If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user

 Actions

Difference between revisions of "Accident and Serious Incident Reports: LOS"

From SKYbrary Wiki

 
(43 intermediate revisions by 6 users not shown)
Line 2: Line 2:
 
|source            = SKYbrary
 
|source            = SKYbrary
 
|source_image      = SKYbrary
 
|source_image      = SKYbrary
|source_caption    = SKYbrary
+
|source_caption    = About SKYbrary
|control          = EUROCONTROL
+
|control          = SKYbrary
|control_image    = EUROCONTROL
+
|control_image    = SKYbrary
|control_caption  = EUROCONTROL
+
|control_caption  = About SKYbrary
 
}}
 
}}
  
 
==Definition==
 
==Definition==
  
Reports relating to accidents which involved [[Loss of Separation]].
+
Reports relating to accidents and incidents which involved [[Loss of Separation]].
  
'''''The accident and serious incident reports are grouped together below in subcategories. '''''
+
'''''The accident and serious incident reports are grouped together below in subcategories.'''''
  
 +
==TCAS RA Mis-flown==
 +
{{#ask:[[LOS::TCAS RA Mis Flown]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
 +
 +
==Accepted ATC Clearance Not Followed==
 +
{{#ask:[[LOS::Accepted ATC Clearance not followed]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
 +
 +
=="See and Avoid" Ineffective==
 +
{{#ask:[[LOS::See and Avoid Ineffective]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
 +
 +
==Required Separation not Maintained==
 +
{{#ask:[[LOS::Required Separation not maintained]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
==Loss of Separation on Take-off or Go Around==
+
==Released to Own Separation==
 +
{{#ask:[[LOS::Released to Own Separation]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[A306, London Heathrow UK, 1996 (LOS)]]: On 5 April 1996 loss of separation occurred when a B747, taking off from runway 27R at London Heathrow, conflicted with an A300 carrying out a missed approach from the parallel runway.
+
==Level Bust==
 +
{{#ask:[[LOS::Level Bust]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[A332, Zurich Switzerland, 2004 (LOS)]]: On 31 October 2004, a Loss of Separation occurred between an A330, on a low go-around from Rwy 14 at Zurich Switzerland, and an RJ100 which had been cleared for take-off on Rwy 10 and was on a convergent flight path.
+
==Lateral Navigation Error==
 +
{{#ask:[[LOS::Lateral Navigation Error]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[B747, LOS, London Heathrow UK, 1996|B747/A300, LOS, London Heathrow UK, 1996]]: On 5 April 1996 loss of separation occurred when a [[B747]], taking off from runway 27R at London Heathrow, conflicted with an [[A300]] carrying out a missed approach from the parallel runway.
+
==ATC Error==
 +
{{#ask:[[LOS::ATC Error]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[A321, LOS, London Heathrow UK, 2000|B747/A321, LOS, London Heathrow UK, 2000]]: On 28 April 2000, a British Airways [[B747]] on go around at London Heathrow Airport, UK, had a near miss vertically from a British Midland [[A321]] stationary on the runway waiting for take-off.
+
==Near Miss==
 +
{{#ask:[[LOS::Near Miss]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
 +
 
 +
==Lateral Offset in Use==
 +
{{#ask:[[LOS::Lateral Offset in use]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[B737, LOS, Geneva Switzerland, 2006|B737/BBJ, LOS, Geneva Switzerland, 2006]]: On 11 May 2006, loss of separation occurred between a [[B737 Series|B737]] taking off from Geneva and a 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 B737.
+
==Mid-Air Collision==
 +
{{#ask:[[LOS::Mid-Air Collision]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
 +
==Uncommanded AP disconnect==
 +
{{#ask:[[LOS::Uncommanded AP disconnect]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
==Loss of Separation En Route==
+
==Military Aircraft Involved==
 +
{{#ask:[[LOS::Military Aircraft involved]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[A340, Air France, LOS, Newfoundland Canada, 1998|A340/B747, LOS, Newfoundland Canada, 1998]]: On 20 July 1998, after an ATC error, an Air France [[A340]] and an Air Canada [[B747]] on directly converging tracks and at the same level, avoided collision by the correct actioning of coordinated TCAS RAs by both aircraft south of Newfoundland.
+
==Apparent de-selection of transponder==
 +
{{#ask:[[LOS::Apparent de-selection of transponder]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[B734, London Heathrow UK, 1996 (LB LOS)]]: On 12 November 1996 (the same day as the fatal mid air over New Delhi), a B737 descended below its assigned holding level in the LHR holding pattern, in IMC, to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level. Neither aircraft was fitted with ACAS.
+
==Transponder non selection==
 +
{{#ask:[[LOS::Transponder non selection]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[E135, 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. '''Mid-Air Collision'''
+
==Go Around Separation==
 +
{{#ask:[[LOS::Go Around Separation]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[B752, Uberlingen Germany, 2002 (LOS)|B757/Tu-154, LOS, Uberlingen Germany, 2002]]: On 1st July 2002, a [[T154|Tu-154]] collided with a [[B752|B757]] over Uberlingen, Germany, following an ATC control lapse and failure of the TU154 to follow the coordintated TCAS RA guidance. '''Mid-Air Collision'''
+
==UAV Involved==
 +
{{#ask:[[LOS::UAV Involved]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[Cessna 152, LOS, Nottinghamshire UK, 1999|Cessna 152/Tornado GR1, LOS, Nottinghamshire UK, 1999]]: On 21 January 1999, a Royal Air Force [[TOR|Tornado]] GR1 and a private [[Cessna 150|Cessna 152]] collided in mid air, at low level, with the loss of both aircraft and all on board. '''Mid-Air Collision'''
+
==Unregulated Manned Flight Involved==
 +
{{#ask:[[LOS::Unregulated Manned Flight Involved]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[H500, London UK, 2007 (LOS)]]: 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. The helicopter pilot's workload at the time of the incident was high as a result of frequency and transponder changes, and he did not notice the Jodel until it passed under his aircraft.
+
==Procedural Control==
 +
{{#ask:[[LOS::Procedural Control]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[IL76/B747, New Delhi India, 1996 (LB LOS)]]: On 12 November 1996, an IL76 collided in mid air with a Saudi B747 near New Delhi India, following a level bust by the IL76. '''Mid-Air Collision'''
+
==ATC control using ADS-B==
 +
{{#ask:[[LOS::ATC control using ADS-B]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[SH36, Air Cargo Carriers, Watertown WI USA, 2006 (LOS LOC RE)]]: 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. '''Mid-Air Collision'''
+
==ATC control supported by ADS-C==
 +
{{#ask:[[LOS::ATC control supported by ADS-C]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
==Loss of Separation Following Level Bust==
+
==Uncontrolled Airspace==
 +
{{#ask:[[LOS::Uncontrolled Airspace]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[A310, PIA, AGC LB LOS, Oslo Norway, 2001|A310/B737, LB LOS, Oslo Norway, 2001]]: On 21 February 2001, a level bust involving a PIA [[A310]] led to loss of separation with a SAS [[B737 Series|B737]] with apparently uncoordinated TCAS RA near Oslo.
+
==TCAS RA Reversal==
 +
{{#ask:[[LOS::TCAS RA Reversal]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
*[[A319, Air France, LB LOS, Geneva Switzerland, 2004|A319/Gulfstream G-V, LB LOS, Geneva Switzerland, 2004]]: On 16 September 2004, a loss of separation occurred over Geneva between an Air France [[A319]] and a [[Gulfstream G-V]] which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.
 
