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Loss of Separation - Pilot-induced Situations
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|Category:||Loss of Separation|
Loss of separation between aircraft sometimes occurs as a result of an aircraft deviating from the cleared track or level without clearance. This may happen for a variety of reasons, captured in the following scenarios:
- Due to pilot inattention, equipment malfunction or the mis-setting of aircraft equipment. An example of this is flying with the transponder switched off or in standby mode.
- Action to avoid a visually-perceived loss of separation from another aircraft.
- Action to avoid severe weather if IFR or to remain in VMC if VFR.
- Pilot failure to follow ATC clearance or delaying their actioning of an accepted clearance.
- Instruction not received or not understood by pilot due to ineffective air-ground communications.
- Pilot taking a clearance intended for another aircraft due to callsign confusion.
- Pilot receiving a TCAS RA but fails to follow it correctly.
- Pilot entering notified airspace without clearance.
The following factors, on their own, are unlikely to cause a loss of separation. They can, however, contribute to the reduction of a pilot's situational awareness which in turn may lead to action (or inaction) that would cause separation breach.
- Weather (e.g. thunderstorm activity). A pilot may start a weather avoiding action without informing the controller. The latter may not anticipate this and consequently their plan may become inadequate. It should be noted, however, that controller training generally emphasises on this possibility.
- Aircraft performance (e.g. a high or low rate of climb or descent may lead to a level bust that, in turn, may result in a loss of separation).
- Interruption or Distraction.
- Pilot workload.
A number of activities are performed so that the risk of loss of separation due to pilot actions is reduced or the consequences of such loss are mitigated so that collision is avoided. The most notable of them are:
- Standard Operating Procedures, on the flight-deck, which detail procedures to be followed to reduce the chance of loss of separation.
- Onboard aircraft equipment designed to warn of potential collision with other aircraft (TCAS).
- Pilot training, especially in:
- Development and improvement of safety nets, e.g. STCA.
- Air traffic controller training emphasizing the importance of:
- Air-ground communication. Appropriate communication reduces the risk of misunderstanding and, consequently, unexpected traffic behaviour.
- Monitoring pilot compliance with the issued clearances. This allows early detection of aircraft deviation which may help prevent a loss of separation.
- Appropriate planning, especially in emergency/abnormal situations and weather avoidance scenarios.
Accidents and Incidents
This section contains examples of occurrences where pilot actions or inactions lead to loss of separation. Note that some events may fall into more than one category. Also, there are situations where both pilot and controller actions contributed to the outcome.
Examples where a TCAS RA was not properly complied with:
- 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.)
- A320 / E195, vicinity Brussels Belgium, 2018 (On 23 February 2018, an Embraer 195LR and an Airbus A320 on SIDs departing Brussels lost separation after the 195 was given a radar heading to resolve a perceived third aircraft conflict which led to loss of separation between the two departing aircraft. STCA and coordinated TCAS RA activations followed but only one TCAS RA was followed and the estimated minimum separation was 400 feet vertically when 1.36 nm apart. The Investigation found that conflict followed an error by an OJTI-supervised trainee controller receiving extended revalidation training despite gaining his licence and having almost 10 years similar experience in Latvia.)
Examples where the pilot failed to comply with an ATC clearance:
- A320 / B738, vicinity Delhi India, 2016 (On 30 January 2016, an Airbus A320 crew cleared for an ILS approach to runway 11 at Delhi reported established on the runway 11 LLZ but were actually on the runway 09 LLZ in error and continued on that ILS finally crossing in front of a Boeing 737-800 on the ILS for runway 10. The Investigation found that the A320 crew had not noticed they had the wrong ILS frequency set and that conflict with the 737 occurred because Approach transferred the A320 to TWR whilst a conflict alert was active and without confirming it was complying with its clearance.)
- 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.)
Examples involving a level bust:
- 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.)
- 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.)
Examples related to transponder operation:
- 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 / 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.)
- F2TH / GLID, vicinity St Gallen-Altenrhein Switzerland, 2017 (On 15 October 2017, a Falcon 2000EX on base leg for an easterly ILS approach at St Gallen-Altenrhein came into close proximity with a reciprocal track glider at 5000 feet QNH in Class ‘E’ airspace in day VMC with neither aircraft seeing the other until just before their minimum separation - 0.35 nm horizontally and 131 feet vertically - occurred. The Investigation attributed the conflict to the lack of relevant traffic separation requirements in Class E airspace and to the glider not having its transponder switched on and not listening out with the relevant ATC Unit.)
- 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.)
- Loss of Separation
- Loss of Separation - ATCO-induced Situations
- Accident and Serious Incident Reports: LOS contains examples of pilot-induced loss of separation.
- Visual Scanning Technique
- Loss of Separation During Weather Avoidance
- Safety Management System Manual v10.1, by the British Gliding Association (BGA), 26 February 2016