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(Loss of Separation En Route)
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==Definition==
 
==Definition==
  
Reports relating to accidents which involved [[Loss of Separation]].
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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. '''''
  
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==TCAS RA Mis-flown==
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{{#ask:[[LOS::TCAS RA Mis Flown]]
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==Loss of Separation on Take-off or Go Around==
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==Accepted ATC Clearance Not Followed==
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{{#ask:[[LOS::Accepted ATC Clearance not followed]]
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*[[A306 / B744, vicinity London Heathrow UK, 1996 (LOS HF)]]: 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.
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=="See and Avoid" Ineffective==
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{{#ask:[[LOS::See and Avoid Ineffective]]
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*[[A332 / RJ1H, vicinity Zurich Switzerland, 2004 (LOS HF)]]: 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.
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==Required Separation not Maintained==
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{{#ask:[[LOS::Required Separation not maintained]]
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*[[B744 / A306, vicinity London Heathrow UK, 1996 (LOS)]]: On 5 April 1996 loss of separation occurred when a [[B744|747-400]], taking off from runway 27R at London Heathrow, conflicted with an [[A306]] carrying out a missed approach from the parallel runway.
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==Released to Own Separation==
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{{#ask:[[LOS::Released to Own Separation]]
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*[[B744 / A321, London Heathrow UK, 2000 (LOS HF)]]: On 28 April 2000, a British Airways [[B744|747-400]] 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.
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==Level Bust==
  
*[[B737 / B737, vicinity Geneva Switzerland, 2006 (LOS HF)]]: 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.
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{{#ask:[[LOS::Level Bust]]
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==Loss of Separation En Route==
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==Lateral Navigation Error==
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{{#ask:[[LOS::Lateral Navigation Error]]
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*[[A343 / B744, en-route, south of Newfoundland Canada, 1998 (LOS HF)]]: 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.
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==ATC Error==
  
*[[B734 / MD81, en-route, Romford UK, 1996 (LB LOS HF)]]: 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.
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{{#ask:[[LOS::ATC Error]]
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*[[E135 / B738, en-route, Amazon Brazil, 2006 (HF AGC LOS)]]: On 29 September 2006, a B737-800, operated by the Brazilian airline Gol, collided head-on with a US owned and operated EMB135 Legacy at FL370 over the Amazon, Brazil. The aircraft were flying at the same altitude in opposite directions along the same airway. '''Mid-Air Collision'''
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==Near Miss==
  
*[[T154 / B752, en-route, Uberlingen Germany, 2002 (LOS HF)]]: 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 coordinated TCAS RA guidance. '''Mid-Air Collision'''
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{{#ask:[[LOS::Near Miss]]
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*[[TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (LOS HF)]]: 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'''
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==Lateral Offset in Use==
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{{#ask:[[LOS::Lateral Offset in use]]
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*[[H500 / D150, en-route, London UK, 2007 (LOS HF)]]: On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet. 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.
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==Mid-Air Collision==
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{{#ask:[[LOS::MidAir Collision]]
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*[[SH36 / SH36, en-route, Watertown WI USA, 2006 (LOS LOC RE HF)]]: On 5 February 2006, two Shorts SD-360-300 aircraft collided in mid air while in formation near Watertown, WI, USA; both aircraft suffered damage. One aircraft experienced loss of control and impacted terrain while the other made an emergency landing, overunning the runway, at a nearby airport. '''Mid-Air Collision'''
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==Uncommanded AP disconnect==
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{{#ask:[[LOS::Uncommanded AP disconnect]]
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==Loss of Separation Following Level Bust==
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==Military Aircraft Involved==
 
 
*[[A310 / B736, en-route, Southern Norway, 2001 (LB LOS HF)]]: On 21 February 2001, a level bust by a PIA [[A310]] inbound to Oslo led to loss of separation with an SAS [[B736]] after only one of the appaently co-ordinated TCAS RAs was followed.
 
 
 
*[[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'''
 
 
 
*[[GLF5 / A319, south-eastern France, 2004 (LB LOS HF)]]: On 16 September 2004, a loss of separation occurred near La Tour-du-Pin (South-eastern France) 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.
 
 
 
== Loss of Separation on the Approach ==
 
 
 
*Bureau d’Enquêtes et d’Analyses (BEA) [http://www.skybrary.aero/bookshelf/books/817.pdf Incidents in Air Transport No 10 - Aerodrome Traffic]
 
 
 
 
 
== TCAS-related Incidents ==
 
 
 
*Bureau d’Enquêtes et d’Analyses (BEA) [http://www.skybrary.aero/bookshelf/books/815.pdf Incidents in Air Transport No 3 - TCAS-related]
 
  
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==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.
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==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 (BEA)]
 +
*Bureau d’Enquêtes et d’Analyses (BEA) [http://www.skybrary.aero/bookshelf/books/815.pdf Incidents in Air Transport No 3 - TCAS-related (BEA)]
  
 
*[http://www.skybrary.aero/bookshelf/books/771.pdf BEA: “Mid-Air Collisions 1989-1999”]
 
*[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]]

Revision as of 16:10, 16 November 2010

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

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

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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".)