  
 +
==VFR Aircraft Involved==
 +
{{#ask:[[LOS::VFR Aircraft Involved]]
 +
| default=None on SKYbrary
 +
|?Synopsis=
 +
|format=ul
 +
|limit=12
 +
}}
  
 
==Related Articles==
 
==Related Articles==
 +
* [[Loss of Separation]]
  
For all accident and serious incident reports held on SKYbrary, see the main section accessible on the side menu to the left-hand side of your view.
+
==Further Reading==
 +
'''Bureau d’Enquêtes et d’Analyses (BEA)'''
 +
* [http://www.skybrary.aero/bookshelf/books/817.pdf Incidents in Air Transport No 10 - Aerodrome Traffic]
 +
* [http://www.skybrary.aero/bookshelf/books/815.pdf Incidents in Air Transport No 3 - TCAS-related]
 +
* [http://www.skybrary.aero/bookshelf/books/771.pdf BEA: “Mid-Air Collisions 1989-1999”]
  
[[category:Loss of Separation]][[category: Operational Issues]]
+
[[Category:Loss of Separation]]
 +
[[Category:Operational Issues]]

Latest revision as of 14:32, 19 February 2018

Article Information
Category: Loss of Separation Loss of Separation
Content source: SKYbrary About SKYbrary
Content control: SKYbrary About SKYbrary

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 (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.)
  • A319 / PRM1, en-route, near Fribourg Switzerland, 2011 (On 10 June 2011 an ATC error put a German Wings A319 and a Hahn Air Raytheon 390 on conflicting tracks over Switzerland and a co-ordinated TCAS RA followed. The aircraft subsequently passed in very close proximity without either sighting the other after the Hahn Air crew, contrary to Company procedures, followed an ATC descent clearance issued during their TCAS ‘Climb’ RA rather than continuing to fly the RA. The Investigation could find no explanation for this action by the experienced crew - both Hahn Air management pilots. The recorded CPA was 0.6 nm horizontally at 50 feet vertically.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (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 Delhi India, 2013 (On 2 September 2013, a B737 crew were not instructed to go around from their approach by ATC as it became increasingly obvious that an A320 departing the same runway would not be airborne in time for a landing clearance to be issued. They initiated a go around over the threshold and then twice came into conflict with the A320 as both climbed on similar tracks without ATC de-confliction, initially below the height where TCAS RAs are functional. Investigation attributed the conflict to ATC but the failure to effectively deal with the consequences jointly to ATC and both aircraft crews.)
  • B752 / B752, en-route, north of Tenerife Spain 2011 (On 20 November 2011, a problem in reading the altitude labels on the ATC radar control display led to a Finnair Boeing 757 being cleared to make a descent which brought it into proximity with a Thomas Cook Boeing 757 in day VMC. Co-ordinated TCAS RAs were generated onboard both aircraft but when the Finnair aircraft failed to respond to its Climb RA and continued descent, the other aircraft, which had responded correctly to its initial RA, received a further RA to reverse their descent to a climb. The Finnair aircraft reported retaining visual contact with the other aircraft throughout.)
  • C525 / B773, vicinity London City UK, 2009 (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 777-300ER. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • DH8A/DH8C, en-route, northern Canada, 2011 (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.)
  • DH8D / DH8D, vicinity Sudbury ON Canada, 2016 (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.)
  • E55P, Blackbushe UK, 2015 (On 31 July 2015 a Saudi-operated Embraer Phenom on a private flight continued an unstabilised day visual approach to Blackbushe in benign weather conditions. The aircraft touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died. The Investigation concluded that the combination of factors which created a very high workload for the pilot "may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model" leading to his continuation of a highly unstable approach.)
  • F100 / EC45, vicinity Bern Switzerland, 2012 (On 24 May 2012, a Fokker 100 descending visual downwind to land at Berne and an EC145 helicopter transiting the Bern CTR (Class 'D' airspace) VFR came within 0.7 nm horizontally and 75 ft vertically despite early traffic advice having been given to both aircraft. The Investigation attributed the conflict to the failure of the F100 crew to follow either their initial TCAS RA or a subsequent revised one and noted that although STCA was installed at Berne it had been disabled "many years before".)
  • F900 / B772, en-route, near Kihnu Island Estonia, 2013 (On 17 October 2013, a Falcon 900 climbing as cleared to FL 340 and being operated as a State Aircraft equipped with TCAS II v7.0 initially responded to a TCAS RA against crossing traffic at FL 350 in day VMC in the opposite direction to the one directed and prescribed separation was lost as a result. The Investigation concluded that the F900 crew had commenced a climb on receipt of a TCAS RA 'ADJUST VERTICAL SPEED' when a reduction in the 800 fpm rate of climb was required. Safety Recommendations were made in respect of TCAS RA requirements for State Aircraft.)
  • GLF5 / A319, south-eastern France, 2004 (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.)

... further results

Accepted ATC Clearance Not Followed

  • A310 / B736, en-route, Southern Norway, 2001 (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.)
  • A319 / A321, en-route, west north west of Geneva, Switzerland 2011 (On 6 August 2011 an Easyjet Airbus A319 on which First Officer Line Training was in progress exceeded its cleared level during the climb after a different level to that correctly read back was set on the FMS. As a result, it came into conflict with an Alitalia A321 and this was resolved by responses to coordinated TCAS RAs. STCA alerts did not enable ATC resolution of the conflict and it was concluded that a lack of ATC capability to receive Mode S EHS DAPs - since rectified - was a contributory factor to the outcome.)
  • A319 / B735, vicinity Prague Czech Republic, 2012 (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.)
  • A319/B733, en-route, near Moutiers France, 2010 (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 only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (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, en-route, Sydney Australia, 2007 (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.)
  • A321 / B738, en-route, south eastern Bulgaria, 2016 (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.)
  • B734 / MD81, en-route, Romford UK, 1996 (On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow in day IMC to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level, 1000 feet below. STCA prompted ATC to intervene and the 737 climbed back to its cleared level. Neither aircraft was fitted with TCAS 2 or saw the other visually.)
  • B737 / B737, vicinity Geneva Switzerland, 2006 (On 11 May 2006, B737-700 taking off from Geneva came into close proximity with a Boeing Business Jet (BBJ) on a non revenue positioning flight which had commenced a go around from the same runway following an unstabilised approach. The Investigation attributed the conflict to the decision of ATC to give take off clearance to the departing aircraft when the approach of the inbound aircraft could have been seen as highly likely to result is a go around which would lead to proximity with the slower departing aircraft.)
  • B738 / C172, en route, near Falsterbo Sweden, 2014 (On 20 July 2014, the pilot of a VFR Cessna 172 became distracted and entered the Class 'C' controlled airspace of two successive TMAs without clearance. In the second one he was overtaken by a Boeing 738 inbound to Copenhagen with less than 90 metres separation. The 738 crew reported a late sighting of the 172 and "seemingly" assessed that avoiding action was unnecessary. Although the 172 had a Mode C-capable transponder, it was not transmitting altitude prior to the incident and the Investigation noted that this had invalidated preventive ATC and TCAS safety barriers and compromised flight safety.)
  • B738, Eindhoven Netherlands, 2012 (On 11 October 2012, the crew of a Ryanair Boeing 737-800 did not change frequency to TWR when instructed to do so by GND whilst already backtracking the departure runway and then made a 180° turn and took off without clearance still on GND frequency. Whilst no actual loss of ground or airborne safety resulted, the Investigation found that when the Captain had queried the receipt of a take off clearance with the First Officer, he had received and accepted a hesitant confirmation. Crew non-compliance with related AIP ground manoeuvring restrictions replicated in their airport briefing was also noted.)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a Boeing 737-800 on go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on. The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around. Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.)

