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  • A319 / A321, en-route, west north west of Geneva, Switzerland 2011 (Synopsis: 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.)
  • C525 / B773, vicinity London City UK, 2009 (Synopsis: 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.)
  • DH8D / B772, vicinity Sydney Australia, 2016 (Synopsis: On 9 December 2016, a Bombardier DHC8-400 departing Sydney lost prescribed separation against an inbound Boeing 777-200 after its crew failed to ensure that the aircraft levelled as cleared at 5,000 feet and this was exceeded by 600 feet. The Investigation found that the First Officer, as Pilot Flying, had disconnected the autopilot prior to routinely changing the selected airspeed because it tended to disconnect when this was done with altitude capture mode active but had then failed to re-engage it. The Captain's lack of effective monitoring was attributed to distraction as he sought to visually acquire the conflicting traffic.)
  • B773, en route, northern Turkey, 2014 (Synopsis: On 8 August 2014, the First Officer of a Boeing 777 in the cruise at night at FL340 inadvertently input a change of desired track into the MCP selected altitude window whilst acting as both PF and PM during controlled rest by the aircraft commander. The aircraft then descended for nearly 2 minutes without her awareness until ATC queried the descent and it was arrested at FL317.)
  • A321 / B738, en-route, south eastern Bulgaria, 2016 (Synopsis: On 8 September 2016, an Airbus A321 en route in Bulgarian airspace at FL 350 was given and acknowledged a descent but then climbed and came within 1.2nm of a descending Boeing 737. The Investigation found that the inexperienced A321 First Officer had been temporarily alone when the instruction was given and had insufficient understanding of how to control the aircraft. It was also found that despite an STCA activation of the collision risk, the controller, influenced by a Mode ā€˜Sā€™ downlink of the correctly-set A321 cleared altitude, had then added to the risk by instructing the 737 to descend.)
  • B738, en-route, south south west of Brisbane Australia, 2013 (Synopsis: On 25 February 2013, a Boeing 737-800 about to commence descent from FL390 began to climb. By the time the crew recognised the cause and began to correct the deviation - their unintended selection of a inappropriate mode - the cleared level had been exceeded by 900 feet. During the recovery, a deviation from track occurred because the crew believed the autopilot had been re-engaged when it had not. The Investigation noted the failure to detect either error until flight path deviation occurred and attributed this to non-compliance with various operator procedures related to checking and confirmation of crew actions.)