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NTSB: ATC issued wrong instructions in Boeing 777-300 near CFIT occurrence near LAX

Christian Fernsby |
On 16 December 2016, EVA Airways flight BR015 from Los Angeles, California, USA to Taipei, Taiwan, came close to mountainous terrain during departure climb after takeoff from Los Angeles Airport.

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The aircraft, a Boeing 777-35EER, took off from runway 07R at 01:19 hours local time. The flight plan showed a Ventura 7 departure, which calls for a climb on heading 071° after which radar vectors would be given to the VTU VOR/DME.

VTU is located near the coast, 60 km to the northwest of LAX. Given the circumstances, a right-hand turn was then to be flown by flight 15.

After switching to the SoCal Departure frequency the flight was instructed to climb to 7000 feet on a heading of 090 degrees.

Subsequently, the SoCal Departure controller cleared the flight to turn left (instead of right) to 180 degrees and continue climb to 7000 feet. This was read back by EVA flight 15 as "Left heading 180". Flight 15 also requested a "high speed climb," which was approved.

Radar data indicated BR015 began to make a left turn. About 41 seconds later, the controller instructed the pilot of BR015 to "turn right, right turn heading one eight zero."

The pilot of EVA015 acknowledged the instruction and read back the right turn to a heading of 180 degrees. Radar data indicated the aircraft stopped the left turn to 180° and slowly began to turn right.

At 01:22:10, the controller instructed the pilot of BR015 to "expedite your right turn." The pilot replied "roger [unintelligible] passing heading zero one zero, continue heading." At that time flight 15 was tracking northbound towards the San Gabriel Mountains.

Meanwhile, the current heading of flight 15 was causing a separation issue with another flight, Air Canada flight AC788. This Boeing 787 Dreamliner had departed runway 06R at LAX one minute after EVA flight 15.

The controller instructed AC788 to expedite the climb and BR015 to stop climbing. Having ensured a safe separation the controller continued instructing BR015 to turn right.

Flight 15 then began climbing in a right-hand turn, passing over Mount Wilson. The closest lateral and vertical proximity between the airplane and terrain/obstructions was about 0.3 miles (482 m) and 0 ft, respectively, which is less than the minimum separation requirements.

The National Transportation Safety Board determines the probable cause(s) of this incident to be: 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.


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