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  • A320 / A346, en-route, Eastern Indian Ocean, 2012 (Synopsis: On 18 January 2012, ATC error resulted in two aircraft on procedural clearances in oceanic airspace crossing the same waypoint within an estimated 2 minutes of each other without the prescribed 1000 feet vertical separation when the prescribed minimum separation was 15 minutes unless that vertical separation existed. By the time ATC identified the loss of separation and sent a CPDLC message to the A340 to descend in order to restore separation, the crew advised that such action was already being taken. The Investigation identified various organisational deficiencies relating to the provision of procedural service by the ANSP concerned.)
  • A320 / AT76, Yangon Myanmar, 2017 (Synopsis: On 18 September 2017, a departing Airbus A320 was instructed to line up and wait at Yangon but not given takeoff clearance until an ATR72 was less than a minute from touchdown and the prevailing runway traffic separation standard was consequently breached. The Investigation found that the TWR controller had been a temporarily unsupervised trainee who, despite good daylight visibility, had instructed the A320 to line up and wait and then forgotten about it. When the A320 crew, aware of the approaching ATR72, reminded her, she “did not know what to do” and the trainee APP controller had to intervene.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (Synopsis: On 30 October 2014, a descending Airbus A320 came close to a Boeing 737-800 at around FL 220 after the A320 crew significantly exceeded a previously-instructed 2,000 fpm maximum rate of descent assuming it no longer applied when not reiterated during re-clearance to a lower altitude. Their response to a TCAS RA requiring descent at not above 1,000 fpm was to further increase it from 3,200 fpm. Lack of notification delayed the start of an independent Investigation but it eventually found that although the A320 TCAS equipment had been serviceable, its crew denied failing to correctly follow their initial RA.)
  • A320 / B738, vicinity Dubai UAE, 2012 (Synopsis: On 22 April 2012, an Airbus A320 and a Boeing 737 came into close proximity near Dubai whilst on the same ATC frequency and correctly following their ATC clearances shortly after they had departed at night from Sharjah and Dubai respectively. The Investigation found that correct response by both aircraft to coordinated TCAS RAs eliminated any risk of collision. The fact that the controller involved had only just taken over the radar position involved and was only working the two aircraft in conflict was noted, as was the absence of STCA at the unit due to set up difficulties.)
  • A320 / B789 / A343, San Francisco CA USA, 2017 (Synopsis: On 7 July 2017 the crew of an Airbus A320, cleared for an approach and landing on runway 28R at San Francisco in night VMC, lined up for the visual approach for which it had been cleared on the occupied parallel taxiway instead of the runway extended centreline and only commenced a go-around at the very last minute, having descended to about 60 feet agl whilst flying over two of the four aircraft on the taxiway. The Investigation determined that the sole direct cause of the event was the poor performance of the A320 flight crew.)
  • A320 / C56X, vicinity Geneva Switzerland, 2011 (Synopsis: On 17 August 2012, a Swiss A320 being positioned under radar vectors for arrival at Geneva was inadvertently vectored into conflict with a Cessna Citation already established on the ILS LOC for runway 23 at Geneva. Controller training was in progress and the Instructor had just taken control because of concerns at the actions of the Trainee. An error by the Instructor was recognised and de-confliction instructions were given but a co-ordinated TCAS RA still subsequently occurred. STCA was activated but constraints on access to both visual and aural modes of the system served to diminish its value.)
  • A320 / CRJ2, Port Elizabeth South Africa, 2014 (Synopsis: On 10 July 2014, the crew of a Bombardier CRJ200 on a visual go around from an approach to runway 26 at Port Elizabeth took visual avoiding action overhead of the aerodrome to ensure safe separation from an Airbus A320 which had just taken off. Both aircraft also received TCAS RAs. Minimum achieved separation from radar was 370 metres laterally and 263 feet vertically. The Investigation noted that the go around resulted from the TWR controller, who was supervising a student controller, clearing the A320 to enter the runway and take off when the CRJ200 was on short final to land.)
  • A320 / F50, Adelaide Australia, 2016 (Synopsis: On 17 August 2016, a Fokker F50 crossed an active runway at Adelaide ahead of an A320 which was about to land after both its pilots and the controller involved had made assumptions about the content of radio transmissions they were aware they had not fully heard. The Investigation found that the A320 crew had responded promptly to the potential conflict by initiating a low go around over the other aircraft and noted that stop bars were not installed at Adelaide. In addition, aircraft taxiing across active runways were not required to obtain their crossing clearances on the runway control frequency.)
  • A320 / GLID, vicinity Memmingen Germany, 2015 (Synopsis: On 6 April 2015, the crew of an A320 under radar control in Class E airspace and approaching 4000 feet made a very late sighting of a glider being flown by a student pilot which appeared ahead at a similar altitude. The glider pilot reported having seen a 'cone of light' coming towards him. Both aircraft took avoiding action as practicable and passed within a recorded 450 metres with the A320 passing an estimated 250 feet over the glider. The glider was not fitted with a transponder and was not required to be, and the controller had only secondary radar.)
  • A320/E190/B712, vicinity Helsinki Finland, 2013 (Synopsis: On 6 February 2013, ATC mismanagement of an Airbus A320 instructed to go around resulted in loss of separation in IMC against the Embraer 190 ahead which was obliged to initiate a go around when no landing clearance had been issued due to a Boeing 737-800 still on the runway after landing. Further ATC mismanagement then resulted in a second IMC loss of separation between the Embraer 190 and a Boeing 717 which had just take off from the parallel runway. Controller response to the STCA Alerts generated was found to be inadequate and ANSP procedures in need of improvement.)
  • A321 / B738, en-route, south eastern Bulgaria, 2016 (Synopsis: On 8 September 2016, an Airbus A321 en route in Bulgarian airspace at FL 350 was given and acknowledged a descent but then climbed and came within 1.2nm of a descending Boeing 737. The Investigation found that the inexperienced A321 First Officer had been temporarily alone when the instruction was given and had insufficient understanding of how to control the aircraft. It was also found that despite an STCA activation of the collision risk, the controller, influenced by a Mode ‘S’ downlink of the correctly-set A321 cleared altitude, had then added to the risk by instructing the 737 to descend.)
  • A332 / A332, en-route, near Adelaide South Australia, 2013 (Synopsis: On 20 September 2013, a loss of separation occurred between two en route Airbus A330s under radar surveillance in controlled airspace near Adelaide. The potential conflict was resolved with TCAS RA action by one of the aircraft involved but the TCAS equipment on board the other aircraft appeared to have malfunctioned and did not display any traffic information or generate an RA. The complex pattern of air routes in the vicinity of the event was identified by the Investigation as a Safety Issue requiring resolution by the ANSP and the response subsequently received was assessed as satisfactory.)