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  • 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.)
  • 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.)
  • B744, en-route, southeast of Hong Kong SAR China, 2017 (Synopsis: On 7 April 2017, a Boeing 747-400 crew did not adjust planned speed at an anticipated holding point when the level given was higher than expected. As a consequence of this and distraction, as the new holding level was approached and the turn began, stall buffet, several stick shaker activations and pilot-induced oscillations occurred when the crew failed to follow the applicable stall warning recovery procedure. Descent below the cleared level occurred and the upset caused injuries in the passenger cabin. Whilst attributing the event to poor crew performance, the Investigation also concluded that related operator pilot training was inadequate.)
  • GLF5 / A319, south-eastern France, 2004 (Synopsis: 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.)
  • 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 ‘S’ downlink of the correctly-set A321 cleared altitude, had then added to the risk by instructing the 737 to descend.)
  • A319/B733, en-route, near Moutiers France, 2010 (Synopsis: 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.)