NTSB CAROL · Event
Event OPS13IA071
Aircraft involved
Probable cause & findings
The Federal Aviation Administration's (FAA) inadequate procedures, which did not require specific separation between aircraft operating on nonintersecting runways where flightpaths may intersect and led to an airborne conflict between two aircraft. Contributing to the incident was the FAA's failure to correct a known procedural deficiency that had previously caused repeated hazardous intersecting flightpath events.
Factual narrative
On July 4, 2013, at 1712 Pacific daylight time, an airborne conflict occurred at McCarran International Airport, Las Vegas, Nevada (LAS), between Southwest Airlines flight 1196 (SWA1196) and N426QS, a Gulfstream 4 business jet. SWA1196 was executing a go-around maneuver following a visual approach to runway 25L under control of the LAS LC1 controller, and N426QS had just departed from runway 19R under control of the LAS LC2 controller. The radar approach controller cleared SWA1196 for a visual approach to Runway 25L and instructed the pilot to contact Las Vegas Tower at 1708:14. SWA1196 turned on to the final approach course about 6 miles from the airport, but did not contact the LC1 controller until 1711:53. At that time, the aircraft was over the runway and passing taxiway A3. The pilot announced his intention to go around because the aircraft was encountering a 20 knot tailwind. The LC1 controller acknowledged the report, immediately advised the pilot of traffic "just lifting off" from runway 19R, and instructed the pilot to report the traffic in sight. At 1712:09, the LC1 controller instructed SWA1196 to fly runway heading and climb to 7,000 feet. The pilot read back the clearance and reported the traffic in sight. The controller told the pilot to maintain visual separation from the traffic. At 1712:29, the LC1 controller called the radar approach controller to coordinate the go-around, stating that SWA1196 would be climbing to 7,000 feet and had N426QS in sight. SWA1196 subsequently completed another approach and landed. The LC2 controller cleared N426QS for takeoff from runway 19R at 1710:59, and the pilot acknowledged the clearance. At 1712:06, the LC2 controller issued a traffic alert to N426QS, stating, "…traffic alert, Boeing 737 off your left going around off 25, stay low." The pilot responded, "all right sir we're looking for him 426QS have him in sight." At 1712:17, the LC2 controller transmitted, "Gulfstream 6QS roger maintain visual separation, he's climbing to 7,000, stay low." The pilot responded, "'k we'll stay low thank you." At 1712:32, the pilot of N426QS transmitted, "and we're getting an RA we're climbing at this time 426QS." The controller replied, "…roger traffic no factor, well behind and lower than you." The controller then instructed the pilot to contact departure control. The pilot of SWA1196 subsequently contacted the tower supervisor via telephone to discuss the handling of the go-around, expressing concern about the apparent lack of urgency on the part of the LC1 controller and the need for clearer instructions to resolve the conflict. Preliminary review of FAA radar data showed that the minumum separation between the two aircraft was about 0.21 nautical miles laterally and 400 to 500 feet vertically. For further information see the air traffic control group chairman's report in the docket for this case. A Boeing 737 (737) executing a go-around from runway 25L and a Gulfstream 4 that had just departed from runway 19R experienced an airborne conflict. When passing over runway 25L, the 737 pilot announced his intention to go around because the airplane was encountering a 20-knot tailwind. The tower controller responsible for runway 25L acknowledged the report, immediately advised the pilot of traffic "just lifting off" from runway 19R, and instructed the pilot to report the traffic in sight. The tower controller then instructed the pilot to fly the runway heading and climb to 7,000 ft. The pilot read back the clearance and reported the traffic in sight. The controller told the pilot to maintain visual separation from the traffic. The 737 subsequently completed another approach and landed. After the Gulfstream 4 departed, the tower controller responsible for runway 19R issued a traffic alert to the pilot, indicating that the 737 was "off your left going around off 25," and instructed the pilot to "stay low." The pilot responded that he had the 737 in sight. The controller transmitted, "maintain visual separation, he's climbing to 7,000, stay low." The pilot acknowledged the instruction. Fifteen seconds later, the Gulfstream pilot stated, "we're getting an RA [resolution advisory] we're climbing at this time." Review of Federal Aviation Administration (FAA) radar data showed that the minimum separation between the two aircraft following the RA was about 0.21 nautical mile laterally and 400 to 500 ft vertically. At the time of the incident, the FAA did not have procedures requiring specific separation between aircraft operating on nonintersecting runways where flightpaths may intersect despite the occurrence of several previous similar incidents. Following this incident and another similar incident, the FAA amended FAA Notice 7110.65, "Air Traffic Control," by adding paragraph 3-9-9, "Non-Intersecting Converging Runway Operations," which directed changes in converging runway operations to prevent similar reoccurrences. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Organizational issues-Management-Policy/procedure-Adequacy of policy/proc-ATC - C
- F Organizational issues-Management-Culture-Safety-ATC - F
Verbatim from NTSB's published report. Source file
NTSB_2013_OPS13IA071.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (go-around). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NASA NTRS 2025 · Conference Paper
A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World
Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- Semantic Scholar 2022 · Article (Journal of Safety Research)
Go-around accidents and general aviation safety.
INTRODUCTION Changes in General Aviation (GA) accident rates, specifically in the go-around phase, are examined by comparing the number of accidents, the proportion of fatal accidents, and the proport…
- Semantic Scholar 2021 · Article (Aerospace)
Classification and Analysis of Go-Arounds in Commercial Aviation Using ADS-B Data
Go-arounds are a necessary aspect of commercial aviation and are conducted after a landing attempt has been aborted. It is necessary to conduct go-arounds in the safest possible manner, as go-arounds …
- NASA NTRS 2021 · Accepted Manuscript (Version with final changes)
Go-Around Criteria Refinement for Transport Category Aircraft
Presently, airline pilots are trained to go around if, when lower than 500 ft above the ground, they are outside of a handful of parameters such as airspeed, position, and rate of descent.
- NASA NTRS 2019 · Conference Paper
Validation of Proposed Go-Around Criteria Under Various Environmental Conditions
This paper evaluates the effects of environmental conditions on touchdown performance under varying approach states and validates proposed go-around criteria developed using data from a previously con…
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