Total Risk A Risk B Risk C Risk D Risk E Airspace (Class) Cranwell ATZ (G) London FIR (G) London FIR (G) London FIR (G) London FIR (G)

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1 Assessment Summary Sheet for UKAB Meeting on 10 th December 2014 Total Risk A Risk B Risk C Risk D Risk E Airprox Reporting (Type) Reported (Type) Airspace (Class) Cause ICAO Risk ERC Score Grob Tutor (HQ air Trg) King Air BE20 (HQ Air Trg) Cranwell ATZ (G) The King Air pilot turned into conflict with the Tutor. C AW159 Wildcat (RN) PA28 (Civ Pte) London FIR (G) A late sighting by the Wildcat pilot and effectively a nonsighting by the PA28 pilot. Contributory: The Wildcat pilot declined a handover to Bournemouth despite being out of Yeovilton surveillance coverage. B Fournier RF5 (Civ Pte) PA28 (Civ Pte) London FIR (G) A late sighting by the RF5 pilot and effectively a non-sighting by the PA28 pilot. Recommend: GASCO consider ways of improving pilot's understanding of RMZs. A C560 (Civ Comm) Quantum Microlight (Civ Club) London FIR (G) A conflict in flight paths resolved by the Citation pilot. E PA28 (Civ Club) PA28 (Civ Pte) London FIR (G) A late sighting by both pilots. Recommend: That the CAA reviews progress on delivery of the Skyway Code. B Tutor (HQ Air Trg) S76 (Civ Comm) London FIR (G) The S76 pilot flew into conflict with the Tutor. Contributory: Lack of Traffic Information to the Tutor pilot from the Lakenheath Radar controller. C ATR42 (CAT) PAC 750XL (Civ Club) Oxford AIAA (G) A conflict in Class G. Contributory: The Oxford controller expected the 750XL pilot to remain within the Hinton Designated Area. C Robin R2160i (Civ Trg) DA40 (Civ Trg) London FIR (G) Effectively a non-sighting by both pilots. A Robin DR221 (Civ Pte) PA28 (Civ Pte) London FIR (G) The PA28 pilot re-entered the Wycombe ATZ without informing ATC and flew into conflict with the Robin. B C550 (Civ Comm) Untraced Gliders London FIR (G) A conflict in Class G resolved by the C550 pilot. C ATR42 (CAT) Glider (Unknown) London FIR (G) A conflict in Class G resolved by the ATR42 pilot. C 102

2 Airprox Reporting (Type) Reported (Type) Airspace (Class) Cause ICAO Risk ERC Score R44 (Civ Pte) PA28 (Civ Pte) London FIR (G) Effectively a non-sighting by the R44 pilot and probably a non-sighting by the PA28 pilot. A Tutor (HQ Air Trg) Untraced Microlight London FIR (G) A late sighting by the Tutor pilot. D N/S

3 AIRPROX REPORT No Date/Time: 31 Jul Z Position: 5301N 00032W (Cranwell Visual Circuit) Airspace: Cranwell ATZ (Class: G) Aircraft 1 Aircraft 2 Type: Grob Tutor King Air BE20 Operator: HQ Air (Trg) HQ Air (Trg) Alt/FL: 1000ft 1000ft QFE (1004hPa) QFE (1009hPa) Conditions: VMC VMC Visibility: 10km >10km Reported Separation: 50ft V/50m H Recorded Separation: 0ft V/0.3nm H 150ft V/50m H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE TUTOR PILOT reports performing a SID 1 1 departure RW26, VFR, with white HISLs and navigation lights illuminated, transponder Modes 3/A, C and S selected and a TAS 2 operating. The student was flying under an IF visor, and changing from the Tower to the Director frequency, when the instructor became aware of a King Air displayed on the TAS joining through initial on the deadside of RW26, around 200ft above them. The Tutor was departing traffic, consequently the instructor expected the King Air crew to avoid the Tutor as it was climbed through the King Air s height. The Tutor instructor saw the King Air turn crosswind immediately ahead of, and around 50ft above his aircraft, so he took control from the student, levelled-off at 950ft and immediately turned to the right to maintain separation. He assessed the risk of collision as Low. THE KING AIR PILOT reports returning to the Cranwell visual circuit, in radio contact with Tower, with strobes and navigation lights illuminated, squawking transponder Modes 3/A, C and S, and with TCAS 3 operating. He was aware of a pair Tutors ahead, and another Tutor about to take-off; in order to allow sufficient separation from the pair of Tutors he positioned the King Air wide on the dead-side and extended upwind. Once he was comfortable that adequate separation from the formation existed, he dipped a wing to look for the departing Tutor prior to initiating the upwind turn onto the downwind leg. The King Air crew received a Traffic Alert from the TCAS and saw the departing Tutor below their aircraft, in their 8 o clock position, and converging with them; they immediate initiated a climb to 1500ft and, once they were clear of it, descended back to circuit height on the downwind leg whilst informing the Tower controller of their actions. He assessed the risk of collision as High. 1 Standard Instrument Departure 2 Traffic Alerting System 3 Traffic and Collision Alerting System 1

4 Airprox THE TOWER CONTROLLER reports that the formation of two Tutors had called to join the visual circuit before the King Air called, on the same frequency, to join the visual circuit on recovery from RAF Waddington. The pilot and instructor in the single Tutor reported ready for departure and was given clearance to take off from RW26. When the formation leader reported at Initial, the Tower controller passed Traffic Information on the departing Tutor; shortly afterwards, the King Air s pilot reported at Initial and was given Traffic Information on the formation ahead on the dead-side, and the Tutor on the runway for departure. The controller recalled seeing the King Air positioning wide on the dead-side to deconflict with the formation, but he lost sight of the departing Tutor, as it travelled upwind, due to the aircraft colour against the clouds. The controller looked at the Hi-Brite 4 and saw that the Tutor was around 1nm up-wind. The controller saw the wing of the King Air dip prior to turning cross-wind, and he asked the pilot if he could see the Tutor; the King Air pilot replied that he could not, so the controller passed further Traffic Information using the data from the Hi-Brite. The King Air then appeared to execute a steep climb to avoid the Tutor. Once the King Air was reestablished downwind, the aircraft descended to normal circuit height and the pilot stated that he had not been in visual contact with the Tutor. Although no Airprox was reported on frequency, the controller decided to note the occurence and the information was passed to the Supervisor. He perceived the severity of the incident as Medium. THE CRANWELL SUPERVISOR reports being in the Approach Control Room at the time of the occurrence, and so did not witness it; the Unit s and the controller s workloads were assessed as medium to low. Factual Background The weather at Cranwell at 1150 was recorded as: METAR EGYD Z 26011KT 9999 FEW036 OVC250 22/12 Q1012 BLU NOSIG An excerpt from the RT transcript is reproduced below: From To Time King Air TWR 11:43:48 Cranwell Tower, [King Air C/S] request join tower to tower from Waddington TWR King Air 11:43:44 [King Air C/S] Cranwell Tower Join runway 26 QFE 1005 circuit clear King Air TWR 11:43:50 26, 1005, [King Air C/S] Formation Formation 11:44:33 [Formation C/S], Two Formation TWR 11:44:34 Tower, [Formation C/S] join with C TWR Formation 11:44:38 [Formation C/S] Cranwell Tower, join C correct one King Air joining from the north Formation TWR 11:44:43 [Formation C/S] Tutor TWR 11:45:23 Cranwell Tower, [Tutor C/S] ready for departure TWR Tutor 11:45:26 [Tutor C/S], Cranwell Tower cleared for take off surface wind knots Tutor TWR 11:45:32 Cleared for take off [Tutor C/S] Formation TWR 11:45:53 [Formation C/S] Initials TWR Formation 11:45:56 [Formation C/S], one on for departure, wind Formation TWR 11:46:00 [Formation C/S] King Air TWR 11:46:07 and [King Air C/S] is initials sitting wide downwind for the formation, er wide deadside for the formation TWR King Air 11:46:12 [King Air C/S] roger, and there's one on for departure wind Formation TWR 11:46:21 [Formation C/S], for formations circuit we'll extend behind the King Air TWR Formation 11:46:26 [Formation C/S] TWR All Stns / Formation 11:47:10 Cranwell all stations, new QFE 1004, [Formation C/S] Formation TWR 11:47:15 [Formation C/S] 1004 set TWR King Air 11:47:17 [King Air C/S] King Air TWR 11:47:18 [King Air C/S] 1004 set 4 Uncallibrated display of radar data-used for situational awareness not for issuing control instructions 2

5 Airprox TWR Tutor 11:47:22 [Tutor C/S] Tutor TWR 11:47:23 [Tutor C/S] 1004 Set TWR Tutor 11:47:23 Roger Tutor TWR 11:47:44 [Tutor C/S] airborne Stud 3 TWR Tutor 11:47:46 [Tutor C/S] TWR King Air 11:47:56 [King Air C/S] are you visual with the Tutor upwind? King Air TWR 11:48:03 [King Air C/S] negative TWR King Air 11:48:04 roger he's left 9 o clock quarter of a mile, tracking east, 100ft below climbing King Air TWR 11:48:11 [King Air C/S] now visual TWR 60K 11:48:12 roger King Air TWR 11:48:54 er [King Air C/S] we {unintelligible transmission} climbed for the traffic we're now descending back down, er downwind to land TWR King Air 11:49:01 [King Air C/S] roger Analysis and Investigation Military ATM The radar recording at 1147:02 (Figure 1) shows the single Airprox Tutor getting airborne, and the King Air wide on the dead-side to overtake the Tutor formation. Figure 1: 1147:02 (King Air squawk 3627; Tutor 2602; Tutor Formation 7010). At 1147:44 (Figure 2), the Tutor had reported airborne and switching to the Director frequency. Figure 2: 1147:44, the Tutor has called transferring from Tower to Director frequency. 3

6 Airprox At 1147:56, the Tower controller asked the King Air crew if they were visual with the departing Tutor (Figure 3). Figure 3: Geometry at 1147:56. At 1148:04 (Figure 4), the Tower controller passed information, using the Hi-Brite, to the King Air: left 9 o clock quarter of a mile, tracking east, 100 feet below climbing. Figure 4: Geometry at 1148:04 Traffic Information. The radar replay shows the CPA between 1148:10 to 1148:14 as 0ft V and 0.3nm H separation (Figure 5). Figure 5: CPA taken at 1148:11. 4

7 Airprox The King Air pilot was aware of the Tutor formation joining and flew a modified circuit to deconflict from it. The Tutor formation was at initials first, but the King Air s greater speed (reported 140kt versus 80kt) meant that it would overtake the Tutors; circuit heights at Cranwell provide vertical separation between Tutors and King Airs (800 ft QFE and 1000 ft QFE respectively) but the King Air pilot was also using lateral separation. The King Air pilot flew a wider than normal and extended deadside/upwind leg of the visual circuit, and the profile of the aircraft meant that the aircraft wing needed to be tipped for him to be able to see the departing Tutor. The Tutor crew were at an elementary phase of training, and the student was wearing an IF visor for the SID 1 departure (climb ahead on RW track to FL50); no climb-out restriction was in place. The instructor had an increased workload because he was responsible for the lookout and the instructional element of the departure. Traffic Information was available to the crew on the shared Tower frequency; as the Tutor switched to the radar frequency (Figure 2), indicating 1000ft on QNH 1014 hpa (QFE was 1005 hpa), the King Air pilot had not initiated the crosswind leg. TAS was used to good effect to increase awareness for the Tutor crew, and the instructor levelled off at 950ft and turned to the right to increase separation. The controller had used standard RT for join calls and this was supplemented with Traffic Information on the departing Tutor. Having lost sight of the departing Tutor, the controller made good use of the Hi-Brite, and showed commendable awareness by asking the King Air crew if they were visual with the Tutor; further Traffic Information was passed several seconds prior to the CPA, which almost certainly aided visual acquisition. The normal barriers to an Airprox in the visual circuit would be see and avoid, Traffic Information (visual or using Hi-Brite data), and safe procedures for separating traffic. Traffic Information was passed by the Aerodrome Controller; all elements were aware of the other aircraft in the circuit or getting airborne. TAS provided an alert for the Tutor crew; ACAS was fitted to the King Air and it indicated a TA but it is not clear how much assistance it provided in helping visual acquisition. The King Air crew modified their circuit slightly to deconflict with the Tutor formation on the deadside, and it was likely that the King Air was not in the usual position for turning crosswind and deconflicting with aircraft climbing out. The pilots in the visual circuit were responsible for their own deconfliction and maintaining situational awareness. All parties were aware of their responsibilities, but certain limitations to see and avoid were apparent: (a) Lookout. The King Air crew had prioritised the lookout towards the Tutor formation until they were well ahead of it. Prior to the King Air crew beginning the crosswind turn, the departing Tutor would have been obscured approximately in the eight o clock position, leading to an incomplete visual picture; the King Air crew s mental model of the normal position of departing aircraft may have become confused because of their extended circuit. The geometry meant that the Tutor crew would have had the King Air in their two o clock position making it easier for them to see it. (b) Aircraft conspicuity. As the King Air turned, the white Tutor was slightly below and may have been more difficult to spot if it was being viewed against the white clouds. The Tower controller lost sight of the Tutor for this reason and it s possible that the King Air crew were subject to the same effect. (c) Cockpit workload. Both crews were in busy phases of flight and on instructional sorties. The Tutor was on an IF departure and the onus was on the instructor to balance the lookout with the other demands of an instructional sortie. The King Air crew were also under training, and having to modify a known circuit procedure would have placed greater demands on their attentional resources, and possibly their situational awareness became degraded. (d) Response times. The Tutor crew was flying an IFR departure, but had received a TAS warning to supplement their lookout before they reported switching to Director s frequency at 5

8 Airprox around 700ft. Having turned crosswind the King Air crew had increased the rate of closure between the two aircraft and therefore reduced the response time available for avoiding action. A climb was initiated by the King Air but at CPA, the aircraft were co-height. (e) Threat recognition. The Tutor pilot was content enough with the proceedings in the visual circuit to change frequency; the King Air pilot was always aware of the departing Tutor and the need to get visual with it because they needed to cross the climb-out lane. The see and avoid barrier was not as robust as it could have been in a visual circuit. The normal dead-side procedures were modified to increase separation with one formation but resulted in limited lookout and reduced separation with the departing Tutor. UKAB Secretariat Both pilots had equal responsibility for avoiding collisions and for ensuring that they did not fly in to such proximity to other aircraft as to create a danger of collision. 5 The King Air pilot was required to conform to the pattern of traffic formed by other aircraft intending to land at the aerodrome or keep clear of the airspace in which the pattern was formed. 6 Comments HQ Air Command The King Air pilot had responsibility to integrate into the visual circuit and avoid traffic already established (ie the formation of Tutors on recovery and the single Tutor on departure), so elected to fly wider on the deadside than would normally be the case to generate separation from the pair. However, having overtaken the pair, and being comfortable with the separation generated by also extending upwind, the radar trace suggests that he then commenced the crosswind turn without being visual with the departing Tutor and now in its climb-out area. Once the Tutor appeared on TCAS he reacted promptly to resolve the conflict, though by this time the instructor in the Tutor, who had been visual with the King Air throughout, had also taken positive measures to prevent the situation deteriorating further. The major lessons to be drawn from this incident are: 1. If in doubt about the position of circuit traffic, ask ATC 2. Having no contacts on TCAS does not mean that there are no aircraft there; and 3. When modifying the normal circuit pattern consider what the 2 nd order effects might be (such as flying through the height band and likely location of departing traffic). Ironically, had the King Air pilot flown a more normal ground track (and accepted direct overflight of the Tutor formation, with a separation of 200ft) then he would never have come into conflict with the departing aircraft. Furthermore, an early turn downwind (prior to having overtaken the formation) would also have kept him well away from the climb-out lane. Summary An Airprox was reported in the Cranwell visual circuit, in VMC, between a King Air being flown on a visual recovery, through initials on the dead-side of the runway, and a Tutor being flown on an IFR departure. Both crews were in contact with Cranwell Tower, the King Air crew received Traffic Information, and both aircraft were equipped with TAS or TCAS. 5 Rules of the Air 2007, Rule 8, Avoiding Aerial Collisions 6 Rules of the Air 2007, Rule 12, Flight in the vicinity of an aerodrome, and Regulatory Article 2307(1) Para 15 6

