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  • SB20 / C510, vicinity Lugano Switzerland, 2011 (Synopsis: On 16 December 2011, a Saab 2000 in the hold and an opposite direction Cessna VLJ joining it lost procedural separation in IMC near Lugano due to conflicting ATC clearances issued by the same controller who had used the wrong Transition Level. Any risk of collision was removed by a TCAS RA activated on the Saab 2000 but the Investigation found that the DFTI radar display available to the controller to help resolve unexpected emergency situations was configured to systematically convert SSR standard pressure altitudes to QNH for altitude display using a distant and inappropriate value of QNH.)
  • E145/E135, Chicago O’Hare USA, 2011 (Synopsis: On 8 August 2011, an Embraer 145 was given take off clearance from runway 32L at O’Hare in day VMC without the controller making the required check for potentially conflicting arrivals to runway 09R which pass over the runway. When the controller realised that the departing aircraft would conflict with an Embraer 135 approaching 09R, he told his aircraft to “stay low” and the runway 09R controller to send his aircraft around. Radar data indicated that the 135 on go around had crossed runway 32L about 125 feet above and just over 100 metres in front of the departing 145.)
  • TBM8, Birmingham UK, 2011 (Synopsis: On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non precision approach to runway 15 prior to the issue of a landing clearance and prior to checking in on the ATC TWR frequency. It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take off in accordance with ATC instructions. No damage or personal injury resulted from the close proximity.)
  • DH8D / DH8D, vicinity Sudbury ON Canada, 2016 (Synopsis: On 14 October 2016, two Bombardier DHC8-400s received coordinated TCAS RAs as they came into opposite direction conflict near Sudbury, an uncontrolled airport, as one was descending inbound and emerging from an overcast layer and the other was level just below that layer after departing. Both aircraft crews ignored their RAs and their respective visual manoeuvring brought them to within 0.4nm at the same altitude. The Investigation noted that the conflict had occurred in Class ‘E’ airspace after the departing aircraft had cancelled IFR to avoid a departure delay attributable to the inbound IFR aircraft.)
  • B744 / A321, vicinity London Heathrow UK, 2000 (Synopsis: 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.)