In both mid-air accidents last year, the pilots were talking to ATC.

That video with the sabreliner was... dreadful.

And the other video... she turned him right into that 150.

Sobering stuff.
 
On that Brown video, did the controller mistakenly call 6ZP(at 2:40) when he was talking to the accident plane 85U? I didn't hear any comms from 85U in the entire video, till the very end. The instruction he gave 6ZP to make a right 360 and rejoin downwind didn't make sense based on where that plane was(departing the vicinity). Also, I was taught that if you didn't have instructions from the tower by midfield to report your position(as Eagle1 did). A mid-field call from 85U might have resolved this confusion.
 
It's easy to say looking from the outside in, but what was she thinking turning the jet right into the Cessna??? You can't help but feel bad for both controllers, these are going to haunt them for a long time.
 
exncsurfer said:
On that Brown video, did the controller mistakenly call 6ZP(at 2:40) when he was talking to the accident plane 85U? I didn't hear any comms from 85U in the entire video, till the very end. The instruction he gave 6ZP to make a right 360 and rejoin downwind didn't make sense based on where that plane was(departing the vicinity). Also, I was taught that if you didn't have instructions from the tower by midfield to report your position(as Eagle1 did). A mid-field call from 85U might have resolved this confusion.
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Yeah I'm not sure if the controller's comments are published yet but it sure does seem he got 85U confused with 6ZP. 6ZP was a downwind departure. He wasn't in closed traffic.

Not 6ZP's fault but if he would have come back with "Tower, 6ZP is no longer in the pattern, we're clear to the north," that would have helped. The LC then would have known he called the wrong aircraft.
 
Velocity173 said:
it sure does seem he got 85U confused with 6ZP
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Exactly how it seems to me. Awful, awful stuff. I have an incredible amount of sympathy for controllers, who get it right millions of times under extraordinary time pressure, knowing that a single error may lead to incidents like this.
 
Grum.Man said:
It's easy to say looking from the outside in, but what was she thinking turning the jet right into the Cessna??? You can't help but feel bad for both controllers, these are going to haunt them for a long time.
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A brief moment of left-right confusion ?

An altitude restriction or climb instruction to 'death 4' may have worked better.
 
Cogito said:
Safety Alert to pilots — Prevent Midair Collisions: Don’t Depend on Vision Alone
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Well, and dont rely on ATC to keep you out of each others hair. In the Frederick,MD midair, both the helicopter and the SR22 were talking to the tower.
 
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Last year I was in the pattern of a towered airport and the controller apparently got me and another aircraft mixed up. He kept giving us wrong instructions, based on where the other one was. When I tried to set him straight, he said "I think there is some confusion here", and insisted I was on right base to runway X, instead of left downwind to Y as I reported. When I kept insisting I was exactly where I said I was, he finally issued me a landing clearance to the correct runway, never apologizing. I had the entire debacle on video, too. I can easily imagine how this "who's on base" situation can lead to dire consequences as per above.
 
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thebruce said:
Exactly how it seems to me. Awful, awful stuff. I have an incredible amount of sympathy for controllers, who get it right millions of times under extraordinary time pressure, knowing that a single error may lead to incidents like this.
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Yep, just read the NTSB report. The LC did confuse the two. Sad.

Any current or former controller can relate to the mistakes in these two accidents. You watch these vids and just cringe, because you know what they're trying to do / say, it just came out wrong. I feel for both of them.
 
weilke said:
A brief moment of left-right confusion ?

An altitude restriction or climb instruction to 'death 4' may have worked better.
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The controller went with a left 180 because she thought it to be quicker. She didn't go with a climb because the C150 altitude was unverified.

In regards to the turn, it's not as easy as it seems with target tracks. The radar in this case has almost a 5 sec "refresh" rate. Instead of a smooth target trail, they click across the scope. Enhancements like predicted track function and mosaic radar help in that regard. Not saying they would have prevented this accident but would have helped.
 
Velocity173 said:
The controller went with a left 180 because she thought it to be quicker. She didn't go with a climb because the C150 altitude was unverified.
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That makes sense.

