Assessment Summary Sheet for UKAB Meeting on 9 th October 2013

Transcription

1 Assessment Summary Sheet for UKAB Meeting on 9 th October 2013 Total Risk A Risk B Risk C Risk D Risk E Airprox Reporting (Type) Reported (Type) Airspace (Class) Cause ICAO Risk ERC Score B738 (CAT) A319 (CAT) UAR UN864 (C) Brest ATC cleared the A319 pilot to climb through the B737 level. C. 50 Recommendation: NATS Ltd review the procedure for Mode S display, especially near the FIR boundary CTSW (Civ Trg) EC120B (Civ Pte) Lon FIR (G) Conflict in Class G airspace, resolved by both pilots. C EC135 (Civ Comm) R44 (Civ Comm) Dunkeswell ATZ (G) The R44 pilot flew close enough to the EC135 to cause concern. C. 4 Recommendation: Dunkeswell review their helicopter entry/exit procedures A319 (CAT) DHC6 (CAT) Newquay ATZ (G) ATC allowed the A319 pilot to get airborne and fly into conflict with the DHC6. C. 50 Contributory: 1. Lack of coordination between controllers. 2. Lack of TI to both pilots. Recommendation: Newquay ATC review their coordination procedures and responsibilities for integrating VFR traffic Ventus 2 CT (Civ Club) PA28 (Civ Club) Lon Fir (G) A non-sighting by the PA28 pilot. B Typhoon (Mil) Grob 109B (Civ Pte) Leuchars MATZ (G) Sighting report. Contributory: Lack of coordination and TI from ATC. 2. The Grob was using QNH and the Typhoon was using QFE. Recommendation: 1. Leuchars review the coordination procedure and responsibilities for MATZ crossers. 2. Leuchars review altimeter setting procedures for MATZ-crossing aircraft. C. 2

2 Airprox Reporting (Type) Reported (Type) Airspace (Class) Cause ICAO Risk ERC Score Ventus (Civ Pte) Alpha Jet (Mil) Lon FIR (G) An effective non-sighting by the Alpha Jet pilot in Class G airspace. A. 100 Recommendation: CAA GA unit consult with non-powered aircraft parent organisations to review prior promulgation of competition task routeing and way-points to AIS and airfields close to task track Tornado GR4 (Mil) Ikarus C42 (Civ Pte) Lon FIR (G) Sighting report. Recommendation: CAA to review education of GA pilots to improve understanding of implications of military lowflying flow arrows. C Lynx (Mil) Tiger Moth (Civ Trg) Lon FIR (G) Conflict in Class G resolved by both pilots. C Tucano T1 (Mil) 2 x Hawk T1 (Mil) Vale of York AIAA (G) Leeming APR allowed the Hawk formation to descend into conflict with the Tucano. B. 21 Contributory: 1. Inappropriate ATS for the flight conditions. 2. Lack of effective ATC cooperation. 3. Lack of effective supervision of the Leeming APR trainee. Recommendation: The MAA consider giving additional guidance on the benefits of DS in IMC Chipmunk (Civ Club) PA24 (Civ Pte) Lon Fir (G) The Chipmunk pilot turned into conflict with the PA24. A Ikarus C42 (Civ Trg) PA28 (Civ Pte) Lon Fir (G) The PA28 pilot flew into conflict with the C42 in the Lee-on-Solent visual circuit. C. 4 Contributory: Lack of planning preparation by the PA28 pilot.

3 AIRPROX REPORT No Date/Time: 14 May Z Position: 4956N 00333W (28nm S of Berry Head) Airspace: UAR UN864 (Class: C) Reporter: LAC S6/S9/S36 (BHD) 1st Ac 2nd Ac Type: B737 A319 Operator: CAT CAT Alt/FL: FL360 FL390 Weather: VMC CLOC NK Visibility: 10nm NK Reported Separation: NK V/5nm H Recorded Separation: 300ft V/ 5.2nm H CONTROLLER REPORTED 0ft V/5nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE LAC S6/S9/S36(BHD) P and T CONTROLLERS report that the southbound Bristol departure A319 was transferred to Brest ATC at FL330 in the Berry Head (BHD) area [20nm S of Exeter]. Shortly afterwards, when the northbound B737 was transferred to the Sector from Brest ATC, ifacts 1 showed a flashing red interaction. Both controllers noticed that the A319 s SFL was at FL390. P telephoned Brest immediately, whilst T issued the B737 with an avoiding action L turn heading 330. Brest was advised of the action taken. As the L turn appeared slow, the B737 was instructed to increase rate of turn and to continue L heading 310. TI was passed to the B737 on 2 or 3 occasions. THE B737 PILOT reports en-route in level cruise, under IFR in VMC at FL360, with a RCS from London ATC. He was just below cloud, between layers, with flight visibility of 10km. Approaching the southern UK coastline, London ATC requested an immediate L turn (about ) to avoid an ac climbing towards him on an opposite track. At first the ac was not displayed on TCAS. Shortly after he started turning, the ac (the subject A319) appeared on TCAS and visually. ATC issued a further L turn (believed 270 ). He selected 25 AOB to speed up the turn. He confirmed there was no TCAS RA warning, with the ac always showing more than 5nm away on the display. When clear of traffic he returned en-route to his destination. His assessment of risk was medium. THE A319 PILOT reports en-route, operating under IFR under the control of Brest ATC. Beacon and strobe lights were selected on. He was in a climb passing FL280 on own navigation to DELOG [a RP on the Brest/Madrid FIR boundary, 54nm N of Santander], when ATC requested a turn. The initial message was garbled and ATC repeated the instruction to 1 ifacts (Interim Future Area Control Tools Support) is a set of computer based predictive tools, developed jointly by NATS Ltd, that enable trajectory prediction and pre-emptive conflict detection. 1

4 turn L 30, which was carried out. Shortly afterwards, a TCAS TA was received on an ac above on a reciprocal track. The TA was quickly resolved and ATC cleared the A319 pilot direct to DELOG again. As far as he was aware ATC separation was not compromised as he believed the other ac was at least 5nm away. However, without the turn instruction he assessed that a TCAS RA would probably have occurred. He reported the severity as low. Factual Background The Airprox occurred in Class C airspace. Standard separation required is 5nm horizontal and/or 1000ft vertical. Analysis and Investigation CAA ATSI CAA ATSI had access to written reports from the BHD T and P controllers and the LAC SUP, together with reports from both pilots, area radar recordings, RTF recordings and transcripts of the London Control frequency and desk-side telephone calls. ATSI also had access to the analysis of the incident conducted by Brest ACC. Further information was provided by NATS Swanwick ATSI. At 1658:00 UTC the A319 was passing FL318, climbing to FL330, 10nm NE of BHD and was transferred to Brest Control by BHD T. At 1658:58 the Mode S SFL of the A319 changed to FL390. At 1659:53, as the aircraft had been OutComm d (selected as being no longer in communication with that sector) in the Interim Future Area Control Tools Support (ifacts) and had crossed the transfer of control point, the SFL of the A319 disappeared from the aircraft s data block. At 1701:37 the B737 contacted the BHD Sector at FL360 on a reciprocal track to the A319, which was passing FL349, 30nm NNE of the B737. The climb rate of the A319 had slowed from approximately 1000fpm to fpm as the aircraft approached FL349. As the BHD T InComm d the B737 (i.e. selected it as being in communication with that sector) the separation monitor displayed a flashing red confliction against the A319 (no confliction would have been displayed by ifacts previously as each pilot was in communication with a different ACC). At 1701:54 the BHD T used the over-ride function to see the SFLs of all ac on the display and observed that the SFL of the A319 was FL seconds later low-level STCA activated. At 1702:06 the A319 and the B737 were 23.7nm and 900ft apart. The BHD T instructed the B737,...turn left immediately avoiding action heading three four zero degrees. At 1702:20 the BHD P telephoned Brest and told them that London was turning the B737 L, to which Brest replied that they were also turning L with the A319. The B737 was given TI on the A319 and at 1702:27, when the two aircraft were 17.8nm and 600ft apart, the B737 was instructed...turn left as much as you can radar heading three one zero degrees now. High-level STCA activated and updated TI was passed to the B737 stating that the A319 was...a range of ten miles climbing passing flight level three five six. 2

5 At 1703:20 the B737 was informed that the A319 was passing down its RHS. At 1703:25 (CPA) both ac had turned away from each other and were 5.2nm apart with the A ft above the B737 (see Figure 1). Figure 1 The report from the A319 pilot stated that, after being asked to turn L by ATC (Brest control), the crew received a TCAS TA; however, it was quickly resolved and the pilot did not believe that separation had been compromised. The BHD T stated that although the SFL was observed to change on the A319 following transfer to Brest he did not think anything of it and became occupied with other tasks. When the B737 pilot called on frequency neither the T nor the P realised that the A319 was climbing. As the ifacts separation monitor displayed a confliction the controllers checked the Mode S SFL and discovered that the selected level of the A319 was FL390. Brest ACC Brest ACC, Local Safety Commission, reports that the KW sector was manned with 2 fully qualified Air Traffic Controllers. The B737 was maintaining FL360, en route to SALCO [a RP on the London/Brest FIR boundary, 40nm S of BHD]. The A319 pilot called Brest still 8nm N of BHD, climbing to FL330. Flight plan management system CAUTRA profile for Bristol departures is London S6 -> Brest VS. This profile is designed to let Brest decide which final flight level will be allocated to these flights. This explains why S6/S9/S36 cleared the A319 to FL330 and not higher. The KW radar controller cleared the A319 to route direct to DELOG. The pilot then read back this message correctly and requested FL390 for his cruising level. In accordance with the LOA between Brest and London ACCs, the A319 was released to continue climbing to FL390 (subject Brest traffic). Flights cleared to climb to, or above, FL 310 by London S6/S36 are released for further climb by Brest, without prior coordination with S36. However, when climb clearance to FL390 was issued to the A319, the conflicting B737 was not detected by Brest ATC. A few minutes earlier, the B737, at FL360, had crossed another ac s track and was cleared to resume its own navigation direct to SALCO. Having 3

