OPS21LA002

NTSB incident investigation · Airbus A319-112 · St Petersburg-Clearwater, FL · April 29, 2021

Incident · No injuriesClass 3 · LimitedFinal report
Date
April 29, 2021, 15:07 local (19:07 UTC)
Place
St Petersburg-Clearwater, FL · PIE airport
Injuries
130 uninjured
Phase of flight
Takeoff
Aircraft
N306NVAirbus A319-112N370SDCessna M337B
Defining events
Takeoff: Air traffic eventApproach-VFR pattern downwind: Near midair/TCAS alert/loss of separation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Operational Factors Division
Parties
National Air Traffic Controllers Association, FAA
Case key
103049

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

On this page

Probable cause

The air traffic controller’s failure to properly scan the runway and local area, and their general loss of situational awareness, resulting in a near midair collision. Contributing to the incident was the Cessna 337 pilot's poor decision making when he failed to fly the standard downwind leg distance from the runway and to maintain the standard traffic pattern altitude.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N306NV · Airbus A319-112

Action: lack of actionPersonnel issues › Action/decision · ATC personnelAirbus A319-112: 1 caseAll aircraft: 792 casesProbable cause
Attention/monitoring: monitoring other aircraftPersonnel issues › Psychological · ATC personnelAirbus A319-112: 1 caseAll aircraft: 231 casesProbable cause
Planning/preparationPersonnel issues › Task performance · ATC personnelAirbus A319-112: 1 caseAll aircraft: 113 casesProbable cause

N370SD · Cessna M337B

Action: lack of actionPersonnel issues › Action/decision · PilotCessna M337B: 1 caseAll aircraft: 792 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotCessna M337B: 1 caseAll aircraft: 1,386 casesProbable cause
Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · ATC personnelCessna M337B: 1 caseAll aircraft: 330 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

N306NV · Airbus A319-112

N370SD · Cessna M337B

Analysis

Review of the radar data showed that N370SD, a Cessna 337, was on a right downwind for runway 22 at 300 feet when it overflew runway 18, and at the same time Allegiant Air flight 803 (AAY803), an Airbus A319, was at 200 feet departing runway 18. The closest proximity was 100 feet vertically and 369 feet laterally. The crew of AAY803 saw the Cessna 337 and took evasive action by stopping their takeoff climb and maintaining 200 feet, and flew underneath the Cessna 337, which was at 300 feet as the airplane’s paths intersected over the runways. The local controller did not visually scan all runways and airspace when he instructed the Cessna 337 pilot to enter a right downwind, and again, when he issued a takeoff clearance to the Allegiant Air flight; the lack of fully scanning all runways and airspace resulted in the local controller losing situational awareness of the Cessna 337, and ultimately not ensuring positive control and separation between the Allegiant Air flight and the Cessna 337. The Cessna 337 pilot’s downwind leg for runway 22 was significantly less than the standard 1/2 to 1 mile defined downwind leg distance from the runway, which placed the Cessna 337 in a closer vicinity to the runway intersections than what was expected. Additionally, the Cessna 337 pilot did not fly a standard traffic pattern altitude, and the local controller did not instruct or advise the pilot that the traffic pattern altitude was 1,000 feet. PIE airport did not have a charted traffic pattern altitude.