In regards to the turn, it's not as easy as it seems with target tracks. The radar in this case has almost a 5 sec "refresh" rate. Instead of a smooth target trail, they click across the scope. Enhancements like predicted track function and mosaic radar help in that regard. Not saying they would have prevented this accident but would have helped.
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That's why I am not sure that any type of electronic on-board gadgetry would have avoided this accident. The F16 pilot was already actively looking for a target at 12 o clock, not sure what short of a full-up TCAS in both could have kept these two out of each others space.
 
weilke said:
That makes sense.



That's why I am not sure that any type of electronic on-board gadgetry would have avoided this accident. The F16 pilot was already actively looking for a target at 12 o clock, not sure what short of a full-up TCAS in both could have kept these two out of each others space.
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I think some sort of electronic traffic alert would have helped. We've got TCAD in our helo and it's brought my attention to traffic that I might not have otherwise seen. Without RA, some of the head on stuff is difficult to determine a course of action though. Especially when you don't know what the other aircraft is doing.
 
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I want to add, never be afraid to make your own decisions. I was flying into a class D airport a few months back. I was on course for a straight in approach but there were 3 other aircraft in the pattern. A Cessna 150 on final, a Cherokee turning base, and a twin on downwind. The controller wanted me to parallel the downwind leg and make a right turn to enter the downwind. I kindly declined and elected to fly an upwind on the right side of the runway and crossing at mid field to enter the downwind. You have no idea how wide airplanes are flying on the downwind leg. I have seen people who stay close enough to glide, and people who have been 3 miles out or more. Heading straight for them wasn't to my liking. The controller wasn't happy at first got over it quickly.
 
I had a close call yesterday at PDK. I was in short final and ATC told a Cirrus to follow me. He turned base way too early and was very very close on my tail while saying "negative traffic". Only thing I could say was "He's right on my tail, suggest you do something". He would have run me over pretty quickly (SR22 vs. 150). Scary stuff.
Traffic patterns scare me.
 
Velocity173 said:
Yep, just read the NTSB report. The LC did confuse the two. Sad.

Any current or former controller can relate to the mistakes in these two accidents. You watch these vids and just cringe, because you know what they're trying to do / say, it just came out wrong. I feel for both of them.
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Velocity173 said:
Yeah I'm not sure if the controller's comments are published yet but it sure does seem he got 85U confused with 6ZP. 6ZP was a downwind departure. He wasn't in closed traffic.

Not 6ZP's fault but if he would have come back with "Tower, 6ZP is no longer in the pattern, we're clear to the north," that would have helped. The LC then would have known he called the wrong aircraft.
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The video is revealing, but only part of the whole bigger scenario. You have to read through all the stuff in the docket to get the whole picture.

Basically it starts with a relatively typical Brown Field day. Trainee controller working the pattern with a qualified Sup overseeing it. Traffic starts to pick up to a point where there are 9 aircraft in the Class D (not uncommon for nearby MYF, but more than normal for SDM).

Trainee is doing a decent job, but starting to get overwhelmed. 85U was originally cleared for right traffic touch and go on 26R, but they shifted him to 26L (this happened before that video starts). Here's the kicker: unless I missed it, when they cleared him for 26L, they never gave him instructions for which way to go. 26L is left traffic, but they never told him whether to stay in the left pattern or go back to the right. He (85U) went right. At some point around then, when the Sup noticed that the Trainee was getting overwhelmed and making mistakes, he took over. That transition happened at a very critical time and they lost the bubble.

I think Tower assumed 85U stayed in the left pattern and forgot about him. I suspect that when they saw the conflict with Eagle 1, the controller assumed it was 6ZP and then realized the mistake (too late at that point). Sadly, this accident setup was very similar to PSA 182.
 
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thebruce said:
Exactly how it seems to me. Awful, awful stuff. I have an incredible amount of sympathy for controllers, who get it right millions of times under extraordinary time pressure, knowing that a single error may lead to incidents like this.
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If you take only one thing away from the Brown Field Midair, it is that it was really not one single error. That accident is a perfect example of the Swiss Cheese model where multiple relatively minor errors can line up to create a big mess.
 