... further results

"See and Avoid" Ineffective

  • AS50 / PA32, en-route, Hudson River NJ USA, 2009 (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.)
  • AT72 / B732, vicinity Queenstown New Zealand, 1999 (On 26 July 1999, an ATR 72-200 being operated by Mount Cook Airlines on a scheduled passenger flight from Christchurch to Queenstown entered the destination CTR without the required ATC clearance after earlier cancelling IFR and in marginal day VMC due to snow showers, separation was then lost against a Boeing 737-200 being operated IFR by Air New Zealand on a scheduled passenger flight from Auckland to Queenstown which was manoeuvring visually (circling) after making an offset VOR/DME approach in accordance with a valid ATC clearance.)
  • B738/B738, vicinity Queenstown New Zealand, 2010 (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.)
  • C525 / P180, south west of Sion Switzerland, 2012 (On 22 March 2013, a Cessna 525 inbound to Sion on a VFR clearance was flown into conflict with an IFR Piaggio P180 departing the same airport in compliance with its clearance and the prescribed separation between the two aircraft was lost in the vicinity of FL140. The Investigation concluded that an inappropriate ATC tactic had been employed in an attempt to achieve separation and recommended the development of a new procedure to better facilitate separation between IFR and VFR traffic in the airspace where the conflict occurred.)
  • D150 / H500, London UK, 2007 (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.)
  • DH8B / BN2P, Horn Island QLD Australia, 2016 (On 12 October 2016, a BN2 Islander and a Bombardier DHC8-200 were involved in a near miss after the DHC8 took off from a runway which intersected with the runway on which the BN2 was about to land. The BN2 broke off its approach just before touchdown when the DHC8 was observed accelerating towards the runway intersection on its take-off roll. The Investigation noted that the aerodrome involved relied on visual separation and use of a CTAF and found that although both aircraft were aware of each other, the DHC8 crew failed to fully utilise visual lookout.)
  • DH8D / TOR, en-route, North Sea UK, 2008 (On 13 October 2008, a DHC-8 Q400 operating in uncontrolled airspace and in receipt of civil radar advisory service was given an avoiding action turn against military traffic but then received and actioned a TCAS RA whilst inside a notified Danger Area as a result of the avoiding action turn. No close proximity to other traffic resulted.)
  • F100 / EC45, vicinity Bern Switzerland, 2012 (On 24 May 2012, a Fokker 100 descending visual downwind to land at Berne and an EC145 helicopter transiting the Bern CTR (Class 'D' airspace) VFR came within 0.7 nm horizontally and 75 ft vertically despite early traffic advice having been given to both aircraft. The Investigation attributed the conflict to the failure of the F100 crew to follow either their initial TCAS RA or a subsequent revised one and noted that although STCA was installed at Berne it had been disabled "many years before".)
  • F16 / C150, vicinity Berkeley County SC USA, 2015 (On 7 July 2015, a mid-air collision occurred between an F16 and a Cessna 150 in VMC at 1,600 feet QNH in Class E airspace north of Charleston SC after neither pilot detected the conflict until it was too late to take avoiding action. Both aircraft subsequently crashed and the F16 pilot ejected. The parallel civil and military investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the F16 to provide appropriate timely resolution of the impending conflict.)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (On 11 February 2009, the plots of two civil-registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and both operating from RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers whilst in the same uncontrolled airspace in day VMC and aware of the general presence of each other when they collided. The aircraft were destroyed and all occupants killed)
  • G115 / GLID, en-route Oxfordshire UK, 2009 (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.)
  • H25B / AS29, en-route / manoeuvring, near Smith NV USA, 2006 (On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.)

... further results

Required Separation not Maintained

  • A310 / B736, en-route, Southern Norway, 2001 (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.)
  • A318 / B738, en-route, Trasadingen Switzerland, 2009 (On 8 June 2009, an Airbus A318-100 being operated by Air France on a scheduled passenger flight from Belgrade, Serbia to Paris CDG in day VMC came into conflict with a Boeing 737-800 being operated by Ryanair on a scheduled passenger flight from Nottingham East Midlands UK to Bergamo Italy. The conflict was resolved mainly by TCAS RA response and there were no injuries to any occupants during the avoidance manoeuvres carried out by both aircraft.)
  • A318/B739, vicinity Amsterdam Netherlands, 2007 (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.)
  • A319 / A321, en-route, west north west of Geneva, Switzerland 2011 (On 6 August 2011 an Easyjet Airbus A319 on which First Officer Line Training was in progress exceeded its cleared level during the climb after a different level to that correctly read back was set on the FMS. As a result, it came into conflict with an Alitalia A321 and this was resolved by responses to coordinated TCAS RAs. STCA alerts did not enable ATC resolution of the conflict and it was concluded that a lack of ATC capability to receive Mode S EHS DAPs - since rectified - was a contributory factor to the outcome.)
  • A319 / B735, vicinity Prague Czech Republic, 2012 (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.)
  • A319 / B738 / B738, en-route, near Lausanne Switzerland, 2013 (On 26 May 2013, an A319 in Swiss Class 'C' airspace received a TCAS 'Level Off' RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts after prescribed minimum separations had been breached to as low as 1.5nm when 675 feet apart vertically.)
  • A319 / PRM1, en-route, near Fribourg Switzerland, 2011 (On 10 June 2011 an ATC error put a German Wings A319 and a Hahn Air Raytheon 390 on conflicting tracks over Switzerland and a co-ordinated TCAS RA followed. The aircraft subsequently passed in very close proximity without either sighting the other after the Hahn Air crew, contrary to Company procedures, followed an ATC descent clearance issued during their TCAS ‘Climb’ RA rather than continuing to fly the RA. The Investigation could find no explanation for this action by the experienced crew - both Hahn Air management pilots. The recorded CPA was 0.6 nm horizontally at 50 feet vertically.)
  • A319/A319, en-route, South west of Basle-Mulhouse France, 2010 (On 29 June 2010, an Easyjet Switzerland Airbus A319 inbound to Basle-Mulhouse and an Air France Airbus A319 outbound from Basle-Mulhouse lost separation after an error made by a trainee APP controller under OJTI supervision during procedural service. The outcome was made worse by the excessive rate of climb of the Air France aircraft approaching its cleared level and both an inappropriate response to an initial preventive TCAS RA and a change of track during the ensuing short sequence of RAs by the Training Captain in command of and flying the Easyjet aircraft attributed by him to his situational ‘anxiety’.)
  • A319/A332, vicinity Barcelona Spain, 2012 (On 8 February 2012, a TCAS RA occurred between an Airbus A330 and an Airbus A319 both under ATC control for landing on runway 25R at Barcelona as a result of an inappropriate plan to change the sequence. The opposite direction aircraft both followed their respective RAs and minimum separation was 1.4 nm horizontally and 400 feet vertically. The Investigation noted that the use of Spanish to communicate with one aircraft and English to communicate with the other had compromised situational awareness of the crew of the latter who had also not had visual contact with the other aircraft.)
  • A319/B733, en-route, near Moutiers France, 2010 (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 only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)
  • A320 / A139 vicinity Zurich Switzerland, 2012 (On 29 May 2012, a British Airways Airbus A320 departing Zürich and in accordance with its SID in a climbing turn received and promptly and correctly actioned a TCAS RA 'CLIMB'. The conflict which caused this was with an AW 139 also departing Zürich IFR in accordance with a SID but, as this aircraft was only equipped with a TAS to TCAS 1 standard, the crew independently determined from their TA that they should descend and did so. The conflict, in Class 'C' airspace, was attributed to inappropriate clearance issue by the TWR controller and their inappropriate separation monitoring thereafter.)
  • A320 / A321, vicinity Barcelona Spain, 2016 (On 25 July 2016, an Airbus A320 and an Airbus A321 both departing Barcelona and following their ATC instructions came into conflict and the collision risk was removed by the TCAS RA CLIMB response of the A320. Minimum separation was 1.2 nm laterally and 200 feet vertically with visual acquisition of the other traffic by both aircraft. The Investigation found that the controller involved had become preoccupied with an inbound traffic de-confliction task elsewhere in their sector and, after overlooking the likely effect of the different rates of climb of the aircraft, had not regarded monitoring their separation as necessary.)