6 resolved this problem, it is possible that ATC considered the B737 would no longer be a factor to other traffic, thus overlooking its presence when issuing the climb clearance to the A319. Additionally, ATC turned its attention to two other ac, which were routeing to DELOG at FL370. Approximately two minutes later, the B737 was transferred to London S36. Meanwhile, the A319 continued climbing at the approximate average rate of 1000fpm (calculated using data from replay software EPOQUES). When the two ac were about 27nm apart, the A319 leveled at FL350 for about 20sec. As soon as climb was resumed, an STCA was displayed on the radar displays. The radar controller reacted, transmitting to the A319 pilot, [A319 C/S] immediately turn errr right errr 2 0 degrees, 3 0. The hesitation in the transmission was as a result of the P telling him to delay any action. The P was in telephone contact with London S36, discovering that S36 had turned the B737 L. After this turn co-ordination, Brest radar instructed the A319 to turn L 30. Meanwhile, S36 had turned the B737 L 50 (at first 20, then another 30 ). Appropriate action ensured that standard separation was maintained between the two ac. Summary Both ac were operating in Class C airspace. At the time of the Airprox, the A319 pilot was under the control of Brest ATC and the B737 pilot was being controlled by LAC BHD sector. The southbound A319 was transferred to Brest ATC at FL330 in the BHD area. Shortly afterwards, when the northbound B737 was transferred to BHD from Brest, at FL360, ifacts showed a flashing red interaction. The T and P noticed that the A319 s SFL was FL390. P telephoned Brest immediately, whilst T issued the B737 with an avoiding action L turn. Brest was advised of the action taken and the A319 was also turned L. A further L turn was issued to the B737. TI was passed to the B737 on 2 or 3 occasions. As a result of turns given to both ac, separation was maintained. Neither ac received a TCAS RA. PART B: SUMMARY OF THE BOARD S DISCUSSIONS Information available included reports from the pilots of both aircraft, transcripts of the relevant RT frequency, radar video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC authorities. The Board members quickly decided that the cause of the Airprox was that Brest ATC had cleared the A319 pilot to climb through the level of the B737; Brest had admitted this was the case in their report. Discussion then took place about the operating aspects of ifacts. Civil controller members were very concerned that when an aircraft is OutComm d i.e. no longer in communication with the sector, the Selected Flight Level (using Mode S information) of the aircraft disappears from the aircraft s data block. This, they commented, removes the ability for controllers to monitor the intended level of an aircraft, especially, as in this case, it was still within UK airspace when it was transferred to Brest ATC. The NATS advisor explained that the reason for removing an aircraft s data, after it had been transferred, was to reduce clutter on the radar display, and that there is no requirement to monitor SFLs. On this occasion, when the A319 was transferred to Brest ATC, neither of the subject aircraft were under the control of the BHD Sector. Consequently, even if the sector had been aware of the potential confliction, avoiding action could not have been taken as there was no communication possible with either aircraft. Civil controller members pointed out that if the A319 s SFL had been displayed, showing the aircraft climbing to FL390 i.e. through the level of the B737, early co-ordination could have taken place with Brest to resolve the confliction. Because of the Members concern about the removal of SFL s it was agreed that a recommendation should be made to NATS Ltd to review the procedure for Mode S display near the FIR boundary. A civil airline pilot member commented that it should be made clear that other safety measures such as TCAS and Short Term Conflict Alert were 4

7 still in force to assist in preventing the possibility of a collision. In the event, ifacts did show the confliction after the B737 had been transferred to the BHD Sector and coordination took place with Brest ATC regarding avoiding action issued to both aircraft resulting in standard separation being maintained with no risk of collision. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Brest ATC cleared the A319 pilot to climb through the B737 s level. Degree of Risk: C. Recommendation: NATS Ltd review the procedure for Mode S display near the FIR boundary. ERC Score: 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

8 AIRPROX REPORT No Date/Time: 16 Jun Z (Sunday) Position: 5131N 00014E (1.7nm NE of Damyns Hall A/D - elevation 56ft) Airspace: London FIR (Class: G) Reporting Ac Reported Ac Type: Flight Design EC120B CTSW (Microlight) Operator: Civ Trg Civ Pte Alt/FL: 1000ft 1300ft QNH (1013hPa) QNH (NR hpa) Weather: VMC NR VMC NR Visibility: 25km 7km Reported Separation: 0ft V/1km H Recorded Separation: 0ft V/0.1nm H 400ft V/400ft H EC ft alt CPA 1258:24 0ft V/< 0.1nm H M25 J29 CTSW 1100ft alt Diagram based on radar data 57:46 57:58 58:10 57:22 57:34 PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE CTSW PILOT reports that navigation lights, beacon and landing lights were illuminated. He was carrying out cct training on RW21, left-hand, at Damyns Hall, with a student handling the ac. While on the late downwind leg (he thought) at 1000ft he observed a helicopter in his 2 o clock, about 1km away, at the same level. As the student turned L onto base leg (heading 300 ) at 1000ft he noticed that the helicopter was still in his 2 o clock, on a collision course, about 300m away. He took control from the student, waggled his wings and turned L onto final approach for RW21. He commented that there was no sign whether or not the helicopter pilot had seen his ac. The helicopter pilot was not on the Damyns Hall A/G frequency. He assessed the risk of collision as High. THE EC120B PILOT reports his helicopter was coloured predominantly blue; strobe and navigation lights were illuminated. He was carrying out a flight from a private site to Rochester Airport. He lifted at 12.38, arriving at Rochester at The weather on lifting was 9999 visibility. His route was via M1 Junction 10 and 9, to avoid over flying Harpenden, then direct to a point S of LAM (staying clear of Stapleford ATZ), then direct to Rochester (but staying clear of Damyns Hall). He was aware that this area can be particularly busy at weekends with local flights. He was transferred from Luton to Farnborough Radar on leaving the Luton ATZ and stayed with Farnborough until 10nm from Rochester receiving a BS. When he was approaching Stapleford, Farnborough advised him of traffic in the cct and he called Stapleford on box 2 to advise them he would pass to the S and they issued TI. Once clear he went back to Farnborough. The visibility was slightly reduced around this area due to a rain shower, he judged it to be about 7km. At some point between here and Damyns Hall (which 1

9 he stayed well clear of despite the lack of ATZ as there are often microlights around this area) he became aware of a small light ac or microlight approaching on a reciprocal track but slightly low and to the R. He moved to the L slightly to pass what, he considered, to be a perfectly safe distance above and to the L behind this ac. He flashed his landing light and the other pilot waggled his wings to indicate he had also seen us. He assessed the risk of collision as None. Factual Background The CTSW was on a VFR training flight conducting ccts on RW21 at Damyns Hall. The pilot was in contact with Hornchurch Radio on MHz and transponding There is no ATZ at Damyns Hall Aerodrome 1 and it is depicted on VFR charts in Class G airspace as a minor aerodrome/limited or no facilities, where flying training may be taking place. The RW orientation is not depicted. Frequency MHz is given on both the 1:250,000 and 1:500,000 VFR charts. The aerodrome is not notified in the UK AIP 2. The prevailing weather at London City Airport was: METAR EGLC Z 22007KT 9999 RA FEW022 BKN030 15/10 Q1014= Under a BS the allocation of an SSR code does not constitute the provision of a surveillance service and there is no requirement for a controller to monitor a flight. The avoidance of traffic is solely the pilot s responsibility and pilots should not expect any form of TI. Rule 9 of the Rules of the Air 2007 states that when two aircraft are converging in the air at approximately the same altitude, the aircraft which has the other on its right shall give way. Rule 12 of the Rules of the Air 2007 states:...a flying machine, glider or airship flying in the vicinity of what the commander of the aircraft knows, or ought reasonably to know, to be an aerodrome shall- (a) conform to the pattern of traffic formed by other aircraft intending to land at that aerodrome or keep clear of the airspace in which the pattern is formed. Analysis and Investigation CAA ATSI had access to the written report of both pilots, recorded area surveillance 3 and recording of the Farnborough LARS (East) frequency MHz. The Airprox was not observed by or reported to Farnborough ATC. The EC120B contacted Farnborough LARS (East), from LARS (North), at 1255:40 UTC. Squawk 5021 was assigned, London QNH 1014hPa passed and a BS agreed. EC120B is 4.4nm NNW of Damyns Hall at 1300ft, CTSW is about to turn downwind RW21 at 1000ft (see Figure 1). No further transmissions were made between the EC120B and LARS (East) until 1301:00. 1 Disestablished 10 January ENR Heathrow 10cm, Stansted 10cm and Debden Radars were reviewed and each gave intermittent or partial coverage of the incident, given the radars location in relation to the incident and level of the aircraft. Therefore, Multi Radar Tracking (MRT) is used in this report. 2