9 Airprox PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, transcripts of the relevant RT frequencies, radar photographs/video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities. The Board was informed that normally in a military visual circuit the pilot joining the circuit has the responsibility to identify all of the traffic reported to him and ensure that he can see the other aircraft before turning onto the downwind leg; if there are any aircraft the pilot cannot see, then they are taught to extend up-wind, and if necessary request to go around and re-join the circuit. This is slightly different from normal practice in a civilian circuit, where it is more usual to fly an orbit to increase spacing or create more time to see other traffic. There was considerable discussion amongst Board members about the differences between military and civilian visual circuit procedures. Some members observed that civilian controllers exercise greater control over the visual circuit and that this avoided the need for pilots to interpret (sometimes wrongly) what sequencing and join procedures were appropriate. Other members reflected that military pilots required greater flexibility in the circuit, especially when aircraft of greatly differing speeds and limited fuel reserves were present. They also opined that military pilots had to be able to operate in extreme conditions (for example: at night, overseas, at airfields with Force Protection constraints) and sometimes without the benefit of ATC, (or with limited ATC capability in war zones), and so needed to develop an ability to self-synchronise and marshal themselves accordingly. Notwithstanding, the Board noted that a recent previous Airprox in a military visual circuit had resulted in a recommendation that the MAA should review the provision of Aerodrome Control Service at military airfields to investigate whether there were procedures or lessons that could usefully be cross-fertilised. Turning to the actions of the controller in this specific case, members remarked that the Tower controller had very effectively used the Hi-Brite and his situational awareness to provide all pilots with accurate Traffic Information with which to make their decisions. The Board noted that the King Air pilot had 4 viable options available: he could have turned downwind early (but this would have left him with a short downwind leg and increased workload); he could have turned normally (and accepted the 200ft vertical separation with the Tutor Formation); he could have elected to extend upwind until he could see the departing Tutor; or he could have cleared the circuit to the west and repositioned for initials. The Board members unanimously agreed that what he should not have done was to have commenced his turn until he had the Tutor in clear sight and it was agreed that the cause was therefore that the King Air pilot had turned in to conflict with the Tutor. Looking at the risk, it was noted that the Tutor pilot had been aware of the King Air from the point that it appeared on his TAS, and that he had taken effective and timely action of his own to avoid it; consequently, it was agreed that the degree of risk was Category C. PART C: ASSESSMENT OF CAUSE AND RISK Cause: The King Air pilot turned in to conflict with the Tutor. Degree of Risk: C. ERC Score 7 : 2. 7 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 7

10 AIRPROX REPORT No Date/Time: 5 Aug Z Position: 5041N 00206W (Wareham) Airspace: LFA 2 (Class: G) London FIR Aircraft 1 Aircraft 2 Type: AW159 Wildcat PA28 Operator: RN Civ Pte Alt/FL: 1200ft NK RPS (1010hPa) Conditions: VMC VMC Visibility: 20km 10km Reported Separation: 20ft V/75yd H Recorded Separation: NK 0ft V/200m H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE WILDCAT PILOT reports in straight and level cruise, about 1nm southeast of Wareham. The grey camouflaged helicopter had upper and lower white anti-collision lights selected on, as was the SSR transponder with Modes A, C and S. The aircraft was not fitted with an ACAS or TAS. The pilot, sitting in the right-hand seat, was operating under VFR in VMC, in receipt of a Basic Service from Yeovilton Approach and assisted by an Observer seated in the left-hand seat. Whilst heading 140 at 120kt, he saw a white and orange Piper PA28 in the left 11 o clock, estimated to be 20ft below and 100yd ahead, crossing left to right. The aircraft had appeared from behind a blind spot caused by the windscreen central pillar. He made a note of the aircraft s registration as he turned left through about 30 in order to avoid it. The other aircraft maintained course and speed; it s crew did not appear to have sighted the helicopter. The Wildcat pilot filed an Airprox with Yeovilton Air Traffic over the radio. The pilot commented that the Observer was under a high workload and that this may have limited his lookout. He assessed the risk of collision as High. THE PA28 PILOT reports in straight and level cruise, tracking westbound along the coast, in the Bridport area. The Orange and white aircraft s lighting state was not reported. The SSR transponder was selected on with Mode A only, he recalled 1. The pilot was operating under VFR in VMC, in receipt of a Basic Service from Yeovil Radar, he reported 2. He suddenly noticed a Lynx helicopter approaching from the right-hand side in the 3 o clock position, at the same level, at very close range and travelling at speed. He was unable to decide on adequate avoiding action in time; an effort was made to accelerate out of the other aircraft s flight path and allow it to pass behind, which it did. He assessed the risk of collision as Medium. THE YEOVILTON APPROACH CONTROLLER reports the Wildcat pilot departed Yeovilton MATZ and called him on Yeovilton Approach for a Basic Service. He was en route to Durston Head to coastout for operational activity in the South Coast Danger Areas. He reported transiting at 1500ft on the 1 The radar replay indicated Mode C derived altitude until the contact faded at 1626:26. 2 Actually a Basic Service from Bournemouth Radar 1

11 Airprox Portland regional 1010hPa. The controller reminded the pilot that Portland Radar was unserviceable and that there would be no radar coverage at low-level over the sea. As the Wildcat pilot was flying close to Bournemouth airspace, the controller suggested he contact Bournemouth as he transited past and then recall the controller when coasting-out at Durston Head. The pilot reported that he would stay clear of Bournemouth's airspace and would re-contact the controller. The controller lost radar contact as the Wildcat was transiting north to south past the western edge of Bournemouth s airspace. At [1628], the Wildcat pilot reported an Airprox. He reported that a PA28 had passed 20ft underneath and 100yd away from him, just southeast of Wareham. Because he had no Portland radar, the controller could not see the Wildcat or any other contacts on his radar display. THE YEOVILTON SUPERVISOR reports that the Approach controller reported the Wildcat pilot had called an Airprox with a light civilian fixed wing aircraft at 1728L. The incident was reported in the vicinity of Wareham, which was below the limits of available surveillance radar cover. Bournemouth were immediately contacted to ascertain if the other aircraft was in receipt of an Air Traffic Service from them. The Bournemouth controller confirmed the callsign and stated that its pilot was in receipt of a Basic Service at the time of the incident. DSATCO was informed immediately and the controller was relieved in order to record his account of the incident. THE BOURNEMOUTH CONTROLLER: In the course of their occurrence investigation, Yeovilton contacted Bournemouth ATC and were told that the PA28 pilot was in receipt of a Basic Service from Bournemouth at the time of the Airprox, that both aircraft were displayed on the controller s radar screen, and that the PA28 pilot had been passed Traffic Information on the Wildcat. Bournemouth reported that the PA28 pilot did not raise any concern. Factual Background The weather at Bournemouth was recorded as follows: METAR EGHH Z 20010KT 9999 FEW016 SCT032 20/16 Q1016 Analysis and Investigation CAA ATSI The PA28 pilot departed from Bournemouth and left the CTR tracking west. At 1623:01, the PA28 was 6.9nm east of Wareham, squawking 7000 and indicating FL015. The Wildcat was 8.7nm northwest of Wareham squawking 7420, see Figure 1. Figure 1: Swanwick MRT at 1623:01 No RTF was available for Bournemouth and the ATSU had indicated that the PA28 was in an area of poor radar coverage and its pilot had not mentioned an Airprox whilst on their frequency. 2

12 Airprox At 1626:02, the PA28 s SSR code changed to 0000, which was considered to be due to poor radar performance because, shortly after, at 1426:26, the PA28 faded from radar, 2.1nm east of Wareham indicating FL014. The Wildcat was at FL013, see Figure 2. Figure 2: Swanwick MRT at 1626:26 At 1627:34, the Wildcat passed 0.2nm east of Wareham. The Wildcat pilot s written report indicated that when 1nm southeast of Wareham he sighted the PA28 to his left and made a left turn to avoid. At 1627:46, the Wildcat (at FL013) is shown in a left turn 0.6nm southeast of Wareham, see Figure 3. Figure 3: Swanwick MRT at 1627:46 It was not possible to show the exact geometry of two aircraft in proximity. At 1628:43, the PA28 reappeared on radar 1.4nm west-southwest of Wareham at FL012. At 1629:15, Figure 4 shows a line projected from the point when the PA28 faded from radar to the point when it reappeared. 3

13 Airprox Figure 4 - Swanwick MRT at 1629:15 Military ATM The Airprox occurred between a Wildcat pilot under a Basic Service with Yeovilton and a PA28 pilot under a Basic Service with Bournemouth. The PA28 faded from radar 2min prior to the reported Airprox; the radar used for the investigation was not the one available to the Yeovilton or Bournemouth controllers. The radar replay did not capture the incident but the aircraft were on a converging geometry at 1625:52, see Figure 1. Figure 1: Geometry at 1625:52 (Wildcat squawk 7420; PA28 squawk 7000) At 1627:34, the Yeovilton controller transmitted, radar contact lost, report feet wet. The CPA is believed to be at 1627:56, as the Wildcat takes a sudden left turn, see Figure 2. 4

14 Airprox Figure 2: CPA believed to be at 1627:56 At 1628:00, the Wildcat pilot reported an Airprox; the details were passed as, I ve just had an Airprox with a PA28 just to the south east of Wareham, 1200 feet, believe the callsign to be [PA28 callsign] was closing from my bearing from my left, about 20 feet below and about 100 yards in front of me. The PA28 was detected again on radar replay at 1628:44, see Figure 3. Figure 3: Geometry at 1628:44 The controller had confirmed to the crew that the Portland Radar was unavailable and Plymouth was closed. In addition, the controller stated that Bournemouth were available to provide a transit service, prior to returning to Yeovilton s frequency, when over the sea. As the Wildcat would remain clear of Bournemouth, the captain elected to remain with Yeovilton. The Wildcat pilot was under a Basic Service below Yeovilton radar cover and this meant that the barrier of Traffic Information was not available; both aircraft were painting on the Bournemouth Radar and it was reported that Bournemouth had called traffic to the PA28 pilot. Neither aircraft had ACAS fitted. Lookout was the key barrier to avoiding other aircraft; the high workload of the pilot in the Wildcat LHS and the width of the windscreen pillar contributed to a late spot on the PA28, which was converging from the left. The PA28 pilot s lookout was such that as the Wildcat was spotted, there was very little time to react and due to the closing geometry, the pilot felt that maintaining heading would allow the Wildcat to pass behind. The Yeovilton Local Investigation highlighted the barriers that were partial or absent. The investigation observed that the windscreen strut on the Wildcat is 5

15 Airprox slightly wider than the Lynx and that more head movement was required to obtain a more comprehensive scan. It was also recognised that all available resources should be utilised in assisting the crews in maintaining safe separation. UKAB Secretariat The Wildcat and PA28 pilots shared an equal responsibility for collision avoidance and not to fly into such proximity as to create a danger of collision 3. If the incident geometry is considered as converging then the PA28 pilot was required to give way to the Wildcat 4. Comments Navy HQ Yeovilton ATC suggested that the Wildcat crew should call Bournemouth for the transit, which was rebuffed by the Wildcat crew as they were remaining clear of Bournemouth. Bournemouth held both aircraft on radar and offered Traffic Information (TI) on the Wildcat to the PA28 pilot. Had this TI been assimilated then this should have improved the PA28 pilot s SA; it is not clear if the PA28 pilot heard the TI as there was no acknowledgment. The fact that the pilot suddenly noticed a Lynx helicopter (the Wildcat) suggests that the TI was not assimilated. Both pilots were operating under VFR in receipt of a Basic Service where see and avoid is the ultimate mitigation against mid-air collision; Bournemouth attempted to add another barrier by offering TI, nevertheless, it was the Wildcat pilot s late sighting and subsequent avoiding action that resolved the conflict, with the GA pilot s resolution being to increase speed. Summary An Airprox was reported when an Agusta Westland AW159 Wildcat and a Piper PA28 flew into proximity at 1628 on Tuesday 5 th August Both pilots were operating under VFR in VMC and in receipt of a Basic Service, the Wildcat pilot from Yeovilton and the PA28 pilot from Bournemouth. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available consisted of reports from the pilots of both aircraft, radar photographs/video recordings, reports from the military air traffic controllers involved and reports from the appropriate ATC and operating authorities. The Board first considered the PA28 pilot s actions. He had been in receipt of a Basic Service from Bournemouth Radar and had reportedly been passed Traffic Information on the Wildcat. Board members felt that the PA28 pilot had probably not assimilated the Traffic Information call and that his subsequent sighting of the Wildcat was later than could have been expected, given the weather conditions. He reported the Wildcat suddenly appearing in his right 3 o clock at close range and at the same level. The Board agreed that he could not have altered the outcome of the Airprox at that stage, and that therefore his was effectively a non-sighting; this reinforced the importance of an effective lookout, such that earlier avoiding action could be made. Although he took the only avoiding action that he felt he was able to make, Board members agreed that the acceleration of a PA28 was such that it would not make a material difference in the time available. The Wildcat pilot was in receipt of a Basic Service from Yeovilton Approach and had not received Traffic Information on the PA28 due to their lack of radar coverage. Members noted that the Wildcat pilot had been offered a handover to Bournemouth as his aircraft reached the limit of Yeovilton s available surveillance coverage. Although the crew were no doubt occupied with their impending entry to the South Coast Danger Areas and task therein, members agreed that they would have been better served by accepting this suggestion and benefiting from the subsequent surveillance coverage 3 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 4 ibid., Rule 9 (Converging). 6

16 Airprox from Bournemouth. Given that the PA28 pilot, under a Basic Service, had been given Traffic Information on the Wildcat, the Board felt that it would have been likely that the Wildcat pilot would also have been given Traffic Information on the PA28, even if under a Basic Service, and that this RT exchange would have probably contributed significantly to an earlier visual sighting by both pilots. Members agreed that this lost opportunity had been a contributory factor. In the event, the Wildcat Observer, seated on the left hand side, did not see the PA28 approaching from the left, and the pilot saw it only at a late stage, although with sufficient time to note the other aircraft s registration as he took avoiding action. The Board agreed that the late sighting by the Wildcat pilot and effective a nonsighting by the PA28 pilot were the cause of the incident. With regard to risk, members agreed that, although avoiding action had been taken to successfully prevent a collision, safety margins had been much reduced below normal. Members also noted that the newly in-service Wildcat was not fitted with a TAS and expressed their surprise. A TAS represented a barrier to mid-air collision which would probably have resolved this event without incident. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Contributory Factor: A late sighting by the Wildcat pilot and effectively a non-sighting by the PA28 pilot. The Wildcat pilot declined a service from Bournemouth. Degree of Risk: B. ERC Score 5 : Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 7

17 AIRPROX REPORT No Date/Time: 3 Aug Z (Sunday) Position: 5129N 00020E (3.5nm SSW of Thurrock) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: Fournier RF5 PA28 Motorglider Operator: Civ Pte Civ Pte Alt/FL: 1800ft 2000ft (1009hPa) QNH (1010hPa) Conditions: VMC VMC Visibility: >10km >30km Reported Separation: 0ft V/50ft H Recorded Separation: 200ft V/<0.1nm H 20ft V/<40m H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE RF5 PILOT reports flying a predominantly white motorglider, without lights fitted, heading 200 at 80kt, squawking transponder Modes 3/A, C & S, whilst leading two other motorgliders, of different types, in a loose formation. The other two pilots were French but spoke excellent English and the formation had successfully been in contact with Mildenhall for a MATZ crossing earlier in the flight. Nonetheless, because of the difficulties involved with checking in a formation on a busy ATC LARS 1 frequency, the RF5 pilot decided keep the pilots on a discrete formation frequency whenever possible, and adjusted the second leg of their route to the west, towards Thurrock and away from the western corner of the Southend RMZ 2, whilst keeping a good visual lookout. He decided not to contact Farnborough LARS East because the frequency is generally impossible to receive and his experience of reception near to Ringmer had been particularly poor. After passing Thurrock, the RF5 pilot looked down at his chart for about 4 seconds and when he looked up he saw another aircraft around ft in his left o clock, and about to pass just behind his aircraft s tail without any noticeable deviation from its course. The RF5 pilot broadcast a warning to the rest of the formation and then selected the Farnborough East frequency. As expected, he could hear other aircraft transmitting but could not hear the Farnborough controller, so he contacted London Information, who were also very busy, and they requested that he file the Airprox after landing. Once the formation had landed, the No 2 pilot confirmed that, when he heard the lead pilot s warning, he had seen a high-wing aircraft with flaps but assessed that it was not a threat to him. With hindsight, the RF5 pilot assessed that he may have been better served to have called Southend, but noted that the funnelling effect of the Southend RMZ pushes pilots without radios, or who do not wish to contact Southend, into a 5nm corridor. He also observed that his experience of the poor coverage of the Farnborough East frequency means that he was far more reluctant to use it, whereas the coverage for Farnborough West and North is good and he uses them frequently. He assessed the risk of collision as High. 1 Lower Airspace Radar Services 2 Radio Mandatory Zone 1

