OPS06IA004

NTSB incident investigation · EADS Socata A320 · Las Vegas, NV · January 28, 2006

Incident · No injuriesIncident investigationFinal report
Date
January 27, 2006, 17:44 local (Jan 28, 2006, 01:44 UTC)
Place
Las Vegas, NV
Injuries
2 uninjured
Phase of flight
Approach
Aircraft
UNKEADS Socata A320UNKBoeing B757
Weather
Visual (VMC)
Status
Completed · report March 31, 2008
Report
Approved by Office Director
NTSB office
Operational Factors Division
Safety recommendations
Yes
Case key
63187

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 NTSB’s determination of the probable cause, and any contributing factors.

Deficient FAA procedures for separation of aircraft using converging runways, which failed to ensure that the tower controllers were able to provide adequate separation in the event of a go-around.

Deficient FAA procedures for separation of aircraft using converging runways, which failed to ensure that the tower controllers were able to provide adequate separation in the event of a go-around.

Analysis

On January 27, 2006, at 0044 UTC, a near midair collision occurred at McCarran International Airport, Las Vegas, Nevada, when UAL1547 was instructed to go around while on a visual approach to runway 19R and came into conflict with AAL1913 departing from runway 25R. UAL1547 made an evasive turn to the right to avoid a potential collision, and AAL1913 made a slight left turn. UAL1547 returned for landing at 0049, and AAL1913 continued to its destination. There was no reported damage to either aircraft, and no reported injuries to passengers or crew.

On January 27, 2006, at 0044 UTC, a near midair collision occurred at McCarran International Airport, Las Vegas, Nevada, when UAL1547 was instructed to go around while on a visual approach to runway 19R and came into conflict with AAL1913 departing from runway 25R. UAL1547 made an evasive turn to the right to avoid a potential collision, and AAL1913 made a slight left turn. UAL1547 returned for landing at 0049, and AAL1913 continued to its destination. There was no reported damage to either aircraft, and no reported injuries to passengers or crew.

Factual narrative

The factual narrative1,298 words

On January 27, 2006, at 0044 UTC, a near midair collision occurred at McCarran International Airport, Las Vegas, Nevada, when UAL1547 was instructed to go around while on a visual approach to runway 19R and came into conflict with AAL1913 departing from runway 25R. UAL1547 made an evasive turn to the right to avoid a potential collision, and AAL1913 made a slight left turn. UAL1547 returned for landing at 0049, and AAL1913 continued to its destination. There was no reported damage to either aircraft, and no reported injuries to passengers or crew.

History of Flight

UAL1547 was an Airbus A320 en route from Chicago to LAS. The pilot first contacted the L30 Lake sector at 0030 and reported having Automatic Terminal Information Service (ATIS) information "E." ATIS E reported visibility 10 miles, few clouds at 10,000 feet, scattered clouds at 25,000, wind 230 degrees at 13, and that the airport was landing on runways 25L, 19R, and 19L, and departing runways 25R, 19R, and 19L. The flight crew contacted the L30 Satellite (SAT) sector at 0035, was vectored for a visual approach to runway 19R at LAS, and reported the airport in sight at 0039. The SAT controller cleared the pilot for a visual approach at 0039 and the pilot acknowledged. UAL1547 was instructed to contact LAS tower at 0040. The local controller responsible for runways 19L and R (LC2) cleared UAL1547 to land, reporting the wind as 320 degrees at 9 knots. The LC1 controller cleared AAL1913 into position and hold on runway 25R at 0041:42, and issued takeoff clearance at 0042:03.

At 0042, the LC2 controller instructed King Air N278SW, who was at that time holding on the east side of taxiway E between runways 19R and 19L after landing on runway 19L, to cross runway 19R without delay. At 0042:44, LC2 transmitted, "King Air 8SW", and at 0042:52 transmitted, "United 1547 go around, traffic on the runway." The pilot of UAL1547 acknowledged and executed a go-around. At 0043:02, LC2 told UAL1547 to maintain 3,500 feet, and the pilot acknowledged.

At 0043:10, the LC1 controller instructed AAL1913 to, "stay low, United is going around off runway 19." The pilot responded, "Say again?", and the controller repeated the instruction. The pilot replied, "OK." Shortly afterward, the LC1 controller apologized for the "late call" and instructed AAL1913 to contact the departure controller.