... further results

Released to Own Separation

  • A320 / B738, vicinity Launceston Australia, 2008 (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.)
  • B738/B738, vicinity Queenstown New Zealand, 2010 (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.)
  • B752/GLID, vicinity Glasgow UK, 2011 (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)
  • B763/B738, vicinity Melbourne Australia, 2010 (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.)
  • D150 / H500, London UK, 2007 (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.)
  • D328 / R44, Bern Switzerland, 2012 (On 2 June 2012, a Dornier 328 and a commercially-operated Robinson R44 helicopter came into close proximity within the airport perimeter whilst both were departing from Bern in VMC as cleared. The Investigation attributed the conflict to inappropriate issue of clearances by the controller in a context of an absence of both a defined final approach and take off area and fixed departure routes to the three designated departure points.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (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.)
  • ULAC / A319 vicinity Southend UK, 2013 (On 18 July 2013, an Airbus A319 level at 2000 feet QNH in Class G airspace and being radar vectored towards an ILS approach at Southend in day VMC had a sudden but brief base leg encounter with a paramotor which was not visible on radar and was seen too late for avoiding action to be practicable, before passing within an estimated 50 metres of the A319. The paramotor pilot could not subsequently be traced. The Investigation made a safety recommendation to the UK CAA to "review the regulation and licensing of paramotor pilots".)

Level Bust

  • A310 / B736, en-route, Southern Norway, 2001 (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.)
  • A319 / A321, en-route, west north west of Geneva, Switzerland 2011 (On 6 August 2011 an Easyjet Airbus A319 on which First Officer Line Training was in progress exceeded its cleared level during the climb after a different level to that correctly read back was set on the FMS. As a result, it came into conflict with an Alitalia A321 and this was resolved by responses to coordinated TCAS RAs. STCA alerts did not enable ATC resolution of the conflict and it was concluded that a lack of ATC capability to receive Mode S EHS DAPs - since rectified - was a contributory factor to the outcome.)
  • A319/B733, en-route, near Moutiers France, 2010 (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 only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)
  • A321 / B738, en-route, south eastern Bulgaria, 2016 (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.)
  • B712, en-route, Western Australia, 2006 (On 28 February 2006, a Boeing 717-200 being operated by National Jet for Qantas Link on a domestic scheduled passenger flight from Paraburdoo to Perth, Western Australia in day IMC experienced an activation of the stall protection system just after the aircraft had levelled at a cruise altitude of FL340. The response of the flight crew was to initiate an immediate descent without either declaring an emergency or obtaining ATC clearance and, as a result, procedural separation against opposite direction traffic at FL320 was lost. The 72 occupants were uninjured and the aircraft was undamaged.)
  • B734 / MD81, en-route, Romford UK, 1996 (On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow in day IMC to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level, 1000 feet below. STCA prompted ATC to intervene and the 737 climbed back to its cleared level. Neither aircraft was fitted with TCAS 2 or saw the other visually.)
  • B738 / C172, en route, near Falsterbo Sweden, 2014 (On 20 July 2014, the pilot of a VFR Cessna 172 became distracted and entered the Class 'C' controlled airspace of two successive TMAs without clearance. In the second one he was overtaken by a Boeing 738 inbound to Copenhagen with less than 90 metres separation. The 738 crew reported a late sighting of the 172 and "seemingly" assessed that avoiding action was unnecessary. Although the 172 had a Mode C-capable transponder, it was not transmitting altitude prior to the incident and the Investigation noted that this had invalidated preventive ATC and TCAS safety barriers and compromised flight safety.)
  • B738/A319 en-route, south east of Zurich Switzerland, 2013 (On 12 April 2013, a Ryanair Boeing 737-800 took a climb clearance intended for another Ryanair aircraft on the same frequency. The aircraft for which the clearance was intended did not respond and the controller did not notice that the clearance readback had come from a different aircraft. Once the wrong aircraft began to climb, from FL360 to FL380, a TCAS RA to descend occurred due to traffic just transferred to a different frequency and at FL370. That traffic received a TCAS RA to climb. STCA was activated at the ATS Unit controlling both Ryanair aircraft.)
  • B763, en-route North Bay Canada, 2009 (On 19 June 2009 a Boeing 767-300 was level at FL330 in night IMC when the Captain’s altimeter and air speed indicator readings suddenly increased, the latter by 44 knots. The altimeter increase triggered an overspeed warning and the Captain reduced thrust and commenced a climb. The resultant stall warning was followed by a recovery. The Investigation found that a circuitry fault had caused erroneous indications on only the Captain’s instruments and that contrary to the applicable QRH procedure, no comparison with the First Officer’s or Standby instruments had been made. A related Operator FCOM error was also identified.)
  • B773, vicinity Houston TX USA, 2014 (On 3 July 2014, a Boeing 777-300 departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS 'CLIMB' and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.)
  • BE20/SF34, vicinity Stornoway UK, 2011 (On 31 December 2011 a USAF C12 Beech King Air descended 700 feet below the cleared outbound altitude on a procedural non precision approach to Stornoway in uncontrolled airspace in IMC and also failed to fly the procedure correctly. As a result it came into conflict with a Saab 340 inbound on the same procedure. The Investigation found that the C12 crew had interpreted the QNH given by ATC as 990 hPa as 29.90 inches, the subscale setting units used in the USA. The Saab 340 pilot saw the opposite direction traffic on TCAS and descended early to increase separation.)
  • C525 / B773, vicinity London City UK, 2009 (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 777-300ER. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)

... further results

Lateral Navigation Error

  • A319 / B735, vicinity Prague Czech Republic, 2012 (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.)
  • A320 / B789 / A343, San Francisco CA USA, 2017 (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, en-route, Sydney Australia, 2007 (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.)
  • CRJ2/ATP, Stockholm Sweden, 2011 (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.)
  • D328 / R44, Bern Switzerland, 2012 (On 2 June 2012, a Dornier 328 and a commercially-operated Robinson R44 helicopter came into close proximity within the airport perimeter whilst both were departing from Bern in VMC as cleared. The Investigation attributed the conflict to inappropriate issue of clearances by the controller in a context of an absence of both a defined final approach and take off area and fixed departure routes to the three designated departure points.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (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.)