10 Figure 1: MRT 1255:59. When the EC120B was 1.9nm NE of Damyns Hall 4, the CTSW had turned base leg at 1100ft and the EC120B was on a south-easterly track at 1200ft. The aircraft were 0.9nm apart on converging tracks. See Figure 2. Figure 2: MRT 1258:07 The tracks of the two ac then crossed (1.7nm NE of Damyns Hall) between 1258:22 and 1258:26 as both ac were at 1100ft, 0.1nm apart. See Figures 3 and 4. Figure 3: MRT 1258:22 Figure 4: MRT 1258: N E (WGS84), which is the previously notified aerodrome reference point. 3

11 The CTSW positioned to final for RW 21 and the EC120B continued to the SE, requesting transfer to Rochester s frequency at 1301:00. Summary The Airprox occurred in Class G uncontrolled airspace, 1.7nm NE of Damyns Hall Aerodrome. The minimum recorded distance between the two ac was 0ft vertical and 0.1nm horizontal. Although the EC120B was in receipt of a BS, in Class G airspace, collision avoidance rests solely with the pilots of both ac. They did obtain visual contact with the other ac and signalled accordingly. However, it would appear that, while the pilot of the EC120B observed the CTSW pilot waggling his wings, the pilot of the latter ac was unaware, at the time, whether or not the helicopter pilot had spotted his ac. PART B: SUMMARY OF THE BOARD S DISCUSSIONS Information available included reports from both pilots, radar video recordings, transcript of the Farnborough LARS (East) frequency and a report from the appropriate ATC authority. The CAA/DAP Member explained that the Damyns Hall ATZ was disestablished, at the request of the aerodrome operator, in January Civil pilot members considered that the circuit carried out at Damyns Hall by the CTSW was wider than would be expected for a microlight aircraft; a GA Member opined that it appeared that the aircraft was carrying out a circuit which was twice the usual distance from an aerodrome. In view of this wide circuit, the civil helicopter member believed that the pilot of the EC120B may not have been aware that the CTSW was actually positioning to land at Damyns Hall and may have thought it was en-route. This was an important aspect because it concerned which pilot had the right of way in accordance with the Rules of the Air Regulations (See Part A.) The CTSW pilot reported sighting the EC120B in his two o clock. Consequently, in accordance with Rule 9, having the other aircraft on his right, he should have given way. However, under Rule 12 the EC120B pilot should have remained clear of the airspace in which the pattern of traffic at Damyns Hall is formed. Members were aware that the EC120B pilot knew the position of Damyns Hall, but as the CAA/NATS Aeronautical Charts do not show the layout of the runways at the aerodrome, he would not necessarily have known the circuit directions. The civil helicopter pilot member considered that the EC120B pilot avoided the aerodrome by a reasonable distance. Because the Board members could not resolve the right of way issue, they decided that the cause of the Airprox was a conflict in Class G airspace. As both pilots took appropriate avoiding action it was considered that there was no risk of a collision. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Conflict in Class G airspace resolved by both pilots. Degree of Risk C. ERC Score: 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

12 AIRPROX REPORT No Date/Time: 27 Jun Z Position: 5053N 00316W (2nm NW Dunkeswell) Airspace: Dunkeswell ATZ (Class: G) Reporting Ac Type: EC135 R44 Reported Ac Operator: Civ Comm Civ Comm Alt/FL: 1500ft 1200ft QNH (1029hPa) NK Weather: VMC CLBC VMC NK A16 A16 A15 A13 Diagram based on radar data CPA 1124:18 200ft V < 0.1nm H A11 A09 23:54 23:30 23:06 A09 A09 R44 A Visibility: >10km 6km 1122:42 Reported Separation: Recorded Separation: 150ft V/0.1nm H 200ft V/0.5nm H EC NM 200ft V/<0.1nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE EC135 PILOT reports positioning to Dunkeswell for fuel. He was operating under VFR in VMC with an A/G service from Dunkeswell Radio [ MHz]. The yellow helicopter had HISLs selected on, as was the SSR transponder with Modes A, C and S. The ac was fitted with a Traffic Avoidance System (TAS). He called Dunkeswell for joining and was cleared in from the N. On entering the ATZ at 1500ft he heard a C/S changing to an Exeter RTF. Routeing to position from the N, heading E at 115kt, he saw a dark coloured R44 helicopter through the R chin window, ft below in level flight, heading W in the opposite direction and which passed before he had time to react. He did not recall observing the other ac on the TAS and reported the Airprox to the Dunkeswell A/G Operator on landing. He assessed the risk of collision as Very High. THE R44 PILOT reports departing Dunkeswell. He was operating under VFR in VMC with an A/G service from Dunkeswell Radio. The black helicopter s landing light was selected on, as was the SSR transponder with Modes A and C. An ACAS was not fitted. He departed the A/D on a N ly track and then turned W. Whilst straight and level at 1200ft, heading 260 at 100kt, he saw a yellow helicopter on a reciprocal heading at a range of 2nm which passed down his RH side, about 200ft above and displaced by 0.5nm laterally. He did not observe any lights illuminated on the other ac. He noted that the other helicopter pilot had stated on RT that he was tracking in to the A/D from the N but that the other helicopter was not tracking as he expected, given the radio call, and that he had seen it tracking in from the W quadrant of Dunkeswell A/D. He also noted that this was a see and be seen event in VFR conditions. He assessed the risk of collision as Low. 1

13 Factual Background The Exeter weather was reported as follows: METAR EGTE Z 31012KT 280V FEW030 19/11 Q1028 The Dunkeswell Local Traffic Regulations 1, paragraph 5 (Helicopter Operations), state: (a) Helicopter pilots wishing to land at Dunkeswell should be aware of the designated area on the grass triangle in line with Runway 22 numbers. (b) Pilots to call on RTF before starting rotors. (c) No rotors are to be turning in the ATZ when parachuting is in progress. The Dunkeswell Flight Procedures 1, paragraph 1 (Circuits), state (verbatim): (a) Circuit directions: Runway 04 - RH; Runway 22 - LH. Circuit heght; 800 ft. (b) No overhead joins as parachuting is in operation seven days a week between daylight hours. (c) Subject to parachuting pilots may request an overhead join only when two way communication is established with the A/G radio station, otherwise the pilot is to join on the downwind or base leg for the runway in use. (d) Helicopter Entry/Exit Routes from the north at 500 ft. (i) No straight in approaches, pilots may request subject to circuit traffic. (ii) No orbits in the circuit or on final approach, i.e extend downwind or go around. UKAB Secretariat Analysis Both pilots had an equal responsibility for collision avoidance 2 and were required to alter course to the R if there was a danger of collision 3. The R44 pilot reported that he was visual with the EC135 at a range of 2nm, just over 33sec before they passed each other at the reported speeds. His description of the other helicopter being on a reciprocal track, along with examination of the radar recording, indicates visual acquisition probably at a range slightly less than 2nm and hence slightly less than 33sec to CPA. The EC135 pilot reported seeing the R44 through his R chin window but did not have time to react before it passed. A CAA ATSI interview with the Dunkeswell A/G Operator established that he had no recollection of the Airprox and that the incident was not recorded in his log. The radar recording was clear, using the Burrington radar head with 8sec rotation period; the EC135 displayed Modes A, C and S and the R44 Modes A and C. Summary An EC135 and R44 flew into proximity at 1124 on 27 Jun 13, 2nm NW of Dunkeswell A/D on the ATZ boundary. Both pilots were operating under VFR in VMC, the EC135 pilot positioning to land at Dunkeswell and the R44 pilot departing the A/D. The Burrington radar recording established that the separation at CPA was 200ft V and <0.1nm H. 1 UK AIP AD 2.EGTU-5, dated 13 Dec The Rules of the Air Regulations 2007, Rule 8 (Avoiding Aerial Collisions) 3 The Rules of the Air Regulations 2007, Rule 10 (Approaching head-on) 2

14 PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both ac, radar video recordings and a report from the appropriate ATC authority. The Board first considered the pilot s actions. Both pilots were operating under VFR and, it appeared, iaw their understanding of the Dunkeswell Flight Procedures pertaining to helicopter entry/exit routes. It was clear that the R44 pilot had seen the EC135 well before the EC135 pilot saw the R44, and that the R44 pilot was surprised by the EC135 pilot s routeing. A helicopter pilot Member opined that it would have been challenging for the EC135 pilot to see the lower, dark coloured, R44 against the background terrain. The pilots gave somewhat differing estimates of the lateral separation at CPA but, given the radar recording and the fact that the EC135 pilot saw the R44 late and through his R chin window, the Board were satisfied that the actual separation was of the order of <0.1nm. In summary, Members opined that the R44 pilot could have chosen to give the EC135 a wider berth given that he had seen it at about 2nm range. Notwithstanding, the Board also opined that both pilots could reasonably be considered to have complied with local procedures but noted that those procedures pertaining to helicopter entry/exit routes were somewhat sparse and called for coaltitude departures and recoveries. Members recognised that there were local noise abatement considerations, and the need to take account of an adjacent G/S at Dunkeswell, but opined that more explicit and deconflicted helicopter flight procedures could enhance safety without compromising operations. The Board considered that the Airprox was caused by the R44 routing into close proximity with the EC135, but that safety margins had not been much reduced below the normal. PART C: ASSESSMENT OF CAUSE AND RISK Cause: The R44 pilot flew close enough to the EC135 to cause concern. Degree of Risk: C. ERC Score: 4 4. Recommendation: Dunkeswell review their helicopter entry/exit procedures. 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. 3