At 0043:14, LC2 informed UAL1549 that there was an aircraft departing from runway 25 and issued a safety alert for traffic. There was no response. At 0043:21, LC2 repeated the warning. UAL1547 acknowledged, and at 0043:28 reported that they were, "coming hard right, hard." The controller then advised the crew of additional traffic, a Cessna at one o'clock at 4,000 feet. UAL1547 reported that, "all we saw was the [Boeing 7] 57 off [runway] 25 right." The LC2 controller then again advised of traffic off UAL1547's right and told the pilot to maintain his present altitude. At 0044:04, LC2 coordinated with the Satellite radar controller, advising that UAL1547 would be heading 330 and climbing to 7,000 feet. At 0044:18, the LC2 controller instructed the pilot to contact Las Vegas Departure on 119.4 for resequencing.

At 0044:28, the SAT controller contacted LC2, stating, "Give me United now." LC2 responded that, "he's coming." At 0044:54, the SAT controller transmitted, "United 1547 turn left immediately if you hear me traffic just north of your position descending out of 7,000 a Falcon jet." The pilot responded and reported the Falcon in sight, and the controller instructed the pilot to maintain visual separation. The SAT controller then continued to vector UAL1547 for another approach to runway 19R at LAS, instructing the pilot to again contact the tower at 0049.

While taxiing to the gate after landing, the pilot of UAL1547 requested and received a telephone number to call the tower in order to discuss the incident.

LAS Approach Control Handling

LAS and L30 are separate ATC facilities although they are located in the same building. L30 is responsible for aircraft arriving and departing LAS as well as other airports in the area. UAL1547 was cleared into the LAS area from the northeast via the GRNPA arrival, ending with a visual approach to runway 19R. The initial arrival was routine. After the go-around occurred, the LAS LC2 controller coordinated with SAT radar to give UAL1547 back to SAT heading 330 degrees and climbing to 7,000 feet. The SAT controller approved the request, but this almost immediately led to a conflict with N908JB, a Falcon jet on a visual approach to North Las Vegas (VGT) airport. The SAT controller had already transferred N908JB to VGT tower, and called VGT the have them send the aircraft back to SAT frequency. Before UAL1547 checked in with SAT, the SAT controller issued an immediate left turn to UAL1547 for traffic, which was acknowledged by the crew, and then established visual separation between UAL1547 and N908JB. Following resolution of that conflict, UAL1547 was vectored back to a visual approach to runway 19R and again instructed to contact LAS ATCT.

AAL1913 departed straight out from runway 25R, and there was no unusual coordination or other action taken by L30 involving the aircraft.

LAS ATCT Handling

UAL1547 was transferred to LAS ATCT on a visual approach to runway 19R. When the flight was about two miles from the threshold, the LC2 controller instructed King Air N8SW to cross runway 19R "without delay." LAS is equipped with an ASDE-3 surface radar and an Airport Movement Area Safety System (AMASS) processor that records surface movements. According to the AMASS replay, the King Air had been holding on taxiway S east of the center taxiway between runways 19L and 19R. After the controller instructed the pilot to cross, N8SW moved toward runway 19R, crossed the hold lines, and then stopped. The aircraft was clear of the east edge of the runway but inside the safety area. The LC2 controller noticed that the aircraft had stopped and would not clear the runway before UAL1547 crossed the landing threshold. LC2 instructed UAL1547 to go around because of the observed conflict.

While this was occurring, the LC1 controller cleared AAL1613 to depart runway 25R. The departure path for runway 25R crosses the departure path for runway 19R. According to his interview, the LC1 controller became aware of the potential conflict when he heard LC2 instructing an aircraft to maintain 3,500 feet, looked over his shoulder and saw UAL1547 on a go-around from the approach end of runway 19R. The LC1 controller advised the pilot of AAL1613 to, "stay low - there's a United going around off runway 19R." The pilot asked the controller to say again, and acknowledged with, "OK" after the second transmission.

After issuing the go-around instruction, LC2 told the pilot of UAL1547 to maintain 3,500 feet, which is in compliance with a facility standard operating procedure requirement to restrict aircraft at or below that altitude until they are abeam the tower. The controller then provided UAL1547 with a safety alert, warning the pilot of traffic departing runway 25 and telling the pilot to, "turn at your discretion." There was no response. The LC2 controller repeated the warning, and the crew responded that they were "going hard right." UAL1547 continued the right turn until the controller instructed the crew to fly heading 330 degrees. At that point, AAL1613 and UAL1547 were on diverging courses. After coordinating with SAT, LC2 instructed the pilot to contact departure for resequencing.

