Beech 1900C N121WV and Piper PA-31-350 N4112K incident near Fairbanks, Alaska

Probable cause

Inadequate air traffic control actions that failed to establish and maintain required separation between the two airplanes. Contributing to the incident was inexperience on the part of the local controller, inadequate oversight by the tower controller-in-charge, and deficient facility procedures and training.

NTSB analysis

An air traffic control operational error and near midair collision occurred between a Raytheon Beech 1900 and a Piper Navajo about 3.5 miles west of the airport. The Beech 1900 was northeast bound toward the airport descending to enter the traffic pattern for runway 20L, while the Piper had just departed from runway 20R and was climbing on a westbound heading. Both airplanes were operating under visual flight rules at the time of the incident, and were receiving air traffic control services from a tower air traffic controller. There were no reports of injuries or damage to either airplane.

The local controller, who had only been certified on the position for 5 weeks, stated that she was trying to establish vertical separation between the two airplanes by restricting the departing Navajo to remain at or below 2,000 feet. The Beech was still on the approach controller's frequency, so the local controller was not aware of what instructions had been issued to the pilot. The approach controller mistakenly believed that the Beech was in communication with the local controller. Neither the local controller nor the controller-in-charge, who was responsible for monitoring the operation and assisting the local controller, initiated any coordination with the approach controller to resolve the conflict.

NTSB review of local procedures and directives found that there was a misunderstanding of required procedures and controller responsibilities for operations in Terminal Radar Service Areas, including separation standards and procedures for transfer of communications between controllers.

Text from the NTSB. Open the NTSB docket for OPS11IA653 for the full record.