15 AIRPROX REPORT No Date/Time: 27 Jun Z Position: 5027N 00502W (2nm NW Newquay Airport) Airspace: Newquay Airport ATZ(Class: G) Reporting Ac Reported Ac Type: A319 DHC6 Operator: CAT CAT Alt/FL: QNH (1031 hpa) QNH (1031 hpa) DHC6 F017 A319 F005 Newquay Airport Weather: VMC CLBC VMC CLAC Visibility: 7km 10km Reported Separation: 0ft V/1nm H Recorded Separation: 1000ft V/0.5nm 600ft V/0.7nm H PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE A319 PILOT reports lining up on RW30 for an IFR departure to the East with the aircraft s beacon, HISLs and landing lights switched on and transponder modes A, C and S on. Noting that the cloud-base was BKN at 400ft, the crew requested a Deconfliction Service on departure; they also noticed an aircraft on TCAS 3nm ahead and the Captain asked the First Officer to monitor it and attempt to gain visual contact with it. After take-off, at around 500ft, the crew received a TCAS TA [UKAB Note 1: the Tower controller also passed traffic information at the same time] and, as the other aircraft was around 2nm away and they could not see it, the Captain elected to make a VMC right turn. As the turn was commenced, the crew saw a twin turbo-prop aircraft in their left, 10 o clock, less than 0.5nm away. They continued their climbing right turn through the other aircraft s level and continued to climb away from it. He assessed severity of the event as High and the risk of collision as Medium. THE DHC6 PILOT reports planning a VFR, left hand down-wind join for RW30, under a Traffic Service from Newquay Approach. The white aircraft had strobes, navigation lights, landing lights and transponder modes A, C and S turned on. The crew noted that the cloud was clear of the coastline but had formed ½ to 1nm inland and, as the cloud was lower than they had expected on the downwind leg, they positioned over the village of Watergate Bay, which would still allow a VFR down-wind join. As they positioned over Watergate Bay, the crew could see the threshold of RW12 and they asked the Approach Controller if they could join right-base for RW12; the controller informed them that the A319 about to depart RW30. Due to the departing aircraft and the cloud in the down-wind area, the crew requested an ILS approach for RW30; they were instructed to turn on to 140, they thought, and commenced a climb. By this time the runway was visible and the crew were able to keep the A319 in sight as it took off and departed in a climbing right turn. He assessed the risk of collision as None. THE TOWER CONTROLLER reports being informed by the Approach Controller that the DHC6 was inbound from the south-west for a visual down-wind join for RW30. Approach also issued a release for the A319 to depart with a right turn on track for DAWLY, climbing to FL190. The Tower Controller could not see any other traffic to affect the A319 on the Air Traffic Monitor (ATM) and so allowed the 1

16 aircraft to take-off. After departure, he saw the A319 make an early right turn and the crew transmitted that they were making the turn against a TCAS Traffic Alert. The controller informed the crew that they were expecting an aircraft to join down-wind left-hand for RW30; at this point the controller could not see the DHC6 but observed its squawk on the ATM, tracking south-east, climbing and in an appropriate position for a right-base join for RW12. THE APPROACH CONTROLLER reports providing a Traffic Service to the DHC6 routing VFR inbound for a left-hand down-wind join for RW30; he had released the A319 for departure from RW30 with a right turn towards DAWLY. He noticed a fast moving contact 20nm south-east of Newquay, which he believed to be a fast-jet, which was climbing and could conflict with the departing A319. He turned his attention to a data system so that he could contact the fast-jet s controlling agency for coordination. On turning his attention back to the radar screen he was surprised to see the DHC6 on a northerly track, 3nm south-west of the airport, as if joining for right-base on RW12. The Approach Controller was about to call the DHC6 crew when they called him to request the surface-wind and a right-base join for RW12. The Controller passed the surface-wind but refused the right-base join and passed Traffic Information that the A319 was about to depart RW30. The DHC6 crew requested vectors for an ILS approach to RW30 and Approach instructed them to turn right on to 130 and climb to 2500ft. Factual Background The Newquay ATZ consists of a circle 2.5nm radius centred on the mid-point of RW 12/30 and extending to a height of 2000ft above aerodrome level (elevation 390ft). The Newquay METAR at 0750Z was: KTS 7000 BKN006 13/13 Q1031 Analysis and Investigation CAA ATSI Analysis Background CAA ATSI had access to Newquay RTF recording, Newquay and area radar recordings together with written reports from the Tower and Approach controllers and the pilots of both aircraft. Traffic levels were reported as light. CAA ATSI interviewed the Tower and Approach controllers. The two controllers were experienced controlling at Newquay and there were no reported distractions or unusual circumstances apart from the weather conditions. The sky was reported clear over the sea and coast with low cloud having formed half a mile inland. Factual History At 0749:40 the DHC6 contacted Newquay Approach reporting at 3000ft on QNH 1031hPa. The Newquay Approach controller acknowledged the call, (DHC6)c/s roger information golf er QNH one zero three one looking for you. The radar displayed the DHC6, 28.1nm southwest of Newquay squawking 1731, which had been code callsign converted on the Newquay radar display. The DHC6 pilot asked for the cloud base and visibility, which was passed as, Visibility seven thousand metres broken six hundred feet. The DHC6 pilot responded, Okay I ll have a quick listen to golf and er but with that in mind we d like a er Traffic Service and a visual downwind join to runway three zero please (DHC6)c/s. This was acknowledged by the Approach controller and then the DHC6 was identified, (DHC6)c/s identified Traffic Service own navigation for a downwind, acknowledged correctly by the DHC6 pilot. At 0750:20, the Approach controller notified the Tower controller, (DHC6)c/s looking for a Traffic Service for a downwind join. This was acknowledged by the Tower controller. 2

17 At 0751:51 the DHC6 requested a VFR descent and the Approach controller replied, (DHC6)c/s thank-you descend er visually and report the aerodrome in sight and the DHC6 pilot acknowledged, Descending wilco (DHC6)c/s. At 0756:52 the Tower controller requested a release on the A319 and the Approach controller responded (A319)c/s released runway 30. The DHC6 was 10nm west-south-west of the airfield indicating an altitude of 1200ft. At 0758:25 the Approach controller contacted Western Radar and requested a joining clearance for the A319 joining CAS at DAWLY. There followed a short discussion regarding an aircraft squawking 6163 at FL150, 17nm east of Newquay and it was agreed that this contact was routeing towards Culdrose and was not a problem. Co-ordination was agreed for the A319 to climb FL190 routeing DAWLY with a squawk of 3770 and frequency 132.3MHz. At interview the Approach controller indicated that he had then focused on 2 other aircraft climbing out from Culdrose which may have presented a potential conflict for the departing A319. At 0758:58 the DHC6 was 5nm west of the airfield and the Tower controller cleared the A319 for take-off. The DHC6 pilot s written report indicated that he planned to join downwind for RW30 and reported the cloud was clear off the coastline, but had formed approximately half a mile inland, and was lower than expected. The DHC6 pilot decided to route over Watergate Bay village at which point the threshold of RW12 became visible. [Watergate Bay is situated 1.3nm west of the end of RW30 and 0.7nm from the extended centreline of RW30]. At 0759:28 the DHC6 was 4nm west-north-west of the airfield at 1100ft and the following RTF exchange occurred: DHC6 Newquay (DHC6)c/s what s your wind on the ground at the moment Approach Three three zero at five knots DHC6 Any chance of er right base for one two Approach I ve got the [A319 company prefix] just about to depart off runway three zero DHC6 Okay in that case er we re going to turn right and request vectors ILS runway three zero please Approach (DHC6)c/s thank you turn right then please heading one three zero degrees DNC6 Right one three zero (DHC6)c/s At interview the Approach controller indicated that he had been monitoring the traffic to the southwest and had not realised that the DHC6 was within 5nm and approaching the ATZ without having called field in sight. At 0800:09 the DHC6 had commenced a right turn, 3nm west-north-west of the airfield and was in a climb, passing 1400ft. The DHC6 was 0.9nm from the extended centreline of RW30 and the Approach controller instructed the DHC6 pilot to climb to an altitude of 2500ft, which was read back correctly as the DHC6 then entered the ATZ. 3

18 At 0800:26 the Tower controller notified Approach that the A319 was airborne on the hour. The A319 then appeared on radar passing 500ft with the DHC6 in the A319 s 11 o clock at a range of 1.8nm, indicating 1700ft as shown in Figure 1. Figure 1 - Newquay Radar at 0800:26 The DHC6 had not completed the right turn and was still converging with the extended centreline. The Approach controller notified the Tower that the DHC6 was now positioning for an ILS approach. At this point the Mode C of the A319 faded from radar. At 0800:29 the A319 pilot advised the Tower controller, (A319)c/s we ve got TCAS traffic traffic er two miles ahead on our left and the Tower controller replied (A319)c/s there s traffic joining downwind routeing now for the ILS. The A319 pilot replied, Roger he s on TCAS (A319)c/s. The Tower controller responded Understood own navigation. At 0800:42 the two aircraft passed abeam at a range of 0.5nm, with the DHC6 passing 1900ft. There was no radar Mode C readout for the A319 (Figure 2). Figure 2 - Newquay Radar at 0800:42 The DHC6 pilot s written report indicated that he had the runway in sight and watched the A319 depart and then make a climbing right turn. At 0800:53 the A319 faded from the Newquay radar display and then re-appeared at 0801:11, passing 2200ft. The Tower controller instructed the A319 pilot to contact Approach on frequency 133.4MHz. The A319 pilot replied, One three three four (A319)c/s er for the (A319)c/s just 4