ATC Error

  • A318 / B738, en-route, Trasadingen Switzerland, 2009 (On 8 June 2009, an Airbus A318-100 being operated by Air France on a scheduled passenger flight from Belgrade, Serbia to Paris CDG in day VMC came into conflict with a Boeing 737-800 being operated by Ryanair on a scheduled passenger flight from Nottingham East Midlands UK to Bergamo Italy. The conflict was resolved mainly by TCAS RA response and there were no injuries to any occupants during the avoidance manoeuvres carried out by both aircraft.)
  • A318/B738, Nantes France, 2010 (On 25 May 2010 an Air France Airbus A318 making an automatic landing off an ILS Cat 2 approach at Nantes experienced interference with the ILS LOC signal caused by a Boeing 737-800 which was departing from the same runway but early disconnection of the AP removed any risk of un-correctable directional control problems during the landing roll. Both aircraft were operating in accordance with their ATC clearances. Investigation attributed the conflict to the decision of TWR not to instruct the A318 to go around and because of diminished situational awareness.)
  • A318/B739, vicinity Amsterdam Netherlands, 2007 (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.)
  • A319 / B738 / B738, en-route, near Lausanne Switzerland, 2013 (On 26 May 2013, an A319 in Swiss Class 'C' airspace received a TCAS 'Level Off' RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts after prescribed minimum separations had been breached to as low as 1.5nm when 675 feet apart vertically.)
  • A319 / PRM1, en-route, near Fribourg Switzerland, 2011 (On 10 June 2011 an ATC error put a German Wings A319 and a Hahn Air Raytheon 390 on conflicting tracks over Switzerland and a co-ordinated TCAS RA followed. The aircraft subsequently passed in very close proximity without either sighting the other after the Hahn Air crew, contrary to Company procedures, followed an ATC descent clearance issued during their TCAS ‘Climb’ RA rather than continuing to fly the RA. The Investigation could find no explanation for this action by the experienced crew - both Hahn Air management pilots. The recorded CPA was 0.6 nm horizontally at 50 feet vertically.)
  • A319/A319, en-route, South west of Basle-Mulhouse France, 2010 (On 29 June 2010, an Easyjet Switzerland Airbus A319 inbound to Basle-Mulhouse and an Air France Airbus A319 outbound from Basle-Mulhouse lost separation after an error made by a trainee APP controller under OJTI supervision during procedural service. The outcome was made worse by the excessive rate of climb of the Air France aircraft approaching its cleared level and both an inappropriate response to an initial preventive TCAS RA and a change of track during the ensuing short sequence of RAs by the Training Captain in command of and flying the Easyjet aircraft attributed by him to his situational ‘anxiety’.)
  • A319/A332, vicinity Barcelona Spain, 2012 (On 8 February 2012, a TCAS RA occurred between an Airbus A330 and an Airbus A319 both under ATC control for landing on runway 25R at Barcelona as a result of an inappropriate plan to change the sequence. The opposite direction aircraft both followed their respective RAs and minimum separation was 1.4 nm horizontally and 400 feet vertically. The Investigation noted that the use of Spanish to communicate with one aircraft and English to communicate with the other had compromised situational awareness of the crew of the latter who had also not had visual contact with the other aircraft.)
  • A320 / A139 vicinity Zurich Switzerland, 2012 (On 29 May 2012, a British Airways Airbus A320 departing Zürich and in accordance with its SID in a climbing turn received and promptly and correctly actioned a TCAS RA 'CLIMB'. The conflict which caused this was with an AW 139 also departing Zürich IFR in accordance with a SID but, as this aircraft was only equipped with a TAS to TCAS 1 standard, the crew independently determined from their TA that they should descend and did so. The conflict, in Class 'C' airspace, was attributed to inappropriate clearance issue by the TWR controller and their inappropriate separation monitoring thereafter.)
  • A320 / A320, Zurich Switzerland, 2011 (On 15 March 2011 two Swiss International Airlines’ Airbus A320 aircraft were cleared for simultaneous take off on intersecting runways at Zurich by the same controller. As both approached the intersection at high speed, the Captain of one saw the other and immediately rejected take off from 130 knots, stopping just at the edge of the intersection shortly after the other aircraft had flown low overhead unaware of the conflict. The Investigation noted a long history of similar incidents at Zurich and concluded that systemic failure of risk management had not been addressed by the air traffic control agency involved.)
  • A320 / A321, vicinity Barcelona Spain, 2016 (On 25 July 2016, an Airbus A320 and an Airbus A321 both departing Barcelona and following their ATC instructions came into conflict and the collision risk was removed by the TCAS RA CLIMB response of the A320. Minimum separation was 1.2 nm laterally and 200 feet vertically with visual acquisition of the other traffic by both aircraft. The Investigation found that the controller involved had become preoccupied with an inbound traffic de-confliction task elsewhere in their sector and, after overlooking the likely effect of the different rates of climb of the aircraft, had not regarded monitoring their separation as necessary.)
  • A320 / A346, en-route, Eastern Indian Ocean, 2012 (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 (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.)

... further results

Near Miss

  • A306 / B744, vicinity London Heathrow UK, 1996 (On 5 April 1996 a significant loss of separation occurred when a B744, taking off from runway 27R at London Heathrow came into conflict to the west of Heathrow Airport with an A306 which had carried out a missed approach from the parallel runway 27L. Both aircraft were following ATC instructions. Both aircraft received and correctly followed TCAS RAs, the B744 to descend and the A306 to adjust vertical speed, which were received at the same time as corrective ATC clearances.)
  • A318 / B738, en-route, Trasadingen Switzerland, 2009 (On 8 June 2009, an Airbus A318-100 being operated by Air France on a scheduled passenger flight from Belgrade, Serbia to Paris CDG in day VMC came into conflict with a Boeing 737-800 being operated by Ryanair on a scheduled passenger flight from Nottingham East Midlands UK to Bergamo Italy. The conflict was resolved mainly by TCAS RA response and there were no injuries to any occupants during the avoidance manoeuvres carried out by both aircraft.)
  • A319 / B738 / B738, en-route, near Lausanne Switzerland, 2013 (On 26 May 2013, an A319 in Swiss Class 'C' airspace received a TCAS 'Level Off' RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts after prescribed minimum separations had been breached to as low as 1.5nm when 675 feet apart vertically.)
  • A319 / PRM1, en-route, near Fribourg Switzerland, 2011 (On 10 June 2011 an ATC error put a German Wings A319 and a Hahn Air Raytheon 390 on conflicting tracks over Switzerland and a co-ordinated TCAS RA followed. The aircraft subsequently passed in very close proximity without either sighting the other after the Hahn Air crew, contrary to Company procedures, followed an ATC descent clearance issued during their TCAS ‘Climb’ RA rather than continuing to fly the RA. The Investigation could find no explanation for this action by the experienced crew - both Hahn Air management pilots. The recorded CPA was 0.6 nm horizontally at 50 feet vertically.)
  • A319/A319, en-route, South west of Basle-Mulhouse France, 2010 (On 29 June 2010, an Easyjet Switzerland Airbus A319 inbound to Basle-Mulhouse and an Air France Airbus A319 outbound from Basle-Mulhouse lost separation after an error made by a trainee APP controller under OJTI supervision during procedural service. The outcome was made worse by the excessive rate of climb of the Air France aircraft approaching its cleared level and both an inappropriate response to an initial preventive TCAS RA and a change of track during the ensuing short sequence of RAs by the Training Captain in command of and flying the Easyjet aircraft attributed by him to his situational ‘anxiety’.)
  • A319/B733, en-route, near Moutiers France, 2010 (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 only a TCAS TA, was given an emergency turn by ATC. The recorded CPA was 2.2 nm and 125 feet.)
  • A320 / A139 vicinity Zurich Switzerland, 2012 (On 29 May 2012, a British Airways Airbus A320 departing Zürich and in accordance with its SID in a climbing turn received and promptly and correctly actioned a TCAS RA 'CLIMB'. The conflict which caused this was with an AW 139 also departing Zürich IFR in accordance with a SID but, as this aircraft was only equipped with a TAS to TCAS 1 standard, the crew independently determined from their TA that they should descend and did so. The conflict, in Class 'C' airspace, was attributed to inappropriate clearance issue by the TWR controller and their inappropriate separation monitoring thereafter.)
  • A320 / A320, Zurich Switzerland, 2011 (On 15 March 2011 two Swiss International Airlines’ Airbus A320 aircraft were cleared for simultaneous take off on intersecting runways at Zurich by the same controller. As both approached the intersection at high speed, the Captain of one saw the other and immediately rejected take off from 130 knots, stopping just at the edge of the intersection shortly after the other aircraft had flown low overhead unaware of the conflict. The Investigation noted a long history of similar incidents at Zurich and concluded that systemic failure of risk management had not been addressed by the air traffic control agency involved.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (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 (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 / B738, vicinity Launceston Australia, 2008 (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.)
  • A320 / B789 / A343, San Francisco CA USA, 2017 (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.)

