Aircraft Accident Report (NTSB/AAR-87/07)
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PB8i-9 10409 TRANSPOltTATION SAFETY WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT COLLISION OF AERONAVES DE MEXICO, S.A. MCDONNELL DOUGLAS DC-9-32, XA-JED AND PIPER PA-28-181, N489lF CERRITOS, CALIFORNIA AUGUST 3’1, 1986 NTSB/AAR-87/07 UNITED STATES GOVERNMENT TECHNIC I REPORT DOCUMENTATION PAGE 3.Recipient’s Catalog No. 6.Performing Organization Code 8.Performing Organization Report No. 5 a Performing Organization Name and Address lO.W&$J~i t No. ational Transportation Safety Board Bureau of Accident Investigation . 11 .Contract or Grant No. Washington, D.C. 20594 13.Type of Report and Period Covered 12.bponsoring Agency Name and Address Aviation Accident Report August 31,1986 NATIONAL TRANSPORTATION SAFETY BOARD Washington, 0. C. 20594 14.Sponsoring Agency Code 15.Supplementary Notes 16.Abstract 0n August 31, 1986, about 1152 Pacific daylight time, .Aeronaves de Mexico, $.A., flight 498, a DC-9-32, Mexican Registration XA-JED, and a Piper PA-28-181, United tates Registration N4891F, collided over Cerritos, California. Flight 498, a regularly scheduled passenger flight, was on an Instrument Flight Rules flight plan from Tijuana, Mexico, Angeles International Airport, California, and was under radar control by the Los terminal radar control facility. The Piper airplane was proceeding from Torrance, California toward Big Bear, California, under Visual Flight’ Rules, and was not in radio contact with any air traffic control facility when the accident occurred. The National Transportation Safety Board determines that the probable cause of the accident was the limitations of the air traffic control system to provide collision protection, through both air traffic control procedures and automated redundancy. Patton contributing to the accident were (1) the inadvertent and unauthorixed entry of into the Los Angeles Terminal Control Area and (2) the limitations of the “*see concept to ensure traffic separation under the conditions of the conflict. 18.Distribution Statement collision: terminal control ar This document is available instrument flight rules; term to the public through trol facility; traffic alert and collision the National Technical m; TCAS; air traffic control; ARTS; Information Service r terminal system; see and avoid Springfield, Virginia 22161 CONTENTS . BXRCUTIVRSUMMARY . ; . ; . i ; ; ; . V 1. ACTUAL WPORMATION ........... .......... 1 1.1 History of the Flights. ............. .......... 1.2 Injuries to Persons ............... .......... ii L3 Damage to Airplanes .............. .......... 1.4 Other Damage. ................ .......... 3” 1.5 Personnel Information ............. .......... 3 1.6 Airplane Information .............. .......... 4 1.7 Meteorological Information ........... .......... 5 1.8 Navigational Aids ............... .......... 5 1.9 Communications. ............... .......... 6 1.10 Aerodrome Information ............. .......... 1.11 Flight Recorders. ............... .......... i 1.12 Wreckage and Impact Information ........ .......... 10 lJ3 Medical and Pathological Information. ...... .......... 12 1.14 Fire ... ; ................. .......... 1.15 Survival Aspects ................ .......... ii 1.16 Tests and Research. .............. .......... 13 1.16.1 Visibility and Vision Studies ........ .......... 1.16.2 Target Acquisition Performance ...... .......... it lJ7 Other Information ........ ; ...... .......... 15 1.17.1 Aeromexico Flight Operation Procedures and Training ................... .......... 15 1.17.2 The Los Angeles Terminal Radar Control. .. .......... 19 1.17.3 Air Traffic Control Procedures ....... .......... 26 1.17.4 Terminal Control Areas .......... .......... 32 L17.5 Traffic Alert and Collision Avoidance Systems . 1.16 New Investigative Techniques .......... ..e . 33; 1.16.1 Retrack Program ............. ...* . 36, 2. ............................ a,1 ........................... xi 2.2 2.3 Entry into the !i’e&inh ‘cdnt’roi Aria : ................................ z! ARTSIII.....O ..................... 44 C Procedures. ......................... 45 See and Avoid. .......................... 49 S.....................* .... 52 ..e......*..........,......................... 52 Cause........ 52 ENDATIONS ....................... 52 ndations Addressing Midair Collision ............. 52 iii ApPBNlrarss....1......1(tt; ;;;;;;;;r, 55 Appendix A-Investigation and Hearing ..... 1 . i . c ! i 1 . i . 55 Appendix B--Personnel @formation Appendix C--FDR Data, Aeromexico .............................. 1 1 8: Appendix D--CVR Transcript .................... 59 Appendix E--Cockpit Visibility Studies ................ 71 Appendix P--ATC ‘lhnscript .................... Appendix G--FAA Recommendations. ................ ii86 Appendix H--Mid-Air and Near Mid-Air Safety Recommendations History .................... ._ . 95 iv EXECUTIVE SUMMARY On August 31; 1986; about 1152 Pacific daylight time; Aeronaves de Mexico, §.A., flight 498, a DC-9-32, Mexican Registration XA-JED, and a Piper PA-28-181, United States gistration N4891F, collided over Cerritos, California. Flight 498, a regularly scheduled passenger flight, was on an Instrument Flight Rules flight plan from Tijuana, Mexico, to Los Angeles International Airport, California, and was under radar control by the Los Angeles terminal radar control facility. ‘Ihe Piper airplane was proceeding from Torrance, California toward Big Bear, California, under Visual Flight Rules, and was not in radio contact with any air traffic control facility when the accident occurred. The collision occurred inside the Los Angeles Terminal Control Area near 6,560 feet mean sea level. At the time of the collision, the sky was clear, and the reported visibility was 14 miles. The air traffic controller providing service to flight 498 did not observe the Piper airplane’s radar return on his display and therefore did not provide any traffic isory to flight 498 concerning the location of the Piper airplane before the collision. h airplanes fell to the ground within the city limits of Cerritos. Five houses were destroyed and seven other houses were damaged by airplane wreckage and postimpact fire. Fifty-eight passengers and six crew members on the DC-9 were killed; the pilot and 2 passengers on the Piper were killed; 15 people on the ground were killed and 8 others received minor injuries. The National Transportation Safety Board determines that the probable cause of the a&dent was the limitations of the air traffic control system to provide collision protection, through both air traffic control procedures and automated redundancy. Factors contributing to the accident were (1) the inadvertent and unauthorized entry of PA-28 into the Los Angeles Terminal Control Area and (2) the limitations of the “‘see and avoid” concept to ensure traffic separation under the conditions of the conflict. V NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20694 AaIRCRAFT ACCIDENT REPORT IDAIR COLLISION OF AERONAVES DE MEXICO, S.A., MCDONNELL DOUGLAS DC-932, XA-JED, AND PIPER PA-28-181, N489lP CERRITOS, CALIFORNIA AWGUST 31,1986 1, FACTUAL INFORMATION 1.1 Qn August 31, 1986, about 1141 Pacific daylight time l/, Piper PA-28-181, N489lF, departed Torrance, California, on a Visual Flight Rules (VFR) flight to Bii Bear, ifornia. The pilot of the Piper had filed a VFR flight plan with the Hawthorne, ifornia, Flight Service Station (FSS). According to the flight plan, his proposed route of flight was direct to Long Beach, California, then direct to the Paradise, California, VQRTAC 2/, and then direct Big Bear. The proposed enroute altitude was 9,500 feet 3/. However, the pilot did not, nor was he required to, activate his fliiht plan. At 1140:36, after being cleared for takeoff, the Piper pilot told Torrance tower that he was “rolling;” this was the last known radio transmission received from the Piper. cording to recorded air traffic control (ATC) radar data, after leaving Torrance, Piper PA-28 pilot turned to an easterly heading toward the Paradise VORTAC. The on board transponder was active with a 1200 code. Postaccident ion revealed that as the Piper proceeded on its eastbound course, it entered the Terminal Control Area (TCA) without receiving clearance from ATC as eral Aviation Regulations (14 Code of Federal Regulations (CFR) Part Aeronaves de Mexico, S.A. (Aeromexico), flight 498, a DC- 9-32, Mexican A-JED, was a regularly scheduled passenger flight between Mexico City, Los Angeles International Airport (L.A. International), California, via eto, and Tijuana, Mexico. At 1120:00, flight 498 departed Tijuana with rs and 6 crew members in accordance with its filed instrument flight rules As the flight proceeded toward LA. International, at 10,000 feet, it Coast Approach Co$rol, which cleared the flight to the Seal Beach, C, and then to %ross one zero miles southeast of Seal Beach at and thousand (feet).?’ At 1144 498 reported that it was leaving , at 1146359, it was instructe t Los Angeles Approach Control. cific daylight based on the 24-hour clock. freqency OMNI range station and ultrahigh frequency tactical zimuth and distance information to the user. a level unless otherwise specified. -2- At 1147:28, fliit 498 contacted the Los Angeles Approach Control’s Arrival Radar-l (AR-11 controller and reported that it was level” at 7,000 feet. ‘Ihe AR-1 controller cleared flight 498 to depart Seal Reach on a heading of 320’ for the ILS (instrument landing system) runway “two five left final approach course...” Plight 498 acknowledged receipt of the clearance. At 1150:05, the AR-l controller requested