19 departing I don t know if you need to file a report erm we turned just before the noise so I couldn t see the traffic and he was coming up on TCAS with an advisory so we needed to do something about it. The UK AIP page AD 2.EGHQ-8 (30 May 2013) para 2.21, noise abatement procedures for RW30, states: Aircraft 5700 kg or more: Climb straight ahead until above 2000ft agl or across the coast before turning on track. The A319 was then transferred to the Approach frequency and continued without further incident. At interview the Approach controller indicated that normally, if VFR inbound traffic had not reported the field in sight by 5nm from the airfield, appropriate instructions would be given together with co-ordination and transfer to the Tower. The Approach controller had been monitoring the two aircraft climbing out of Culdrose and had not realised the DHC6 was approaching Watergate Bay and the ATZ. When the DHC6 then asked for RW12, late traffic information had been given regarding the departing A319. Both controllers indicated that DHC6 pilots would often position towards Watergate Bay and it was common practise for them to request right base for RW12 if traffic permitted. However, the A319 operation had only recently commenced and the changed operational aspects had probably not been fully assimilated or integrated into local practises. When asked, the Approach controller agreed that had the DHC6 crew been made aware of the A319 departure earlier, it was likely that the DHC6 would have integrated into a wider circuit or requested an ILS approach earlier. Both controllers recognised that the DHC6 pilot was not aware of the departing A319 as it routed towards Watergate Bay. This together with the added complexity of low cloud, probably prompted the DHC6 pilot to consider the option of RW12. Due to the low traffic levels the controllers had an expectation that there was not likely to be a conflict as the DHC6 was positioning downwind lefthand for RW30 and the A319 was departing with a right turn to the east. Had the circuit been busier there would have been a greater degree of coordination and planning. The Tower controller indicated that he was busy watching the A319 s taxi and departure, observing the runway and looking for birds. The Tower controller had not noticed the DHC6 on the ATM until the A319 was airborne and had reported a TCAS contact. The Tower controller reported watching the A319 climbing and turning right, in an area of blue sky, on climb out over the coast, but at no point was the DHC6 sighted visually. The Tower controller indicated that when the A319 reported the TCAS contact he passed late traffic information regarding the DHC6 joining downwind. With the benefit of hindsight, had he known the DHC6 was going to position close to the climb out area, he would have given earlier traffic information and coordinated with Approach. Since this incident the ATSU has reminded all controllers of the MATS Part 1 and 2 requirements to ensure that inbound VFR aircraft are properly coordinated before the aircraft reaches 5nm from the aerodrome, to ensure that the aircraft is able to integrate properly into the visual circuit. The Newquay Manual of Air Traffic Services (MATS) Part 2, Page 55 paragraph (VFR Inbound), states: APP/APS will provide details of inbound VFR aircraft to the VCR assistant as soon as practicable after first contact. APP/APS will then co-ordinate join with ADI before the aircraft reaches 5 nm from the aerodrome. APP/APS may decide to level restrict inbound VFR aircraft depending on other traffic and ADI will be informed if this is the case. The MATS Part 1, Section 2, Chapter1, Page 13, paragraph , states: 5

20 Clearance to enter a traffic circuit is issued when an aircraft is still some distance from the aerodrome to enable the pilot to conform with the traffic circuit, pending clearance to land. Information concerning landing direction or runway in use and any other necessary instructions are given at the same time so that the pilot may intelligently position himself in the traffic pattern. The ATSU and two controllers were aware of CAA Safety Notice SN-2013/001, (Integrating Traffic in the Vicinity of an Aerodrome) which highlights that, in order to achieve a safe, orderly and expeditious flow of air traffic and to assist pilots in preventing collisions, specific traffic information is needed as the pilot gets closer to the aerodrome and is required to integrate with other traffic Newquay ATS Investigation The A319 was departing RW30 on an IFR flight plan from Newquay to the east. This aircraft was receiving an Aerodrome Control Service from Newquay Tower and was due to receive a Deconfliction Service once safely airborne. The DHC6 was operating VFR, receiving a Traffic Service from the Approach controller and making a downwind left visual join for RW30. At 0756 ADI requested a release from Approach for the A319. This was granted by Approach without any restriction. At this point the DHC6 was 10nm from Newquay some 2nm clear of the coastline and approximately 3nm north-west of Perranporth airfield. At 0758 Approach arranged departure handover details for the A319 with Western Radar. A short discussion over a potential conflict with an aircraft at FL150 15nm east of Newquay took place, but it was agreed that this track s heading posed no threat to the A319 and the pre-note was agreed the DHC6 pilot asked for the wind at Newquay and then whether an approach to RW12 was possible. He was told No, A319 for departure off 30. The DHC6 then said in that case, we're going to turn right and we'll take vectors for ILS Runway 30 please. He was instructed to turn right heading 130 degrees. The DHC6 was 2.5nm west of Newquay at 1200ft QNH and 1.5nm to the left of the extended centreline for the climb out of RW30. SSR Mode C indicates that it started to climb at this point. At 0800:19 Approach instructed the DHC6 to climb to 2500 feet. The aircraft was now 1nm south of the climb-out lane, 2.5nm west of the airfield and passing 1500ft. At 0800:23 The Tower Controller reported [A319 c/s] airborne on the hour '. Approach replied cheers mate, [DHC6 c/s] breaking out, he wants ILS now. Approach acknowledged. The A319 appears on radar for the first time over the airfield and indicating 500ft on Mode C. Shortly after the A319 pilot called we have TCAS traffic two miles ahead on our left, the Tower Controller replies traffic joining downwind routing now for the ILS. The A319 pilot replies Roger, he s on TCAS, the Tower Controller replies Roger, own navigation. The A319 passed approximately 0.5nm port-to-port with the DHC6 indicating 1900ft. The A319's Mode C is garbled, 4 sweeps later it appears 2.5nm north of the DHC6 indicating 2200ft while the DHC6 indicates 2500ft with both diverging from each other. Approach asked Tower how close was that? Tower replied that was the [DHC6], wasn't it? At 0801:12 the A319 was transferred to 133.4MHz, as the pilot acknowledged he said I don't know if you need to file a noise report but we turned early due a TCAS with an advisory so we had to do something about it. The Tower Controller replied Yes, no problem at all, I have my Manager with me now. 6

21 Conclusions There were several opportunities for the Approach Controller to tell the DHC6 that its track for the visual downwind join was too close to the climb out track and to suggest a rerouting. Visual downwind joins for RW30 generally follow the coastline until Newquay town then run parallel to the runway and are automatically well clear of the climb out. The Tower Controller would therefore not normally call visual downwind joining traffic to a departing IFR aircraft as their paths are not in conflict. This was not the case here, and the situation warranted an additional call to ADI to coordinate and draw the Tower Controller s attention to the unusual routing and positioning of the DHC6, so that he could call the traffic to the departing A319 crew. Notwithstanding the Traffic Service being provided to the VFR DHC6, once it asked for an ILS to RW30 and started to climb into conflict with the A319, the term 'avoiding action' should have been used and a bold turn to 210 degrees instructed; this would have given a little additional distance from the climb-out, while ensuring terrain clearance, until the aircraft was at safety altitude and may have reduced the TCAS severity. Traffic Information on the departing A319 should have been passed urgently to the DHC6, although it is recognised that the notification of the departure was the trigger for his turn and climb. An urgent warning should also have been called to Tower to pass on to the A319. Finally, the instruction to fly a heading of 130 degrees and an altitude of 2500 feet were quite inadequate to ensure safe separation from the departing traffic. The Approach reply demonstrates that the two aircraft were unlikely to have collided even if the A319 had not started its turn, and the DHC6 pilot had not been visual with the departing A319 throughout. He also said that he had received a TA on the departing A319, but not an RA. However, positive, authoritative control of the situation to ensure safety was not exercised by the Approach Controller throughout this series of events. Summary The A319 was an IFR flight departing from Newquay, in receipt of an Aerodrome Control Service from Newquay Tower. The DHC6 was inbound VFR to Newquay and was in receipt of a Traffic Service from Newquay Approach. The Airprox occurred when the inbound DHC6, operating VFR and, initially, unaware of the departing A319, positioned close to the climb-out area of RW30 due to the presence of low cloud in the vicinity of the airfield, which resulted in the A319 responding to a TCAS TA by making an early avoiding right turn. The DHC6 was in receipt of a Traffic Service. CAP774 UK Flight Information Services, Chapter 3, Page 1, paragraph 5, states: The controller shall pass traffic information on relevant traffic, and shall update the traffic information if it continues to constitute a definite hazard, or if requested by the pilot. However, high controller workload and RTF loading may reduce the ability of the controller to pass traffic information, and the timeliness of such information. Once the DHC6 was within 5nm of the airfield, the departing A319 was likely to be relevant traffic. However, the DHC6 pilot was not made aware of any other traffic and the Approach controller had asked the DHC6 pilot to report aerodrome in sight. This would normally have prompted the Approach controller to update joining instructions and give traffic information on circuit activity prior to transferring to the Tower. Due to the low cloud in the vicinity of the airfield, the DHC6 continued along the coast towards Watergate Bay un-challenged and reached a position adjacent to the climb out area for RW30, which in the absence of traffic information resulted in the Airprox report by the A319. 7

