History of Flight

Immediately before the incident, SWA1390 was preparing to depart LAX for a flight to Las Vegas, Nevada, and was in communication with the Local Control 2 (LC2) controller at LAX. The pilot was instructed to taxi into position and hold on runway 24L at 1245:41. SWA1390 was cleared for takeoff at 1249:42. At 1250:24, the LC2 controller instructed SWA1390 to contact SoCal departure and the pilot acknowledged. At 1251:28, SWA1390 returned to the LC2 frequency, asking the LC2 controller, "... are you guys talking to the helicopter that was off the right-hand side when we departed?" The LC2 controller replied, "SWA1390 he had just come on frequency." The pilot continued, "... he was probably impinging on your airspace definitely passing through 1000 feet.” The LC2 controller replied, "... actually he was south of the he was just south of the 25 left and they were talking to helicopters I'll let him know." There were no further communications with SWA1390.

Mercy 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, and then continued south toward Rancho Palos Verdes, California. The route required the pilot to contact LAX ATCT for clearance through the class B airspace surrounding LAX. The pilot first contacted the LAX ATCT helicopter position (HC) at 1248:36, reporting altitude 1,500 feet. Mercy 19 was about 3.7 miles northwest of the airport. The HC controller asked the pilot to “ident” (activate the identification feature of his transponder) and state his request. The pilot replied, “…just Shoreline and then we’re going southeastbound toward San Diego.” At 1248:54, the HC controller asked, “…would you like to go to the Shoreline or you can stay at 1,500 and transition over the airport midfield.” The pilot replied, “We just couldn’t get down to your 125 that’s why we are this way but if you could turn me [toward] the Shoreline as soon as able that would be great.” The controller then instructed the pilot to continue southeastbound on his present heading and expect a turn in about one mile. At 1249:21, the HC controller stated, “Mercy Air 19 you can start the right turn now to the Shoreline at your discretion at this point.” The pilot responded, “…appreciate that sir and we have your takeoff traffic visual separation.”

At 1249:42, the HC controller transmitted, “Mercy Air 19 cleared through the class bravo airspace via the Shoreline route south and at the Shoreline at or below 150 feet please.” The pilot asked, “… Mercy air 19 you want us to drop down now or wait until your departure end?” The HC controller replied, “You can start now or wait but we’ll need you at 150 by the time you’re crossing past our departure corridor.” At 1250:03, the pilot transmitted, “…starting down out of one-five for – say at altitude again you want me down to 500?” The controller responded, "at or below 150 feet Mercy air 19." At 1250:13, the pilot transmitted "Roger that we have your takeoff traffic do you want us to hold this way or do you want me down now?” At 1250:18, the controller instructed the pilot to, "... start descending now and if you are not able to make the altitude then stay north of the airport until you can.” At 1250:24, the pilot replied, "okay Mercy air 19 we're starting down now.” At 1250:30, the pilot transmitted, "yeah we got a 737 coming over too so we're going to move." At 1250:40, the pilot continued, "Mercy air 19 we would like to clear to the north and then come around the airport so as to go through the traffic area." The controller replied, "Mercy air 19 that's approved and like I said you can stay at the same altitude and transition over the middle of the airport at 1500 or if you want to stay at the Shoreline that it will be at it will have to be at or below 150 feet cause you're going to go below all departures.” At 1250:58, the pilot replied, "okay Mercy air 19 we're climbing to past 1000, 1500 we’ll clear and get out of your way." The helicopter continued eastbound to the east end of the airport before turning southbound and leaving the area.

Radar data for this incident was obtained from the LAX-N ASR-9 sensor located on the north side of runway 24R. Review of the recorded information showed that the closest point of approach between the two aircraft occurred at approximately 1250:39 when they were separated by 750 feet laterally and 100-200 feet vertically. Graphics of the radar tracks for Mercy 19 and SWA1390 have been placed in the docket.

Personnel Interviews

The controller assigned to the Helicopter Control (HC) position responsible for handling Mercy 19 entered on duty with the FAA in May 2007 at LAX. He completed training in August 2008. Before coming to the FAA, he was a tower controller with four years 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. According to the HC controller, 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 stated that he 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 1000 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.

When handling Class B transitions, the HC controller stated that the facility practice was to radar identify aircraft operating above 1000 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 1500 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.

The local controller responsible for SWA1390 (LC2) first became aware of the incident when SWA1390 called him on the radio from about 1 1/2 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.

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.

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.

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 1500 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.”

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 1500 feet as Mercy 19 did usually continued at 1500 feet along the Sepulveda transition.

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 .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.

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