... further results

Lateral Offset in Use

None on SKYbrary

Mid-Air Collision

  • AS50 / PA32, en-route, Hudson River NJ USA, 2009 (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.)
  • B738 / E135, en-route, Mato Grosso Brazil, 2006 (On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.)
  • C130 / C27J, manoeuvring, near Mackall AAF NC USA, 2014 (On 1 December 2014, a night mid-air collision occurred in uncontrolled airspace between a Lockheed C130H Hercules and an Alenia C27J Spartan conducting VFR training flights and on almost reciprocal tracks at the same indicated altitude after neither crew had detected the proximity risk. Substantial damage was caused but both aircraft were successfully recovered and there were no injuries. The Investigation attributed the collision to a lack of visual scan by both crews, over reliance on TCAS and complacency despite the inherent risk associated with night, low-level, VFR operations using the Night Vision Goggles worn by both crews.)
  • F16 / C150, vicinity Berkeley County SC USA, 2015 (On 7 July 2015, a mid-air collision occurred between an F16 and a Cessna 150 in VMC at 1,600 feet QNH in Class E airspace north of Charleston SC after neither pilot detected the conflict until it was too late to take avoiding action. Both aircraft subsequently crashed and the F16 pilot ejected. The parallel civil and military investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the F16 to provide appropriate timely resolution of the impending conflict.)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (On 11 February 2009, the plots of two civil-registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and both operating from RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers whilst in the same uncontrolled airspace in day VMC and aware of the general presence of each other when they collided. The aircraft were destroyed and all occupants killed)
  • G115 / GLID, en-route Oxfordshire UK, 2009 (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.)
  • H25B / AS29, en-route / manoeuvring, near Smith NV USA, 2006 (On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.)
  • H25B / B738, en-route, south eastern Senegal, 2015 (On 5 September 2015, a Boeing 737-800 cruising as cleared at FL350 on an ATS route in daylight collided with an opposite direction HS 125-700 which had been assigned and acknowledged altitude of FL340. The 737 continued to destination with winglet damage apparently causing no control impediment but radio contact with the HS 125 was lost and it was subsequently radar-tracked maintaining FL350 and continuing westwards past its destination Dakar for almost an hour before making an uncontrolled descent into the sea. The Investigation found that the HS125 had a recent history of un-rectified altimetry problems which prevented TCAS activation.)
  • L35 / EUFI, manoeuvring, Olsberg-Elpe, Germany 2014 (On 23 June 2014, a civil-operated Learjet 35 taking part in a German Air Force interception training exercise collided with the intercepting fighter aircraft as it began a follow-me manoeuvre. It became uncontrollable as a result of the damage sustained in the collision and crashed into terrain, killing both pilots. The Investigation found that whilst preparation for the exercise by all involved had been in compliance with requirements, these requirements had been inadequate, especially in respect of co-ordination between all the pilots involved, with both the civil and military safety regulatory authorities failing to detect and act on this situation.)
  • SH36 / SH36, manoeuvring, Watertown WI USA, 2006 (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.)
  • T154 / B752, en-route, Uberlingen Germany, 2002 (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.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (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.)

Uncommanded AP disconnect

None on SKYbrary

Military Aircraft Involved

  • BE20/SF34, vicinity Stornoway UK, 2011 (On 31 December 2011 a USAF C12 Beech King Air descended 700 feet below the cleared outbound altitude on a procedural non precision approach to Stornoway in uncontrolled airspace in IMC and also failed to fly the procedure correctly. As a result it came into conflict with a Saab 340 inbound on the same procedure. The Investigation found that the C12 crew had interpreted the QNH given by ATC as 990 hPa as 29.90 inches, the subscale setting units used in the USA. The Saab 340 pilot saw the opposite direction traffic on TCAS and descended early to increase separation.)
  • C130 / C27J, manoeuvring, near Mackall AAF NC USA, 2014 (On 1 December 2014, a night mid-air collision occurred in uncontrolled airspace between a Lockheed C130H Hercules and an Alenia C27J Spartan conducting VFR training flights and on almost reciprocal tracks at the same indicated altitude after neither crew had detected the proximity risk. Substantial damage was caused but both aircraft were successfully recovered and there were no injuries. The Investigation attributed the collision to a lack of visual scan by both crews, over reliance on TCAS and complacency despite the inherent risk associated with night, low-level, VFR operations using the Night Vision Goggles worn by both crews.)
  • DH8D / TOR, en-route, North Sea UK, 2008 (On 13 October 2008, a DHC-8 Q400 operating in uncontrolled airspace and in receipt of civil radar advisory service was given an avoiding action turn against military traffic but then received and actioned a TCAS RA whilst inside a notified Danger Area as a result of the avoiding action turn. No close proximity to other traffic resulted.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (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.)
  • F15 / B752, en-route, South East of Birmingham UK, 2000 (On 22 November 2000, near Birmingham UK, a dangerous loss of vertical and lateral separation occurred between a Boeing B757-200 being operated by Britannia Airways on a passenger flight and a formation flight of two F-15Es being operated by the United States Air Force (USAF).)
  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell 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.)
  • F16 / C150, vicinity Berkeley County SC USA, 2015 (On 7 July 2015, a mid-air collision occurred between an F16 and a Cessna 150 in VMC at 1,600 feet QNH in Class E airspace north of Charleston SC after neither pilot detected the conflict until it was too late to take avoiding action. Both aircraft subsequently crashed and the F16 pilot ejected. The parallel civil and military investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the F16 to provide appropriate timely resolution of the impending conflict.)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (On 11 February 2009, the plots of two civil-registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and both operating from RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers whilst in the same uncontrolled airspace in day VMC and aware of the general presence of each other when they collided. The aircraft were destroyed and all occupants killed)
  • G115 / GLID, en-route Oxfordshire UK, 2009 (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.)
  • L35 / EUFI, manoeuvring, Olsberg-Elpe, Germany 2014 (On 23 June 2014, a civil-operated Learjet 35 taking part in a German Air Force interception training exercise collided with the intercepting fighter aircraft as it began a follow-me manoeuvre. It became uncontrollable as a result of the damage sustained in the collision and crashed into terrain, killing both pilots. The Investigation found that whilst preparation for the exercise by all involved had been in compliance with requirements, these requirements had been inadequate, especially in respect of co-ordination between all the pilots involved, with both the civil and military safety regulatory authorities failing to detect and act on this situation.)
  • NIM / AS32, vicinity RAF Kinloss UK, 2006 (On 17 October 2006, at night, in low cloud and poor visibility conditions in the vicinity of Kinloss Airfield UK, a loss of separation event occurred between an RAF Nimrod MR2 aircraft and a civilian AS332L Puma helicopter.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (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.)

Apparent de-selection of transponder

  • B738 / E135, en-route, Mato Grosso Brazil, 2006 (On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.)
  • F15 / E145, en-route, Bedford UK, 2005 (On 27 January 2005, two USAF-operated McDonnell 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.)

Transponder non selection

  • B738 / C172, en route, near Falsterbo Sweden, 2014 (On 20 July 2014, the pilot of a VFR Cessna 172 became distracted and entered the Class 'C' controlled airspace of two successive TMAs without clearance. In the second one he was overtaken by a Boeing 738 inbound to Copenhagen with less than 90 metres separation. The 738 crew reported a late sighting of the 172 and "seemingly" assessed that avoiding action was unnecessary. Although the 172 had a Mode C-capable transponder, it was not transmitting altitude prior to the incident and the Investigation noted that this had invalidated preventive ATC and TCAS safety barriers and compromised flight safety.)
  • B752, vicinity Atlanta GA USA, 2011 (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.)
  • E170 / F900, en-route, east of Varna Bulgaria, 2015 (On 30 June 2015 the crew of an en route Embraer 170 failed to notice that their transponder had reverted to Standby and the ATC response, which involved cross border coordination, was so slow that the aircraft was not informed of the loss of its transponder signal for over 30 minutes by which time it had already passed within 0.9nm of an unseen Dassault Falcon 900 at the same level. The Investigation found that the Embraer crew had failed to follow appropriate procedures and that the subsequent collision risk had been significantly worsened by a muddled and inappropriate ATC response.)
  • H25B / AS29, en-route / manoeuvring, near Smith NV USA, 2006 (On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.)