18 Airprox THE PA28 PILOT reports flying VFR, heading 355 at 100kt, with white wing-tip strobes and a tail beacon illuminated, squawking transponder Modes 3/A, C and S and in receipt of a Reduced Traffic Service from Farnborough LARS East. He was accompanied by another qualified pilot sitting in the right-hand seat, but they had experienced difficulty with the seat adjustment and, consequently, the right-hand seat was in a reclined position resulting in a reduced field of view below them on that side. They were routing towards the east of Damyns Hall to keep clear of a NOTAM d air display and, as they approached Thurrock, they received Traffic Information on an aircraft converging from their right and passing ahead and above their aircraft; they had been keeping a good lookout and saw that aircraft pass clear of them before another aircraft then passed at high speed, from right to left, immediately in front, and slightly below their forward field of view. Just 2 to 3 seconds before this second aircraft passed them, they received Traffic Information from the Farnborough Radar controller, on traffic converging from their 1 o clock. There was not enough time to take any avoiding action and, shortly after the aircraft passed, the PA28 pilot saw another two aircraft, which he believed to be motorgliders, pass in the opposite direction around 200m clear to their right-hand side. He assessed the risk of collision as High. Factual Background The weather for London City at 1050 was recorded as: METAR EGLC Z AUTO 24010KT 210V BKN040/// 22/10 Q1010= Analysis and Investigation CAA ATSI The Farnborough LARS(E) controller s workload and RTF loading were assessed as high. The CAA ATSI had access to RTF and area radar recording together with written reports from both pilots and the investigation report from the Farnborough ATSU. At 1103:32 the PA28 contacted Farnborough Radar and reported en-route from Lashenden to Elstree and requested a Traffic Service on QNH 1010hPa and 8nm northwest of Lashenden. The Farnborough controller confirmed the QNH 1010hPa and instructed the PA28 to squawk 1734, which was acknowledged correctly by the PA28 pilot. At 1105:10 the Farnborough controller advised (PA28)c/s identified to the south of Rochester by six miles Traffic Service may be late warning of traffic due to traffic density on frequency and in the local area. The PA28 pilot replied Reduced traffic (PA28)c/s. During the next few minutes the Farnborough controller passed Traffic Information to the PA28 pilot on a number of other on aircraft not involved with the Airprox: 1108:27 ATC (PA28)c/s north of you range of three miles believed to be inbound to Rochester present track should clear on your righthand side one o clock three miles PA28 Roger traffic (PA28)c/s 1111:42 ATC (PA28)c/s in your two o clock range of three miles two thousand feet converging from your righthand side PA28 Roger traffic (PA28)c/s 1112:30 ATC and (PA28)c/s that traffic is now one o clock one and a half miles crossing you right left ahead PA28 Have traffic contact with traffic (PA28)c/s 2

19 Airprox At 1112:44 the PA28 had reported this traffic in sight and the controller then passed Traffic Information on an aircraft approaching from the north [the RF5], (PA28)c/s further traffic north of you four miles southbound one thousand eight hundred feet not working this unit. There was no response from the PA28 pilot. The RF5, squawking 7000, was 1nm south-southwest of Thurrock airfield, tracking south at an altitude of 1800ft and in the PA28 s half past twelve at a range of 4.4nm Figure 1. Figure 1 Swanwick MRT at 1112:44 The two aircraft continued to route on reciprocal tracks and the position of the two other motor gliders is unclear but radar showed a following radar contact positioned 1nm northeast of the RF5. At 1114:10 the controller updated the Traffic Information (PA28)c/s the other traffic is just north of you range less than a mile pass [1114:20] on your righthand side further traffic west of you one and a half miles two thousand one hundred feet. There was no response from the PA28 pilot. Radar showed the vertical distance between the two aircraft was 300ft Figure 2. Figure 2 Swanwick MRT at 1114:12 3

20 Airprox It is likely that the two aircraft passed abeam each other whilst Farnborough were transmitting the Traffic Information. The PA28 pilot s written report indicated that the RF5 passed at high speed from right to left, immediately in front of and slightly below. At 1115:10 the controller advised the PA28 pilot that he was clear of the previously reported [RF5] traffic. The controller continued to provide Traffic Information and at 1117:10 the PA28 was transferred to Farnborough LARS(N) on frequency 123.8MHz. The written report from the RF5 pilot indicated that, due to the potential difficulties in checking in a formation on a very busy ATC frequency, he elected to remain on a discrete frequency routeing via Thurrock to remain west of the Southend RMZ. The RF5 pilot added there are difficulties in communicating with Farnborough LARS(E) in that area. The Farnborough ATSU have recommended that Thurrock and Damyns Hall are contacted to establish if any aircraft operating in the vicinity of the airfields have difficulty in communicating with Farnborough LARS(E) and if so then a further technical investigation may be required. The controller had a high workload and was viewing a situational display set at 60nm range. The area around Thurrock would have shown multiple contacts in close proximity and the controller agreed a Traffic Service with the PA28 pilot but advised that there may be late warning of traffic due to traffic density on frequency and in the local area. The PA28 pilot acknowledged being in receipt of a reduced traffic service and although not considered a causal factor, it was noted that the controller did not use the correct phraseology to reduce the Traffic Service. CAP 413, Radio Telephony Manual, Chapter 6, Paragraph 6.75/76 state: When providing a surveillance derived ATS, there may be circumstances that prevent controllers from passing timely Traffic Information and/or deconfliction advice, e.g. high workload, areas of high traffic density, against aircraft conducting high energy manoeuvres, or when traffic is not displayed to the controller. Controllers shall inform the pilot of reductions in Traffic Information along with the reason and the probable duration; however, it may not always be possible to provide these warnings in a timely fashion. In high workload situations, which may not always be apparent from RTF loading, it may not be possible for controllers to always provide timely Traffic Information and/or deconfliction advice. High workload situations may not necessarily be linked to high traffic density. The controller passed Traffic Information on a number of other contacts and then passed information on the RF5, further traffic north of you four miles southbound one thousand eight hundred feet not working this unit but there was no acknowledgement from the PA28 pilot and the controller did not challenge the pilot, probably due to workload. As the two aircraft closed on reciprocal tracks the controller gave a further late warning of the conflicting [RF5] traffic just north of you range less than a mile pass on your righthand side. It was considered likely that due the controller s workload and urgency of the warning, the phraseology used was non-standard. UKAB Secretariat Both pilots had equal responsibility to avoid a collision 3 and, because the aircraft were approaching more or less head-on, both pilots were required to alter course to the right. 4 3 Rules of the Air 2007, Rule 8, Avoiding Aerial Collisions 4 Rules of the Air 2007, Rule 10, Approaching Head-on 4

21 Airprox Summary An Airprox occurred at 3.5nm to the south-southwest of Thurrock airfield, within Class G airspace between a Fournier RF5 motorglider and a PA28 Piper Cherokee Warrior II. The Airprox occurred when the RF5, not in receipt of an Air Traffic Service, and the PA28, in receipt of a reduced Traffic Service from Farnborough LARS(E), came in to proximity. Neither pilot saw the other aircraft in time to take any avoiding action. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, transcripts of the relevant RT frequencies, radar photographs/video recordings, reports from the appropriate ATC and operating authorities. Board members agreed that this Airprox had occurred during a very busy day in a busy piece of airspace; considerable discussion about the funnelling effect of the Southend RMZ then ensued. Some members thought that many GA pilots did not understand the difference between an RMZ and controlled airspace and, consequently, they perceived that contacting Southend ATC would result in unwanted control restrictions. In fact, an RMZ only requires them to attempt radio contact with ATC so that controllers can better manage their traffic without unnecessary avoiding action, and does not oblige pilots to accept any form of Air Traffic Service. A Board member commented that he had been in touch with the Southend SATCO 5 about the RMZ, who reported that they very rarely have to refuse a service and that Southend ATC actively encourages pilots to contact them for the benefit of all airspace users. There was agreement that understanding of the use of RMZs could be improved to the benefit of all airspace users, and the Board resolved to make a recommendation that GASCO should consider ways of improving pilots understanding of RMZs. It was also noted that the RF5 pilot reported frequent problems with the Farnborough LARS(E) frequency; the NATS advisor informed the Board that radio coverage and sectorization for Farnborough LARS were already being reviewed. Board members noted that the PA28 pilot had managed to achieve two-way contact with Farnborough LARS and agreed that, despite the limitations placed on the Traffic Service provided, the controller had done well to pass relevant Traffic Information given the busy airspace. Turning to the actions of the pilots, the Board thought that, notwithstanding the difficulties involved with leading such a loose formation, the pilot of the RF5 would have been better served by attempting to obtain an Air Traffic Service from Farnborough LARS, or alternatively using the Southend RMZ to simplify his routing. Regardless of the radio problems, formation problems and Air Traffic Services on the day, the Board agreed that both pilots were required by the Rules of the Air to avoid colliding with each other s aircraft. It seemed likely to the Board that the RF5 pilot had experienced an increased workload due to the demands of leading a formation, and that the PA28 pilot, having seen one conflicting aircraft and likely focussed on monitoring it, had probably not maintained an effective scan and so had not seen the RF5 approaching him. The Board agreed that the lesson for all aviators here was captured in the old adage aviate, navigate, communicate ; no matter what other demands are placed on a pilot s attention, the requirement to fly the aircraft, look-out, and avoid collision must come above all other actions. It was agreed that the cause of the incident lay in a late sighting by the RF5 pilot and, because he saw the RF5 so late as to be unable to take action, effectively a non-sighting by the PA28 pilot. Turning to the degree of risk, the Board noted that the CPA reported by both pilots and confirmed by the radar recording was extremely close, and that neither pilot had been able to take any action to improve matters. They therefore classified it as a Category A situation that had just stopped short of an actual collision, where separation had been reduced to the minimum and / or where chance had played a major part in events. 5 Senior Air Traffic Control Officer 5

22 Airprox PART C: ASSESSMENT OF CAUSE AND RISK Cause: A late sighting by the RF5 pilot and effectively a non-sighting by the PA28 pilot. Degree of Risk: A. ERC Score 6 : 100. Recommendation(s): GASCO considers ways of improving pilots understanding of Radio Mandatory Zones. 6 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 6

23 Airprox AIRPROX REPORT No Date/Time: 7 Aug Z Position: 5208N 00002W (8nm SW Cambridge) Airspace: LON FIR (Class: G) Aircraft 1 Aircraft 2 Type: C560XL Quantum Microlight Operator: Civ Exec Civ Club Alt/FL: 1600ft 1600ft QNH (1014hPa) QNH Conditions: VMC VMC Visibility: 10km 20km Reported Separation: 0ft V/1nm H Recorded Separation: NK 300ft V/0m H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE C560XL (C56X) PILOT reports flying a predominantly white aircraft with all lights illuminated and SSR transponder selected with Mode A, C and S. The aircraft was fitted with TCAS. Flying IFR in VMC at 160kt, he was undertaking a NDB approach to RW05 at Cambridge and was descending to 1600ft when ATC warned him about an aircraft on the SW side of the airfield, not in contact with ATC. He looked for, and saw, this aircraft, and then received further traffic information from ATC about an ultralight aircraft approximately 8nm from CAM NDB southeast bound. He saw the ultralight at 1600ft within 1nm of his position as he was approaching the base turn point and took avoiding action by turning and climbing above it at a safe distance. In doing so he turned towards the runway so, with the runway in sight, he continued his approach visually. He believed the ultralight pilot had not seen him. He noted that Cambridge ATC were not using the radar at the time and were very vigilant in their passing of Traffic Information. He assessed the risk of collision as Medium. THE QUANTUM FLEX-WING MICROLIGHT PILOT reports flying at blue and white aircraft without any lights or SSR transponder. He reports that he was on a solo cross-country training flight at 1600ft. Whilst flying straight and level on a heading of 180 in the vicinity of Royston, an aircraft flew directly overhead on approximately the same heading, passing an estimated ft above. He had not seen the aircraft approach as it was behind him and assumed the pilot had decided to buzz him but, because the vertical separation was adequate, had not considered it to be an Airprox, (although he noted that this assumed the other pilot was visual with him throughout the manoeuvre). After passing overhead, the other aircraft turned in a wide arc until it was north by a distance of 3-5 miles, heading towards Cambridge. He felt no effects of wake turbulence and, although he experienced some surprise at seeing the other aircraft, he was not unduly concerned by it. He mentioned it in passing to his instructor on his return. He assessed the risk of collision as Medium. THE CAMBRIDGE CONTROLLER reports that, whilst working as ADI/APP combined, he cleared the C56X for an NDB approach on RW05. As the pilot reported beacon outbound he noticed an aircraft to the west of the airfield by 8-10nm at an estimated 1500ft. He passed Traffic Information to the C56X, who reported visual. Shortly afterwards he noticed a microlight to the right of the C56X and again he informed the pilot, ensuring that he made it clear it was not radar derived Traffic Information. 1

24 Airprox The C56X pilot was not initially visual but, shortly afterwards, reported that he was visual and taking avoiding action. The pilot then confirmed that he was happy to continue the approach. Factual Background The weather at Cambridge was reported as: METAR EGSC Z 02004KT 350V SCT046 22/11 Q1014 Analysis and Investigation CAA ATSI The C56X pilot was operating an IFR flight inbound to Cambridge and was in receipt of a Procedural Service from Cambridge Approach. The Cambridge controller was providing a combined Aerodrome and Approach Control service, without the aid of surveillance equipment. (The UK AIP page AD 2.EGSC-9 (29 May 2014) states, for Radar: Available intermittently Mon- Fri during normal working hours and by arrangement only). ATSI had access to Cambridge RTF and area radar recording, together with the written report from the controller and both pilots. At 1749:20 the C56X, inbound from the southwest, contacted Cambridge Approach and reported descending to 4000ft on QNH 1014 hpa with information H. The controller advised of no delay and cleared the C56X for the NDB approach for runway zero five with further descent to 3000ft. The C56X crossed the beacon and completed the entry procedures before crossing the beacon outbound at 3000ft on a southwesterly track. At 1755:30 the C56X reported beacon outbound and was instructed to report base turn complete. At 1756:13 the controller advised the C56X about an aircraft which the controller had sighted from the VCR about 7 to 8 miles west of Cambridge. This aircraft was not involved in the Airprox and the C56X pilot reported the traffic in sight and was happy to continue with the approach. At 1758:00 the controller transmitted (C56X) I m visual I believe with a Microlight on your righthand side is that the one you have in sight and the C56X pilot responded Oh negative we got him in sight now Figure 1. Figure 1 Swanwick MRT at 1758:00 Neither of these contacts was believed to have been involved in the Airprox. The C56X pilot s written report indicated that when approaching the 8.5DME point for base turn they spotted the Quantum Microlight at 1600ft within 1nm and took avoiding action. At 1758:35 radar recording showed the C56X had commenced a left turn and had climbed to 1800ft. At 1758:56 the C56X had reversed the turn to the right and at 1759:22 the Quantum Microlight started to show on the radar recording tracking south-southeast (Figure 2). 2

25 Airprox Figure 2 Swanwick MRT at 1759:22 At 1759:10 the C56X pilot reported Er (C56X)c/s we had to do avoiding action turn and returning inbound the field this time. The C56X pilot confirmed that he was happy to pick up the procedure from base leg. At 1759:40 the controller advised (C56X)c/s I still have the Microlight in sight it appears to be approaching the final approach er now at about er one zero miles do you have him in sight. The C56X pilot responded Yeah he s on my right hand side about one mile over and on the righthand side (C56X)c/s. The controller informed the C56X pilot that the Microlight hadn t called Cambridge and the C56X continued the approach without further incident. The Quantum Microlight pilot s written report indicated flying straight and level on a solo crosscountry training flight and when approaching Royston on a southerly track at 1600ft, an aircraft overflew him from behind at 300ft to 400ft above and the aircraft then turned right towards Cambridge Airport. The C56X was in receipt of a Procedural Service. CAP774, UK Flight Information Services, Chapter 5, Paragraph 5.1 and 5.5 state: A Procedural Service is an ATS where, in addition to the provisions of a Basic Service, the controller provides restrictions, instructions, and approach clearances, which if complied with, shall achieve deconfliction minima against other aircraft participating in the Procedural Service. Neither traffic information nor deconfliction advice can be passed with respect to unknown traffic. The controller shall provide traffic information, if it is considered that a confliction may exist, on aircraft being provided with a Basic Service and those where traffic information has been passed by another ATS unit; however, there is no requirement for deconfliction advice to be passed, and the pilot is wholly responsible for collision avoidance. The controller may, subject to workload, also provide traffic information on other aircraft participating in the Procedural Service, in order to improve the pilot s situational awareness. The controller was vigilant and having observed the unknown traffic from the VCR he passed appropriate traffic information which resulted in the C56X pilot acquiring both unknown aircraft on his right hand side. The C56X then sighted the Quantum Microlight as he started the base turn and took avoiding action. 3

26 Airprox UKAB Secretariat Both pilots shared an equal responsibility for collision avoidance and for not flying into such proximity as to create a danger of collision 1. The geometry was a converging situation so the C56X pilot was required to give way 2, which he did. Summary An Airprox was reported when a C56X and a Quantum Mircrolight flew into proximity on 7 Aug 2014, 8nm south-west of Cambridge. The C56X pilot was operating under IFR in VMC and was receiving a Procedural Service from Cambridge; the Quantum Microlight was VFR and VMC not under a ATS. The C56X pilot received Traffic Information from the Cambridge controller which enabled him to see the Microlight and take avoiding action. The Mircrolight pilot did not see the C56X until after CPA. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, transcripts of the relevant RT frequencies, radar photographs/video recordings and reports from the air traffic controllers involved. The Board first commended the Cambridge controller for his timely and accurate Traffic Information, which had enabled the C56X pilot to see and avoid the conflicting traffic. The Board also commended the pilot of the C56X for his look-out, and avoiding action, whilst still acknowledging that it was his responsibility to avoid the micro-light, which he did. Noting that he was a student, the Board wondered whether the micro-light pilot had been sufficiently briefed on the proximity of Cambridge Instrument Approaches, and opined that pilots of cross-country exercises should take into careful consideration other airspace users and the pattern of traffic at airfields when planning their routing especially at the altitude that he was flying at, which was very likely to conflict with airfield approach tracks. The Board noted that it had previously made a recommendation to the CAA that a chart be produced outlining the IFR holding patterns in the UK (Airprox number ), and considered that this would provide a very valuable aid for assisting in deconfliction of flight paths for pilots planning and flying cross-country routes. In looking at the cause of the Airprox, the Board agreed that this had been a simple conflict in flight paths that had been resolved by the C56X pilot. They assessed that this event represented normal operations in Class G airspace wherein normal safety standards had pertained; the risk was therefore categorised as E. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Degree of Risk: A conflict in flight paths resolved by the C56X Pilot. E ERC Score 3 : 4 1 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 2 ibid., Rule 9 (Converging). 3 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 4

