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Accident and Serious Incident Reports: LOS

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Category: Loss of Separation Loss of Separation
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Contents

Definition

Reports relating to accidents and incidents which involved Loss of Separation.

The accident and serious incident reports are grouped together below in subcategories.

TCAS RA Mis-flown

  • A310 / B736, en-route, Southern Norway, 2001 (LB LOS HF) (On 21 February 2001, a level bust 10 nm north of Oslo Airport by a climbing PIA A310 led to loss of separation with an SAS B736 in which response to a TCAS RA by the A310 not being in accordance with its likely activation (descend). The B736 received and correctly actioned a Climb RA.)
  • GLF5 / A319, south-eastern France, 2004 (LB LOS HF) (On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.)
  • C525 / B773, vicinity London City UK, 2009 (LB LOS AGC HF) (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • T154 / B752, en-route, Uberlingen Germany, 2002 (LOS HF) (On 1st July 2002, a Russian-operated Tu154 on a passenger flight collided at night with a cargo Boeing 757-200 over Überlingen, Germany with the consequent loss of control of both aircraft and the death of all occupants. The collision occurred after an ATC control lapse had led to a conflict which generated coordinated TCAS RAs which the B757 followed but the TU-154, in the presence of a conflicting ATC instruction, did not.)
  • DH8A/DH8C, en route, northern Canada, 2011 (LB LOS HF) (On 7 February 2011 two Air Inuit DHC8s came into head-to-head conflict en route over the eastern shoreline of Hudson Bay in non radar Class ‘A airspace when one of them deviated from its cleared level towards the other which had been assigned the level 1000 feet below. The subsequent investigation found that an inappropriate FD mode had been used to maintain the assigned level of the deviating aircraft and noted deficiencies at the Operator in both TCAS pilot training and aircraft defect reporting as well as a variation in altitude alerting systems fitted to aircraft in the DHC8 fleet.)


Accepted ATC Clearance Not Followed

  • F50 / T6, vicinity Maastrict Netherlands, 2007 (HF LOS) (On 2 August 2007, a Fokker F50 being operated by KLM Cityhopper making a daylight ILS approach in IMC to Maastricht came into close proximity inside the CTZ with a privately operated North American T6 Harvard which had failed to follow its clearance to enter the CTZ.)
  • SF34/SF34, Vicinity Stornoway UK, 2011 (LOS HF) (On 15 October 2011, a Loganair Saab 340 in uncontrolled airspace and inbound and level at 2000 feet QNH on a procedural non precision approach in day IMC to runway 18 at Stornoway received a TCAS RA ‘DESCEND’ when a second Loganair Saab 340 outbound on the same procedure descended prematurely to the same altitude contrary to ATC clearance. The subsequent investigation concluded that the failure of the controller to re-iterate the requirement to remain at 3000 feet outbound until advised had contributed the crew error. Minimum separation after the TCAS RA was less than 0.1nm horizontally when 500 feet vertically.)
  • DH8A/DH8C, en route, northern Canada, 2011 (LB LOS HF) (On 7 February 2011 two Air Inuit DHC8s came into head-to-head conflict en route over the eastern shoreline of Hudson Bay in non radar Class ‘A airspace when one of them deviated from its cleared level towards the other which had been assigned the level 1000 feet below. The subsequent investigation found that an inappropriate FD mode had been used to maintain the assigned level of the deviating aircraft and noted deficiencies at the Operator in both TCAS pilot training and aircraft defect reporting as well as a variation in altitude alerting systems fitted to aircraft in the DHC8 fleet.)
  • C525 / B773, vicinity London City UK, 2009 (LB LOS AGC HF) (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • B763, en route North Bay Canada, 2009 (LOC HF AW LOS) (On 19 June 2009 a Boeing 767-300 being operated by Polish carrier LOT on a scheduled passenger flight from Chicago O’Hare to Warsaw was in the cruise at FL330 feet in night IMC when one of the air speed indicators suddenly displayed a false high reading, which triggered an over speed warning. The flight crew response was based on the presumption that the speed increase was real and thrust was reduced and the aircraft put into a climb. A stall warning followed and descent was then made.)
  • … further results


