AIRBUS A319-112 near St Petersburg-Clearwater, FL — 2021-04-29

Probable cause

The air traffic controller’s failure to properly scan the runway and local area, and their general loss of situational awareness, resulting in a near midair collision. Contributing to the incident was the Cessna 337 pilot's poor decision making when he failed to fly the standard downwind leg distance from the runway and to maintain the standard traffic pattern altitude.

NTSB narrative

Review of the radar data showed that N370SD, a Cessna 337, was on a right downwind for runway 22 at 300 feet when it overflew runway 18, and at the same time Allegiant Air flight 803 (AAY803), an Airbus A319, was at 200 feet departing runway 18. The closest proximity was 100 feet vertically and 369 feet laterally. The crew of AAY803 saw the Cessna 337 and took evasive action by stopping their takeoff climb and maintaining 200 feet, and flew underneath the Cessna 337, which was at 300 feet as the airplane’s paths intersected over the runways. The local controller did not visually scan all runways and airspace when he instructed the Cessna 337 pilot to enter a right downwind, and again, when he issued a takeoff clearance to the Allegiant Air flight; the lack of fully scanning all runways and airspace resulted in the local controller losing situational awareness of the Cessna 337, and ultimately not ensuring positive control and separation between the Allegiant Air flight and the Cessna 337. The Cessna 337 pilot’s downwind leg for runway 22 was significantly less than the standard 1/2 to 1 mile defined downwind leg distance from the runway, which placed the Cessna 337 in a closer vicinity to the runway intersections than what was expected. Additionally, the Cessna 337 pilot did not fly a standard traffic pattern altitude, and the local controller did not instruct or advise the pilot that the traffic pattern altitude was 1,000 feet. PIE airport did not have a charted traffic pattern altitude.

Analysis

Primary failure mode

Human factors

First missed decision gate

N370SD could have maintained a safe altitude to avoid conflict.

NTSB coding

• Air traffic event · Takeoff
• Near midair/TCAS alert/loss of separation · Approach-VFR pattern downwind
• Attention / Monitoring
• Planning / Preparation

Evidence available

• ATC audio
• ADS-B / radar
• 19 docket documents

Docket documents19

• AIR TRAFFIC CONTROL ATTACHMENT 1 FAA ADMINISTRATIVE DOCUMENTSatc
• AIR TRAFFIC CONTROL ATTACHMENT 2 INTERVIEW TRANSCRIPTSatc
• AIR TRAFFIC CONTROL ATTACHMENT 3 LOCAL CONTROL AUDIOatc
• AIR TRAFFIC CONTROL ATTACHMENT 4 GROUND CONTROL AUDIOatc
• AIR TRAFFIC CONTROL ATTACHMENT 5 FAA RADAR DATAatc
• AIR TRAFFIC CONTROL GROUP FACTUAL REPORTatc
• OPERATIONAL FACTORS - ATTACHMENT 9 - FLIGHT RECORDER DATA [EXCERPT]fdr
• PILOT/OPERATOR AIRCRAFT ACCIDENT REPORT, NTSB FORM 6120.1 - AAY803form
• PILOT/OPERATOR AIRCRAFT ACCIDENT REPORT, NTSB FORM 6120.1 - CESSNA N370SDform
• OPERATIONAL FACTORS - ATTACHMENT 1 - ALLEGIANT AIR FLIGHT 803 FLIGHT CREW STATEMENTSinterview
• OPERATIONAL FACTORS - ATTACHMENT 2 - CESSNA PILOT STATEMENT AND FLIGHT REVIEW LOGBOOK ENTRYinterview
• OPERATIONAL FACTORS - ATTACHMENT 3 - CERTIFICATED FLIGHT INSTRUCTOR FOR CESSNA PILOT - INTERVIEW SUMMARYinterview
• OPERATIONAL FACTORS - ATTACHMENT 4 - EYEWITNESS STATEMENTSinterview
• OPERATIONAL FACTORS - ATTACHMENT 10 - ALLEGIANT AIR FLIGHT 803 ACARS COMMUNICATION [EXCERPTS]other
• OPERATIONAL FACTORS - ATTACHMENT 5 - NUMBER OF OCCUPANTS ON ALLEGIANT AIR FLIGHT 803other
• OPERATIONAL FACTORS - ATTACHMENT 6 - PIE AIRPORT MASTER RECORD AND CHART SUPPLEMENTother
• OPERATIONAL FACTORS - ATTACHMENT 7 - ALLEGIANT AIR PROCEDURES AND TCAS MEMORY ITEMSother
• OPERATIONAL FACTORS - ATTACHMENT 8 - ALLEGIANT AIR FLIGHT CREW OPERATIONS MANUAL TCAS DESCRIPTION [EXCERPT]other
• OPERATIONAL FACTORS SPECIALIST REPORTreport

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