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Loss of Separation - Pilot-induced Situations

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

Description

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.

Contributory Factors

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.

Defences

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:

  • 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.)
  • 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 feet QNH SID Stop altitude and at 4000 feet QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. The 777, on which line training was being conducted, failed to follow any of the three TCAS RAs generated. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 feet and 200 feet vertically. It was noted that the Cessna had been given a stepped climb SID.)

... further results

Examples where the pilot failed to comply with an ATC clearance:

  • 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.)
  • A319 / WT9, vicinity Stuttgart Germany, 2017 (On 26 June 2017, an Airbus A319 which had just taken off from Stuttgart came into conflict in Class ‘D’ airspace with a VFR light aircraft crossing its track and when, at 1,200 feet agl, the TCAS RA to descend which resulted was followed, an EGPWS Mode 3 Alert was generated. Clear of Conflict was annunciated after 10 seconds and climb resumed. The Investigation concluded that the light aircraft pilot had failed to follow the clearance which had been accepted and had caused the flight path conflict which was resolved by the response of the A319 to the TCAS RA.)

... further results

Examples involving a level bust:

  • 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 feet QNH SID Stop altitude and at 4000 feet QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. The 777, on which line training was being conducted, failed to follow any of the three TCAS RAs generated. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 feet and 200 feet vertically. It was noted that the Cessna had been given a stepped climb SID.)
  • 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.)

... further results

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.)
  • 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.)

... further results


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