22 A number of factors were considered by ATSI to have been contributory: The low traffic levels resulted in lower levels of co-ordination and the controllers believed that with the DHC6 positioning downwind to the west of the airfield and the A319 departing to the east, that there was not likely to be any conflict between the two aircraft. The DHC6 pilot had requested a downwind join but the lower than expected cloud inland, resulted in the DHC6 routeing along the coast until sighting Watergate Bay and the threshold of RW 12. The Approach controller did not provide early traffic information to the DHC6 pilot, which would have aided awareness and influenced the pilot s tactical planning relative to the departing A319. The Approach controller was distracted whilst monitoring traffic climbing out of Culdrose and did not immediately notice that the DHC6 was closer than expected, having passed the 5nm buffer from the airfield without any further co-ordination or updated traffic information. The Tower controller was visually monitoring the airfield for birds as the A319 departed and did not notice the position of the DHC6 on the ATM. The A319 pilot had not been passed any traffic information prior to departure and was not aware of the type, flight rules or intentions of the DHC6. The A319 responded to a TCAS TA immediately after departure which resulted in the A319 commencing an early right turn and the Airprox report. The Tower and the Approach controllers passed late traffic information to their respective aircraft once the potential conflict was recognised. ATSI considered that the following factors are likely to have been contributory: The weather around the airfield was likely to make VFR flight and the field in sight call difficult. The implications had not been fully anticipated by either the DHC6 pilot or the two controllers. It was reported to be common practise for arriving DHC6 aircraft to route via Watergate Bay, often requesting the use of RW12. The controllers were probably conditioned to the practice, without appreciating the requirements for the recently introduced A319 operation and added complexity of the low cloud. The Tower controller was busy monitoring the A319 as it taxied, looking for bird activity as it departed and didn t notice the DHC6 on ATM. The DHC6 pilot was VFR and sighted the A319 as it departed from RW30, making a climbing right turn. The A319 was not passed any traffic information prior to departure. The A319 pilot would not have known the type, flight rules or intentions of the DHC6 aircraft. The A319 pilot received and responded to a TCAS TA immediately after departure and reported a concern that he had not complied with noise abatement requirements. 8

23 PART B: SUMMARY OF THE BOARD S DISCUSSIONS Information available to the Board consisted of the reports from both crews, the air traffic controllers, the RT transcripts and the radar recordings. The Airline Pilot Members were asked to comment on the actions of the A319 crew, who had elected to take-off with the DHC6 showing on their TCAS display. They informed the Board that it is completely normal to have contacts on TCAS during take-off and that crews understand that azimuth and range displays are not as accurate as the vertical information; it was agreed that the A319 crew could have asked the Tower controller for information on the DHC6 before deciding to take-off, but that they subsequently took action to resolve the confliction. Crews are normally advised to exercise caution against taking avoiding action based on TCAS azimuth information alone, but in this case traffic information on the DHC6 was passed by Tower at around the time that the A319 crew elected to turn right, and so the Board agreed this was an appropriate course of action in the circumstances. Discussion turned to the actions of the DHC6 crew, and whether they should have informed Approach of their change of intentions before they positioned for a right-base join to RW12. It was agreed that it was quite normal for crews flying in and out of coastal airports to adapt their approach, as the weather conditions over the land often differ considerably from those over the sea, and that in the absence of traffic information on the departing A319, the crew may not have perceived a problem with a change of approach; nonetheless, the Board felt that, if the DHC6 crew had informed the Approach controller of their change of intentions, he may have taken earlier action to provide greater separation. Some members felt that, as the DHC6 crews fly this route regularly, they may have become habituated to a late change of approach and that may have been why they omitted to inform the Approach controller. The Board agreed that the Approach controller had a responsibility to monitor the climb-out lane because he had released the A319 for an IFR departure. The DHC6 was 10nm from the airport when Approach released the A319, and the Board agreed that the release was appropriate. Several members observed that this is the point at which they would have expected Approach to take more positive control of the DHC6 and offer traffic information to the crew. ATC members felt that Approach should have offered vectors at this point, and it would have been reasonable to prompt the DHC6 crew by a range of 5nm, if they had not positioned appropriately and reported visual with the airport. The Board agreed with the Newquay ATS Investigation that, once the A319 was airborne and the conflict was apparent, Approach could have taken more positive avoiding action to achieve greater separation. Noting that both controllers were reported to be experienced, it was felt likely that the Approach controller may have become distracted at the point when he should have taken positive control of the DHC6. The A319 was operating on a relatively new schedule and it was also possible that the low levels of traffic experienced at this airport, along with the recency of the operation, may also have influenced the actions of the pilots and air traffic controllers involved. There was considerable discussion around the cause of this Airprox; some members felt that the initial cause was the DHC6 crew s decision to reposition without informing Approach, whilst others felt that the lack of traffic information from both controllers and lack of positive control by the Approach controller were the initial cause. Others pointed out that, as the DHC6 was flying VFR, the A319 crew s decision to take-off, IFR, with the confliction displayed on TCAS, could have been causal or contributory. The Board agreed that the cause had been that ATC had allowed the A319 pilot to get airborne and fly in to conflict with the DHC6, and that a lack of co-ordination between the two controllers and a lack of traffic information had been contributory. The Board also recommended that Newquay ATC should review their co-ordination procedures and responsibilities for integrating VFR traffic. When assessing the Risk, the Board noted that the A319 crew had taken effective action, and that the DHC6 crew maintained visual contact with the A319 on the runway and throughout its take-off; they agreed on a Risk of C. 9

24 The safety barriers 1 pertinent to this Airprox were: ATC rules and procedures, controller action, aircrew rules and procedures, visual sighting, aircrew action, situational awareness from RT, and SA from TCAS. The Board concluded that, as the A319 crew had used traffic information and their TCAS TA to take effective action, and the DHC6 crew could see the A319 throughout its take-off, the barriers had been effective ; the total number of POB was greater than 19, so an Event Risk Classification score of 50 was allocated. PART C: ASSESSMENT OF CAUSE AND RISK Cause: ATC allowed the A319 pilot to get airborne and fly into conflict with the DHC6. Contributory Factors: 1. Lack of co-ordination between controllers. 2. Lack of traffic information to both pilots. Recommendation: Newquay ATC review their coordination procedures and responsibilities for integrating VFR traffic. Degree of Risk: C. ERC Score: 50 1 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. 10

25 AIRPROX REPORT No Date/Time: 26 Jun Z Position: 5212N 00152W (Alcester) Airspace: Lon FIR (Class: G) Reporting Ac Type: Ventus 2 CT PA28 Reported Ac Operator: Civ Club Civ Club Alt/FL: 3100ft 2200ft QNH (1030hPa) QNH (1030hPa) Weather: VMC NK VMC NK Visibility: 30km >10km Reported Separation: 0ft V/100m H Recorded Separation: NK 1 200ft V/0.5nm H NM 1 0 Diagram based on radar and glider logger data 1251:00 A :00 A26 A19 A19 47:15 47: :27 A21 46:51 A :03 A23 Ventus 2 PA28 PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE VENTUS PILOT reports conducting a cross-country route. He was flying under VFR in VMC without an ATS. The white and orange glider was not fitted with lighting or an SSR transponder. The ac was fitted with FLARM. He was approaching Alcester, cruising between 70-80kt when a powered ac approached from behind on his L side at a distance of around 100m and slightly below. The other pilot then turned slowly R in front of him, the distance between them now being less than 100m, and at the same height, as the glider had descended slightly. The distance was sufficiently close that he was able to make a note of the other ac s registration. The other pilot continued to clear to the R, took no avoiding action, and the glider pilot doubted that he had been seen. He assessed the risk of collision as High. THE PA28 PILOT reports transiting from Evesham to Alcester. He was operating under VFR in VMC with a BS from Wellesbourne Information [ MHz]. The white and blue ac had the SSR transponder selected on with Modes A and C; the lighting selection was not reported. The ac was not fitted with an ACAS. He stated that there were many gliders operating throughout the area and that he was aware of having to keep a good look out. He saw a glider at around 1nm in his L 11 o clock position and pointed it out to his passenger. He decided to steer clear as the glider had right of way and noted that it was initially difficult to ascertain in which direction the glider was turning. He decided the glider was in a RH turn passing from R to L in his L 11 o clock, so he turned to the R. He did not believe the two ac came dangerously close. He stated that he was a PPL holder with IMC and Night ratings, that he flew for enjoyment and that he took his flying very seriously. He believed he tried to practice good airmanship. He assessed the risk of collision as Medium. 1 A clear radar recording and glider logger file were obtained with the relative flight paths corresponding to the reported confliction, however, the flight paths did not correlate in time. This may have been due to an error in the radar and/or glider logger time base but it was not possible to establish the reason definitively. 1