"See and Avoid" Ineffective

  • G115 / G115, near Porthcawl South Wales UK, 2009 (LOS HF FIRE) (On 11 February 2009, two civil registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and based at RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers in uncontrolled airspace near Porthcawl in day VMC when they collided.)
  • SH36 / SH36, en-route, Watertown WI USA, 2006 (LOS LOC RE HF) (On 5 February 2006, two Shorts SD-360-300 aircraft collided in mid air while in formation near Watertown, WI, USA; both aircraft suffered damage. One aircraft experienced loss of control and impacted terrain while the other made an emergency landing, overunning the runway, at a nearby airport.)
  • H500 / D150, en-route, North of London UK, 2007 (LOS HF) (On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.)
  • F50 / T6, vicinity Maastrict Netherlands, 2007 (HF LOS) (On 2 August 2007, a Fokker F50 being operated by KLM Cityhopper making a daylight ILS approach in IMC to Maastricht came into close proximity inside the CTZ with a privately operated North American T6 Harvard which had failed to follow its clearance to enter the CTZ.)
  • DH8D / TOR, en-route, North Sea UK, 2008 (AI LOS) (On 13 October 2008, a DHC-8 Q400 executed ATC instructions, followed by TCAS TA and RA to avoid unknown traffic. Recorded minimum lateral separation was 2.5 NM.)
  • … further results


Required Separation not Maintained

  • SF34/SF34, Vicinity Stornoway UK, 2011 (LOS HF) (On 15 October 2011, a Loganair Saab 340 in uncontrolled airspace and inbound and level at 2000 feet QNH on a procedural non precision approach in day IMC to runway 18 at Stornoway received a TCAS RA ‘DESCEND’ when a second Loganair Saab 340 outbound on the same procedure descended prematurely to the same altitude contrary to ATC clearance. The subsequent investigation concluded that the failure of the controller to re-iterate the requirement to remain at 3000 feet outbound until advised had contributed the crew error. Minimum separation after the TCAS RA was less than 0.1nm horizontally when 500 feet vertically.)
  • MD82 / A319, vicinity Helsinki Finland, 2007 (LOS HF) (On 5 September 2007 in day VMC, an MD82 being operated by SAS was obliged to carry out an own-initiative avoiding action orbit in day VMC against an Airbus A319 being operated by Finnair on a scheduled passenger after conflict when about to join final approach. Both aircraft were following ATC instructions which, in the case of the MD 82, had not included maintaining own separation so that the applicable separation minima were significantly breached.)
  • A318/B739, vicinity Amsterdam, 2007 (LOS HF) (On 6 December 2007 an Airbus A318 being operated by Air France on a scheduled passenger flight from Lyon to Amsterdam carried out missed approach from runway 18C at destination and lost separation in night VMC against a Boeing 737-900 being operated by KLM on a scheduled passenger flight from Amsterdam to London Heathrow which had just departed from runway 24. The conflict was resolved by correct responses to the respective coordinated TCAS RAs after which the A318 passed close behind the 737. There were no abrupt manoeuvres and none of the 104 and 195 occupants respectively on board were injured.)
  • E135 / B738, en-route, Amazon Brazil, 2006 (HF AGC LOS) (On 29 September 2006, a B737-800, operated by the Brazilian airline Gol, collided head-on with a US owned and operated EMB135 Legacy at FL370 over the Amazon, Brazil. The aircraft were flying at the same altitude in opposite directions along the same airway.)
  • CRJ2/ATP, Stockholm Sweden, 2011 (LOS HF) (On 21 January 2011, a Belarusian Bombardier CRJ200 failed to fly the prescribed missed approach procedure at night in IMC and when ATC observed a developing conflict with another aircraft which had just departed another runway with a conflicting clearance, both aircraft were given heading instructions to mitigate the proximity risk. The resulting CPA was 1.8nm at an altitude of 1600 feet. The subsequent investigation attributed the pilot error to a change of aircraft control in the flare when it became apparent that a safe landing was not assured.)
  • … further results


