LAX Near-Miss Involving Southwest Flight 1390 and Mercy Air 19

Incident Overview and Radar Data<br><br>On the day of the incident, Southwest Flight 1390 (SWA1390) was preparing to depart Los Angeles International Airport (LAX) for Las Vegas, Nevada. The aircraft was in communication with the Local Control 2 (LC2) controller and was cleared for takeoff at 1249:42. At 1250:24, the LC2 controller instructed SWA1390 to contact SoCal departure, which the pilot acknowledged. At 1251:28, SWA1390 returned to the LC2 frequency to ask about a helicopter that had been off the right-hand side during departure. The pilot noted the helicopter was likely passing through 1,000 feet. There were no further communications with SWA1390.<br><br>Meanwhile, Mercy Air 19 departed the University of California Medical Center in Westwood at 1246 under visual flight rules. The helicopter traveled southbound past Santa Monica and LAX, heading toward Rancho Palos Verdes, California. The pilot contacted the LAX ATCT helicopter position (HC) at 1248:36, reporting an altitude of 1,500 feet. The pilot requested to proceed to the Shoreline route and then southeastbound toward San Diego. The HC controller instructed the pilot to continue southeastbound and expect a turn. At 1249:42, the HC controller cleared Mercy Air 19 through the class B airspace via the Shoreline route, requiring the helicopter to be at or below 150 feet at the Shoreline. The pilot asked whether to descend immediately or wait until the departure end. The controller instructed the pilot to start descending now and stay north of the airport if unable to make the altitude. At 1250:30, the pilot reported seeing a 737 coming over and requested to clear to the north and come around the airport. The controller approved this, noting the helicopter could stay at 1,500 feet and transition over the middle of the airport, or stay on the Shoreline route at or below 150 feet. At 1250:58, the pilot replied that they were climbing past 1,000 to 1,500 feet to clear the area. The helicopter continued eastbound to the east end of the airport before turning southbound and leaving the area.<br><br>Radar data from the LAX-N ASR-9 sensor showed that the closest point of approach between the two aircraft occurred at approximately 1250:39. At that time, the aircraft were separated by 750 feet laterally and 100-200 feet vertically. Graphics of the radar tracks for Mercy 19 and SWA1390 were placed in the docket.<br><br>## Personnel Interviews and Operational Context<br><br>The controller assigned to the Helicopter Control (HC) position entered on duty with the FAA in May 2007 at LAX and completed training in August 2008. Before joining the FAA, he was a tower controller with four years of experience in the United States Air Force. The HC position was responsible for controlling VFR helicopters and fixed-wing aircraft passing through the class B airspace around LAX. The HC controller stated that the area around the airport was clear except for some low fog and haze along the beach to the west. When the pilot asked to turn toward the west side of the airport, the helicopter was still in Santa Monica tower’s airspace, so the HC controller could not immediately approve the turn. Once the helicopter cleared Santa Monica's airspace, the HC controller approved the turn and issued the pilot clearance into the LAX class B airspace. The HC controller expected the pilot to turn toward Marina Del Rey and enter the Shoreline route from there. However, the pilot did not do so, instead turning toward the departure end of runways 24L/24R. As Mercy Air 19 approached the airport, the HC controller walked to the northwest corner of the tower to visually monitor the progress of the helicopter. He saw SWA1390 take off and observed the helicopter nearby at 1,000 feet. Based on his observations, the HC controller stated that the separation between the helicopter and SWA1390 appeared to be acceptable, and that he never saw SWA1390 turning or making other maneuvers besides taking off. When the helicopter pilot stated that he was turning toward the north to clear the area, the HC controller returned to his normal location in the tower and began doing coordination with the LC1 and LC2 controllers for the helicopter to proceed south across the airport via the Sepulveda route.<br><br>When handling Class B transitions, the HC controller stated that the facility practice was to radar identify aircraft operating above 1,000 feet. This did not include helicopters proceeding via the Shoreline route because they descend too low to reliably track with radar. He did not follow the full radar identification procedure with Mercy 19, only instructing the pilot to ident rather than issuing aircraft position and advising the pilot of radar contact. Asked if he would handle the situation differently now, the HC controller stated that he would possibly instruct the pilot to report over the Marina before issuing class B clearance, or offer the Sepulveda transition at 1,500 feet. He stated that the pilot of Mercy 19 sounded confident and knowledgeable, which made him think that the pilot was familiar with the Shoreline route. The HC controller also noted that the pilot’s report of departure traffic in sight was somewhat ambiguous because there was more than one departing aircraft at the time, and he could have clarified what the pilot was looking at.