27 AIRPROX REPORT No Date/Time: 8 Aug Z Position: 5101N 00145W (8.4nm S of Boscombe Down) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: PA28 PA28 Archer Operator: Civ Club Civ Pte Alt/FL: 2300ft 2500ft QNH (1007hPa) QNH (1012hPa) Conditions: VMC VMC Visibility: 20km >10km Reported Separation: 0ft V/200m H Recorded Separation: 100ft V/0.1nm H 0ft V/100m H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE PA28 (1) PILOT reports flying a red, white and blue aircraft with a red rotating beacon and wingtip white strobe lights illuminated, and squawking transponder Modes 3/A, C and S; no TCAS 1 was installed. He was flying with a passenger, VFR, heading 250, cruising at 105kt, level at 2300ft and reports flying on QNH 1007hPa. He was receiving a Basic Service from Boscombe Zone and had received approval to penetrate the Middle Wallop / Boscombe Down CMATZ whilst remaining clear of the Middle Wallop ATZ. He had been instructed to report at Chilbolton and abeam Alderbury; the PA28 pilot recalls complying with these instructions whilst maintaining 2300ft. He noted that traffic in the area was busy, and he was having difficulty hearing Boscombe ATC transmissions, which were crackly, although Farnborough Tower, Radar and Compton Radio were all perfectly clear later in his journey. The PA28 pilot recalls receiving Traffic Information on a variety of other aircraft and considered one or two of the calls to be closer than ideal but put this down to the communications difficulties, assuming that he had missed some earlier calls. He then received Traffic Information on an aircraft ahead but did not register the range due to the RT distortion. Shortly afterwards he saw a bi-plane passing below, and just to his left, approximately on a reciprocal heading and the PA28 pilot took the bi-plane to be the reported aircraft. Another call from Boscombe Zone followed immediately, but halfway through the Traffic Information, the pilot looked up and simultaneously heard his passenger say straight ahead, when he spotted another PA28, around 0.5nm ahead, heading directly towards them, at the same altitude. Making an immediate right turn, the PA28(1) pilot saw the other aircraft turn right at the same time, and then heard the other pilot call Boscombe Zone to say that the aircraft had passed each other. The PA28(1) pilot assessed that the busy traffic situation combined with the corralled nature of the local airspace and the RT problems lead to a high workload which made maintaining a good lookout more difficult. He assessed the risk of collision as Medium. THE PA28 (2) PILOT reports flying a red, white and blue aircraft with a red fin strobe light and white wing-tip strobe lights illuminated, and squawking transponder Modes 3/A, C and S; no TCAS was installed. He was flying VFR in good VMC, heading 075, at 105kt and level at 2500ft and reports flying on the Boscombe Zone QNH 1012hPa. He agreed a Basic Service with Boscombe Zone and received clearance to cross the MATZ but was instructed to remain clear of the Middle Wallop ATZ. 1 Traffic and Collision Alerting System 1

28 Airprox The pilot read back the clearance and agreed to report south-abeam Alderbury. As he approached Alderbury, he received Traffic Information on an aircraft in his 11 o clock, 200ft below him. The pilot acknowledged the Traffic Information and his co-pilot spotted a similar aircraft approaching at the same altitude; a fraction of a second later the pilot also saw it. He executed a steep, 60 banked turn to the right onto a heading of around 120 whilst maintaining his altitude; he noticed the other aircraft making a similar sharp turn to the right at about the same time. The PA28(2) pilot reports that he normally avoids flying directly over visual reference points, and in this case he was around 2nm south of Alderbury; he also normally avoids flying at round numbers of altitudes (2000 /2500 etc), to reduce the risk of collision; however, on this occasion he intended to carry out an overhead join at Popham (airfield elevation 550ft amsl), so he elected to transit at 2500ft QNH. He assessed the risk of collision as Medium. THE BOSCOMBE ZONE CONTROLLER AND SUPERVISOR report that they were not informed of the Airprox until nearly 2 weeks after the occurrence and could not recall specific details of the event, however they recalled that the unit s and controller s workloads as medium. Factual Background The Boscombe Down weather at 1050 was recorded as: METAR EGDM Z 19006KT 9999 FEW030 BKN100 21/12 Q1008 BLU NOSIG The Middle Wallop weather at 1050 was recorded as: METAR EGVP Z 19006KT 9999 FEW035 BKN100 22/13 Q1008 BLU NOSIG Analysis and Investigation Military ATM The Boscombe Zone controller passed Traffic Information to the pilot of PA28(1) on non-airprox traffic at 1101:47. At 1102:32 (Figure 1), Zone passed further Traffic Information as, [PA28(1) callsign] traffic believed to be you has traffic west 1 mile tracking east indicating 200 feet above believed to be a PA28 working this frequency. The PA28(1) replied that he was, not visual with anything above. Figure 1: Geometry at 1102:32. PA28(1) heading 250 (blue circle); PA28(2) heading 075 (red square), both squawking At 1102:45 (Figure 2), Zone began to call information to PA28(2) and after a delay the information was confirmed at 1102:54 (Figure 3), as [PA28(2) callsign] traffic believed to be you has traffic 2

29 Airprox east half a mile tracking west indicating 200 feet below believed to be a PA28 working this frequency. Figure 2: Geometry at 1102:45. The CPA was at 1102:58 with 100ft vertical separation and 0.1nm horizontal separation; at 1103:01, the PA28(2) pilot confirmed that traffic had passed down the left side. Figure 3: Traffic Information at 1102:54. Despite being under a Basic Service, the controller had passed Traffic Information on other non- Airprox traffic. The controller demonstrated duty of care and commendable maintenance of trackidentity to be able to pass Traffic Information to individual callsigns wearing non-discrete squawks, under a Basic Service. The phrase traffic believed to be you was used correctly. Prior to the CPA, Traffic Information was passed to the pilot of PA28(1) at 1nm and the pilot of PA28(2) was provided Traffic Information at 0.5nm. The pilot of PA28(1) reported RT issues; the tape transcript does not indicate an issue with either the frequency or that other callsigns were experiencing problems; however, the frequency was congested, and some calls appear to have been stepped-on with multiple transmissions. The Traffic Information prior to CPA was acknowledged and appears to have helped both pilots to achieve visual contact. Neither aircraft was fitted with any form of TCAS, and this barrier was completely absent. Traffic Information was passed and appeared to have provided crucial information for the crews; given that the crews requested a Basic Service, they were fortunate on this occasion that the controller could see the squawks and had kept some form of track identity, even though it was not required under a Basic Service and controller workload was high. The look-out for both crews appears to 3

30 Airprox have been partially absent because the sightings were at 0.5nm for PA28(1) (Traffic Information passed at 1 nm) and PA28(2) reported first sighting at 200 metres (Traffic Information passed at 0.5nm). Ultimately, the information from Boscombe Zone and the late sightings, allowed the crews to take effective avoiding action. UKAB Secretariat At 1052:03 the Boscombe Zone controller passed the Portland QNH 1005hPa to the pilot of PA28(1) and approved his MATZ crossing; whilst the pilot did not readback the QNH, his report indicates that he was flying on 1005hPa. At 1056:56, the controller passed the Portland QNH 1005hPa to the pilot of PA28(2), who read it back correctly. From this point on the controller would have believed that both aircraft were on the same altimeter setting datum and would have passed Traffic Information accordingly. In fact, the pilot of PA28(1) reports flying at 2300ft on QNH 1007hPa, and the pilot of PA28(2) reports flying at 2500ft on QNH 1012hPa, which means, if their recollections are correct, that the aircraft were 65ft apart (1hPa=27ft). Both pilots had equal responsibility to avoid a collision. 2 The aircraft were approaching head-on so both pilots were required to alter course to the right 3, which they did. Summary An Airprox was reported between two PA28s in Class G airspace. Both pilots were in receipt of Basic Services from Boscombe Zone and received Traffic Information. Both pilots saw the other aircraft and took avoiding action in compliance with the Rules of the Air. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, transcripts of the relevant RT frequencies, radar photographs/video recordings, reports from the air traffic controller involved and reports from the appropriate ATC and operating authorities. Whilst both pilots had received Traffic Information, one of them had reported that it had been received quite late and the Board therefore discussed the actions of the Boscombe Zone controller. Noting that both pilots were in receipt of Basic Services (under which there is no requirement at all for the controller to identify or maintain track-identity on aircraft or to pass any Traffic Information), the Board agreed that the controller had done extremely well to pass both pilots as much information as he had, given the traffic situation and workload. The Board opined that if the pilots desired more Traffic Information then they would have been better served to have requested a Traffic Service. It was evident from this Airprox (and others) that many pilots had false expectations of what a Basic Service provides within ATSOCAS and the UK FIS. In this respect, the Board noted that the CAA had previously reported working on a Skyway Code project, which was aimed at improving the awareness of the practical application of regulations amongst airspace users in the same easily digestible way that the Highway Code does for road users. Noting that this project had been ongoing for some time, the Board resolved to recommend that the CAA reviews progress on delivering the Skyway Code as an aid to improving understanding of ATSOCAS / UK FIS. Turning to the cause and degree of risk, there was some discussion as to whether this was a late sighting by both pilots or whether they had flown into conflict with each other. Observing that both pilots had received Traffic Information, some members argued that, being aware of each other s presence, the pilots had then flown into conflict; however, others pointed out that the pertinent Traffic Information had been passed at around 1nm (under the controller s duty of care), and that this had only just given the pilots enough time to cue their lookout, see each other, and make avoiding action turns to the right. In the end it was agreed that the cause was best described as a late sighting by both pilots. Some members thought that the degree of risk was C because both pilots had turned 2 Rules of the Air 2007, Rule 8, Avoiding Aerial Collisions 3 Rules of the Air 2007, Rule 10, Approaching Head-on 4

31 Airprox effectively and averted the collision; however, after some discussion, it was agreed that, although the turns had been effective in increasing separation, they had come so late that the CPA had only been extended to 0.1nm and 100ft head-on, representing a much reduced safety margin. Therefore, a Category B assessment was agreed. PART C: ASSESSMENT OF CAUSE AND RISK Cause: A late sighting by both pilots. Degree of Risk: B. ERC Score 4 : 20. Recommendation(s): The CAA reviews progress on delivering the Skyway Code. 4 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 5

32 AIRPROX REPORT No Date/Time: 7 Aug Z Position: 5231N 00001W (IVO Benwick) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: Tutor S76 Operator: HQ Air (Trg) Civ Comm Alt/FL: 2300ft 2000ft RPS (1010hPa) QNH (1004hPa) Conditions: VMC VMC Visibility: 30km >10km Reported Separation: 100ft V/20m H Recorded Separation: NK V/0.1nm H 300ft V/0.5nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE TUTOR PILOT reports flying a white aircraft with strobes and navigation lights illuminated and SSR transponder Mode A, C and S selected. The aircraft was fitted with a TAS. He was receiving a Traffic Service from Lakenheath and conducting a PFL to a field, initially on a northerly heading. On descending through 2300ft and turning crosswind, he saw a dark-blue coloured rotary aircraft transiting directly below on a northerly heading. The traffic had not appeared on the TAS 1, and there had been no warning from Lakenheath ATC. The Captain took avoiding action by conducting an emergency break up and left. He reported the Airprox to ATC over the radio and elected to return to Wyton to continue the PFL exercise there. He assessed the risk of collision as Very High. THE S76 PILOT reports flying a blue aircraft with silver stripes. He did not report which lights were illuminated. He reported that his transponder had Modes A, C and S selected, and the aircraft was fitted with TCAS I. He was receiving a Basic Service from Cambridge, and first received a TCAS warning at 2nm. He saw the aircraft approaching from his left at about the same altitude; because it was approaching from the left he expected it to turn to go behind him but it appeared to do nothing, so he initiated a descent. He thought there was no risk of collision, and opined that as a professional pilot he was used to seeing aircraft close by. He assessed the risk of collision as None. THE LAKENHEATH CONTROLLER reports that he has no recollection of the incident. THE LAKENHEATH SENIOR CONTROLLER reports that, unfortunately, Lakenheath were notified 46 days after the event 2 and recordings are automatically deleted after 45 days. An investigation into the event found that the controllers involved could not remember the incident, and no record of a reported Airprox was in the Daily Record of Facility Operations. A flight strip was found with the 1 Traffic Advisory System 2 Lakenheath had become aware of the Airprox only when the UKAB staff had followed up the initial Aiprox notification procedure. It appeared that there had been a disconnect in formally notifying Lakenheath of the event, and UKAB staff are pursuing a more formalised process for notification of USAFE units and others through RAC, ATSI and BM investigative stakeholders.

33 Airprox details of the Tutor aircraft, but the flights strips do not indicate the Lakenheath controllers were speaking to a helicopter at that time. Factual Background The weather at Cambridge was reported as: EGSC Z VRB02KT 9999 SCT046 23/10 Q1014 Analysis and Investigation CAA ATSI The S76 departed from Cambridge and was in receipt of a Basic Service from Cambridge Approach who were providing the service without the aid of Surveillance Equipment. At 1621:47 the S76 reported that he was happy to QSY en-route and did not state the onward frequency he was going to. The S76 was not displaying an SSR code so it was not possible to determine his onward frequency from the transponder indication. The Airprox occurred just under 2 minutes after the S76 left the Cambridge frequency. The tracks of the S76 and Tutor crossed and the S76 reported the vertical distance between the two aircraft as 300ft with the Tutor reporting it as 100ft. Screenshot 1623:32 with S76 tracking north, Tutor displaying transponder code 0451 (Lakenheath) and tracking east. UKAB Secretariat Both pilots shared an equal responsibility for collision avoidance and for not flying into such proximity as to create a danger of collision 3. The geometry was a converging situation so the Tutor pilot was required to give way 4. Comments HQ Air Command This incident serves as a reminder that TAS will not always detect another transponding aircraft (though it is not clear in this case why the Tutor s TAS display did not show the helicopter) and also that TI from ATC may not be forthcoming; it is therefore essential to visually clear any intended flight path. The Tutor pilot was clearly surprised by the proximity of the helicopter, though the S76 pilot had received a TCAS contact at 2nm and gained visual with the Tutor coaltitude. However, it seems that the S76 pilot assumed that the Tutor pilot would have been visual and would then turn behind a flawed assumption that allowed the separation to decrease further. The S76 pilot could perhaps have been more proactive and manoeuvred in more than 3 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 4 ibid., Rule 9 (Converging). 2

34 Airprox one plane to increase the miss distance, noting that he states that he was comfortable with the separation generated. Notably, the two pilots had vastly differing assessments of the collision risk in this incident. USAFE UK It is regrettable that information on this Airprox reached Lakenheath too late for the production of a tape transcript. Further, had the controller been aware of Airprox immediately after its occurrence then, as is normal, the tapes would have been impounded at the time. That there is no record of the Airprox, either on the FPS or in the Daily Record of Facility Operation (Watch Log), as well as the controller having no memory of the incident, suggests that the airborne report from the Tutor was not received by the Lakenheath controller. That said, the Tutor appeared not to have received any Traffic Information on the S76, a matter which has been addressed by the Unit. Summary An Airprox was reported on 7 Aug 2014 at 1620 when a Tutor and a S76 flew into proximity at about 2000ft SW of Peterborough. The Tutor pilot was conducting a PFL instructional sortie and was receiving a Traffic Service from Lakenheath but did not receive any Traffic Information. The S76 was flying VFR and VMC; he received a traffic alert from his TCAS. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, radar photographs/video recordings, and reports from the appropriate ATC and operating authorities. The Board first expressed their disappointment that notification had not reached Lakenheath in time for the RT recordings to be saved and for the controller to recall the details. There was some discussion about whether the controller had assimilated the Airprox call because the reporting of the Airprox on the frequency by the Tutor pilot should have been a trigger to start the reporting process and impound the RT tapes. The Board noted that the Tutor pilot could not recall being given Traffic Information on the helicopter, which, under the terms of a Traffic Service, should have been passed. In looking at his actions, the Board members noted that, prior to conducting a PFL, pilots are required to visually check for a clear flight path. They could only conclude that, having presumably done so, the pilot had not seen the approaching helicopter because it was probably on a constant sightline at that point and presented a dark object against a dark background. Compounded by the lack of Traffic Information and no warning from the TAS, this meant that the Tutor pilot was unaware of the converging S76. Turning to the S76 pilot, the Board noted that he may have been better served getting a radar service from Lakenheath LARS instead of a Basic Service from Cambridge which had no radar. They were also mystified as to the status of his SSR; the pilot had reported it as on, but it didn t show on any of the NATS radars at the time of the Airprox, and the Tutor s TAS did not alert. The SSR of the S76 did show on radar 6 minutes after the incident (when it appeared with a squawk from another unit), which led the Board to conclude that it may have been turned to standby thus negating an important safety barrier for both ATC and electronic alerting systems. There then followed a discussion about whether the pilot was correct to continue on his track, despite having seen the Tutor on his TCAS reportedly at 2nm. Some Board members wondered whether the Tutor s change in height and direction took him by surprise but, notwithstanding, he had a degree of situational awareness which he should not have assumed was the same with the Tutor pilot. The Board agreed that, although he acted correctly in his interpretation of the Rules of the Air and in eventually taking action to avoid the Tutor, there was a fine line between maintaining course and speed and the benefits of taking action early enough to break the collision geometry before avoiding action became necessary. 3