Released to Own Separation

  • B738/B738, Vicinity Queenstown New Zealand, 2010 (LOS HF AGC) (On 20 June 2010, a Boeing 737-800 being operated by New Zealand company Pacific Blue AL on a scheduled passenger flight from Auckland to Queenstown lost IFR separation assurance against a Boeing 737-800 being operated by Qantas on a scheduled passenger flight from Sydney to Queenstown whilst both aircraft were flying a go around following successive but different instrument approaches at their shared intended destination. There were no abrupt manoeuvres and none of the respectively 88 and 162 occupants of the two aircraft were injured.)
  • D150 / H500, London UK, 2007 (LOS HF) (On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.)
  • RJ1H/UNKN, vicinity Malmo Sweden, 2009 (LOS) (On 13 October 2009, an Avro RJ100 being operated by Malmo Aviation on a scheduled passenger flight from Stockholm Bromma to Malmo in day VMC came into proximity with a unseen light aircraft crossing below which activated a TCAS RA which was followed. The flight crew were unaware that they were outside controlled airspace at the time. No abrupt manoeuvring occurred and none of the 85 occupants were injured.)
  • B763/B738, vicinity Melbourne Australia, 2010 (LOS HF) (On 5 December 2010 a Boeing 767-300 being operated by Qantas and departing Melbourne for Sydney in day VMC was following a Boeing 737-800 being operated by Virgin Australia which had also just departed Melbourne for Brisbane on the same SID and a loss of prescribed separation occurred. ATC became aware that the 767 was catching up with the 737 but were aware that it was in visual contact and therefore took no action to ensure separation was maintained. No TCAS activation occurred.)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (LOS HF FIRE) (On 11 February 2009, two civil registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and based at RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers in uncontrolled airspace near Porthcawl in day VMC when they collided.)
  • … further results


Level Bust

  • B763, en route North Bay Canada, 2009 (LOC HF AW LOS) (On 19 June 2009 a Boeing 767-300 being operated by Polish carrier LOT on a scheduled passenger flight from Chicago O’Hare to Warsaw was in the cruise at FL330 feet in night IMC when one of the air speed indicators suddenly displayed a false high reading, which triggered an over speed warning. The flight crew response was based on the presumption that the speed increase was real and thrust was reduced and the aircraft put into a climb. A stall warning followed and descent was then made.)
  • DH8A/DH8C, en route, northern Canada, 2011 (LB LOS HF) (On 7 February 2011 two Air Inuit DHC8s came into head-to-head conflict en route over the eastern shoreline of Hudson Bay in non radar Class ‘A airspace when one of them deviated from its cleared level towards the other which had been assigned the level 1000 feet below. The subsequent investigation found that an inappropriate FD mode had been used to maintain the assigned level of the deviating aircraft and noted deficiencies at the Operator in both TCAS pilot training and aircraft defect reporting as well as a variation in altitude alerting systems fitted to aircraft in the DHC8 fleet.)
  • A310 / B736, en-route, Southern Norway, 2001 (LB LOS HF) (On 21 February 2001, a level bust 10 nm north of Oslo Airport by a climbing PIA A310 led to loss of separation with an SAS B736 in which response to a TCAS RA by the A310 not being in accordance with its likely activation (descend). The B736 received and correctly actioned a Climb RA.)
  • SF34/SF34, Vicinity Stornoway UK, 2011 (LOS HF) (On 15 October 2011, a Loganair Saab 340 in uncontrolled airspace and inbound and level at 2000 feet QNH on a procedural non precision approach in day IMC to runway 18 at Stornoway received a TCAS RA ‘DESCEND’ when a second Loganair Saab 340 outbound on the same procedure descended prematurely to the same altitude contrary to ATC clearance. The subsequent investigation concluded that the failure of the controller to re-iterate the requirement to remain at 3000 feet outbound until advised had contributed the crew error. Minimum separation after the TCAS RA was less than 0.1nm horizontally when 500 feet vertically.)
  • A319/B733, En route, near Moutiers France, 2010 (LOS LB HF) (On 8 July 2010 an Easyjet Airbus A319 on which line training was being conducted mis-set a descent level despite correctly reading it back and, after subsequently failing to notice an ATC re-iteration of the same cleared level, continued descent to 1000 feet below it in day VMC and into conflict with crossing traffic at that level, a Boeing 737. The 737 received and actioned a TCAS RA ‘CLIMB’ and the A319, which received on a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)
  • … further results