26 Factual Background The weather at Birmingham was recorded as follows: METAR EGBB Z 31010KT 9999 SCT033 SCT039 19/11 Q1030 UKAB Secretariat Analysis Both pilots were operating under VFR in VMC and were equally responsible for collision avoidance 2 ; the glider pilot had right of way 3. Whilst the combined radar recording and glider logger picture at first sight showed tracks that correlated to the glider pilots report, on closer examination it was apparent that there was a timing discrepancy and an estimated 700ft difference in altitudes. The glider pilot read the PA28 registration as the ac passed. Summary A Ventus glider pilot and a PA28 pilot, both operating under VFR in VMC in Class G airspace, flew into proximity with each other at about 1247 on the 26 th June 2013, in the vicinity of Alcester. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both ac, radar video recordings and a GPS logger file. Given the reported facts and the recorded data, Board members were unsure whether the PA28 pilot had seen the subject glider. There was no doubt that the Ventus pilot had seen the PA28, as he had recorded the registration. Ultimately, the Board opined that the PA28 pilot probably hadn t seen the subject glider but was reporting his encounter with a different glider. The timing and altitude of the 2 aircraft s recorded tracks introduced a significant degree of confusion but the Board decided that the geometry was such that the diagram was most probably an appropriate representation of the incident, notwithstanding requiring coincident timing. A glider pilot member noted that the performance of the Ventus was such that there would not have been much overtake from the PA28 and that both pilots therefore had plenty of time to see the other. He also noted that where one glider was seen, there were often others, especially in thermic conditions, where they could well be found in a vertical stack, whilst thermalling. The Board considered that the cause of the Airprox was a non-sighting by the PA28 pilot; whilst some Members opined that safety margins were not significantly reduced, the majority considered that they had been reduced much below normal. PART C: ASSESSMENT OF CAUSE AND RISK Cause: A non-sighting by the PA28 pilot. Degree of Risk: B. ERC Score: The Rules of the Air Regulations 2007, Rule 8 (Avoiding Aerial Collisions) 3 The Rules of the Air Regulations 2007, Rule 11 (Overtaking) 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. 2

27 AIRPROX REPORT No Date/Time: 26 Jun Z Position: 56 19N W (Approx 4nm S of RAF Leuchars) Airspace: Leuchars MATZ (Class: G) Reporting Ac Reported Ac Type: Typhoon Grob 109B (Motor-glider) Operator: HQ Air (Ops) Civ Pte Alt/FL: 3000ft 2500ft QFE (1028hPa) RPS (1025hPa) Weather: VMC CAVOK VMC CLBC Visibility: 10km 50km Reported Separation: 400ft V/NR H Recorded Separation: NR V/NR H 100ft V/200m H Diagram based on radar data and pilot reports Typhoon 3000ft QFE 1300:01 F036 F036 Reported route of G109B 2500ft RPS NM F025 00:56 F027 01:56 F026 F037 F027 CPA 1301:25 F026 PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE TYPHOON PILOT reports flying a visual recovery to Leuchars from the west, at 4000ft QFE and 480kts, receiving a Traffic Service from Leuchars Approach, who had informed him of an aircraft crossing the MATZ. He reported visual with the aerodrome at around 10nm, but was asked to remain on the approach frequency due to the MATZ crossing aircraft. The Approach Controller instructed him to maintain heading to position 5nm south of Leuchars, and the Typhoon pilot expected to flow behind the north-bound MATZ crossing aircraft. Approach instructed him to descend to 3000ft and asked if he could see the Grob 109B (G109B); he replied that he could not and requested traffic information. Approach replied that the G109B was in his 12 o clock at a range of 2nm. The Typhoon pilot then saw the motor-glider on a reciprocal heading and took avoiding action resulting in an estimated separation of 400ft as the other aircraft passed to his left-hand side. He assessed the risk of collision as High. THE G109B PILOT reports flying in a level cruise at 2500ft on the RPS of 1025hPa, heading 260 at 85kts. The G109B is a white motor-glider which was operating VFR in receipt of a Basic Service from Leuchars Zone, routing Anstruther, St Andrews, passing south of Cupar en-route to Portmoak at 2500ft on the Tyne RPS of 1025hPa; the aircraft had strobe lights turned on but was not equipped with a transponder. He was following his planned route and contacted Leuchars Approach on passing the town of Leven. He was placed under a Basic Service and reported west-bound from St. Andrews. He reports that there was no apparent activity at Leuchars and he did not receive any information on local traffic. Shortly after passing south-abeam Leuchars, the pilot saw a Typhoon in his left, 11 o clock, tracking down his left-hand side. He reported visual with the Typhoon and continued west-bound. He assessed the risk of collision as Medium. THE ZONE CONTROLLER reports operating at medium intensity with a number of aircraft receiving a service. The G109B pilot called and requested a Basic Service and MATZ transit, and informed the Zone Controller that his aircraft was not transponder equipped. The pilot planned to enter the MATZ from the south then route from St Andrews to Cupar then Fife Airfield. Zone instructed the pilot to fly 1

28 at 2500ft on the Tyne RPS(1025hPa) and then established a climb-out restriction, in accordance with SOPs, so that departing aircraft would not be above 2000ft. Zone decided to keep the G109B on the RPS as the 3hPa difference from the QFE of 1028hPa would provide an extra 90ft separation from any departing traffic. Zone informed the other control positions of the climb-out restriction but, on reflection, reports that he could have passed more information on the routing and pressure setting of the motor-glider. Zone recalls that he could see the Typhoon routing towards the general area of the motor-glider but he could see that the Typhoon s Mode C indicated slightly above the motor-glider s reported altitude and felt there was no risk of collision. The G109B pilot reported visual contact with the Typhoon and Zone reports, on reflection, that he could have provided more information to assist the Grob pilot s situational awareness. He perceived the severity of the incident as Low. THE APPROACH CONTROLLER reports being 40 minutes in to a busy and complex recovery wave when the traffic level dropped and only the Typhoon remained for recovery. When the Typhoon pilot contacted Approach, the controller provided a Traffic Service with the aircraft inbound to Leuchars for a visual approach. The pilot was instructed to descend in accordance with the radar vector chart and Approach noticed the Zone controller promulgating a climb-out restriction of 2000ft QFE against a MATZ crossing aircraft at 2500ft, on QFE he thought; the Approach controller reports that, when operating in the Zone position he routinely puts aircraft crossing the MATZ on QFE. He expected that the MATZ crosser would track from south-east to north-west and planned to route the Typhoon to the south to avoid the G109B. On realising that the G109B was going the turn to head west, Approach decided that the Typhoon s southerly routing would not be the most expeditious track but was still appropriate. The Typhoon pilot was instructed to descend to 3000ft QFE and was passed traffic information on the motor-glider at a range of 8-10nm. When the Typhoon pilot reported visual with the airfield, Approach asked if he was also visual with the motor-glider. The pilot requested the Grob s position and Approach, noticing that the Grob had faded from the radar picture, passed an estimated position, based on the radar trail, of 12 o clock, 2nm, 500ft below. The Typhoon pilot reported visual contact with the motor-glider and was given clearance to contact Tower. He perceived the severity of the incident as Low. THE ATC SUPERVISOR reports monitoring the Approach frequency and queried the southerly routing of the Typhoon. Approach explained that the route was against the MATZ crossing motorglider; the Supervisor was satisfied with that plan and continued to monitor, noting that Approach passed traffic information on the Grob to the Typhoon pilot several times. Factual Background The Leuchars weather at 1250 was: METAR EGQL Z 08005KT 9999 FEW038 SCT042 BKN250 16/06 Q1029 BLU NOSIG This Airprox occurred approx 4nm south of RAF Leuchars at approx 1301:34 on 26 Jun 13, between a Typhoon and a G109B. The Typhoon was operating VFR conducting a visual recovery to Leuchars Rwy 26RH, in receipt of a reduced Traffic Service from Leuchars Approach, with transponder modes A, C and S turned on. The Approach control position was manned by a trainee and OJTI mentor team. 2

29 Analysis and Investigation Military ATM Analysis Figure 1 depicts the approximate route of the motor glider, starting from the point at which it first called Zone. All heights/altitudes quoted are based upon SSR Mode C from the radar replay unless otherwise stated; however, the G109B passed outside NATS radar coverage at 1259:19, prior to the CPA. Both pilots reported VMC with the Typhoon pilot reporting BKN cloud at 6000ft. Approach was manned by a trainee and an instructor who reported their workload as medium to low and the task complexity at the time as medium. The trainee and instructor had been on console for approx one hour, and the incident Typhoon was the only ac on frequency, and the last ac of what the trainee considered to be a busy and complex recovery wave. Zone was operating in the bandboxed Departures/Zone position, a standard configuration for Leuchars ATC, and reported providing Air Traffic Services to multiple aircraft with a moderate workload. The incident sequence commenced at 1257:16 as the Typhoon made initial contact with Approach, was identified and provided with a Traffic Service, reduced as the Watchman was limited awaiting a flight check. At this point, the Typhoon was 35nm west of Leuchars, tracking north-easterly, indicating descent through FL148; a primary contact believed to be the G109B was 5.3nm south-east of Leuchars, tracking northerly at 2500ft on the Tyne RPS of 1024hPa, changing to 1025hPa at 1258:20. It is worthy of note that the G109B had not been identified by Zone and the radar return that Zone believed to be the G109B was intermittent throughout the incident sequence. At 1259:07, Approach advised the Typhoon that they were going to vector [them] to the south, we ve got one MATZ crosser routing south-east to north-west. Both the Approach instructor and trainee reported that they made an assumption of the G109B s routing through the MATZ based 3

