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A319 / B735, vicinity Prague Czech Republic, 2012

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Summary
On 7 September 2012, the crew of an Air France Airbus A319 failed to follow their arrival clearance at destination and turned directly towards the ILS FAF and thereby into conflict with a Boeing 737-500 on an ILS approach. When instructed to turn left (and clear of the ILS) by the controller, the crew replied that they were "following standard arrival" which was not the case. As the separation between the two aircraft reduced, the controller repeated the instruction to the A319 to turn left and this was acknowledged. Minimum lateral separation was 1.7nm, sufficient to activate STCA.
Event Details
When September 2012
Actual or Potential
Event Type
HF, LOS
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft AIRBUS A-319
Operator Air France
Domicile France
Type of Flight Public Transport (Passenger)
Intended Destination Prague/Václav Havel Airport
Flight Details
Aircraft BOEING 737-500
Operator Czech Airlines
Domicile Czech Republic
Type of Flight Public Transport (Passenger)
Intended Destination Prague/Václav Havel Airport
Flight Phase Descent
ENR / APR
Location - Airport
Airport vicinity Prague/Václav Havel Airport
General
Tag(s) Aircraft-aircraft near miss
HF
Tag(s) Authority Gradient
Ineffective Monitoring
Plan Continuation Bias
Procedural non compliance
LOS
Tag(s) Accepted ATC Clearance not followed
Required Separation not maintained
Lateral Navigation Error
Safety Net Mitigations
Malfunction of Relevant Safety Net No
STCA Effective
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 7 September 2012, an Airbus A319 being operated by Air France as AFR 1482 and a Boeing 737-500 being operated by Czech Airlines as CSA77E lost separation in the vicinity of the runway 24 ILS at Prague in day VMC when the A319 did not follow its clearance. Controller action prior to STCA activation was able to resolve the situation and the 737 continued its ILS approach without interruption.

Investigation

An Investigation was carried out by the Czech Air Accidents Investigation Institute (AAII).

It was established that both aircraft involved in the conflict were inbound to Prague. The Czech Airlines Boeing 737 was about to become established on the ILS for runway 24 and the Air France A319 was flying a LOMKI 4S STAR and approaching the IAF at waypoint ERASU. The charted STAR instructions were that "unless otherwise instructed, after ERASU continue on heading 062°, radar vectoring will be provided". It was noted that after checking in with APP, the A319 crew asked whether APP wanted to shorten the aircraft track but the response (which was acknowledged) was "expect normal vectoring from 4000".

However, after passing ERASU, the A319 turned right on a base leg for the 24 ILS contrary to clearance whilst continuing descent to 4000 feet as cleared. At that, time, the 737 was establishing on the ILS LOC at 4000 feet. ATC observed the A319 turn and to prevent loss of separation (at that time the two aircraft were 4.1 nm apart) ATC instructed the A319 to turn left. Although acknowledged, this action was not immediately commenced and the crew responded "we are following standard arrival". Given the slow response to the "turn left" instruction, ATC repeated it (the separation was now 3nm). This was again acknowledged and the instruction to climb to FL060 was also given and also acknowledged. The tracks of the two aircraft up to the point where conflict resolution began to take effect are shown on the radar recording reproduced below.

The radar-recorded position of the two aircraft as the A319 begins the left turn given by ATC to de-conflict it from the 737 on the ILS (reproduced from the Official Report)

The minimum lateral separation from the 737, which continued on the ILS, was 1.7nm. The STCA activated as configured at a 2nm separation

A statement to the Investigation from the A319 Captain indicated that the aircraft FMS appeared to have been mis-programmed so that after ERASU, it turned towards waypoints PR531 and PR532 which are published on the ILS procedure chart but not on the LOMKI 4S STAR chart which includes only waypoints PR511 and PR512. It was also noted that the A319 First Officer had suggested to the Captain that the clearance after ERASU should be clarified with ATC but that thus suggestion had not been accepted.

The formally-stated Conclusions of the Investigation included that "the A319 crew could have prevented the incident occurrence by enquiry at APP for clarification of the flight procedure after passing ERASU point".

The Investigation concluded that the Cause of the Serious Incident was "A human factors failure - failure of the procedure specified by the ATS by the A319 crew"

The Final Report was completed in September 2013. No Safety Recommendations were issued.


Further Reading