ANC94IA075

NTSB incident investigation · Boeing 737-400 · Juneau, AK · July 2, 1994

Incident · No injuriesIncident investigationFinal report
Date
July 1, 1994, 19:00 local (Jul 2, 1994, 03:00 UTC)
Place
Juneau, AK
Injuries
63 uninjured
Phase of flight
Approach
Aircraft
N769ASBoeing 737-400N1470QCessna 185
Weather
Visual (VMC) · Day
Status
Completed · report October 31, 1995
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Case key
2458

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The failure of the local controller to exercise his responsibility to have each aircraft adjust its flightpath to remain clear of the other, and the failure of the pilot of the Cessna 185 to maintain adequate visual separation from the Boeing 737.

The failure of the local controller to exercise his responsibility to have each aircraft adjust its flightpath to remain clear of the other, and the failure of the the pilot of the Cessna 185 to maintain adequate visual separation from the Boeing 737.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Near collision between aircraftApproach - vfr pattern - base turn
Traffic advisory - inadequateAtc personnel(lcl/gnd/clnc)Cause
Visual separation - not maintainedPilot of other aircraftCause
Near collision between aircraftClimb - to cruise
Traffic advisory - inadequateAtc personnel(lcl/gnd/clnc)Cause
Visual separation - not maintainedPilot in commandCause

Analysis

Approaching the airport, the flightcrew of the B-737, N769AS, made initial contact with the local controller, and was advised of a left downwind for runway 26. At about 5 mi sw of the arpt, the flightcrew was advised of pattern traffic that included the departing C-185, N1470Q, starting a left downwind. The pilot of the C-185 was also advised of the B-737 entering downwind, to which the pilot replied '...roger have traffic in sight will stay low.' The pilot was not instructed to adjust his flightpath to remain clear of the B-737. The flightcrew of the B-737 subsequently reported a 'near miss' to the tower. The B-737 flightcrew and the C-185 pilot estimated their separation as less than 50 ft, at aprx 800 ft AGL. The pilot of the B-737 took 'max nose up...' Evasive action.

Approaching the airport, the flightcrew of the B-737, N769AS, made initial contact with the local controller, and was advised of a left downwind for runway 26. At about 5 mi sw of the arpt, the flightcrew was advised of pattern traffic that included the departing C-185, N1470Q, starting a left downwind. The pilot of the C-185 was also advised of the B-737 entering downwind, to which the pilot replied '...roger have traffic in sight will stay low.' The pilot was not instructed to adjust his flightpath to remain clear of the B-737. The flightcrew of the B-737 subsequently reported a 'near miss' to the tower. The B-737 flightcrew and the C-185 pilot estimated their separation as less than 50 ft, at aprx 800 ft AGL. The pilot of the B-737 took 'max nose up...' Evasive action.

Factual narrative

On July 1, 1994, at 1900 Alaska daylight time, a Cessna 185 float plane, N1470Q, was involved in a near midair collision (NMAC) with a Boeing 737-400 airplane, N769AS, operating as Alaska Airlines flight 77, within the Juneau, Alaska, class D airspace (airport traffic area and control zone). Alaska flight 77 was operating under 14 CFR 121, as a scheduled domestic air carrier arriving from Gustavus, Alaska, and N1470Q was operating under 14 CFR Part 91 as a personal flight to Ketchikan from Juneau. Both aircraft were on a VFR flight plan in visual meteorological conditions and were in contact with the Juneau Air Traffic Control Tower. The Boeing was reportedly in an approach turn to final and the Cessna was on a downwind departure. Alaska flight 77 reportedly had five crewmembers and fifty-six passengers on board. The Cessna had a private pilot and a passenger on board. There were no reported injuries and no reported aircraft damage.

Both pilots reported a "near miss" condition had occurred and estimated the distance to be 30 to 50 foot separation, at approximately 800 foot (agl). The captain of the Boeing reported that he took evasive action by employing "max nose up and full power." The private pilot reported that the Boeing passed in front of him at a distance of 50 feet and did not take evasive action.

On July 1, 1994, at 1659 Alaska daylight time, a Boeing 737-400, N769AS, operating as Alaska Airlines flight 77, was involved in a near-midair-collision (NMAC) with a float equipped Cessna 185 airplane, N1470Q, within the Juneau, Alaska, class D airspace (airport traffic area and control zone). Alaska flight 77 was operating under 14 CFR 121, as a scheduled domestic air carrier arriving from Gustavus, Alaska, and N1470Q was operating under 14 CFR Part 91 as a personal flight to Ketchikan from Juneau. Both aircraft were on a VFR flight plan in visual meteorological conditions and were in contact with the Juneau Air Traffic Control Tower. The Boeing was reportedly in an approach turn to final and the Cessna was on a downwind departure. Alaska flight 77 reportedly had five crewmembers and fifty-six passengers on board. The Cessna had a private pilot and a passenger on board. There were no reported injuries and no reported aircraft damage.

Both pilots reported a "near miss" condition had occurred and estimated the distance to be 30 to 50 foot separation, at approximately 800 foot (agl). The captain of the Boeing reported that he took evasive action by employing "max nose up and full power." The private pilot reported that the Boeing passed in front of him at a distance of 50 feet and did not take evasive action.

Refer to the Operations Group and Air Traffic Group Chairmans' Factual Reports attached.

Aircraft · 2

Registration
N769AS
Reported as
Boeing 737-400
Category
Airplane
Engine
GE CFM56-3B-2, turbo fan
Damage
No damage
Flight
Part 121
Operator
Alaska Airlines, Inc, doing business as Alaska Airlines
Registered owner
Alaska Airlines
Airworthiness certificate
Standard, Transport
Departed
GST · Gustavus, AK
Flight plan
VFR
Airport
Juneau Intl
Registration
N1470Q
Reported as
Cessna 185
Category
Airplane
Engine
Continental O-520, 300 horsepower, reciprocating
Damage
No damage
Flight
Personal · Part 91
Operator
Ernest B. Meloche
Registered owner
Ernest B. Meloche
Airworthiness certificate
Standard, Normal
Destination
KTN · Ketchikan, AK
Flight plan
VFR
Airport
Juneau Intl

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N769AS
Age
45
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Seat
Left
Flight hours
15,763 total · 5,738 in this make and model · 10,000 as pilot in command · 136 in the last 90 days · 2 in the last 24 hours
Role
Pilot, aircraft N1470Q
Certificate
Private
Airplane ratings
Single-engine sea
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
568 total · 530 in this make and model · 560 as pilot in command · 90 in the last 90 days · 30 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 8 knots
Visibility
30 statute miles
Lowest ceiling
8,000 ft broken
Temperature
66 °F, dew point 45 °F
Altimeter
29.00 inHg
Observed at
JNU, 3 nm away