Lateral Navigation Error

  • CRJ2/ATP, Stockholm Sweden, 2011 (LOS HF) (On 21 January 2011, a Belarusian Bombardier CRJ200 failed to fly the prescribed missed approach procedure at night in IMC and when ATC observed a developing conflict with another aircraft which had just departed another runway with a conflicting clearance, both aircraft were given heading instructions to mitigate the proximity risk. The resulting CPA was 1.8nm at an altitude of 1600 feet. The subsequent investigation attributed the pilot error to a change of aircraft control in the flare when it became apparent that a safe landing was not assured.)
  • A320, en-route, Sydney Australia, 2007 (LOS HF AW) (On 11 January 2007, an Air New Zealand Airbus A320 which had just departed Sydney Australia for Auckland, New Zealand was observed to have turned onto a heading contrary to the ATC-issued radar heading. When so advised by ATC, the crew checked the aircraft compasses and found that they were reading approximately 40 degrees off the correct heading.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (AI LOS AGC HF) (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • F50 / T6, vicinity Maastrict Netherlands, 2007 (HF LOS) (On 2 August 2007, a Fokker F50 being operated by KLM Cityhopper making a daylight ILS approach in IMC to Maastricht came into close proximity inside the CTZ with a privately operated North American T6 Harvard which had failed to follow its clearance to enter the CTZ.)


ATC Error

  • B737 / B737, vicinity Geneva Switzerland, 2006 (LOS HF) (On 11 May 2006, loss of separation occurred between a B737-700 taking off from Geneva and another B737-700 configured as a Boeing Business Jet (BBJ) which had commenced a go around from the same runway following an unstabilised approach. The speed of the BBJ was such that it rapidly caught up with the departing 737.)
  • B738/B738, Vicinity Queenstown New Zealand, 2010 (LOS HF AGC) (On 20 June 2010, a Boeing 737-800 being operated by New Zealand company Pacific Blue AL on a scheduled passenger flight from Auckland to Queenstown lost IFR separation assurance against a Boeing 737-800 being operated by Qantas on a scheduled passenger flight from Sydney to Queenstown whilst both aircraft were flying a go around following successive but different instrument approaches at their shared intended destination. There were no abrupt manoeuvres and none of the respectively 88 and 162 occupants of the two aircraft were injured.)
  • B744 / A321, London Heathrow UK, 2000 (LOS HF) (On 28 April 2000, a British Airways Boeing 747-400 on go around at London Heathrow Airport, UK, had a loss of separation vertically from a British Midland A321 stationary on the runway waiting for take-off.)
  • B752, vicinity Atlanta GA USA, 2011 (LOS HF) (On 11 March 2011, a Delta AL Boeing 757 departed Atlanta GA with no secondary radar indication visible to ATC and also failed to make contact with departure radar after accepting the frequency transfer instruction. During the eight minutes out of radio contact, it successively lost separation against two light aircraft and another passenger aircraft as it followed the cleared RNAV departure routing for eight minutes until the crew queried further climb on the TWR frequency and were invited to select their transponder on and contact the correct frequency.)
  • A318/B739, vicinity Amsterdam, 2007 (LOS HF) (On 6 December 2007 an Airbus A318 being operated by Air France on a scheduled passenger flight from Lyon to Amsterdam carried out missed approach from runway 18C at destination and lost separation in night VMC against a Boeing 737-900 being operated by KLM on a scheduled passenger flight from Amsterdam to London Heathrow which had just departed from runway 24. The conflict was resolved by correct responses to the respective coordinated TCAS RAs after which the A318 passed close behind the 737. There were no abrupt manoeuvres and none of the 104 and 195 occupants respectively on board were injured.)
  • … further results