Go Around Separation

  • A320/B738, vicinity Delhi India, 2013 (On 2 September 2013, a B737 crew were not instructed to go around from their approach by ATC as it became increasingly obvious that an A320 departing the same runway would not be airborne in time for a landing clearance to be issued. They initiated a go around over the threshold and then twice came into conflict with the A320 as both climbed on similar tracks without ATC de-confliction, initially below the height where TCAS RAs are functional. Investigation attributed the conflict to ATC but the failure to effectively deal with the consequences jointly to ATC and both aircraft crews.)
  • B737 / B737, vicinity Geneva Switzerland, 2006 (On 11 May 2006, B737-700 taking off from Geneva came into close proximity with a Boeing Business Jet (BBJ) on a non revenue positioning flight which had commenced a go around from the same runway following an unstabilised approach. The Investigation attributed the conflict to the decision of ATC to give take off clearance to the departing aircraft when the approach of the inbound aircraft could have been seen as highly likely to result is a go around which would lead to proximity with the slower departing aircraft.)
  • B737 / F100, vicinity Geneva Switzerland, 2006 (On 29 December 2006, Geneva ATC saw the potential for runway 23 conflict between a departing 737 and an inbound F100 and instructed them to respectively reject take off and go around respectively. Although still at a relatively slow speed, the 737 continued its take off and subsequently lost separation in night IMC against the F100. The Investigation noted that take off clearance for the 737 had been delayed by a slow post-landing runway clearance by a business jet and that the 737 had not begun take off after clearance to do so until instructed to do so immediately.)
  • B738/B738, vicinity Oslo Norway, 2012 (On 31 October 2012, a Boeing 737-800 on go around after delaying the breaking off of a fast and high unstable ILS approach at Oslo lost separation in IMC against another aircraft of the same type and Operator which had just taken off from the same runway as the landing was intended to be made on. The situation was aggravated by both aircraft responding to a de-confliction turn given to the aircraft on go around. Minimum separation was 0.2nm horizontally when 500 feet apart vertically, both climbing. Standard missed approach and departure tracks were the same.)
  • B773 / B738 / B738, Melbourne Australia, 2015 (On 5 July 2015, as a Boeing 777-300ER was departing Melbourne, two Boeing 737-800s which were initially on short final for intersecting runways with their ground separation dependent on one receiving a LAHSO clearance, went around. When both approaching aircraft did so, there was a loss of safe terrain clearance, safe separation and wake vortex separation between the three aircraft. The Investigation attributed the event to the actions of an inadequately supervised trainee controller and inappropriate intervention by a supervisory controller. It also identified a systemic safety issue generated by permitting LAHSO at night and a further flaw affecting the risk of all LAHSO at Melbourne.)
  • CRJ2 / A320, vicinity Port Elizabeth South Africa, 2014 (On 10 July 2014, Bombardier CRJ-200 instructed to go around at Port Elizabeth by ATC came into close proximity with an A320 which had just taken off from the same runway and initiated avoiding action to increase separation. The Investigation concluded that the TWR controller had failed to effectively monitor the progress of the aircraft on final approach before issuing a take off clearance to the A320.)

UAV Involved

None on SKYbrary

Unregulated Manned Flight Involved

  • ULAC / A319 vicinity Southend UK, 2013 (On 18 July 2013, an Airbus A319 level at 2000 feet QNH in Class G airspace and being radar vectored towards an ILS approach at Southend in day VMC had a sudden but brief base leg encounter with a paramotor which was not visible on radar and was seen too late for avoiding action to be practicable, before passing within an estimated 50 metres of the A319. The paramotor pilot could not subsequently be traced. The Investigation made a safety recommendation to the UK CAA to "review the regulation and licensing of paramotor pilots".)

Procedural Control

  • A332 / A333, en-route, North West Australia, 2012 (On 31 March 2012, after the implementation of contingency ATC procedures for a period of 5 hours due to controller shortage, two Garuda A330 aircraft which had been transiting an associated Temporary Restricted Area (TRA) prior to re-entering controlled airspace were separately involved in losses of separation assurance, one when unexpectedly entering adjacent airspace from the TRA, the other when the TRA ceased and controlled airspace was restored. The Investigation did not find that any actual loss of separation had occurred but identified four Safety Issues in relation to the inadequate handling of the TRA activation by ANSP Airservices Australia.)
  • F50 / T6, vicinity Maastricht Netherlands, 2007 (On 2 August 2007, a Fokker F50 on an ILS approach to Maastricht in IMC came into close proximity inside the CTZ with an unseen light aircraft which had failed to comply with its Special VFR transit clearance. The Investigation found that the transiting aircraft had come within 0.14nm / 260 metres of the opposite direction F50 at a similar altitude without either aircraft having sight of the other, and that the Harvard had been wrongly assumed by ATC to be a helicopter after an initial lack of call sign prefix clarity on first contact had not been positively resolved.)
  • H25B / B738, en-route, south eastern Senegal, 2015 (On 5 September 2015, a Boeing 737-800 cruising as cleared at FL350 on an ATS route in daylight collided with an opposite direction HS 125-700 which had been assigned and acknowledged altitude of FL340. The 737 continued to destination with winglet damage apparently causing no control impediment but radio contact with the HS 125 was lost and it was subsequently radar-tracked maintaining FL350 and continuing westwards past its destination Dakar for almost an hour before making an uncontrolled descent into the sea. The Investigation found that the HS125 had a recent history of un-rectified altimetry problems which prevented TCAS activation.)

ATC control using ADS-B

None on SKYbrary

ATC control supported by ADS-C

None on SKYbrary

Uncontrolled Airspace

  • C130 / C27J, manoeuvring, near Mackall AAF NC USA, 2014 (On 1 December 2014, a night mid-air collision occurred in uncontrolled airspace between a Lockheed C130H Hercules and an Alenia C27J Spartan conducting VFR training flights and on almost reciprocal tracks at the same indicated altitude after neither crew had detected the proximity risk. Substantial damage was caused but both aircraft were successfully recovered and there were no injuries. The Investigation attributed the collision to a lack of visual scan by both crews, over reliance on TCAS and complacency despite the inherent risk associated with night, low-level, VFR operations using the Night Vision Goggles worn by both crews.)
  • C525 / C42, en-route / manoeuvring, near Eastbourne UK, 2017 (On 7 March 2017, an en-route Cessna Citation and a manoeuvring Ikarus C42 light aircraft approaching almost head-on at speeds of 240 knots and 55 knots respectively almost collided at an altitude of 3,500 feet in VMC outside controlled airspace. The Investigation found that only the C42 pilot had seen a conflicting aircraft and that they had then taken avoiding action which had mitigated the high risk of collision. The closest point of approach was recorded on radar as less than 100 feet vertically and less than 185 metres laterally. The near miss was categorised as an ICAO 'A' event.)
  • DH8B / BN2P, Horn Island QLD Australia, 2016 (On 12 October 2016, a BN2 Islander and a Bombardier DHC8-200 were involved in a near miss after the DHC8 took off from a runway which intersected with the runway on which the BN2 was about to land. The BN2 broke off its approach just before touchdown when the DHC8 was observed accelerating towards the runway intersection on its take-off roll. The Investigation noted that the aerodrome involved relied on visual separation and use of a CTAF and found that although both aircraft were aware of each other, the DHC8 crew failed to fully utilise visual lookout.)
  • E55P, Blackbushe UK, 2015 (On 31 July 2015 a Saudi-operated Embraer Phenom on a private flight continued an unstabilised day visual approach to Blackbushe in benign weather conditions. The aircraft touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died. The Investigation concluded that the combination of factors which created a very high workload for the pilot "may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model" leading to his continuation of a highly unstable approach.)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (On 11 February 2009, the plots of two civil-registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and both operating from RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers whilst in the same uncontrolled airspace in day VMC and aware of the general presence of each other when they collided. The aircraft were destroyed and all occupants killed)
  • RJ1H/UNKN, vicinity Malmo Sweden, 2009 (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.)
  • ULAC / A319 vicinity Southend UK, 2013 (On 18 July 2013, an Airbus A319 level at 2000 feet QNH in Class G airspace and being radar vectored towards an ILS approach at Southend in day VMC had a sudden but brief base leg encounter with a paramotor which was not visible on radar and was seen too late for avoiding action to be practicable, before passing within an estimated 50 metres of the A319. The paramotor pilot could not subsequently be traced. The Investigation made a safety recommendation to the UK CAA to "review the regulation and licensing of paramotor pilots".)

