Aircraft near Kahului, HI — 2011-11-03

Probable cause

Failure of the Honolulu Control Facility controller to issue control instructions necessary to establish and maintain required separation between all three aircraft. Contributing to the losses of separation was inadequate training provided to controllers about the use of the approach to runway 2 at Kahului.

NTSB narrative

Three aircraft were approaching Kahului Airport to land on runway 2 and were receiving air traffic control sequencing and separation services from the Honolulu Control Facility (HCF). Aircraft 1 was conducting an instrument approach from the northeast and conflicted with aircraft 2, which was conducting a visual approach from the southwest. The controller attempted to correct the situation by vectoring aircraft 1, even though it was below the minimum vectoring altitude for the area. Aircraft 2 continued the approach and landed. The controller re-sequenced aircraft 1 for another instrument approach in front of aircraft 3, which was arriving from the northeast. Aircraft 3 was faster than aircraft 1 and overtook aircraft 1 while both aircraft were on final approach to the runway. The controller did not intervene in time to ensure separation. Review of HCF training materials and procedures showed that the simulator problems given to controllers to familiarize them with the new approach at that airport were not realistic and did not properly prepare controllers to manage the approach procedure.

Analysis

Primary failure mode

Human factors

First missed decision gate

AAL253 could have been maintained at a safe altitude to avoid conflict with HAL126.

NTSB coding

• Near midair/TCAS alert/loss of separation · Approach-IFR final approach
• Decision Making / Judgment

Evidence available

• 3 docket documents

Docket documents3

• ATC 3 - Factual Report of Group Chairmanatc
• ATC 3 - HCF SOPatc
• ATC 3 - Maui MVA Mapatc