... further results

Accepted ATC Clearance Not Followed

  • 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.)
  • 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.)
  • 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.)
  • GLEX/F2TH, vicinity Ibiza Spain, 2012 (On 21 September 2012, two aircraft came into conflict in Class 'A' airspace whilst under radar control at night and loss of separation was resolved by TCAS RA responses by both aircraft. Investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English. A Safety Recommendation on resolving the "persistent problem" of such language issues was made, noting that a similar recommendation had been made 11 years earlier.)
  • 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.)

... further results

"See and Avoid" Ineffective

  • 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.)
  • 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.)
  • 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.)
  • 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.)

... further results

Required Separation not Maintained

  • 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.)
  • SF34/SF34, vicinity Stornoway UK, 2011 (On 15 October 2011, a Loganair Saab 340 in uncontrolled airspace and inbound and level at 2000 feet QNH on a procedural non precision approach in day IMC to runway 18 at Stornoway received a TCAS RA ‘DESCEND’ when a second Loganair Saab 340 outbound on the same procedure descended prematurely to the same altitude contrary to ATC clearance. The subsequent investigation concluded that the failure of the controller to re-iterate the requirement to remain at 3000 feet outbound until advised had contributed the crew error. Minimum separation after the TCAS RA was less than 0.1nm horizontally when 500 feet vertically.)
  • 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.)
  • 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.)
  • A320/E190/B712, vicinity Helsinki Finland, 2013 (On 6 February 2013, ATC mismanagement of an Airbus A320 instructed to go around resulted in loss of separation in IMC against the Embraer 190 ahead which was obliged to initiate a go around when no landing clearance had been issued due to a Boeing 737-800 still on the runway after landing. Further ATC mismanagement then resulted in a second IMC loss of separation between the Embraer 190 and a Boeing 717 which had just take off from the parallel runway. Controller response to the STCA Alerts generated was found to be inadequate and ANSP procedures in need of improvement.)

... 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.)
  • 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.)
  • 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".)
  • 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)

... further results

Level Bust

  • 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.)
  • 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.)
  • 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.)
  • 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.)

... further results

Lateral Navigation Error

  • 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.)
  • 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.)
  • 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.)

... further results

ATC Error

  • AT72 / JS32, en-route, north east of Jonkoping Sweden, 2012 (On 20 June 2012, an ATR72-200 level at FL140 and a climbing opposite direction Jetstream 32 received and correctly responded to co-ordinated TCAS RAs after ATC error. The controller had not noticed visual MTCD and STCA alerts and had attempted to continue active controlling after a TCAS RA declaration. The Investigation observed that the ineffectiveness of visual conflict alerts had previously featured in a similar event at the same ACC and that the ANSP had advised then that its addition was planned. TCAS RA response controller training was considered to be in need of improvement to make it more effective.)
  • 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’.)
  • DH8D/DH8D, vicinity Toronto City Airport Canada, 2010 (On 11 May 2010, a Bombardier DHC8-400 aircraft being operated by Porter AL on a scheduled passenger flight Toronto City to Ottawa and another aircraft of the same type and operator on a scheduled passenger flight from Montreal to Toronto City came into close proximity south east of the airport and received and actioned co-ordinated TCAS RAs. Minimum separation was 300 feet vertically at the same altitude. There were no abrupt manoeuvres and none of the occupants were injured.)
  • 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.)
  • 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.)

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Near Miss

  • 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.)
  • GLEX/F2TH, vicinity Ibiza Spain, 2012 (On 21 September 2012, two aircraft came into conflict in Class 'A' airspace whilst under radar control at night and loss of separation was resolved by TCAS RA responses by both aircraft. Investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English. A Safety Recommendation on resolving the "persistent problem" of such language issues was made, noting that a similar recommendation had been made 11 years earlier.)
  • DC95 / C206, Toronto Canada, 2002 (On 25 August 2002, a Douglas DC9-51 being operated by North West Airlines on a scheduled passenger flight from Toronto to Minneapolis had just taken off in day VMC when a Cessna 206 being operated on a passenger charter flight from Georgian Bay to Toronto unexpectedly carried out a missed approach from another runway. And despite last minute visual avoiding action came within close airborne proximity whilst still within the airport perimeter. There were no injuries to any of the 109 occupants of the DC9 or the 4 occupants of the Cessna.)
  • 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.)
  • 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.)

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Lateral Offset in Use

None on SKYbrary

Mid-Air Collision

None on SKYbrary

Uncommanded AP disconnect

None on SKYbrary

Military Aircraft Involved

  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)

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