Factual narrative

On April 29, 2021, about 1507 EDT, a near midair collision occurred at the St. Pete-Clearwater International Airport (PIE), St Petersburg-Clearwater, Florida, when AAY803, while on initial climb from runway 18, took evasive action to avoid a midair collision with N370SD that was crossing over head of the runway about midfield, while on the right downwind for runway 22. AAY803 was being operated under Title 14 Code of Federal Regulations (CFR) Part 121 and N370SD was operated under Title 14 CFR Part 91. There were no injuries reported to the crew or passengers of either flight, and no damage to the aircraft. Daytime visual meteorological conditions prevailed at the time of the incident. About 1457, N370SD departed Albert Whitted Airport (SPG), St. Petersburg, Florida and flew to the west and then northwest along the intercoastal waterway about 1,100 ft above mean sea level (msl). The flight made a 270 degree turn and then flew to the northeast towards PIE. Figure 1 is the PIE airport diagram and shows the locations of runway 22 and runway 18 circled in red. Figure 1. PIE airport diagram showing locations of runway 18 and runway 22. About 1501, the pilot of N370SD checked in with the PIE LC controller and said they had Automatic Terminal Information Service (ATIS) information November. The LC controller asked the pilot to “say again.” The pilot of N370SD responded with his call sign. About 1502, the LC controller instructed the pilot of N370SD to squawk 0163 and requested the pilot to say his intentions. The pilot readback the squawk and informed the controller that he wanted to make a full stop landing. The LC controller instructed the pilot to fly eastbound and then enter a left downwind for runway 22. The pilot readback, “eastbound left downwind runway 22.” The LC controller asked the pilot of N370SD if he had ATIS information November. The pilot acknowledged “affirmative, November.” About 1504, the LC controller instructed AAY803 to line up and wait (LUAW) on runway 18 and told the crew they had traffic on a 7-mile final. The crew of AAY803 responded, “line up and wait.” About 1505, the LC controller informed the pilot of N370SD that he had to change plans and instructed the pilot to turn 20 degrees to the left and enter a right downwind to runway 22. The pilot readback, “right downwind runway 22.” About 1506, the LC controller cleared AAY803 for takeoff from runway 18. The crew responded, “cleared for takeoff 18, Allegiant 803.” About 1507, the crew of AAY803 stated, “tower, Allegiant 803 what’s with the aircraft that we almost just hit.” The pilot of N370SD transmitted, “I have the aircraft in sight, sir, right downwind 22.” The LC controller instructed N370SD to continue to the right downwind. The LC controller advised the crew of AAY803 that, “there’s traffic at 10 o’clock but they’re turning northeast bound and they’re no factor, and there was traffic that flew over the runway at 1,000 feet towards the approach end and they’re in a rightdownwind for runway 22, is that who you are talking about.” The crew of AAY803 stated, “yeah, we had to level off we were climbing right into them.” The pilot of N370SD stated, “I had the traffic in sight at all times sir.” According to the AAY803 Captain’s statement, they were light and rotated about five hundred feet before the old runway 9/27. He called positive climb and the pilot flying (PF) called for the gear up. Since they were light the aircraft was climbing very fast. He reached over for the gear handle and saw an aircraft coming right at them about 200 feet higher at our one-thirty [clock] position. He immediately called for the PF to level off, pointed out the traffic and he left the gear down. When clear of traffic they continued the climb. He contacted the tower to report the near midair and the controller responded the aircraft was at 1,000 feet. The LC controller then instructed AAY803 to contact Tampa departure control. The crew of AAY803 responded “contact departure.” FAA radar data showed that at 1507:02 N370SD was on a right downwind for runway 22, at an altitude of 300 feet and a lateral distance of about 800 feet from the centerline of runway 22, when it overflew runway 18. At the same time AAY803 was at 200 feet departing runway 18. The closest proximity was 100 feet vertically and 369 feet laterally. Figure 2 is satellite imagery overlaid with FAA radar data showing the closest proximity between N370SD and AAY803. The figure provides a close-up overhead view of the location. A legend of pertinent information is located in the bottom right corner of this figure. Figure 2. FAA Radar data overlaid on satellite imagery illustrating the flights routes of N370SD and AAY803, and the location of the closest proximity to each other. Figure 3 is satellite imagery overlaid with FAA radar data illustrating flight paths of N370SD and AAY803 from a side view. A legend of pertinent information is located in the bottom right corner of this figure. Figure 3. FAA Radar data overlaid satellite imagery illustrating the flight paths of N370SD and AAY803, from a side view perspective. About 1508, the LC controller advised the pilot of N370SD that he would call his base turn. Then the LC controller instructed the pilot to turn his base and asked what his altitude was. The first part of the pilot’s transmission was indiscernible, and although the last part of the transmission was intermittently distorted, the pilot was heard stating, “turn base.” The LC controller asked the pilot again what his altitude was. The pilot responded, “700 feet at the moment.” The LC informed the pilot that he could not understand him. The first part of the pilot’s transmission was indiscernible, and although the last part of the transmission was intermittently distorted, the pilot of N370SD was heard stating, “700 feet at this time.” The LC controller said, “understand 700 feet” and informed the pilot that he was not receiving his mode C at that point. About 1509,the LC controller cleared N370SD to land on runway 22. The pilot read back “cleared to land.” Two minutes later N370SD landed on runway 22. According to the pilot of N370SD, “My recollection of the flight into KPIE on the day in question is very clear, the air traffic controller cleared me to "left downwind 22" whilst established left downwind 22 I was instructed "change of plan RIGHT downwind 22." At all times I had the Allegiant jet in view. On approaching [runways] 36-18 I saw the jet start to climb then heard the pilot of the jet comment about my position to which the air-traffic controller replied, "you have sufficient clear airspace the aircraft is at 1000 ft mid field. " My assumption was the controller moved me to right downwind to give sufficient clearance so that the airbus could pass safely under me.”