35 Airprox In assessing the cause and risk, the Board noted a discrepancy in the reported pressure settings but believed this to be a recall, or typing, error by one of the pilots and therefore not a reliable way of assessing separation. The Board discussed the cause and agreed that the S76 pilot, having been visual with the Tutor from a good distance out, had flown into conflict with the Tutor. They also agreed that there was a contributory factor in that the Lakenheath Radar controller did not pass Traffic Information to the Tutor pilot which may have cued him to the S76 s presence. With regard to the risk, the Board agreed that, in the end, effective avoiding action by the S76 pilot had been taken, that he had been visual with the Tutor from a good distance out, and that this event was therefore best classified as a Category C. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Contributory Factor(s): Degree of Risk: The S76 pilot flew into conflict with the Tutor. Lack of Traffic Information to the Tutor pilot from the Lakenheath Radar controller. C ERC Score 5 : 4 5 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 4

36 AIRPROX REPORT No Date/Time: 16 Aug Z (Saturday) Position: 5159N 00117W (9nm N Oxford) Airspace: Oxford AIAA (Class: G) Aircraft 1 Aircraft 2 Type: ATR42 PAC 750XL Operator: CAT Civ Club Alt/FL: 3800ft ~ 3000ft NK NK Conditions: VMC VMC Visibility: >10km NK Reported Separation: Recorded Separation: 100ft V/0.5nm H 2-3nm H 500ft V/0.4nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE ATR42 PILOT reports making a radar vectored ILS approach to Oxford RW19. The blue and white aircraft had navigation, anti-collision and strobe lights on, as was the SSR transponder with Modes A, C and S selected. The aircraft was equipped with TCAS II. The pilot was operating under IFR in VMC and had been offered a Traffic Service by Oxford Radar, which he accepted. He had received multiple Traffic Information from ATC during the approach, many of which were against non-transponding contacts. During the base turn, given at about 10 mile range, Traffic Information was passed on a parachuting aircraft in the climb, east of the final approach track. The ATR42 pilot was cleared to descend from 4000ft to 3000ft. Whilst established on heading 090, passing 3800ft at a descent rate of 500fpm and 160kt, a TCAS alert was received on traffic in the left 11 o clock, range 4nm, 500ft below and climbing, followed about 5sec later by a Climb, Climb RA, with a commanded climb rate of 2000fpm. A climb was initiated and the Pilot Monitoring called TCAS RA on the radio. After about 5-10sec the RA changed to Monitor Vertical Speed with a 0-500fpm band. About 5sec after this the crew received a second TCAS RA Climb, Climb, with a commanded climb rate of 2000fpm. The RA cleared 5-10sec later with Clear of Conflict. The conflicting aircraft was not seen. The pilot noted that a short base-leg, at a range of about 10nm from Oxford, combined with the other aircraft climbing quickly gave them very little time to see the other aircraft or assess the situation. He assessed the risk of collision as High. THE 750XL PILOT reports conducting normal skydiving ops. The predominantly white aircraft had strobe lights selected on, as was the SSR transponder with Modes A and C. The aircraft was not equipped with an ACAS or TAS. The pilot was operating under VFR in VMC, listening out on London Control and Hinton Traffic on 2 radios. Whilst passing 3000ft, at 90kt, in a climbing left turn, the rearward-facing parachutist seated next to him pointed out a white and blue twin-engine, high-wing aircraft in the right 4-5 o clock at about the same level and flying towards them. He increased his rate of turn to the left and rolled out heading northeast to track back towards his airfield. Not the subject 750XL He assessed the risk of collision as Low to Medium.

37 Airprox THE OXFORD RADAR CONTROLLER: a report was not received from the Oxford controller. Factual Background The weather at Brize Norton and Oxford was recorded as follows: METAR EGVN Z 26006KT 9999 FEW024 16/10 Q1021 BLU NOSIG METAR EGTK Z 25006KT 9999 SCT049 15/11 Q1021 A transcript of the Oxford Radar RTF is reproduced below: From To Transcript ATR42 Oxford Oxford hello [ATR42 C/S] A T R forty three 1, information (0831:30) November, one zero two one, descending six thousand feet Q N H, one zero two one, direct to the Oxford Oxford ATR42 [ATR42 C/S] Oxford Radar good morning (0831:40)????? information is November, Q N H one zero two one is correct, vectoring for the I L S approach runway one nine ATR42 Oxford radar vectors I L S two er one nine [ATR42 C/S] (0831:50) Oxford ATR42 [ATR42 C/S] leaving controlled airspace in three miles, Traffic Service, fly heading three four five (0832:00) ATR42 Oxford fly heading three four five [ATR42 C/S] other traffic Oxford ATR42 (0836:30) [ATR42 C/S] descend to altitude three thousand feet ATR42 Oxford descend altitude three thousand feet [ATR42 C/S] (0836:40) Oxford ATR42 (0837:40) [ATR42 C/S] there's traffic in your twelve o'clock three miles er no- one thousand five hundred feet at least below your cleared level ATR42 Oxford looking (0837:50) [ATR42 C/S] Oxford ATR42 [ATR42 C/S] turn right heading three six zero degrees ATR42 Oxford (0838:20) right three six zero degrees [ATR42 C/S] Oxford ATR42 (0839:00) and [ATR42 C/S] traffic in your two o'clock range of five miles indicating two thousand two hundred feet climbing, it's [parachuting site] parachute dropper, turn right heading one one (0839:10) zero degrees ATR42 Oxford right one one zero degrees [ATR42 C/S] Oxford ATR42 [ATR42 C/S] that previously called traffic is east of you by two (0839:50) miles, three thousand feet, continue the right turn heading one six zero ATR42 Oxford TCAS RA Oxford ATR42 roger turn south Oxford ATR42 [ATR42 C/S] that aircraft's indicating three thousand two hundred feet in the climb, suggest a turn (0840:10) er due south, he's in a left turn ATR42 Oxford turn south [ATR42 C/S] ATR42 Oxford (0840:20) TCAS RA Oxford ATR42 roger Oxford ATR42 [ATR42 C/S] I ll vector you back round then I will be speaking to London about that they're supposed to stay in a dedicated area and he's gone way outside of (0840:50) it ATR42 Oxford er [ATR42 C/S] we're clear of traffic, we're heading er one eight zero and er altitude four thousand three hundred Oxford ATR42 [ATR42 C/S] roger (0841:00) turn right again heading er three four zero degrees ATR42 Oxford right heading three four zero degrees [ATR42 C/S] (0841:10) The Oxford Radar controller issued a total to 8 heading changes to the ATR42 pilot over the next 8min whilst vectoring for 2 further repositions to the localizer. 1 An ATR 42, 300 series, commonly referred to as ATR 43 although from the ATR 42 family of regional airliners. 2

38 Airprox Analysis and Investigation CAA ATSI ATSI had access to reports from both pilots together with area radar recordings and RTF and transcript of the Oxford Radar frequency. The ATR42 pilot was operating under IFR on a flight to Oxford and was in receipt of a Traffic Service from Oxford Radar. The 750XL pilot was operating under VFR, conducting parachute dropping while displaying SSR code 5007 (displayed as HINTON on the screenshots) and was in contact with Hinton Radio whilst listening out on TC Cowly East. At 0831:27, the ATR42 pilot contacted Oxford Radar, descending to 6000ft. The Oxford Radar controller informed the ATR42 pilot that it would be a Traffic Service outside controlled airspace and instructed the ATR42 pilot to fly heading 345 in order to position for the ILS RW19. At 0835:30, the ATR42 pilot was instructed to descend to 3000ft and subsequently instructed to turn right heading 360, see Figure 1 (0838:16). Figure 1 At 0839:00, the ATR42 pilot was informed of, traffic in your two o clock range of five miles indicating two thousand two hundred feet climbing, it s Hinton in the Hedges parachute dropper, turn right heading one one zero degrees. The heading was read back correctly, see Figure 2. Figure 2 3

39 Airprox At 0839:40, the Oxford Radar controller informed the ATR42 pilot, that previously called traffic is east of you by two miles three thousand feet continue the right turn heading one six zero, see Figure 3. Figure 3 The ATR42 pilot reported a TCAS RA at 0839:54 (see Figure 4) and the controller responded, turn south, before transmitting [ATR42 C/S] that aircraft s indicating three thousand two hundred feet in the climb suggest a turn er due south he s in a left turn. The ATR42 pilot read back turn south [ATR42 C/S]. Figure 4 The two aircraft continued to converge laterally as the ATR42 pilot was climbing, see Figure 5. Figure 5 At 0840:20, the ATR42 pilot again reported a TCAS RA to which the Oxford Radar controller replied, Roger, see Figure 6. 4

40 Airprox Figure 6 CPA occurred at 0840:23 when the two aircraft were 0.4nm apart, with the ATR42 500ft above the 750XL, see Figure 7. Figure 7 The Oxford Radar controller then informed the ATR42 pilot that they would be vectored again for the approach and that the parachute aircraft was supposed to stay in a dedicated area but was outside that. The ATR42 pilot reported clear of traffic heading 180 at 4300ft. The Oxford Radar controller initiated a phone call to LTC which was answered at 0843:18 by the TC North Supervisor. The Oxford controller stated that Oxford had a 3nm buffer against Hinton in the Hedges which was part of the TC agreement with Hinton and that recently aircraft had been outside the 3nm area. In the letter of Agreement between NATS, Hinton skydiving centre, Birmingham ATC and Oxford ATC there is an area of Designated Airspace defined as follows: That airspace within the DTY CTA within a 3nm radius of Hinton-in-the-Hedges, position N W excluding that portion of airspace contained within a circle of 7nm radius of Weston-on-the- Green position N W, the centre of EG D129. NOTE: The Drop Zone has a published radius of 1.5nm (AIP ENR). The Designated Airspace can be seen marked by a steady blue line in the top right hand corner of Figure 1 and is the only steady blue line in the subsequent screenshots. The section listing Hinton s associated responsibilities states that: f)all parachuting and associated aircraft operation is to be contained within the Designated Area whilst within Controlled Airspace.... 5

41 Airprox Oxford s responsibilities under the agreement include: 10.3 Subject to ATSOCAS Oxford ATC shall endeavour where possible to avoid the Drop Zone by informing aircraft of the activation of Hinton-in-the-Hedges. Oxford ATC shall warn any aircraft on frequency who appear to be operating in the vicinity of Hinton during notified operational hours of the likely activity of Hinton-in-the-Hedges, workload permitting. The letter of agreement only requires the Hinton parachuting aircraft to stay within the Designated Area when they are above FL65, which is the base of controlled airspace. The vectors the Oxford controller gave the ATR42 pilot were designed to position the aircraft onto the ILS whilst remaining clear of the Designated Area. The Oxford Radar controller was providing the ATR42 pilot with a Traffic Service (in accordance with Oxford s entry in the UK AIP, Oxford s standard service is a Traffic Service) and twice passed traffic information on the 750XL. The controller was not required to achieve deconfliction minima and the ATR42 pilot remained responsible for collision avoidance (although a controller should not knowingly introduce a confliction when providing headings for positioning). The Oxford Radar controller expected that the Hinton in the Hedges parachuting aircraft would stay in the Designated Area although the aircraft was below the base of controlled airspace. When the ATR42 pilot reported the first TCAS RA the Oxford Radar controller passed further instructions and traffic information to the ATR42 pilot on the 750XL. CAP493, the Manual of Air Traffic Services, Section 1, Chapter 10, Paragraph 5 states: 5.2 When a pilot reports a TCAS RA, controllers shall not attempt to modify the aircraft s flight path or reiterate previously issued instructions, until the pilot reports Clear of Conflict. Once an aircraft departs from an ATC clearance in compliance with an RA, or a pilot reports an RA, the controller ceases to be responsible for providing separation between that aircraft and any other aircraft affected as a direct consequence of the manoeuvre induced by the RA. The controller shall resume responsibility for providing separation for all the aircraft affected when: (1) The controller acknowledges a report from the flight crew that the aircraft has resumed the current clearance; or (2) The controller acknowledges a report from the flight crew that the aircraft is resuming the current clearance and issues an alternative clearance which is acknowledged by the flight crew. 5.3 The passing of traffic information by controllers to aircraft conducting, or affected by a TCAS RA, is not proscribed, but such information has, if provided inappropriately, the potential to be misheard or to distract flight crews during a period of very high workload. Consequently, controllers should not routinely pass traffic information to aircraft conducting RA manoeuvres, or other aircraft affected by such manoeuvres. Nevertheless, there may be circumstances where the passing of traffic information is justified; consequently, controllers may provide traffic information under the following circumstances: (1) To aircraft conducting an RA manoeuvre if it is considered essential for flight safety (e.g. information on aircraft which are known to be in close proximity that are not transponding Mode C information). (2) To other aircraft affected by an RA manoeuvre if judged necessary by the controller (e.g. in airspace where the carriage and operation of TCAS and/or SSR transponders is not mandatory). The Oxford Radar controller was vectoring the ATR42 pilot with the expectation that the 750XL pilot would remain in the Designated Area for Hinton in the Hedges despite the 750XL pilot being below the base of controlled airspace. The ATR42 pilot was ultimately responsible for his collision avoidance and the Oxford Radar controller provided traffic information twice on the 750XL pilot, fulfilling the requirements of both the CAP774 and the responsibilities allocated to Oxford under the Letter of Agreement with LTC, Birmingham and Oxford. Although it is recognised that the Oxford Radar controller was providing a Traffic Service to the ATR42 pilot and complied with both the requirements of the service and the letter of agreement, it is recommended that Oxford ATC either agree a course of action with Hinton in the Hedges whereby aircraft conducting parachuting remain in the designated area of airspace below the base of controlled airspace, or ensure that controllers at the unit are familiar with the exact nature of the existing agreement between LTC, Birmingham, Hinton and Oxford so that a risk of collision 6

42 Airprox is not inadvertently introduced to aircraft being vectored into Oxford, due to the assumption that Hinton parachuting aircraft will remain in the Designated Area below the base of controlled airspace. It is further recommended that Oxford ATSU issue a reminder of the requirements for controllers following the declaration of a TCAS RA by pilots. UKAB Secretariat The ATR42 and PAC 750XL pilots shared an equal responsibility for collision avoidance and not to fly into such proximity as to create a danger of collision 2. If the incident geometry is considered as converging then the 750XL pilot was required to give way 3. If the incident geometry is considered as overtaking then the 750XL pilot had right of way and the ATR42 pilot was required to keep out of the way of the other aircraft by altering course to the right 4. Summary An Airprox was reported when an ATR42 and a PAC 750XL flew into proximity at 0840 on Saturday 16 th August Both pilots were operating in VMC, the ATR42 pilot under IFR, in receipt of a Traffic Service from Oxford Radar, and the 750XL pilot under VFR, listening out on a London ACC TC frequency. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available consisted of reports from the pilots of both aircraft, a transcript of the relevant RT frequency, radar photographs/video recordings and a report from the appropriate ATC authority. Board members first considered the pilots actions. The ATR42 pilot was in receipt of a Traffic Service and was receiving radar vectors to the RW19 ILS. He followed the vectors issued by the Oxford controller and eventually received two TCAS RAs as the aircraft flew into proximity. Members noted that the ATR42 pilot shared responsibility for collision avoidance with the 750XL pilot and, although the pilot did not gain visual contact with the 750XL, he was passed Traffic Information on 2 occasions before the first RA and once afterwards. For his part, the 750XL pilot was operating in Class G airspace with the intention of climbing into CAS at base FL65. He was not in receipt of an Air Traffic Service but was listening out on both radios to frequencies which would be used during his climb and subsequent recovery. He did not see the ATR42 until it was pointed out to him in the right 4-5 o clock by the rear-facing parachutist seated next to him. Members agreed that the 750XL pilot would have been far better served by making RT contact with Oxford whilst conducting his flight in the immediate vicinity of the Oxford RW19 centre-line at a height which placed him close to aircraft descending to the glide-path. This would have allowed all parties to establish a greater degree of situational awareness and promote the safe, efficient and timely flow of traffic inbound to Oxford, in the Oxford AIAA. The Oxford controller had provided radar vectors to the ATR42 pilot, and members discussed whether the ATR42 had been vectored into conflict with the 750XL. It was apparent that the right turn on to a heading of 100 had been issued before the 750XL pilot had started his left turn. As such, the Board considered that the Oxford controller s vector was not into conflict at that time. Indeed, it was considered likely that the Oxford controller was operating under the assumption that the 750XL pilot was required to remain within the Hinton Designated Area and that he would turn right, away from the ATR42 track. However, the Board noted that this requirement only applied inside CAS (above FL65) and that the 750XL was entitled to climb up to FL65 in whichever manner he chose. As a result, the Oxford controller s assumption was flawed and members agreed that this false expectation was contributory to the Airprox because it had led the controller to discount the fact that the 750XL might 2 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 3 ibid., Rule 9 (Converging). 4 ibid., Rule 11 (Overtaking). 7