Joshuajayg said:
That video with the sabreliner was... dreadful.
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No kidding. I had read through all the docket material a couple weeks ago and I still had to replay the video second by second to find where the 172 came from. The window frame blocked it perfectly through the turn until less than 2 seconds before the collision.

The really scary thing was that if you read the CVR transcript, both pilots and one of the mission specialists were actively looking for the 172 the whole time.

'See and avoid' sounds great, but it doesn't always work.
 
The video reenactment shows the Saberliner's view. It is 5:18 but if the depiction is accurate you cannot see the Cessna as a substantial size in the windshield until 5:13 and contact is made around 5:14. Not much time.
 
mtuomi said:
I had a close call yesterday at PDK. I was in short final and ATC told a Cirrus to follow me. He turned base way too early and was very very close on my tail while saying "negative traffic". Only thing I could say was "He's right on my tail, suggest you do something". He would have run me over pretty quickly (SR22 vs. 150). Scary stuff.
Traffic patterns scare me.
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One night at Bowman Field(Class D) in Louisville, on one of our first family trips in our new homebuilt...we were #3 sequenced behind an Eclipse jet and C150. I know that 150 driver was nervous. He requested to land long and cleared the runway quickly as we were rolling out. He chose to knock off the pattern work for the night. We were prepared to go around at any time.
 
Let'sgoflying! said:
The video reenactment shows the Saberliner's view. It is 5:18 but if the depiction is accurate you cannot see the Cessna as a substantial size in the windshield until 5:13 and contact is made around 5:14. Not much time.
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The view from the Cessna wasn't much either...

 
Velocity173 said:
The controller went with a left 180 because she thought it to be quicker. She didn't go with a climb because the C150 altitude was unverified.

In regards to the turn, it's not as easy as it seems with target tracks. The radar in this case has almost a 5 sec "refresh" rate. Instead of a smooth target trail, they click across the scope. Enhancements like predicted track function and mosaic radar help in that regard. Not saying they would have prevented this accident but would have helped.
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She told him to turn left to 180, not a left 180 and she clearly,told him traffic was at 1200' and finally told him 1400'.
 
2 out of the three mid-airs in my area involved ATC....and miscomunication.:(
 
EppyGA said:
She told him to turn left to 180, not a left 180 and she clearly,told him traffic was at 1200' and finally told him 1400'.
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Yes a 180 heading. Point being, she wasn't confused with left or right. She said the 180 HEADING would be "quicker."

The altitude was unverified. That's why she used indicated. The final transmission she didn't use indicated in the transmission. Not that it mattered because it was too late by then anyway. At any rate, she didn't go with a climb because the altitude was unverified.
 
Fearless Tower said:
The video is revealing, but only part of the whole bigger scenario. You have to read through all the stuff in the docket to get the whole picture.

Basically it starts with a relatively typical Brown Field day. Trainee controller working the pattern with a qualified Sup overseeing it. Traffic starts to pick up to a point where there are 9 aircraft in the Class D (not uncommon for nearby MYF, but more than normal for SDM).

Trainee is doing a decent job, but starting to get overwhelmed. 85U was originally cleared for right traffic touch and go on 26R, but they shifted him to 26L (this happened before that video starts). Here's the kicker: unless I missed it, when they cleared him for 26L, they never gave him instructions for which way to go. 26L is left traffic, but they never told him whether to stay in the left pattern or go back to the right. He (85U) went right. At some point around then, when the Sup noticed that the Trainee was getting overwhelmed and making mistakes, he took over. That transition happened at a very critical time and they lost the bubble.

I think Tower assumed 85U stayed in the left pattern and forgot about him. I suspect that when they saw the conflict with Eagle 1, the controller assumed it was 6ZP and then realized the mistake (too late at that point). Sadly, this accident setup was very similar to PSA 182.
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Yeah. So much like PSA 182. Both had the traffic in sight, then lost sight, then the midair.
 
Fearless Tower said:
The video is revealing, but only part of the whole bigger scenario. You have to read through all the stuff in the docket to get the whole picture.

