Eva B773 at Los Angeles on Dec 16th 2016, ATC instructs turn left instead of right, loss of separation, confusion, dangerous closure to terrain

Last Update: May 8, 2019 / 19:56:22 GMT/Zulu time

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Incident Facts

Date of incident
Dec 16, 2016

Classification
Incident

Airline
Eva Air

Flight number
BR-15

Destination
Taipei, Taiwan

Aircraft Registration
B-16726

Aircraft Type
Boeing 777-300

ICAO Type Designator
B773

An Eva Air Boeing 777-300, registration B-16726 performing flight BR-15 (scheduled Dec 15th, actual Dec 16th) from Los Angeles,CA (USA) to Taipei (Taiwan), departed Los Angeles' runway 07R, contacted departure and was instructed to climb to 7000 feet, heading 090. The aircraft was subsequently instructed to climb to 7000 feet and turn left heading 180. The crew correctly acknowledged the instruction and turned left.

Shortly after BR-15 an Air Canada Boeing 787-800, registration C-GHPX performing flight AC-788 (scheduled dep Dec 15th, actual dep 16th) from Los Angeles,CA (USA) to Toronto,ON (Canada), departed Los Angeles' runway 06R, was instructed to climb to 7000 feet and join GABRE departure (which involves a left turn to the north).

A conflict arose between AC-788 and BR-15, when BR-15 unexpectedly turned to the north, the controller instructed BR-15 to turn right heading 180. The crew acknowleded turn right heading 180, but continued to turn left. With raised voice the controller instructed BR-15 to stop climb. In an attempt to resolve the situation the controller now instructed BR-15 to turn left onto a heading 270, the aircraft continued to the north however. "What are you doing now" the controller asked and instructed to turn southbound NOW, crew asked "confirm heading", "turn southbound NOW", "left or right?" In the meantime the controller instructed AC-788 to climb to 12000 feet and expedite the climb, AC-788 complied and continued to Toronto for a safe landing without further incident.

BR-15 still continued to the north at about 4900-5000 feet, mountains rising there to 6653 feet. The controller instructed BR-15 to climb to 7000 feet, abeam of Pasadena,CA (USA) the crew finally began to turn right, which brought the aircraft even closer to Mount Wilson (peak and Mount Wilson Observatory at 5715 feet MSL), and to climb. The aircraft passed the peak 0.3nm south of the peak still at about 6000 feet at a heading of about 090 degrees, rolled out at heading 180, climbed to 7000 feet and continued the flight to Taipei for a safe landing without further incident.

The FAA reported:

The air traffic controller who was handling EVA instructed the pilot to make a left turn to a 180 degree heading. She meant to tell the pilot to make a right turn to a 180 degree heading. The pilot turned to the left.

The controller quickly realized EVA was turning in the wrong direction. She took immediate action to keep EVA safely separated from an Air Canada jet that had departed LAX off the north runway complex. Those planes remained the required distance from each another.

The controller then turned her attention to getting EVA to turn south. The controller issued the EVA pilot a series of instructions to get him to turn south.

The controller wanted to make sure the EVA aircraft was safely above or away from nearby terrain. FAA regulations require aircraft to be at least 3 miles away laterally or 2,000 feet vertically above obstacles such as mountains.

The FAA have opened an investigation into the occurrence.

On May 19th 2017 the NTSB reported the occurrence was rated an incident and is being investigated by the NTSB. The NTSB reported the aircraft "conducted flight below minimum vectoring altitude near Mt. Wilson, CA while receiving vectors from Southern California Terminal Radar Approach Control after departing from Los Angeles International Airport (LAX) Los Angeles, California."

On May 8th 2019 the NTSB released their final report concluding the probable causes of the incident were:

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.

The NTSB reported the aircraft maneouvered at 6,200 feet in an area where the minimum vectoring altitude was 7,800 feet. In close proximity to the TV antennas near Mount Wilson the aircraft was still at 6,300 feet with the top of the obstacles being at 6,630 feet.

The NTSB analysed:

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.
Incident Facts

Date of incident
Dec 16, 2016

Classification
Incident

Airline
Eva Air

Flight number
BR-15

Destination
Taipei, Taiwan

Aircraft Registration
B-16726

Aircraft Type
Boeing 777-300

ICAO Type Designator
B773

This article is published under license from Avherald.com. © of text by Avherald.com.
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