Aircraft · 2

Registration
N306NV
Reported as
Airbus A319-112
Category
Airplane
Serial number
2420
Built
2005
Airframe hours
46,011.3
Engines
CFM Intl CFM56-5B6/P, 23,500 lbs thrust, turbo fanCFM Intl CFM56-5B6/P, 23,500 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Allegiant Air, doing business as Allegiant Travel Company
Registered owner
Sunrise Asset Management LLC
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 28, 2021
Destination
ORF · Norfolk, VA
Flight plan
IFR
Airport
PIE · St Pete-Clearwater Intl, runway 18, 9,730 × 150 ft, concrete
Equipment
ADS-B, Stall warning system, Onboard weather, Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Data recorder, Angle of attack indicator, Auto-pilot

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.

Registration
N370SD
Reported as
Cessna M337B
Category
Airplane
Serial number
69-7659
Built
1969
Engines
Cont Motor IO-360 C/D, 210 horsepower, reciprocatingCont Motor IO-360 C/D, 210 horsepower, reciprocating
Damage
No damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
March 29, 2021
Departed
KSPG · St. Petersburg, FL
Destination
Same as departure
Equipment
ADS-B

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N306NV
Age
51
Injuries
None
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 30, 2020
Seat
Left
Restraint
5-point
Flight hours
6,454 total · 6,111 in this make and model · 2,815 as pilot in command · 252 in the last 90 days · 84 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot, aircraft N306NV
Age
37
Injuries
None
Certificates
Private, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 30, 2020
Seat
Right
Restraint
5-point
Flight hours
4,224 total · 2,270 in this make and model · 0 as pilot in command · 207 in the last 90 days · 56 in the last 30 days · 3 in the last 24 hours
Role
Pilot, aircraft N370SD
Age
69
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
April 14, 2021
Seat
Left
Restraint
3-point
Flight hours
2,100 total · 341 in this make and model · 2,000 as pilot in command · 11.5 in the last 90 days · 11.5 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 7 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 66 °F
Altimeter
30.04 inHg
Observed at
KPIE, 1 nm away
METAR
KPIE 291853Z 17007G18KT 10SM SCT045 31/19 A3004 RMK AO2 SLP174 T03060194

Docket · 19

The files NTSB released with the investigation on September 22, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 494 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1 - Cessna N370SDItem 1 · PDF · 9 pages · 4.4 MBPilot/operator aircraft accident report, NTSB form 6120.1 - AAY803Item 2 · PDF · 11 pages · 2.1 MBOperational factors specialist reportItem 3 · PDF · 35 pages · 2.8 MBOperational factors - attachment 1 - allegiant air flight 803 flight crew statementsItem 4 · PDF · 3 pages · 74 KBOperational factors - attachment 2 - Cessna pilot statement and flight review logbook entryItem 5 · PDF · 3 pages · 2.9 MBOperational factors - attachment 3 - certificated flight instructor for Cessna pilot - interview summaryItem 6 · PDF · 2 pages · 110 KBOperational factors - attachment 4 - eyewitness statementsItem 7 · PDF · 3 pages · 348 KBOperational factors - attachment 5 - number of occupants on allegiant air flight 803Item 8 · PDF · 2 pages · 120 KBOperational factors - attachment 6 - pie airport master record and chart supplementItem 9 · PDF · 2 pages · 113 KBOperational factors - attachment 7 - allegiant air procedures and TCAS memory itemsItem 10 · PDF · 13 pages · 757 KBOperational factors - attachment 8 - allegiant air flight crew operations manual TCAS description [excerpt]Item 11 · PDF · 19 pages · 731 KBOperational factors - attachment 9 - flight recorder data [excerpt]Item 12 · PDF · 3 pages · 763 KBOperational factors - attachment 10 - allegiant air flight 803 acars communication [excerpts]Item 13 · PDF · 6 pages · 674 KBAir traffic control group factual reportItem 14 · PDF · 14 pages · 2.0 MBAir traffic control attachment 1 FAA administrative documentsItem 15 · PDF · 26 pages · 8.1 MBAir traffic control attachment 2 interview transcriptsItem 16 · PDF · 132 pages · 1.0 MBAir traffic control attachment 3 local control audioItem 17 · WAV · 83.5 MBAir traffic control attachment 4 ground control audioItem 18 · WAV · 134 MBAir traffic control attachment 5 FAA radar dataItem 19 · PPB · 250 MB