43 Airprox turn left when he was providing vectors to the ATR42. The Board agreed with the ATSI recommendation that clarification and updating of the Hinton/Oxford Letter of Agreement and associated responsibilities would be beneficial to all associated operators and controllers. The Board discussed the cause and risk and were of the opinion that this Airprox had arisen due to a conflict in Class G airspace where effective and timely actions had been taken by the ATR42 pilot to prevent aircraft collision, albeit due in the main to the ATR42 s TCAS. In the course of the discussion, members noted that the declaration of TCAS RA by a pilot was a formal declaration that the pilot was now responsible for collision avoidance and that the controller no longer held that responsibility. Similarly, the declaration of Clear of conflict, represented the formal handover of collision avoidance responsibility back to the controller. Members reiterated the importance of controllers not issuing instructions after a declaration of TCAS RA until the declaration of Clear of conflict. It was also noted that a TCAS RA event fell under the provisions of the Mandatory Occurrence Reporting Scheme, that the Oxford controller was required to report such, but that CAA Safety Data had not yet received a report from them. PART C: ASSESSMENT OF CAUSE AND RISK Cause: A conflict in Class G. Contributory Factor: The Oxford controller expected the 750XL pilot to remain within the Hinton Designated Area. Degree of Risk: C. ERC Score 5 : Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 8

44 Airprox AIRPROX REPORT No Date/Time: 15 Aug Z Position: 5047N 00044W (4.4nm SSE of Goodwood) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: Robin R2160i DA40 Operator: Civ Trg Civ Trg Alt/FL: 3000ft 3200ft QNH (1018hPa) QNH (1017hPa) Conditions: VMC VMC Visibility: 15km 10km Reported Separation: 0ft V/50m H Recorded Separation: 0ft V/<0.1nm H 0ft V/10m H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE ROBIN (HR20) PILOT reports flying an instructional sortie with a student pilot in a red and white aircraft. Strobe light and landing light were illuminated, and transponder Modes 3/A, C and S were selected; no ACAS 1 was fitted. The student was carrying out a medium-level turn exercise, VFR at 100kt, and deliberate look-out had been carried out. They saw an aircraft to their left, around 1000ft below and going away from them. They elected to turn right, away from this aircraft but, during the turn, a white single-engine low-wing aircraft, possibly a Diamond or Cirrus, flashed past them on their right, around 50m away and at the same level; they thought that this was the same aircraft that they had seen below them around 90sec earlier. He assessed the risk of collision as High. THE DA40 PILOT reports flying an instructional sortie, with a student pilot, in a blue and white aircraft with a strobe light illuminated and Squawking transponder Modes 3/A, C and S; no ACAS was fitted. Prior to departure, the crew had briefed to emphasize their lookout, and the Instructor had reminded the student that they were not flying IFR, but VFR using the VOR for lateral navigation. The student was practicing tracking to and from a VOR, and intercepting selected radials (under a Basic Service with Shoreham Approach) without the use of IFR goggles or hood. The instructor assessed the workload as low; they had tracked towards the GWC VOR, passed overhead it significantly above the ATZ, and then began practicing tracking to the south. Once this exercise was complete, the student was tasked to tune to the SFD VOR, intercept the 287 radial, track to the Shoreham overhead and then descend to 2000ft for an overhead join. Whilst heading 070 at 120kt, to intercept the 287 radial at 3200ft (QNH 1017hPa), they saw a red and white low-wing, single-engine aircraft, possibly a Vans or similar tail-dragger with black and white checker flag markings they recalled. They saw the other aircraft very late (around 10-15m away) descending towards them; there was only time for the student to raise the right wing but not to achieve any heading or altitude change. They saw the other aircraft veer to its left and thought that the other pilot was taking avoiding action. He assessed the risk of collision as High. 1 Airborne Collision Avoidance System 1

45 Airprox Factual Background The weather at Southampton at 1450 was recorded as: METAR EGHI Z 33004KT 300V FEW028 17/09 Q1018= Analysis and Investigation CAA ATSI The HR20 was in communication with Goodwood Information and the DA40 was in receipt of a Basic Service from Shoreham Approach. At 1457:51 the radar recording showed the HR20, squawking Mode 3/A 7000, in a left-hand orbit 3.5nm southeast of Goodwood Airport. The DA40 was squawking Mode 3/A 3763 (Shoreham VFR conspicuity) 4.4nm southwest of Goodwood tracking east. Both aircraft were indicating an altitude of 3000ft. At 1458:42 the HR20 took up a southerly heading and the distance between the two aircraft was 1.8nm (Figure 1). An unknown aircraft was shown at 2000ft, tracking west (also squawking Mode 3/A Shoreham VFR conspicuity). The HR20 pilot s written report indicated that he had sighted an (unknown) aircraft, 1000ft below, and going away from him, so he elected to turn right. Figure 1 Swanwick MRT at 1458:42 At 1459:06 the HR20 was shown turning right towards the DA40 at a horizontal distance of 0.8nm. The HR20 was indicating 100ft above the DA40 (Figure 2). 2

46 Airprox Figure 2 Swanwick MRT at 1459:06 The HR20 continued the right turn and, at 1459:18, the two aircraft were shown in close proximity at a range of less than 0.1nm and at the same level (3100ft) (Figure 3). The CPA occurred between radar sweeps; at 1459:18 both radar returns are shown with no measurable separation and both Mode Cs indicating A31, the next sweep of the radar showed that the two aircraft had passed and were diverging at the same level. The HR20 pilot reported that both aircraft were at the same level, and estimated the horizontal distance to be 50m. Figure 3 Swanwick MRT at 1459:18 No mention of the Airprox was made on the RT by the HR20 pilot to Goodwood information and the Goodwood FISO was not aware of the DA40 in transit. The DA40 was in receipt of a Basic Service from Shoreham Approach wherein: Pilots should not expect any form of traffic information from a controller, as there is no such obligation placed on the controller under a Basic Service, and the pilot remains responsible for collision avoidance at all times. 2 2 CAP774, Chapter 2, Paragraph 2.5 3

47 Airprox The DA40 pilot s written report was not received within 30 days of the occurrence and it was not possible to obtain RT recordings from Shoreham approach. UKAB Secretariat Both pilots had equal responsibility for avoiding collisions and for ensuring that do not fly in such proximity to other aircraft as to create a danger of collision. 3 Summary An Airprox was reported in Class G airspace 4.4nm to the south-southeast of Goodwood, between a Robin R2160i, being flown VFR on an instructional sortie, and a DA40 being flown VFR on an instructional sortie with a Basic Service from Shoreham Approach. Both crews became aware of the other aircraft very late and had little time in which to take avoiding action. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, radar photographs/video recordings and reports from the appropriate ATC and operating authorities. The Board agreed that given that the HR20 pilot was not in receipt of an Air Traffic Service, and that the DA40 pilot was in receipt only of a Basic Service, look-out was the central theme to this occurrence. Members with good local knowledge opined that the DA40 pilot may have been better served by talking to Goodwood in that area given that Shoreham was quite distant. This may then have alerted the pilots to each other s presence, but this was not the central cause of the Airprox. It was noted that both aircraft were being flown on instructional sorties and members opined that the demands of instructing may have had an impact on the pilots respective lookouts; equally, the HR20 pilot may have had his attention captured by the aircraft that he saw 1000ft below him just before the Airprox. The Board quickly agreed that, although the crews had seen each other s aircraft, the sightings were so late that they could not have taken any effective action. They determined therefore that the cause was effectively a non-sighting by both pilots. Turning to the degree of risk, members noted that both pilots reports had correlated with a radar-recorded CPA of <0.1nm H and 0ft V. They therefore agreed that this had been a situation that had just stopped short of an actual collision, where separation had been reduced to the minimum and / or where chance had played a major part in events; consequently, they agreed that this was a risk Category A incident. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Effectively a non-sighting by both pilots. Degree of Risk: A. ERC Score 4 : Rules of the Air 2007, Rule 8, Avoiding Aerial Collisions 4 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 4

48 Airprox AIRPROX REPORT No Date/Time: 9 Aug Z (Saturday) Position: 5138N 00049W (NW Wycombe Air Park) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: Robin DR221 PA28 Operator: Civ Pte Civ Pte Alt/FL: 2000ft 2000ft QNH (1017 hpa) Conditions: VMC VMC Visibility: 50km >10km Reported Separation: 50ft V/0ft H 100ft V/75m H Recorded Separation: 100ft V/ 0.1nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE DR221 PILOT reports flying a white aircraft with transponder Modes 3A and C selected, he did not report which lights were illuminated. The aircraft was not fitted with a TCAS. He called Wycombe prior to entering their ATZ to request a transit 2nm to the northwest. This was granted and, shortly after entering the zone, a white single-engine aircraft flew underneath him on a reciprocal track. He reported the situation to the controller who replied that the aircraft was not talking to them. He opined that as an experienced pilot with well over 2500 hours flown in this aircraft, he was well aware that having been cleared into the Wycombe ATZ he was responsible for his own separation but, although he was looking for gliders, both being towed and soaring, and powered aircraft taking off, landing, and in the circuit, he was not expecting to see aircraft at the same level in the opposite direction frighteningly close. He saw it too late to take any avoiding action. He was concerned enough to telephone Wycombe on his return and was told that no action had been taken to trace the infringing aircraft, it was recommended to him that he file an Airprox. He assessed the risk of collision as Very High. THE PA28 PILOT reports flying a predominately white aircraft with all lights illuminated and transponder Modes 3A, C and S selected. The aircraft was fitted with TAS. The pilot had just got airborne from Wycombe Air Park and was transiting back through the ATZ prior to calling Luton to transit through their zone. There were 3 very experienced pilots in the aircraft. The co-pilot could recall hearing a clearance being given to another aircraft to transit the Wycombe ATZ at 2000ft, but the PF could not recall this and opined it must have been a late call, otherwise the other pilot would have heard his calls to get airborne and transfer to Luton. He also thought that routing through the overhead at 2000ft wasn t a good idea because Wycombe Air Park can be extremely busy with fixed wing aircraft, gliders and helicopters, operating from different surfaces and strips. He felt that routing 2400ft, ie above the ATZ was a better idea. He had chosen to route back through the valley at 2000ft to be noise neighbourly and had switched to Luton frequency early to enable him to make the request to transit through the Luton zone. His Monroy TAS sounded, (it doesn t give a direction, just a height difference, and experience has shown that it doesn t give very much time warning), so he instantly searched for the traffic and saw it 400m away. He judged that there was no need to take avoiding action, as there was no risk of collision, and, although he acknowledged that it was closer that he would have liked, he did not judge it to be an Airprox. He thought that ATC at Wycombe were very professional and did a good job of controlling an incredibly busy airfield. 1

49 Airprox He assessed the risk of collision as None. THE WYCOMBE CONTROLLER reports that he had limited recollection of the details leading to the event. He noted that although many eastbound departures left the ATZ downwind, others left via local positions outside the circuit; however, he would expect a pilot to remain on the Wycombe Tower frequency if leaving downwind, and, in this case, having left the frequency climbing crosswind, not to re-enter the ATZ. Factual Background The weather at Benson was recorded as: METAR EGUB Z AUTO 23008KT 9999 FEW024 18/12 Q1008 Analysis and Investigation CAA ATSI The DR22 called Wycombe routeing NE-SW requesting a clearance through the northern portion of the ATZ at 2100ft QNH (approx 1600ft QFE) which was approved by the Wycombe Tower controller. The PA28 reported ready for departure from Wycombe and was given take-off clearance. The PA28 departed to the west, reporting clear of the ATZ at 0946:25 and changing frequency to Luton Radar on MHz. The PA28 subsequently requested a Basic Service from the Luton Radar controller, which was agreed, and an SSR code 4670 allocated to the PA28. The PA28 turned to the northeast, re-entered the Wycombe ATZ without a clearance and came into conflict with the DR22. The Airprox occurred 1.6nm north-northwest of the aerodrome, inside the ATZ. The DR22 reported to Wycombe Tower that traffic had just passed underneath approximately 200ft below, to which the Tower controller replied that he did not know who the traffic was. The Wycombe Tower controller reported that he would expect a pilot to remain on the Wycombe Tower frequency if leaving downwind and if that had been the case then appropriate traffic information would have been passed to both aircraft. As the PA28 reported changing frequency having left the ATZ to the West the Tower controller did not pass traffic information to either aircraft. The Wycombe Tower controller could remember little of the incident however it is likely that, with the PA28 outside the ATZ to the west and the DR22 entering the ATZ to the northeast, the controller did not think that the two aircraft were relevant to each other. The Luton Radar controller did not pass traffic information to the PA28 and, because the PA28 was under a Basic Service, was not required to monitor the flight. The Luton Radar controller had no recollection of the incident afterwards. 0948:55 PA28 squawking 4670, range 1.8nm from Wycombe 2

50 Airprox CPA at 0949:06, 1.6nm from Wycombe UKAB Secretariat Both pilots shared an equal responsibility for collision avoidance and for not flying into such proximity as to create a danger of collision 1. The geometry was head-on; therefore, both pilots were required to alter course to the right. 2 Additionally, pilots are required to seek permission from the ATCU to enable flight to be conducted safely within an ATZ, and to advise on entering the ATZ. 3 Summary An Airprox was reported on 9 Aug 2014 at 0949 when a Robin DR221 and a PA28 flew into proximity at 2000ft. The DR221 was transiting through the ATZ and receiving a Basic Service and the PA28 had just got airborne, was transiting back through the ATZ and had switched frequency to Luton. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, radar photographs/video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities. The Board first looked at the action of the DR221 pilot and agreed that he acted correctly in calling Wycombe ATC for an ATZ crossing in plenty of time, and that his choice of height seemed a reasonable one given the surrounding airspace restrictions. Having received a clearance to cross, he was aware of the need to continue his look-out, although was understandably not expecting to see an aircraft at the same height in the opposite direction. For the PA28 pilot, having got airborne and left the ATZ, the Board thought he had probably become task focused in calling Luton for his zone crossing and had not considered the consequences of leaving the Wycombe frequency early. It was clear that the controller had not expected him to reenter the ATZ, had he remained on frequency he would have known about the other aircraft and would have been able to inform the controller (and provide valuable SA to the DR221 pilot) as he reentered or flew close to the edge of the ATZ. If he needed the extra time to call Luton for the subsequent routing he would have been better placed to have remained outside the Wycombe ATZ and perhaps conducted an orbit to allow himself more time. Furthermore, the Board noted that he had criticised the DR221 pilot for crossing the ATZ at 2000ft when a higher altitude was available, but had proceeded to do the same thing himself. 1 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 2 Ibid., Rule 10 (Approaching Head-on) 3 Ibid., Rule 45 (Flights within Air Traffic Zones) 3

51 Airprox Considering the cause, the Board concluded that the PA28 pilot had re-entered the Wycombe ATZ without informing ATC and had then flown into conflict with the DR221. With regard to the risk, the Board could not reconcile the differing opinion in the assessment of risk of collision by the two pilots; however, given that the recorded separation was 100ft vertically and less than 0.1nm horizontally, they concluded that it was probably best described as Category B, safety margins had been much reduced below the normal. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Degree of Risk: The PA28 pilot re-entered the Wycombe ATZ without informing ATC and flew into conflict with the Robin. B ERC Score 4 : Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 4

52 AIRPROX REPORT No Date/Time: 9 Aug Z (Saturday) Position: 5212N 00010E (Cambridge) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: C550 Untraced Gliders Operator: Alt/FL: Conditions: VMC Visibility: Civ Comm 4000ft QNH (1007hPa) >10km Reported Separation: 0ft V/<1nm H Recorded Separation: NK PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE C550 PILOT reports starting the RW23 ILS procedure at Cambridge. The white and blue aircraft had beacon, wing-tip strobes and recognition lights selected on, as was the SSR transponder with Modes A, C and S. The aircraft was fitted with TCAS. The pilot was operating under IFR in VMC in receipt of a Procedural Service from Cambridge Approach. He was inbound to the CAM NDB from the southwest, had been cleared to descend to 4000ft, and was number 2 to traffic already outbound on the procedure. When within a mile or two of the NDB, heading 030 at 180kt and level at 4000ft, opposite direction glider traffic was seen rather late and at a similar altitude. The auto-pilot was disengaged and the aircraft visually turned away from the contact. A second glider was subsequently seen in the direction the aircraft was being turned and a descent and turn back towards the first glider was made. A third, non-conflicting, glider was also seen and the pilot noted that all three gliders were within 1nm range. ATC was notified that IFR was being cancelled. The pilot stated that no Traffic Information was available regarding the presence of any traffic for the arrival. He assessed the risk of collision as High. THE GLIDER PILOT: Despite extensive tracing action, none of the glider pilots involved could be located. THE CAMBRIDGE CONTROLLER reports the C550 was cleared in the decent to the CAM [NDB] initially for an ILS approach RW23. At approximately 1352, and 2nm before reaching the CAM the pilot reported at least three gliders in the CAM overhead all in the altitude block 3500ft to 4500ft. The pilot reported taking avoiding against all three gliders, all within 1nm, one 100ft above and the other two 200ft and 300ft below. The gliders were unknown to Cambridge. Factual Background The Cambridge weather was recorded as follows: METAR EGSC Z 23014KT 150V SCT048 22/11 Q1007 A transcript of the Cambridge Approach RTF was provided, as follows: 1