Near Miss

  • A388/A320, vicinity Frankfurt Germany, 2011 (LOS LOC WAKE HF) (On 13 December 2011, an Airbus 320 was allowed to depart from runway 25C at Frankfurt on a left turning SID just prior to the touchdown of an A380 on runway 25L. The A380 had then initiated a low go around which put it above, ahead of and parallel to the A320 with a closest proximity of 1nm / 200 ft, in breach of the applicable wake vortex separation minima of 7nm / 1000ft. The Investigation found that there had been no actual encounter with the A380 wake vortices but that systemic ATC operational risk management was inadequate.)
  • PC12 /A318, en-route north east of Toulouse France, 2010 (LOS AW HF) (On 2 June 2010, an Airbus A318 being operated by Air France on a scheduled passenger flight from Lyon to Toulouse was about 90nm northeast of Toulouse when it came into close proximity in day VMC with a Spanish-registered Pilatus PC12 being operated by Norestair SL on a non revenue positioning flight from Buochs, Switzerland to San Sebastian, Spain which was travelling on the same track and in the same direction.)
  • B752/GLID, Vicinity Glasgow UK, 2011 (LOS HF) (On 23 July 2011 a Boeing 757 in Class ‘E’ airspace east of Glasgow in VMC encountered a glider ahead at the same altitude and deviated right to avoid a collision. The glider, climbing in a thermal, had not seen the 757 until it passed during avoiding action. The closest proximity was estimated as 100 metres at the same level as the glider passed to the left of the 757 in the opposite direction. Since the circumstances were considered to have demonstrated a safety critical risk by the UK CAA, an interim airspace reclassification Class ‘D’ was implemented)
  • A320 / B738, vicinity Launceston Australia, 2008 (LOS HF) (On 1 May 2008 an Airbus A320-200 being operated by JetStar on a scheduled passenger flight from Melbourne to Launceston, Tasmania was making a missed approach from runway 32L when it came into close proximity in night VMC with a Boeing 737-800 being operated by Virgin Blue and also inbound to Launceston from Melbourne which was manoeuvring about 5nm north west of the airport after carrying out a similar missed approach. Minimum separation was 3 nm at the same altitude and the situation was fully resolved by the A320 climbing to 4000 feet.)
  • MD82 / A319, vicinity Helsinki Finland, 2007 (LOS HF) (On 5 September 2007 in day VMC, an MD82 being operated by SAS was obliged to carry out an own-initiative avoiding action orbit in day VMC against an Airbus A319 being operated by Finnair on a scheduled passenger after conflict when about to join final approach. Both aircraft were following ATC instructions which, in the case of the MD 82, had not included maintaining own separation so that the applicable separation minima were significantly breached.)
  • … further results


Lateral Offset in Use

None on SKYbrary

Mid-Air Collision

  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (LOS HF) (On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.)
  • T154 / B752, en-route, Uberlingen Germany, 2002 (LOS HF) (On 1st July 2002, a Russian-operated Tu154 on a passenger flight collided at night with a cargo Boeing 757-200 over Überlingen, Germany with the consequent loss of control of both aircraft and the death of all occupants. The collision occurred after an ATC control lapse had led to a conflict which generated coordinated TCAS RAs which the B757 followed but the TU-154, in the presence of a conflicting ATC instruction, did not.)
  • G115 / GLID, en-route Oxfordshire UK, 2009 (LOS HF AW) (On 14 June 2009, a Grob 115E Tutor being operated by the UK Royal Air Force (RAF) and based at RAF Benson was conducting aerobatics in uncontrolled airspace near Drayton, Oxfordshire in day VMC when it collided with a Standard Cirrus Glider on a cross country detail from Lasham. The glider was sufficiently damaged that it could no longer be controlled and the glider pilot parachuted to safety. The Tutor entered a spin or spiral manoeuvre which it exited in a steep dive from which it did not recover prior to a ground impact which killed both occupants.)
  • AS50 / PA32, en-route, Hudson River NJ USA, 2009 (LOS HF) (On August 8, 2009 a privately operated PA32 and a Eurocopter AS350BA helicopter being operated by Liberty Helicopters on a public transport sightseeing flight collided in VMC over the Hudson River near Hoboken, New Jersey whilst both operating under VFR. The three occupants of the PA32, which was en route from Wings Field PA to Ocean City NJ, and the six occupants of the helicopter, which had just left the West 30th Street Heliport, were killed and both aircraft received substantially damaged.)
  • E135 / B738, en-route, Amazon Brazil, 2006 (HF AGC LOS) (On 29 September 2006, a B737-800, operated by the Brazilian airline Gol, collided head-on with a US owned and operated EMB135 Legacy at FL370 over the Amazon, Brazil. The aircraft were flying at the same altitude in opposite directions along the same airway.)
  • … further results


Uncommanded AP disconnect

None on SKYbrary

Military Aircraft Involved

  • G115 / G115, near Porthcawl South Wales UK, 2009 (LOS HF FIRE) (On 11 February 2009, two civil registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and based at RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers in uncontrolled airspace near Porthcawl in day VMC when they collided.)
  • DH8D / TOR, en-route, North Sea UK, 2008 (AI LOS) (On 13 October 2008, a DHC-8 Q400 executed ATC instructions, followed by TCAS TA and RA to avoid unknown traffic. Recorded minimum lateral separation was 2.5 NM.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (AI LOS AGC HF) (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (LOS HF) (On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.)
  • F15 / E145, en-route, Bedford UK, 2005 (LB AI LOS AGC HF) (On 27 January 2005, two USAF-operated McDonald Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • … further results


Related Articles

Further Reading

Bureau d’Enquêtes et d’Analyses (BEA)

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