NTSB: Controller Error Led To Midair Collision

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Key Takeaways:

  • A 2015 midair collision near San Diego that killed five people was primarily caused by an air traffic controller's failure to properly identify an aircraft and ensure control instructions were followed.
  • Contributing factors included the controller's high workload (nine aircraft under his control) and inherent limitations of the "see-and-avoid" concept for the pilots, who lacked traffic detection equipment.
  • Following the incident, the NTSB issued recommendations for enhanced controller training and promoted the use of traffic display equipment for pilots.
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A busy traffic pattern and a controller’s mistaken identity of an aircraft led to the midair collision of a Sabreliner jet and a Cessna 172 near San Diego in 2015, the NTSB found. All four on board the Sabreliner twin-engine aircraft and the solo pilot in a Cessna 172 were killed on Aug. 16 during landing approaches at Brown Field Municipal Airport. The San Diego Union-Tribune reported this week the Cessna 172 pilot was Michael A. Copeland, an executive at the San Diego-based tech company Qualcomm. The Sabreliner, called Eagle1, was registered to military contractor BAE Systems, with company employees on board. The NTSB’s probable cause was a controller’s “failure to properly identify the aircraft in the pattern and to ensure control instructions provided to the intended Cessna on downwind were being performed before turning Eagle1 into its path for landing.”

Contributing factors were the controller’s high workload when taking over the radios from a trainee and what the board called “inherent limitations of the see-and-avoid concept” for the two pilots. The controller, who had 37 years of experience, told investigators his “personal limit” for workload was seven aircraft between the airport’s two parallel runways, but at the time of the collision there were nine under his control. He appeared to have confused the accident Cessna, N1285U, with another 172 while trying to resolve potential traffic conflicts in the pattern. The collision occurred as the controller “tried to verify N1285U’s position,” according to the report. The NTSB also noted that the cockpit views and surrounding environment made it difficult for the pilots to spot each other until it was too late to avoid a collision, and neither aircraft had traffic detection equipment. The board recently issued recommendations for additional training for controllers based on the accident and a safety alert for pilots to promote the use of traffic displays.

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