53 Airprox From To Transcript C550 Cambridge Cambridge????? [C550 C/S] information November, Q N H one zero zero seven, (1348:00) five thousand feet er request visual join if available, visual with the A T R Cambridge C550 [C550 C/S] roger it's er (1348:10) non-radar procedural service, inbound, information November, runway two three's in use, the Q N H one zero zero seven, just confirm your range from the field C550 Cambridge (1348:20) two miles from the field [C550 C/S] Cambridge C550 [C550 C/S] roger, descend altitude four thousand feet on the Q N H one zero zero seven C550 Cambridge descend altitude four thousand feet Q N H one zero (1348:30) zero seven [C550 C/S] and just for information glider twelve o'clock directly overhead the airport approximately (1348:40) four thousand eight hundred feet descending and????? there's about two or three gliders in the overhead, request er we- go visual now Cambridge C550 [C550 C/S] (1348:50) roger take your own avoiding action on that traffic and contact Cambridge Tower one two five decimal niner C550 Cambridge okay one two five niner and for further information there's at least three gliders directly (1349:00) in the overhead of Cambridge between er about three and a half to four and half thousand feet manoeuvring Cambridge C550 roger that's understood, we were aware of some north of the field but not in the overhead, thanks for the call (1349:10) Cambridge C550 [C550 C/S] contact Cambridge Tower one two five decimal niner Analysis and Investigation CAA ATSI ATSI had access to Cambridge RTF and area radar recording, together with the written reports from the controller and the C550 pilot. The C550 pilot was operating under IFR inbound to Cambridge, and was in receipt of a Procedural Service from Cambridge Approach. The glider pilots were untraced but Cambridge ATC believed that they may have been operating from Gransden Lodge. The Cambridge Manual of Air Traffic Services (MATS) Part 2, Page 29, Paragraph 10.2, states: Gliding takes place at Gransden Lodge 10nm SW of Cambridge. Gliders can be launched up to 3000 feet altitude by cable winch, or launched by glider-tug. Gransden shall be considered always active although details are usually faxed to ATC when gliding events are scheduled. The site is marked on situational displays. A/C should be warned where it is suspected that gliding may be occurring. A/C being vectored should be vectored to avoid the site if any doubt exists. Gransden Lodge occasionally host gliding competitions. Prior to launch a member of the club should telephone ATC with details of numbers, routing etc. Information is also available online. If doubt exists, or for traffic updates, ATC will contact the club. Information on known intense gliding activity will be displayed on a temporary basis at each operational position, and updated as required by the ATCO I/C. Cambridge ATC were providing a split Aerodrome and Approach Control service without the aid of surveillance equipment. Controller training was in progress in both positions and workload was assessed as light to medium. The UK AIP page AD 2.EGSC-9 (29 May 2014) states for Radar: Available intermittently Mon-Fri during normal working hours and by arrangement only. Radar would not have shown gliders operating in the overhead. At 1347:00, the Stansted single source radar replay showed the inbound C550, 7.3nm south of Cambridge, passing 5600ft following an ATR 42 at 3100ft. Both aircraft s pilots were inbound IFR in receipt of a Procedural service. Also shown are a number of intermittent glider contacts, see Figure 1. 2

54 Airprox Figure 1: Stansted single source radar at 1347:00 At 1347:50, the C550 pilot contacted Cambridge Approach reporting in receipt of information N with QNH 1007hPa.. At 1348:52, radar replay showed the C550 overhead the airfield at FL049 (5000ft) with intermittent gliders showing 2.5nm west and 2.7nm southeast. It was likely that other gliders in the area were not shown on the radar replay, see Figure 2. Figure 2: Stansted single source radar at 1348:52 3

55 Airprox At 1349:30, the C550 pilot contacted the Tower and continued to join on a right base to land without further incident. In discussion, the Approach controller recalled that he had received a couple of calls from glider pilots operating north of Cambridge but, prior to the Airprox, Cambridge ATC had not been aware of the full extent of the gliding activity in the Cambridge overhead. The Cambridge Approach controller believed that the gliders were operating from Gransden Lodge but no notification had been received regarding a gliding event or of any other planned activity in the vicinity of Cambridge. When asked, the Cambridge controller confirmed that he had been aware of gliders to the north but not in the immediate vicinity. He thought that arriving aircraft were being advised to look out for gliders but couldn t recall if this had been broadcast on the ATIS prior to the incident. He explained that when Cambridge are aware of gliding activity the ATIS would be updated together with the local ATC webpage. In order to try and address concerns about aircraft routeing close to gliders a meeting occurred earlier in 2014 between Cambridge Airport, the Cambridge Airlines safety representative and a Gransden Lodge gliding club representative. As a result of the meeting, and in order to mitigate against IFR traffic coming into proximity with gliders, Cambridge ATSU asked the CAA to update the Cambridge UK AIP approach charts, to indicate the intense gliding activity at Gransden Lodge. Additionally Cambridge ATSU issued a MATS Part 2 supplementary instruction (SI-02/14) to controllers, effective 24 July 2014, which states: Gransden Lodge is a notified gliding site making up to 15,000 winch launches per year. Winch launching can take place with a maximum release altitude of 3300 feet AMSL and aerotow to any altitude outside of CAS. Intense gliding activity can be expected within 1nm from the airfield with further activity in the local area. The site should be considered active seven days a week during daylight hours. Even when weather conditions are poor there may be winch launching in progress (practising aborted launches or cable breaks etc). Following a number of encounters with traffic routing close to Gransden Lodge gliding site it is necessary to introduce measures to mitigate against traffic routing IFR to Cambridge to ensure that Gransden Lodge is avoided by a sensible margin to remove the possibility of an encounter with an IFR aircraft and a glider/winch cable combination. The supplementary instruction outlines procedures to be implemented to ensure that arriving IFR aircraft are routed clear of Gransden Lodge not below 4000ft. The C550 pilot contacted Cambridge Approach as he approached the airfield and 40sec later reported taking avoiding action against gliders in the overhead. The Approach controller had earlier received RT calls from two glider pilots operating to the north, but there had not been sufficient time to pass any warning to the C550 pilot. The controller was unprepared and unaware of the intense gliding activity in the overhead and in the vicinity of Cambridge Airport. The C550 pilot was in receipt of a Procedural Service and CAP774, UK Flight Information Services, Chapter 5, Paragraph 5.1 states: A Procedural Service is an ATS where, in addition to the provisions of a Basic Service, the controller provides restrictions, instructions, and approach clearances, which if complied with, shall achieve deconfliction minima against other aircraft participating in the Procedural Service. Neither traffic information nor deconfliction advice can be passed with respect to unknown traffic. The radar replay only showed gliders intermittently and it was therefore not possible to identify the glider involved or to show the specific geometry of the occurrence. Cambridge airfield is situated close to Gransden Lodge in a busy Class G airspace environment. The issues regarding gliders is complex and gliders are often intermittent on radar and will not be seen in the overhead. Glider pilots may call Cambridge but this is often dependant on whether they carry a radio and hold an RT licence. The ATSU have been pro-active in trying to reduce risk and mitigate against encounters between IFR aircraft and gliders. Cambridge have updated the appropriate charts in the UK AIP and have introduced procedures to avoid Gransden Lodge. 4

56 Airprox UKAB Secretariat All pilots shared an equal responsibility for collision avoidance and not to fly into such proximity as to create a danger of collision 1. If the incident geometry is considered as converging then the C550 pilot was required to give way to the glider pilot 2. If the incident geometry is considered as head-on then both pilots were required to turn to the right 3. If the incident geometry is considered as overtaking then the glider pilot had right of way and the C550 pilot was required to keep out of the way of the other aircraft by altering course to the right 4. Comments BGA As noted above, this is a busy Class G environment with a mix of traffic types. Effective lookout is the primary means of risk mitigation in these circumstances and worked in this case. It is unfortunate that the glider pilots could not be traced; however it is unlikely that they were familiar with the NDB procedure routings and altitudes as these are not shown on VFR charts. It is encouraging to note that at least some glider pilots in the area notified Cambridge of their activity. Summary An Airprox was reported when a Cessna 550 and gliders flew into proximity at about 1349 on Saturday 9 th August All pilots were operating in VMC, the C550 pilot under IFR in receipt of a Procedural Service from Cambridge and the glider pilots under VFR, most likely not in receipt of an Air Traffic Service. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available consisted of a report from the C550 pilot, a transcript of the relevant RT frequency, radar photographs/video recordings, a report from the air traffic controller involved and a report from the appropriate ATC authority. The Board first considered the C550 pilot s actions. The C550 pilot was inbound to Cambridge and, although operating under IFR, nevertheless remained responsible for collision avoidance. Without the aid of surveillance, his Procedural Service would only include ATC-derived separation against other aircraft participating in the same service, although his TCAS would provide traffic information on traffic equipped with, and using, an SSR transponder. Therefore, his only means of mitigation against mid-air collision with non-transponder equipped aircraft was the use of see-and-avoid. In the event, he saw 3 conflicting gliders and took appropriate and timely avoiding action. The glider pilots were operating in Class G airspace in accordance with the privileges afforded them within that airspace; however, members were of the opinion that soaring in the overhead of an established commercial airport at a reported altitude of 5000ft should be avoided if possible and, if necessary, would be conducted much more safely with associated RT contact with the aerodrome concerned if possible. Members were aware that many glider pilots were not in possession of an RT license and consequently could not make such a call; although in that case it was felt appropriate that such glider pilots should include the position of a likely IFR hold in their assessment of desired track and avoid it. Members noted that the presence of the feathers symbol on the CAA VFR 1: scale chart indicated aerodromes with instrument procedures outside CAS, and should also serve as an indication that the airfield may have an IFR holding pattern in or near the overhead. Members recalled that, as a result of Airprox and , the CAA had been recommended to consider producing a chart of UK airfield IFR holding pattern positions and that such a chart could have provided valuable deconfliction information in this case. 1 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 2 ibid., Rule 9 (Converging). 3 ibid., Rule 10 (Approaching head-on). 4 ibid., Rule 11 (Overtaking). 5

57 Airprox With regard to Gransden Lodge, a gliding member stated that he had contacted them about this incident and they had reported that glider pilots operating from Gransden Lodge were very aware of the traffic patterns around Cambridge airport; consequently, they opined that the glider pilots in this incident were most likely based at another airfield further away. It was reiterated that the Airprox occurred on a weekend on a good weather day, that Cambridge was located at a point that was regularly traversed by glider pilots on cross-country flights, and that there was a high likelihood that the glider pilots could have flown from airfields which were hundreds of kilometres distant from the Airprox location. With this in mind, members were also of the opinion that more could be done, in particular to inform other airspace users of glider competition or daily task tracks, and resolved that Director UKAB would continue his contact with the BGA with a view to understanding how this might best be achieved. In the absence of a report from any of the glider pilots, it was not possible to ascertain their perspective of the event or whether a system such as PowerFLARM was fitted and of use. However, the Board were content that sufficient information existed to determine that the cause of the Airprox was a conflict in Class G airspace, and that the C550 pilot had resolved it by taking effective and timely avoiding action. PART C: ASSESSMENT OF CAUSE AND RISK Cause: A conflict in Class G resolved by the C550 pilot. Degree of Risk: C. ERC Score 5 : Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 6

58 AIRPROX REPORT No Date/Time: 9 Aug Z (Saturday) Position: 5216N 00023E (9.4nm NE Cambridge Airport) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: ATR 42 Glider Operator: CAT Unknown Alt/FL: 1700ft NK QNH (1007hPa) Conditions: VMC NK Visibility: >10km NK Reported Separation: 0ft V/0.5nm H Recorded Separation: NK NK PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE ATR 42 PILOT reports being inbound to Cambridge airport (CBG) under IFR/VMC. The aircraft was company coloured; strobes, navigation and landing lights were illuminated; SSR Modes C and S were selected. TCAS 2 was fitted. As they were in the procedure turn for the ILS RW23, turning inbound to intercept the course, the crew noticed a glider, same altitude, at about 0.5nm, heading towards them. They altered their course from 300 ( they were in the turn) to heading 330 by turning right quickly to avoid it. The glider pilot was turning left and right, and they were not sure that they had been noticed. It was uncomfortable as they did not know the pilot s intentions. They reported the traffic to the Approach controller who had no radar return from the glider or radio contact with its pilot. They were eventually able to turn safely onto final, keeping the glider in sight at all times, to continue the approach. They informed ATC that an Airprox report would be filed. She assessed the risk of collision as High. THE GLIDER PILOT could not be not traced. THE CBG AERODROME CONTROLLER reports that the ATR42 pilot was transferred to the CBG Tower frequency on establishing on the localiser RW23. On coming onto frequency, he spotted a glider in close proximity to the aircraft which he called to the pilot. The pilot reported that they had come very close to another glider on completion of the base turn onto the localiser. Due to the workload at the time, and because he was screening a trainee controller, he asked the pilot to contact him on the ground if it was their intention to file an Airprox. The pilot telephoned and reported an Airprox at 1353 at 1700ft when avoiding action had been taken against a glider before re-establishing on the ILS. The pilot estimated the miss distance as less than 1nm. The weather at the time was good VMC. Two minutes earlier, an arriving Citation pilot had taken avoiding action in the CMB overhead against further gliders. Factual Background The CBG weather was: METAR EGSC Z 23014KT 150V SCT048 22/11 Q1007= 1

59 Airprox CAP774 1, UK Flight Information Services, defines a Procedural Service: A Procedural Service is an ATS where, in addition to the provisions of a Basic Service, the controller provides restrictions, instructions, and approach clearances, which if complied with, shall achieve deconfliction minima against other aircraft participating in the Procedural Service. Neither traffic information nor deconfliction advice can be passed with respect to unknown traffic. Analysis and Investigation CAA ATSI ATSI had access to CBG RTF and area radar recordings, together with the written report from the controller and the ATR 42 pilot. The Airprox occurred at 1351:20, 9.4nm northeast of CBG within Class G uncontrolled airspace between an ATR 42 and a glider. The AT42 was operating an IFR flight inbound to CBG and was in receipt of a Procedural Service from CBG Approach on frequency 123.6MHz. CBG ATC believed that the glider may have been operating from Gransden Lodge. The CBG Manual of Air Traffic Services (MATS) Part 2 2 states: Gliding takes place at Gransden Lodge 10nm SW of Cambridge. Gliders can be launched up to 3000 feet altitude by cable winch, or launched by glider-tug. Gransden shall be considered always active although details are usually faxed to ATC when gliding events are scheduled. The site is marked on situational displays. A/C should be warned where it is suspected that gliding may be occurring. A/C being vectored should be vectored to avoid the site if any doubt exists. Gransden Lodge occasionally host gliding competitions. Prior to launch a member of the club should telephone ATC will details of numbers, routing etc. Information is also available online. If doubt exists, or for traffic updates, ATC will contact the club. Information on known intense gliding activity will be displayed on a temporary basis at each operational position, and updated as required by the ATCO I/C. CBG ATC were providing a split Aerodrome and Approach Control service on a Saturday, without the aid of surveillance equipment. Controller training was in progress in both positions and workload was assessed as light to medium. The UK AIP 3 states for Radar: Available intermittently Mon-Fri during normal working hours and by arrangement only. Radar would not have shown gliders operating in the overhead. At 1345:52 the ATR42 pilot contacted CBG Approach descending to 4000ft on QNH 1007hPa. The controller replied advising a non-radar Procedural Service. The ATR42 pilot was instructed to continue towards the Cambridge (CAM) NDB in the descent to 3000ft on QNH 1007hPa. This was acknowledged correctly and the ATR42 pilot reported passing 3900ft. The controller cleared the ATR42 pilot for the ILS approach RW23 with no delay to report beacon outbound. At 1347:00 the Stansted single-source radar replay showed the ATR42 4.3nm southwest of CBG at 3100ft. Also shown are a number of intermittent glider contacts - Figure 1. 1 Chapter 5, Paragraph Page 29, Paragraph Page AD 2.EGSC-9 (29 May2014). 2

60 Airprox Figure 1 Stansted single source radar at 1347:00 At 1349:20 the ATR42 pilot reported beacon outbound and the controller instructed them to report when localiser established. At 1351:20 the ATR42 pilot reported and (ATR42 C/S) we have a glider just er er on our right sion the left side. The controller replied (ATR42 C/S) roger understood roger it s unknown to us we are non-radar. At 1351:37 radar reply showed the ATR42 commencing the base turn with an unknown contact (glider) 0.9nm to the west-southwest of the ATR42. It was not known if this was the glider involved in the Airprox Figure 2. Figure 2 Stansted single source radar at 1351:37 3