TCAS RA Reversal

  • A319/A319, en-route, South west of Basle-Mulhouse France, 2010 (On 29 June 2010, an Easyjet Switzerland Airbus A319 inbound to Basle-Mulhouse and an Air France Airbus A319 outbound from Basle-Mulhouse lost separation after an error made by a trainee APP controller under OJTI supervision during procedural service. The outcome was made worse by the excessive rate of climb of the Air France aircraft approaching its cleared level and both an inappropriate response to an initial preventive TCAS RA and a change of track during the ensuing short sequence of RAs by the Training Captain in command of and flying the Easyjet aircraft attributed by him to his situational ‘anxiety’.)
  • A320 / B738, en-route, near Córdoba Spain, 2014 (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 Delhi India, 2013 (On 2 September 2013, a B737 crew were not instructed to go around from their approach by ATC as it became increasingly obvious that an A320 departing the same runway would not be airborne in time for a landing clearance to be issued. They initiated a go around over the threshold and then twice came into conflict with the A320 as both climbed on similar tracks without ATC de-confliction, initially below the height where TCAS RAs are functional. Investigation attributed the conflict to ATC but the failure to effectively deal with the consequences jointly to ATC and both aircraft crews.)
  • E55P, Blackbushe UK, 2015 (On 31 July 2015 a Saudi-operated Embraer Phenom on a private flight continued an unstabilised day visual approach to Blackbushe in benign weather conditions. The aircraft touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died. The Investigation concluded that the combination of factors which created a very high workload for the pilot "may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model" leading to his continuation of a highly unstable approach.)
  • RJ1H/UNKN, vicinity Malmo Sweden, 2009 (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.)


VFR Aircraft Involved

  • A320 / B789 / A343, San Francisco CA USA, 2017 (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 / GLID, vicinity Memmingen Germany, 2015 (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.)
  • A343 / GLID, en-route, north of Waldshut-Tiengen southwest Germany, 2012 (On 11 August 2012, the augmenting crew member in the flight deck of an Airbus A340 about to join final approach to Zurich in Class 'C' airspace as cleared suddenly saw a glider on a collision course with the aircraft. The operating crew were alerted and immediately executed a "pronounced avoiding manoeuvre" and the two aircraft passed at approximately the same level with approximately 260 metres separation. The Investigation attributed the conflict to airspace incursion by the glider and issue of a clearance to below MRVA to the A340 and noted the absence of relevant safety nets.)
  • B737/C212 en-route/manoeuvring, near Richmond NSW Australia, 2011 (On 5 November 2011, ATC cleared a Virgin Australia Boeing 737-700 to climb without speed restriction through an active parachute Drop Zone contrary to prevailing ATC procedures. As a result, prescribed separation from the drop zone was not maintained, but an avoiding action turn initiated by the 737 crew in VMC upon recognising the conflict eliminated any actual risk of collision with either the drop aircraft or its already-departed free-fall parachutists. The incident was attributed to a combination of inadequate controller training and inadequate ATC operational procedures.)
  • B738 / AS25, en-route, near Frankfurt Hahn Germany, 2013 (On 25 April 2013, the experienced pilot of an en-route motor glider which was not under power at the time and therefore not transponding observed a potentially conflicting aircraft in Class 'E' airspace near Frankfurt Hahn and commenced avoiding action. Although the glider was within their field of view, neither of the pilots of the other aircraft, a Boeing 737 in a descent, was aware of the proximity of the glider until it passed them on an almost parallel opposite-direction track 161 feet below them at a range of 350 metres as their aircraft was passing approximately 6,500 feet QNH.)
  • B738 / C172, en route, near Falsterbo Sweden, 2014 (On 20 July 2014, the pilot of a VFR Cessna 172 became distracted and entered the Class 'C' controlled airspace of two successive TMAs without clearance. In the second one he was overtaken by a Boeing 738 inbound to Copenhagen with less than 90 metres separation. The 738 crew reported a late sighting of the 172 and "seemingly" assessed that avoiding action was unnecessary. Although the 172 had a Mode C-capable transponder, it was not transmitting altitude prior to the incident and the Investigation noted that this had invalidated preventive ATC and TCAS safety barriers and compromised flight safety.)
  • C130 / C27J, manoeuvring, near Mackall AAF NC USA, 2014 (On 1 December 2014, a night mid-air collision occurred in uncontrolled airspace between a Lockheed C130H Hercules and an Alenia C27J Spartan conducting VFR training flights and on almost reciprocal tracks at the same indicated altitude after neither crew had detected the proximity risk. Substantial damage was caused but both aircraft were successfully recovered and there were no injuries. The Investigation attributed the collision to a lack of visual scan by both crews, over reliance on TCAS and complacency despite the inherent risk associated with night, low-level, VFR operations using the Night Vision Goggles worn by both crews.)
  • C525 / C42, en-route / manoeuvring, near Eastbourne UK, 2017 (On 7 March 2017, an en-route Cessna Citation and a manoeuvring Ikarus C42 light aircraft approaching almost head-on at speeds of 240 knots and 55 knots respectively almost collided at an altitude of 3,500 feet in VMC outside controlled airspace. The Investigation found that only the C42 pilot had seen a conflicting aircraft and that they had then taken avoiding action which had mitigated the high risk of collision. The closest point of approach was recorded on radar as less than 100 feet vertically and less than 185 metres laterally. The near miss was categorised as an ICAO 'A' event.)
  • C525 / P180, south west of Sion Switzerland, 2012 (On 22 March 2013, a Cessna 525 inbound to Sion on a VFR clearance was flown into conflict with an IFR Piaggio P180 departing the same airport in compliance with its clearance and the prescribed separation between the two aircraft was lost in the vicinity of FL140. The Investigation concluded that an inappropriate ATC tactic had been employed in an attempt to achieve separation and recommended the development of a new procedure to better facilitate separation between IFR and VFR traffic in the airspace where the conflict occurred.)
  • D328 / R44, Bern Switzerland, 2012 (On 2 June 2012, a Dornier 328 and a commercially-operated Robinson R44 helicopter came into close proximity within the airport perimeter whilst both were departing from Bern in VMC as cleared. The Investigation attributed the conflict to inappropriate issue of clearances by the controller in a context of an absence of both a defined final approach and take off area and fixed departure routes to the three designated departure points.)
  • DH8D / DH8D, vicinity Sudbury ON Canada, 2016 (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.)
  • F16 / C150, vicinity Berkeley County SC USA, 2015 (On 7 July 2015, a mid-air collision occurred between an F16 and a Cessna 150 in VMC at 1,600 feet QNH in Class E airspace north of Charleston SC after neither pilot detected the conflict until it was too late to take avoiding action. Both aircraft subsequently crashed and the F16 pilot ejected. The parallel civil and military investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the F16 to provide appropriate timely resolution of the impending conflict.)

... further results

Related Articles

Further Reading

Bureau d’Enquêtes et d’Analyses (BEA)