Basically it starts with a relatively typical Brown Field day. Trainee controller working the pattern with a qualified Sup overseeing it. Traffic starts to pick up to a point where there are 9 aircraft in the Class D (not uncommon for nearby MYF, but more than normal for SDM).

Trainee is doing a decent job, but starting to get overwhelmed. 85U was originally cleared for right traffic touch and go on 26R, but they shifted him to 26L (this happened before that video starts). Here's the kicker: unless I missed it, when they cleared him for 26L, they never gave him instructions for which way to go. 26L is left traffic, but they never told him whether to stay in the left pattern or go back to the right. He (85U) went right. At some point around then, when the Sup noticed that the Trainee was getting overwhelmed and making mistakes, he took over. That transition happened at a very critical time and they lost the bubble.

I think Tower assumed 85U stayed in the left pattern and forgot about him. I suspect that when they saw the conflict with Eagle 1, the controller assumed it was 6ZP and then realized the mistake (too late at that point). Sadly, this accident setup was very similar to PSA 182.
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I went "down the tubes" one time when I let an approach student get too far behind. He looked up at me and just said "I've lost it." Crap! Then I made the mistake like the LC at Brown did. I didn't sectorize the airspace to take some of the load off me. Fortunately the sup showed up and un****ed the mess I had made.

Kinda like a CFI who lets a student take a manuver too far. You gotta set limits and step in early before it gets out of hand.
 
Velocity173 said:
I went "down the tubes" one time when I let an approach student get too far behind. He looked up at me and just said "I've lost it." Crap! .
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Been there a few times when I controlled. Not fun. One time my relief was plugged in and getting the picture of what I had and I had a mess. Asked him, "got it?", he says "**** no, clean that shet up first". I was tubin' for sure!

But I got it cleaned up, got the hell outa that dark room, went to another dark room called a bar, and washed my day away. :D
 
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If having been previously instructed to make left traffic, a pilot is in error if he elects to make right traffic. That can be a deadly mistake.
 
mtuomi said:
I had a close call yesterday at PDK. I was in short final and ATC told a Cirrus to follow me. He turned base way too early and was very very close on my tail while saying "negative traffic". Only thing I could say was "He's right on my tail, suggest you do something". He would have run me over pretty quickly (SR22 vs. 150). Scary stuff.
Traffic patterns scare me.
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Why would you wait for the tower to do something knowing a collision is imminent? You're responsible for your own separation up there. I would have gone around.
 
Harold Rutila said:
If having been previously instructed to make left traffic, a pilot is in error if he elects to make right traffic. That can be a deadly mistake.
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The thing is he wasn't instructed to make either left or right.

He had been originally cleared for right traffic on 26R, then they told him to shift to 26L without any further guidance as to whether they wanted him to go back to the right or continue in the left traffic.

I have been in that same scenario at SDM, but they specifically told me to make right traffic after landing 26L.

IMO, that was the first error in the chain.
 
Harold Rutila said:
Why would you wait for the tower to do something knowing a collision is imminent? You're responsible for your own separation up there. I would have gone around.
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If you saw what I saw (a plane slightly higher and way faster and a bit behind you), you really would not want to go around in a plane with not much climb capability. I kept an eye on it and made sure someone did something before he would hit me. It was a close call, not an imminent death situation.
 
Holy crap these are sobering... I'm still just starting to make my solo cross countries, and this kinda stuff scares the crap out of me. Being in the pattern at a non-towered airport with 3, 4 or more other planes is bad enough - but at least we are all generally announcing like crazy and keeping visual separation. Neither of these saw it coming at ALL.
 
One thing that was puzzling to me was that the copilot(I think) said to the pilot that he had the Cessna at one point. Then they turn into his path later. I guess they lost him and just trusted the atc instructions. Plus, I don't see how the Cessna was quiet so long while receiving no instructions. Maybe he didn't want to add to the clutter but he might have called for left/right traffic clarification. Mid field with no landing clearance warrants a call. No red flags that atc just told someone to turn base into your path. Hindsight I know but a reminder how critical it is to maintain situational awareness and when in doubt call for clarification
 
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