61 Airprox At 1351:40 the ATR42 pilot reported (ATR42 C/S) he s at the exact er same altitude as us and the controller responded (ATR42 C/S) roger keep a good lookout we non radar so I m unable to assist in any traffic information which was acknowledged. The ATR42 pilot s written report indicated that when in the procedure turn the crew sighted a glider at the same altitude at a range of about half a mile heading towards them. The ATR42 pilot reported turning right to avoid from a heading of 300 to 330. The ATR42 pilot kept the glider in sight and continued the base turn onto final approach. At 1352:50 the ATR42 pilot reported, (ATR42 C/S) localiser established keeping an eye on the er gliders?????. The controller advised (ATR42 C/S) roger just be advised traffic has gliders have been reported overhead the field so keep a very good lookout descend on the glidepath QNH one zero zero seven. The ATR42 pilot was transferred to the Tower at 1353:14. When asked the CBG controller confirmed that he had been aware of gliders to the north but not in the immediate vicinity. He thought that arriving aircraft were being advised to look out for gliders but could not recall if this had been broadcast on the ATIS prior to the incident. He explained that when CBG were aware of gliding activity the ATIS would be updated together with the local ATC webpage. The ATR42 pilot had reported beacon outbound at 3000ft but had not mentioned sighting any gliders. It was only when a following aircraft reported taking avoiding action in the overhead that the controller became aware of the intense glider activity overhead the airfield. In order to try and address concerns about aircraft routeing close to gliders a meeting occurred earlier in 2014 between CBG, the CBG Airlines safety representative and a Gransden Lodge gliding club representative. As a result of the meeting, and in order to mitigate against IFR traffic coming into proximity with gliders, CBG ATSU asked the CAA to update the CBG UK AIP approach charts, to show the intense glider activity at Gransden Lodge. Additionally CBG ATSU issued a MATS Part 2 Supplementary Instruction (SI-02/14) to controllers effective 24 July 2014: Gransden Lodge is a notified gliding site making up to 15,000 winch launches per year. Winch launching can take place with a maximum release altitude of 3300 feet AMSL and aerotow to any altitude outside of CAS. Intense gliding activity can be expected within 1nm from the airfield with further activity in the local area. The site should be considered active seven days a week during daylight hours. Even when weather conditions are poor there may be winch launching in progress (practising aborted launches or cable breaks etc). Following a number of encounters with traffic routing close to Gransden Lodge gliding site it is necessary to introduce measures to mitigate against traffic routing IFR to Cambridge to ensure that Gransden Lodge is avoided by a sensible margin to remove the possibility of an encounter with an IFR aircraft and a glider/winch cable combination. The Supplementary Instruction outlines procedures to be implemented to ensure that arriving IFR aircraft are routed clear of Gransden Lodge not below 4000ft. The radar replay only showed gliders intermittently and it was therefore not possible to identify the glider involved or to show the specific geometry of the occurrence. The ATR42 pilot sighted the Glider as they commenced the base turn and took avoiding action by reversing the turn from a heading of 300 to 330. CBG is situated close to Gransden Lodge in a busy Class G airspace environment. The issues regarding gliders is complex and gliders are often intermittent on radar and will not be seen in the overhead. Gliders may call CBG but this is often dependant on whether they carry a radio or hold 4

62 Airprox an RT licence. The ATSU have been pro-active in trying to reduce risk and mitigate against encounters between IFR aircraft and gliders. CBG have updated the appropriate charts in the UK AIP and have introduced procedures to avoid Gransden Lodge. UKAB Secretariat Both pilots shared an equal responsibility for collision avoidance and not to fly into such proximity as to create a danger of collision 4. If the incident geometry was converging then the ATR42 pilot was required to give way to the glider 5. If the aspect was head-on both pilots were required to alter course to the right 6. The ATR42 pilot turned right to avoid the glider. Comments BGA It is not known whether the glider pilot concerned was operating from Gransden. In August, at the middle of the day, this glider could have come from as far away as 100nm or more and from any of the clubs engaged in a cross-country flight on that day. Cambridge is very much on the way for gliders carrying out tasks into East Anglia. It has been confirmed with Gransden that all pilots based there are aware of the shape of the instrument pattern at Cambridge and do call Cambridge whenever possible. Gransden commented that they have had some incidents when gliders have passed above and clear of Cambridge traffic but the controller at Cambridge had no height read out and assumed they were conflicting. It would appear that Gransden are aware of the Cambridge procedures, however, it is considered that more needs to be done to publicise instrument patterns to all gliding clubs and to request pilots to call ATC when passing these areas. Summary The Airprox occurred when the ATR42 and a glider came into proximity whilst the ATR42 pilot was making a base turn on the procedural ILS approach to RW23 at CBG. The aircraft were operating in Class G airspace where pilots were ultimately responsible for their own collision avoidance. The CBG controller was aware of some earlier glider activity to the north of CBG, but was unaware of gliders operating in the vicinity of CBG until after the ATR42 pilot had commenced the procedure. Because the CBG controller was not using surveillance equipment and the glider pilot was not in contact, he was unable to pass specific Traffic Information about the gliders to the ATR42 pilot. The ATR42 pilot reported the minimum separation as 0ft vertical and 0.5nm horizontal. The glider pilot could not be traced. PART B: SUMMARY OF THE BOARD S DISCUSSIONS Information available included reports from the AT42 pilot and the controller concerned, area radar and RTF recordings and reports from the appropriate ATC and operating authorities. The Board noted that this Airprox occurred 2min after Airprox , which had taken place overhead Cambridge airport between an inbound IFR flight and an untraced glider. This Airprox occurred 9.4nm to the northeast of the airport, again with an unknown glider and an aircraft inbound under IFR. Cambridge ATC thought that the glider concerned might have been operating from Gransden Lodge as others from there were known to be operating in the area. However, the BGA member commented that without establishing positive identity of the glider it would not be possible to be certain where the pilot had departed from. He stressed that gliders operate over a wide area, and that the vicinity of Cambridge was popular airspace to route through. He added that he had had a lengthy discussion with the gliding club at Gransden Lodge, and he was satisfied that pilots operating 4 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 5 Ibid., Rule 9 (Converging). 6 Ibid., Rule 10 (Approaching head-on). 5

63 Airprox from there were well aware of the airspace used by Cambridge ATC, especially for inbound IFR aircraft. Similar to Airprox , the glider pilots were operating in Class G airspace in accordance with the privileges afforded them within that airspace; however, members were of the opinion that soaring in the overhead of an established commercial airport at a reported altitude of 5000ft should be avoided if possible and, if necessary, would be conducted much more safely with associated RT contact with the aerodrome concerned if possible. Members were aware that many glider pilots were not in possession of an RT license and consequently could not make such a call; although in that case it was felt appropriate that such glider pilots should include the position of a likely IFR hold in their assessment of desired track and avoid it. Members noted that the presence of the feathers symbol on the CAA VFR 1: scale chart indicated aerodromes with instrument procedures outside CAS, and should also serve as an indication that the airfield may have an IFR holding pattern in or near the overhead. Members recalled that, as a result of Airprox and , the CAA had been recommended to consider producing a chart of UK airfield IFR holding pattern positions and that such a chart could have provided valuable deconfliction information in this case. With this in mind, members were also of the opinion that more could be done, in particular to inform other airspace users of glider competition or daily task tracks, and resolved that Director UKAB would continue his contact with the BGA with a view to understanding how this might best be achieved. In the absence of a report from any of the glider pilots, it was not possible to ascertain their perspective of the event or whether a system such as PowerFLARM was fitted and of use. However, the Board were content that sufficient information existed to determine that the cause of the Airprox was a conflict in Class G airspace, and that the ATR42 pilot had resolved it by taking effective and timely avoiding action. PART C: ASSESSMENT OF CAUSE AND RISK Cause: A conflict in Class G resolved by the ATR42 pilot. Degree of Risk: C. ERC Score 7 : Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 6

64 Airprox AIRPROX REPORT No Date/Time: 8 Aug Z Position: 5210N 00127W (IVO Gaydon) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: R44 PA28 Operator: Civ Pte Civ Pte Alt/FL: 1500ft NK QNH (NK) Conditions: VMC VMC Visibility: 10km NK Reported Separation: Recorded Separation: 0ft V/50-100m H NK 200ft V/0.1nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE R44 PILOT reports flying a blue aircraft with all lights illuminated and SSR transponder Modes 3A and C selected. The aircraft was not fitted with TCAS. He was on his way to land at a private site and was receiving a Basic Service from Birmingham Approach. Birmingham advised of traffic in the Wellesbourne area and advised him to call Wellesbourne for further information. He did this, but the ATC was closed; however, another pilot advised that there were two aircraft operating in the area. The R44 pilot passed details about his own transit and then switched back to the Birmingham frequency. Within one minute of returning to the Birmingham frequency, he saw another aircraft in his 11 o clock approximately 300m away, in the opposite direction and at the same height. Given the closing speed no avoiding action was possible, and the other aircraft did not seem to take any action either. The other aircraft passed m down his left-hand side. He opined that the change of frequency, as well as descending to go beneath airspace ahead whilst looking for his approaching landing site, all contributed to a high workload, which, although he had thought he was maintaining a good look-out for the reported traffic, may have contributed to the late sighting. He assessed the risk of collision as High. THE PA28 PILOT reports flying in a red and yellow aircraft, with transponder Modes 3A and C selected. He did not report which lights were illuminated, and the aircraft was not fitted with a TCAS. He reported that he was very surprised to receive the news that he had been involved in an Airprox; although he recalled seeing a helicopter as he left Wellesbourne, neither he, nor his passengers, felt it was unduly close. As a consequence, he could not recall specific flight details but believed that he was probably swapping between Wellesbourne and Coventry frequencies at the time. He assessed the risk of collision as None. Factual Background The weather at Birmingham was reported as: METAR EGBB Z VRB03KT CAVOK 22/10 Q1014= 1

65 Airprox Analysis and Investigation CAA ATSI The written reports from both pilots were not received within 30 days and it was not therefore possible to obtain RTF recordings from the air traffic units concerned. At 1649:13 radar recording showed the R44, 12.5nm southeast of Wellesbourne squawking Shortly afterwards the R44 changed squawk to 0401 (Birmingham Approach). The R44 pilot s written report indicated that whilst in receipt of a Basic Service from Birmingham Approach he was made aware of traffic in the Wellesbourne area and advised to contact Wellesbourne information. There was no response from Wellesbourne and another aircraft on the frequency advised the R44 pilot of about two aircraft in the vicinity. At 1651:46 the R44 was 8.5nm southeast of Wellesbourne at 1800ft. The PA28 squawking 7000 begins to show on the radar recording 3.5nm east of Wellesbourne tracking southeast at 1200ft Figure 1. Figure 1 Swanwick MRT at 1651:46 The two aircraft were on reciprocal tracks and continued to converge. At 1653:22 the horizontal distance between the two aircraft was 0.4nm and the vertical distance 300ft Figure 2. Figure 2 Swanwick MRT at 1459:06 The R44 pilot recalled changing back to Birmingham Approach frequency and within a minute of doing so he sighted an aircraft in his 11 o clock at a similar level and an estimated range of 300m. The R44 pilot indicated that there was not sufficient time to take avoiding action. At 1653:26 the horizontal distance between the two aircraft was 0.2nm. The R44 was descending and indicating 1500ft with the PA28 at 1300ft Figure 3. 2

66 Airprox Figure 3 Swanwick MRT at 1653:26 The next sweep of the radar [1653:30] showed the two aircraft had passed abeam and were diverging Figure 4. It was estimated that at the CPA the horizontal distance was less than 0.1nm and the vertical distance was 150ft. Figure 4 Swanwick MRT at 1653:30 The R44 was in receipt of a Basic Service from Birmingham Approach where: Pilots should not expect any form of traffic information from a controller, as there is no such obligation placed on the controller under a Basic Service, and the pilot remains responsible for collision avoidance at all times 1. The Birmingham controller passed general traffic information concerning activity in the vicinity of Wellesbourne Mountford and advised the R44 to contact Wellesbourne Information which resulted in the pilot becoming aware of two aircraft operating in the vicinity. The R44 returned to Birmingham Approach frequency just prior to the Airprox. UKAB Secretariat Both pilots shared an equal responsibility for collision avoidance and for not flying into such proximity as to create a danger of collision 2. If the geometry was considered to be a converging situation, the PA28 pilot was required to give way; 3 if it was considered to be head-on then both pilots were required to alter course to the right. 4 1 CAP774, Chapter 2, Paragraph Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 3 ibid., Rule 9 (Converging). 4 Ibid., Rule 10 (Approaching head-on) 3

67 Airprox Summary An Airprox was reported on 8 August 2014 when a R44 and a PA28 flew into proximity at 1500ft; both aircraft were flying VFR in VMC. The R44 pilot was receiving a Basic Service from Birmingham, the PA28 pilot was not receiving an ATS. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, radar photographs/video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities. The Board first looked at the actions of the R44 pilot. They praised him for his pro-active calls to Birmingham and then Wellesbourne in an attempt to obtain traffic information, and agreed that there was little more he could have done to alert others to his presence. It had simply been unfortunate that, despite his best efforts, the timing of the calls meant that the PA28 traffic was probably not on frequency at the time. Looking at his track, the Board wondered whether he was following the motorway geographical feature and, even if not, the Board opined that other aircraft might well have expected him to place his aircraft to its right if he was tracking along it for any significant distance. 5 That said, the Board observed that the right-hand rule was notable more for its lack of adherence by pilots in general, and the UKAB Secretariat noted that, as of the 10 th December 2014, the new rules under SERA 6 removed the right-hand rule altogether. Turning to the PA28 pilot, given the closeness of the encounter and the PA28 pilot s seeming lack of concern, the Board were not convinced that he had seen the Airprox R44 before the incident and had perhaps either seen a different helicopter or the R44 at a different time, and therefore had a different perception of the proximity. More generally, the Board noted that the Birmingham controller was providing a Basic Service and so the responsibility for separation rested with the pilots; the Board opined that his decision to ask the R44 to call Wellesbourne was a sound one, albeit unknown to him it had probably caused the R44 pilot to go head-in to change frequencies at the critical point. The Board also commented on the fact that reports from the pilots were not received within 30 days of the incident, and therefore RT transcripts were not available; the Board wished to highlight to the aviation community the importance of early reporting of incidents so that all the available information could be saved for analysis the RT transcripts would likely have provided useful granularity to the Airprox investigation. In deciding the cause, the Board noted that the R44 pilot had reported that it was too late for him to take avoiding action and therefore this was effectively a non-sighting by the R44 pilot and probably a non-sighting by the PA28. Taking into account the separation shown on the radar recording, the Board judged the risk to be Category A, stopping just short of an actual collision and where chance had played a major part. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Effectively a non-sighting by the R44 pilot and probably a non-sighting by the PA28 pilot. Degree of Risk: A. ERC Score 7 : Ibid., Rule 16 (Right-hand Rule) 6 SERA Standardised European Rules of the Air. 7 Although the Event Risk Classification (ERC) trial had been formally terminated for future development at the time of the Board, for data continuity and consistency purposes, Director UKAB and the UKAB Secretariat provided a shadow assessment of ERC. 4

68 AIRPROX REPORT No Date/Time: 15 Aug Z Position: 5056N 00143W (Fordingbridge) Airspace: London FIR (Class: G) Aircraft 1 Aircraft 2 Type: Tutor T1 Untraced Microlight Operator: Alt/FL: Conditions: VMC Visibility: HQ Air (Trg) 1500ft QNH (1012hPa) 40km Reported Separation: 100ft V/0m H Recorded Separation: NK PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE TUTOR PILOT reports conducting general handling in a predominantly white aircraft with white strobes, landing and navigation lights selected on, as was the SSR transponder with Modes A, C and S. The aircraft was fitted with a TAS. The pilot was operating under VFR, in VMC, in receipt of a Basic Service from Middle Wallop Approach. Whilst the PF practiced a deceleration to 80kt, heading 090, in level flight at 1500ft altitude, the instructor (PM) saw an aircraft head-on, which passed about 100ft under them. The instructor took control and made a climbing turn to identify the other aircraft. He saw a white high-wing, single-engine, pusher configuration microlight with a thin tail boom. He thought it was a Streak Shadow but was not able to read the registration. The instructor noted that the Tutor was in a nose-high attitude as they decelerated, that the TAS had not given a warning and that, although they were under a Basic Service, ATC had been giving Traffic Information when pertinent in a busy period but that there had been no Traffic Information given on the conflicting aircraft. He reported the Airprox to ATC by phone after landing. He assessed the risk of collision as Very High. THE MICROLIGHT PILOT: Extensive tracing action was undertaken, including an to every registered Streak Shadow owner in the UK, but regrettably, the Microlight pilot could not be located. THE MIDDLE WALLOP ATC SUPERVISOR reports that there has been much discussion regarding the ATS provided to Army Flying Grading (AFG) Tutors operating to the southwest of Middle Wallop. AFG operations are always conducted in VMC and, as such, the most appropriate service would appear to be a Basic Service. However, due to the nature of the airspace, and in particular the amount of autonomous traffic operating in this area, there was a strong argument for an upgrade to a Traffic Service. That said, the nature of the training carried out by AFG instructors can mean a Traffic Service constitutes a distraction. There was no clear answer; the TAS fit to the Tutor aircraft does enhance the air picture and a Traffic Service would further enhance this but some of the aircraft operating to the southwest of Middle Wallop are very small, not fitted with SSR and consequently are not always seen on radar. The frequency used to provide either the Basic or Traffic Service to AFG aircraft is the ICF for Wallop Approach and is used primarily for RTC traffic. This can mean the frequency is congested, which further impacts on the cockpit workload of the AFG instructors. A solution to this element of the problem would be to provide a quiet frequency, as Middle Wallop does for rotary-wing aircraft operating to the north and northeast of Wallop. In order to ensure this 1

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