, but since ACA was laterally behind EVA I can see the hold-both.) After one minute the EVA flight isn't making the required right turn. She tries to Climb ACA above and slide EVA left 270 to pass under ACA (then maybe continue left to 180 since EVA can't seem to turn right but who knows?) EVA still does not comply (at least not in time,) but the controller further gives an immediate turn southbound order. I'm willing to be corrected, but if given "Fly Southbound" (or "Fly Heading XXX") without turn direction implies the controller doesn't care which way the turn is executed. It's only clear the controller wants it now. (In reality it's clear the controller should have still wanted a left turn at that point, but either way when the controller moved onto another aircraft EVA should have executed the turn either way.)

It would be really interesting to see the actual flight track at the end of the YouTube video correlated with the real-time communications - the YouTube video skip-aheads don't make it easy to correlate how long EVA failed to obey commands and does make it clear the airplane locations are only approximate and not true to radar track.

What I see is three separate orders given for an aircraft to turn in very tight, congested, and controlled airspace over an apparent minimum of two-three minutes and failure of the aircraft to execute or expedite those orders.

But I'm a novice at controlling. But also very glad there was no loss of life (and also of Mt. Wilson observatory!)

Edits to add: I wonder if, when directed to turn right 180 if they dialed 018 on the autopilot? And it would have been interesting to hear the cockpit voice recorder had to say.