# NTSB ANC94IA075: Boeing 737-400, N769AS, Juneau, AK, July 2, 1994

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: July 1, 1994, 19:00 local (Jul 2, 1994, 03:00 UTC)
- Place: Juneau, AK
- Coordinates: 58.58052, -134.770339 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=58.5805&lon=-134.7703&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 63 uninjured
- Status: Completed, report October 31, 1995
- Report: Approved by Office Director
- NTSB office: Alaska Regional Office
- NTSB case key (mKey): 2458
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC94IA075
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2458/pdf
- Page: https://openairdocs.org/ntsb/ANC94IA075

## Probable cause (aircraft 2)

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.

## Probable cause (aircraft 1)

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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Near collision between aircraft, approach - vfr pattern - base turn
  - traffic advisory - inadequate, atc personnel(lcl/gnd/clnc) (cause)
  - visual separation - not maintained, pilot of other aircraft (cause)
- Near collision between aircraft, climb - to cruise
  - traffic advisory - inadequate, atc personnel(lcl/gnd/clnc) (cause)
  - visual separation - not maintained, pilot in command (cause)

## Analysis (aircraft 2)

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.

## Analysis (aircraft 1)

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 (aircraft 2)

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.

## Factual narrative (aircraft 1)

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 1

- Registration: N769AS (not matched to a registry record)
- Reported make and model: BOEING 737-400
- Category: Airplane
- Engines: 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

## Aircraft 2

- Registration: [N1470Q](https://openairdocs.org/aircraft/N1470Q), registered now, S/N 18503483, built 1977 (OpenAirDocs)
- Reported make and model: CESSNA 185
- Registry model: [Cessna A185F](https://openairdocs.org/model/cessna-a185f) (registry code 2072821) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N769AS; age 45; 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
- Pilot, aircraft N1470Q; 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

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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