<br><br>The local controller responsible for SWA1390 (LC2) first became aware of the incident when SWA1390 called him on the radio from about 1.5 miles offshore, after having been transferred to departure control. The pilot asked questions about a helicopter that had been off the right side of his aircraft during departure. The LC2 controller stated that he did not see the helicopter at any time during the incident, or later when it flew by the tower. The radio call from SWA1390 was the first time he became aware that anything had happened. He responded to the pilot’s question by stating that the helicopter must have just entered the airspace. He checked with the Local Assist controller to see if he knew anything about the helicopter, and also asked the helicopter controller about it. The helicopter controller stated that he was in communication with the helicopter, and the LC2 controller noted that the supervisor was talking to the helicopter controller.<br><br>The LC2 controller stated that his normal procedure when clearing an aircraft for takeoff was to scan the runway, the ground radar, and the departure route right off the end of the runway. Aircraft on the Shoreline route were typically restricted to operate at or below 150 feet. The LC2 controller noted that if he had been handling Mercy 19, his expectation would have been that the pilot would turn straight to the beach, and then enter the class B airspace at or below 150 feet in the area of Marina del Rey. Asked how often he assigned specific headings to aircraft in the class B area, the LC2 controller responded, not often. If an aircraft was not turning as directed, he might suggest a heading, and then if necessary, assign a specific heading.<br><br>The supervisor on duty stated that when the incident occurred he was monitoring the local control 1 (LC1) position with a wireless headset. It was a normal day with no unusual circumstances except for a small fog bank just offshore. Asked if it was affecting the use of the Shoreline route, the supervisor replied, I'm not sure I would've used [the route], but it was hard to tell exactly where the fog was, and noted that the Sepulveda transition would have been a viable alternative. The supervisor first found out about the incident when he received a phone call from the supervisor at Southern California TRACON stating that SWA1390 had reported some kind of an issue with a helicopter. The supervisor spoke with the HC controller, who stated that the helicopter pilot had not followed instructions. The supervisor began collecting information including voice and radar recordings, and reviewed the incident with the HC controller after both of them had been relieved from their positions in the cab. Radar review showed that the helicopter had overflown both runways 24L and 24R. After discussing the sequence of events, the supervisor released the HC controller to go home. The supervisor then deferred further review of the incident to the operations manager and the air traffic manager. Based on the preliminary information available, the air traffic manager determined that there had been no loss of separation between Mercy Air 19 and SWA1390, but directed that the incident receive comprehensive review on Monday, September 6, the next business day. On September 7, the supervisor was notified via telephone that the incident had been classified as an operational error.<br><br>The supervisor noted that the required coordination between the helicopter controller and the local control position had not occurred. He believed this was likely because the HC controller was waiting until the helicopter got closer to the Shoreline route entry point before engaging in the coordination. Asked how he would handle the situation himself if he had been working the helicopter position, the supervisor stated that he would have either turned Mercy 19 hard right toward the beach or brought the helicopter over the airport at 1,500 feet via the Sepulveda transition. Asked for some examples of phraseology he might use, the supervisor replied, turn right proceed direct to the Shoreline, follow the Shoreline route southbound at or below 150 feet.<br><br>The supervisor stated that, in his opinion, the coordination between the helicopter position and the local control position should have occurred sooner than it did because of the pilot's seeming confusion over what was expected. He noted that the HC controller generally does a very good job, but he is somewhat low on experience and may have been caught out by the unusual situation. 98% of the helicopter pilots in the area are familiar with the operation, and most pilots who ask for the Shoreline route are already on or near it. Overflights entering the airspace at 1,500 feet as Mercy 19 did usually continued at 1,500 feet along the Sepulveda transition.<br><br>Asked about the applicability of simulation to LAX operations, the supervisor noted that simulation capabilities are available in a tower simulator at the regional office, but that simulation has its pluses and minuses. It is sometimes difficult to train on unusual situations. When the supervisor reviewed the radar replay of the situation, he found the separation between the aircraft to be approximately 0.13 nautical miles and 100 feet. The lateral separation exceeded the 500-foot standard usually applied for near midair collisions. However, when the Southwest pilot called the tower back, the supervisor asked the LC2 controller to determine if the pilot wished to file a near midair collision report. The controller may not have heard the request and did not do so. The SWA pilot did not report receiving a warning from the aircraft's anti-collision system resulting from the incident.