When UAL1547 returned to the airport, the crew reported a TCAS traffic advisory involving a helicopter on final for runway 19R. After landing, the crew asked for a phone number to call the tower. The captain called, initially spoke to the supervisor, and was referred to the facility quality assurance specialist for further discussion.

Following

The factual narrative1,298 words

On January 27, 2006, at 0044 UTC, a near midair collision occurred at McCarran International Airport, Las Vegas, Nevada, when UAL1547 was instructed to go around while on a visual approach to runway 19R and came into conflict with AAL1913 departing from runway 25R. UAL1547 made an evasive turn to the right to avoid a potential collision, and AAL1913 made a slight left turn. UAL1547 returned for landing at 0049, and AAL1913 continued to its destination. There was no reported damage to either aircraft, and no reported injuries to passengers or crew.

History of Flight

UAL1547 was an Airbus A320 en route from Chicago to LAS. The pilot first contacted the L30 Lake sector at 0030 and reported having Automatic Terminal Information Service (ATIS) information "E." ATIS E reported visibility 10 miles, few clouds at 10,000 feet, scattered clouds at 25,000, wind 230 degrees at 13, and that the airport was landing on runways 25L, 19R, and 19L, and departing runways 25R, 19R, and 19L. The flight crew contacted the L30 Satellite (SAT) sector at 0035, was vectored for a visual approach to runway 19R at LAS, and reported the airport in sight at 0039. The SAT controller cleared the pilot for a visual approach at 0039 and the pilot acknowledged. UAL1547 was instructed to contact LAS tower at 0040. The local controller responsible for runways 19L and R (LC2) cleared UAL1547 to land, reporting the wind as 320 degrees at 9 knots. The LC1 controller cleared AAL1913 into position and hold on runway 25R at 0041:42, and issued takeoff clearance at 0042:03.

At 0042, the LC2 controller instructed King Air N278SW, who was at that time holding on the east side of taxiway E between runways 19R and 19L after landing on runway 19L, to cross runway 19R without delay. At 0042:44, LC2 transmitted, "King Air 8SW", and at 0042:52 transmitted, "United 1547 go around, traffic on the runway." The pilot of UAL1547 acknowledged and executed a go-around. At 0043:02, LC2 told UAL1547 to maintain 3,500 feet, and the pilot acknowledged.

At 0043:10, the LC1 controller instructed AAL1913 to, "stay low, United is going around off runway 19." The pilot responded, "Say again?", and the controller repeated the instruction. The pilot replied, "OK." Shortly afterward, the LC1 controller apologized for the "late call" and instructed AAL1913 to contact the departure controller.

At 0043:14, LC2 informed UAL1549 that there was an aircraft departing from runway 25 and issued a safety alert for traffic. There was no response. At 0043:21, LC2 repeated the warning. UAL1547 acknowledged, and at 0043:28 reported that they were, "coming hard right, hard." The controller then advised the crew of additional traffic, a Cessna at one o'clock at 4,000 feet. UAL1547 reported that, "all we saw was the [Boeing 7] 57 off [runway] 25 right." The LC2 controller then again advised of traffic off UAL1547's right and told the pilot to maintain his present altitude. At 0044:04, LC2 coordinated with the Satellite radar controller, advising that UAL1547 would be heading 330 and climbing to 7,000 feet. At 0044:18, the LC2 controller instructed the pilot to contact Las Vegas Departure on 119.4 for resequencing.

At 0044:28, the SAT controller contacted LC2, stating, "Give me United now." LC2 responded that, "he's coming." At 0044:54, the SAT controller transmitted, "United 1547 turn left immediately if you hear me traffic just north of your position descending out of 7,000 a Falcon jet." The pilot responded and reported the Falcon in sight, and the controller instructed the pilot to maintain visual separation. The SAT controller then continued to vector UAL1547 for another approach to runway 19R at LAS, instructing the pilot to again contact the tower at 0049.

While taxiing to the gate after landing, the pilot of UAL1547 requested and received a telephone number to call the tower in order to discuss the incident.

