# NTSB OPS12IA122: Kahului, HI, November 3, 2011 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: November 3, 2011, 11:31 local (21:31 UTC) - Place: Kahului, HI - Coordinates: 20.869083, -156.450729 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=20.8691&lon=-156.4507&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260) - Highest injury: No injuries - Status: Completed, report May 30, 2013 - Report: Approved by Office Director - NTSB office: Operational Factors Division - NTSB case key (mKey): 82345 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS12IA122 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82345/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82345 - Page: https://openairdocs.org/ntsb/OPS12IA122 ## Probable cause Failure of the Honolulu Control Facility controller to issue control instructions necessary to establish and maintain required separation between all three aircraft. Contributing to the losses of separation was inadequate training provided to controllers about the use of the approach to runway 2 at Kahului. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · ATC personnel (probable cause) - [Training](https://openairdocs.org/ntsb-findings/04031000): Organizational issues › Support/oversight/monitoring · ATC (probable cause) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · ATC personnel (probable cause) ## Analysis Three aircraft were approaching Kahului Airport to land on runway 2 and were receiving air traffic control sequencing and separation services from the Honolulu Control Facility (HCF). Aircraft 1 was conducting an instrument approach from the northeast and conflicted with aircraft 2, which was conducting a visual approach from the southwest. The controller attempted to correct the situation by vectoring aircraft 1, even though it was below the minimum vectoring altitude for the area. Aircraft 2 continued the approach and landed. The controller re-sequenced aircraft 1 for another instrument approach in front of aircraft 3, which was arriving from the northeast. Aircraft 3 was faster than aircraft 1 and overtook aircraft 1 while both aircraft were on final approach to the runway. The controller did not intervene in time to ensure separation. Review of HCF training materials and procedures showed that the simulator problems given to controllers to familiarize them with the new approach at that airport were not realistic and did not properly prepare controllers to manage the approach procedure. ## Factual narrative On November 3, 2011, about 1131 Hawaii Standard Time, three air traffic control operational errors occurred at the Honolulu Control Facility (HCF). The first operational error occurred when American Air Lines flight 253 (AAL253), flying the RNAV Z runway 2 approach to Kahului Airport (OGG), Kahului, Hawaii, passed within 0.98 miles laterally and 0 feet vertically of Hawaiian Air Lines flight 126 (HAL126) conducting a visual approach to the Kahului Airport. The second operational error occred when AAL253 was re-sequenced for the instrument landing system (ILS) approach to runway 2, in front of United Airlines flight 575 (UAL575) also being vectored for the ILS runway 2, while AAL253 was below the minimum vectoring altitude. The third operational error occurred when separation between AAL253 and UAL575 decreased to 3.62 nautical miles as a result of a loss of longitudinal separation on final. There was no damage reported to any of the aircraft, or any injuries to passengers or crew. AAL245, a Boeing 757, was a scheduled 14 Code of Federal Regulations Part 121 (14 CFR part 121) passenger flight operating from Los Angeles, California, to OGG. HAL126, a B717, was a scheduled 14 CFR part 121 passenger flight operating from Honolulu, Hawaii to OGG. UAL575, a Boeing 767, was a scheduled 14 CFR part 121 passenger flight operating from San Francisco, California, to OGG. AAL253 was conducting the RNAV Z runway 2 approach to OGG. HAL126 was on a visual approach to OGG runway 2. At 2129:48, as AAL253 passed ZEGUN on the approach, the CPC transmitted, “AAL253 speed 1-7-0 knots or less, you are following traffic over McGregor point coming up on 12 o’clock and 5 miles northbound, 7-1-7 [HAL126] three thousand five hundred.” AAL253 subsequently reported HAL126 in sight at eleven o’clock. At 2130:07 the CPC responded “Yeah, yeah, 11 o’clock moving to 12 o’clock on your turn, can you follow him to the field on the visual?” AAL253 responded that it would require a turn to follow HAL126 to the airport. The CPC issued AAL253 a right turn and instructed the pilot to maintain 2500 feet. AAL253 turned right from the arc on the RNAV Z approach to a heading of 180 degrees as HAL126 passed 0.98 NM off the left wing of AAL253 at the same altitude. HAL126 continued on the visual approach and landed without further incident. The CPC vectored AAL253 to the south at 2500’ and re-sequenced the aircraft for a Localizer runway 2 approach to be in front of UAL575. At 2132:22, the CPC informed the UAL575 “…gonna extend you downwind just for a little bit, get you behind ah an American ah that’s gonna be in front of you United 575.” At 2134:42 AAL253 was cleared for the ILS runway 2 approach into OGG and was switched to the tower at 2136:21. At 2135:23, UAL575 was cleared for the ILS runway 2 approach into Kahului airport and switched to the tower at 2138:44. The Kahului Airport weather for November 3, 2012 was obtained from the OGG Automatic Surface Observing System (ASOS). The 2054UTC recorded weather observation at PHOG included wind from 050 degrees at 12 knots with gusts to 22 knots, few clouds at 3000 feet, 10 statute miles of visibility, temperature 28 degrees C, dew point 19 degrees C, and an altimeter setting of 30.09 inches of mercury. For further information, see the Air Traffic Control Group Chairman's Report in the docket for this case. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260) (defining event) ## Aircraft - Damage: No damage - Destination: PHOG, Kahului, HI - Flight plan: Unknown - Airport: PHOG, Kahului Airport, runway 02, 6,995 × 150 ft ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 12 knots, gusting 22 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 66 °F - Altimeter: 30.09 inHg - Observed at: PHOG ## Docket (3 files) The files NTSB released with the investigation on October 25, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82345. 5.7 MB in all. - ATC 3 - Maui MVA Map (item 1, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379024&FileExtension=.PDF&FileName=ATC%203%20-%20Maui%20MVA%20Map-Master.PDF - ATC 3 - hcf SOP (item 2, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379169&FileExtension=.PDF&FileName=ATC%203%20-%20HCF%20SOP-Redacted.PDF - ATC 3 - Factual Report of Group Chairman (item 3, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379237&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.