LAS Approach Control Handling

LAS and L30 are separate ATC facilities although they are located in the same building. L30 is responsible for aircraft arriving and departing LAS as well as other airports in the area. UAL1547 was cleared into the LAS area from the northeast via the GRNPA arrival, ending with a visual approach to runway 19R. The initial arrival was routine. After the go-around occurred, the LAS LC2 controller coordinated with SAT radar to give UAL1547 back to SAT heading 330 degrees and climbing to 7,000 feet. The SAT controller approved the request, but this almost immediately led to a conflict with N908JB, a Falcon jet on a visual approach to North Las Vegas (VGT) airport. The SAT controller had already transferred N908JB to VGT tower, and called VGT the have them send the aircraft back to SAT frequency. Before UAL1547 checked in with SAT, the SAT controller issued an immediate left turn to UAL1547 for traffic, which was acknowledged by the crew, and then established visual separation between UAL1547 and N908JB. Following resolution of that conflict, UAL1547 was vectored back to a visual approach to runway 19R and again instructed to contact LAS ATCT.

AAL1913 departed straight out from runway 25R, and there was no unusual coordination or other action taken by L30 involving the aircraft.

LAS ATCT Handling

UAL1547 was transferred to LAS ATCT on a visual approach to runway 19R. When the flight was about two miles from the threshold, the LC2 controller instructed King Air N8SW to cross runway 19R "without delay." LAS is equipped with an ASDE-3 surface radar and an Airport Movement Area Safety System (AMASS) processor that records surface movements. According to the AMASS replay, the King Air had been holding on taxiway S east of the center taxiway between runways 19L and 19R. After the controller instructed the pilot to cross, N8SW moved toward runway 19R, crossed the hold lines, and then stopped. The aircraft was clear of the east edge of the runway but inside the safety area. The LC2 controller noticed that the aircraft had stopped and would not clear the runway before UAL1547 crossed the landing threshold. LC2 instructed UAL1547 to go around because of the observed conflict.

While this was occurring, the LC1 controller cleared AAL1613 to depart runway 25R. The departure path for runway 25R crosses the departure path for runway 19R. According to his interview, the LC1 controller became aware of the potential conflict when he heard LC2 instructing an aircraft to maintain 3,500 feet, looked over his shoulder and saw UAL1547 on a go-around from the approach end of runway 19R. The LC1 controller advised the pilot of AAL1613 to, "stay low - there's a United going around off runway 19R." The pilot asked the controller to say again, and acknowledged with, "OK" after the second transmission.

After issuing the go-around instruction, LC2 told the pilot of UAL1547 to maintain 3,500 feet, which is in compliance with a facility standard operating procedure requirement to restrict aircraft at or below that altitude until they are abeam the tower. The controller then provided UAL1547 with a safety alert, warning the pilot of traffic departing runway 25 and telling the pilot to, "turn at your discretion." There was no response. The LC2 controller repeated the warning, and the crew responded that they were "going hard right." UAL1547 continued the right turn until the controller instructed the crew to fly heading 330 degrees. At that point, AAL1613 and UAL1547 were on diverging courses. After coordinating with SAT, LC2 instructed the pilot to contact departure for resequencing.

When UAL1547 returned to the airport, the crew reported a TCAS traffic advisory involving a helicopter on final for runway 19R. After landing, the crew asked for a phone number to call the tower. The captain called, initially spoke to the supervisor, and was referred to the facility quality assurance specialist for further discussion.

Following

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 - final approach
Atc clearance procedure - inadequateCause
Near collision between aircraftTakeoff - initial climb
Atc clearance procedure - inadequateCause

Aircraft · 2

Registration
UNK
Reported as
EADS Socata A320
Category
Airplane
Damage
No damage
Flight
Part 121
Operator
United Air Lines Inc
Departed
ORD · Chicago, IL
Destination
Las Vegas, NV
Flight plan
IFR
Registration
UNK
Reported as
Boeing B757
Category
Airplane
Damage
No damage
Flight
Part 121
Operator
American Airlines Inc
Departed
LAS · Las Vegas, NV
Destination
DFW · Dallas, TX
Flight plan
IFR

Weather

Conditions
Visual (VMC)
Wind
260° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Altimeter
30.07 inHg
Observed at
KLAS