30 on previous experience, a brief talk with zone and from looking at his flt strip. No formal landline liaison between Zone and the other radar positions was recorded. Moreover, although when Zone advised Ground of the MATZ Crosser they made reference to the pressure setting that the G109B was operating on, based on the report from Approach, it appears that the liaison within the Approach Control Room did not include this information. Approach then assumed that the G109B was operating on the QFE based on their experience of operating in the Zone control position. Although MMATM Chapter 25 Paras 6-8 discusses a MATZ Penetration Service, it does not stipulate whether aircraft crossing the MATZ should be placed onto the aerodrome QFE but does make reference to the altitude at which aircraft are permitted to cross the MATZ. That said, CAP 413 Chapter 10 Para 3.32 provides examples of phraseology which refer to the use of QFE and CAP 413 Chapter Figure 29 Note 3 states that Military units employ QFE in the circuit area, the instrument pattern and for MATZ penetration. At 1259:58, the Typhoon advised Approach that they were visual with field, confirm position of the MATZ crosser. At this point the Typhoon was 12.4nm west of Leuchars, heading 110 at 4000ft QFE; the G109B had passed outside NATS radar coverage at 1259:19, 4nm south-east of Leuchars, tracking northerly. Approach replied to the Typhoon, MATZ crosser is err believed to be 12 o clock, 10 miles, opposite direction at 2500ft which was acknowledged. Approach s inclusion of the phrase believed to be was arguably as a result of knowing that the G109B had not been identified by Zone. Approach s description of the G109B s relative direction as opposite direction suggests that the G109B had adopted a westerly track en-route Portmoak. Approach then descended the Typhoon to 3000ft QFE which was acknowledged. Given the 3hPa difference between the Leuchars QFE (1028hPa) and the Tyne RPS (1025hPa), the G109B was at 2590ft and thus 410ft vertical separation existed between them and the Typhoon, rather than the 500ft that Approach believed. Based upon Approach s report, at some point after 1259:07, the Supervisor advised them that the G109B was not crossing the MATZ but turning at St Andrews en-route to Portmoak. Both the trainee and instructor considered that their plan was still workable, given the good visibility reported and the separation that they believed existed between the Typhoon and the G109B; however, they did not update the Typhoon on the routing of the MATZ crosser, having previously advised them of the south-east to north-west track. At 1300:44, the Typhoon advised Approach that they were happy to switch to Tower, I ll maintain 3000ft. Approach instructed the Typhoon to maintain this as they were conscious that the Typhoon had not reported visual with the G109B. After a brief exchange of R/T where Approach was asked to repeat his instruction, at 1301:20, Approach asked the Typhoon are you visual with the MATZ crosser? At this point, the Typhoon was 2.7nm south-south-west of Leuchars, heading 115 at 3000ft QFE. The Typhoon s pilot replied negative, request position and Approach advised them that they were unsure of position, he s dropped off radar, believed to be 12 o clock, 2 miles 1 mile, opposite direction. The Typhoon pilot immediately advised Approach that they were visual glider. 4 seconds later at 1301:38, the G109B pilot advised Zone that they were westbound, visual with the Typhoon ; Zone did not provide a warning on the Typhoon to the G109B pilot as he could see that the Typhoon was indicating slightly above my aircraft and that there was no risk of collision and, arguably, they were aware that Approach had descended the Typhoon to 3000ft QFE. The guidance material to CAP 774 Chapter 3 Para 6 states that under a Traffic Service, when providing headings/levels for the purpose of positioning and/or sequencing or as navigational assistance, the controller should take into account traffic in the immediate vicinity, so that a risk of collision is not knowingly introduced by the instructions passed. However, the controller is not required to achieve defined deconfliction minima. CAP 774 Chapter 2 Para 5 states that a controller with access to surveillance-derived information shall avoid the routine provision of traffic information on specific aircraft [to ac in receipt of a Basic Service], and a pilot who considers that he requires such a regular flow of specific traffic 4

31 information shall request a Traffic Service. However, if a controller/fiso considers that a definite risk of collision exists, a warning may be issued to the pilot. The Typhoon pilot reported visually acquiring the G109B at a slant range of 3000ft (approx 0.5nm) 400ft below, which accords with the actual vertical separation of around 410ft; the G109B pilot reported acquiring the Typhoon at 0.5nm, with a minimum reported separation of 100ft vertical and 200m horizontal. It was pleasing to note that Approach had exhibited elements of defensive controlling in deconflicting the Typhoon and the G109B and ensured that there was no risk of a collision; however, by assuming that the G109B was operating on QFE, the separation that they imposed was 410ft, rather than 500ft. Moreover, whilst their assumption of the radar identity of the G109B was proven with hindsight, Approach was deconflicting the Typhoon from what they assumed to be the G109B. It is also reasonable to argue that had Approach re-iterated the altitude of the G109B in their updated Traffic Information to the Typhoon at 1301:26, this may have ameliorated the Typhoon pilot s concern over the conflict. Comments HQ Air Command Comment HQ Air Command agrees with the ATM analysis, particularly the role played by Approach in providing a degree of collision avoidance assistance by providing a degree of vertical separation through their descent instructions. However, having not sighted the MATZ crosser the Typhoon pilot also made a crucial decision to maintain that height when he might have inferred it was clearing to the North from Approach s initial call. Retaining the Typhoon on frequency was also commendable and ultimately ensured the existing separation was maintained. Summary An Airprox occurred approx 4nm S of RAF Leuchars between 1301 and 1302 on 26 Jun 13, between a Typhoon and a G109B within the MATZ but outside the ATZ. The Typhoon was operating VFR conducting a visual recovery to Leuchars RW26RH, at 3000ft QFE (1028hPa), in receipt of a reduced Traffic Service from Leuchars Approach. The G109B was operating VFR in receipt of a Basic Service from Leuchars Zone, routing Anstruther, St Andrews, passing south of Cupar en-route to Portmoak at 2500ft Tyne RPS (1025hPa) and was not equipped with a transponder and the aircraft had not been identified on radar. Estimated vertical separation of 410ft existed between the aircraft. Both aircraft were in Class G airspace, both pilots had equal collision avoidance responsibility and, if approaching head on and there was a danger of collision, were required to alter course to the right. PART B: SUMMARY OF THE BOARD S DISCUSSIONS Information available to the Board consisted of the reports from both pilots, the air traffic controllers, the RT transcripts and the radar recordings. The Board noted that although there had been some areas of concern in this occurrence, there were also some very positive aspects; specifically, the G109B pilot had elected to call ATC for a MATZ crossing service when he was not obliged to, and Approach had exhibited sound defensive controlling by keeping the Typhoon on frequency and planning to route the aircraft to the south at a height that they thought would be 500ft above the G109B. It was agreed that, in this case, the controllers assumptions on pressure settings had not materially affected the sequence of events but this could have led to a far worse outcome in other circumstances; the Board therefore recommended that RAF Leuchars ATC should review its altimeter setting procedure for MATZ-crossing aircraft. Discussion turned to the degree of co-operation between the controllers and it was agreed that this aspect had not been effective in preventing the occurrence; the Board recommended that RAF Leuchars ATC Leuchars should review the coordination procedure and responsibilities for controlling MATZ crossing aircraft. 5

32 Some Board members were surprised that the Typhoon pilot had not seen the G109B on his aircraft s radar and noted that, in the absence of TCAS/ACAS, radar was one of the Typhoon Force s primary mitigations against mid-air collision. One of the Fast-Jet pilot members informed the Board that there are many reasons why the radar may not have detected the G109B, including the difficulty of detecting small radar cross-section aircraft. It was also noted that, in this case, TCAS would not have been effective either because the G109B was not squawking. When assessing the Risk the Board noted that the separation achieved by ATC was likely to have been in excess of 400ft, which is not uncommon in Class G airspace. They also noted that the Typhoon pilot, despite being surprised by the appearance of the Grob109B, had been able to take effective horizontal avoiding action. They therefore agreed that there was no risk of collision and graded the event as a sighting report. The safety barriers 1 pertinent to this Airprox were: ATC rules and procedures, controller action, aircrew rules and procedures, visual sighting, aircrew action, situational awareness from RT, and SA from on-board systems. The Board concluded that, as the Typhoon pilot had seen and avoided the Grob109B and ATC had provided vertical separation, overall the barriers had been effective ; the total number of POB was 2 so an Event Risk Classification score of 2 was allocated. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Sighting report. Contributory Factors: 1. Lack of coordination and TI from ATC. 2. The Grob was using QNH and the Typhoon was using QFE. Degree of Risk: C. ERC Score: 2. Recommendations: 1. RAF Leuchars ATC should review the coordination procedure and responsibilities for controlling MATZ crossing aircraft. 2. RAF Leuchars ATC should review the altimeter setting procedure for MATZ-crossing aircraft. 1 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

33 AIRPROX REPORT No Date/Time: 1 Jul Z Position: 5102N 00158W (10nm SW MOD Boscombe Down) Airspace: Lon FIR (Class: G) Reporting Ac Reported Ac Type: Ventus Alpha Jet Operator: Civ Pte MoD ATEC Alt/FL: 7300ft NK QNH (1019hPa) (1013hPa) Weather: VMC CLAC VMC CLAC Visibility: 40km 10km Reported Separation: 50ft V/0m H Recorded Separation: NK V/ <0.1nm H 100m V/150m H F086 F086 Alpha Jet 1446:34 46:42 Ventus track F084 46:50 Compton Abbas 3nm Diagram based on radar and GPS data Boscombe Down 10nm F080 46:58 47:06 F076 CPA 1447:10 xft V < 0.1nm H NM F074 Group of PSR faded by CPA 47:14 47:22 F071 PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE VENTUS PILOT reports taking part in a NOTAM ed glider competition, climbing in wave WSW of Salisbury. The white glider was not fitted with lights or an SSR transponder but was fitted with FLARM and a radio. He was operating under VFR in VMC with the BGA cloud-flying frequency [ MHz] selected. At the time of the incident he was tracking 130, about 2000ft above the upwind edge of a wave bar and climbing at about 200fpm through 7300ft. He first heard, and momentarily after saw, a Tornado aircraft, he thought, pass about 50ft vertically above, travelling fast in a roughly E ly direction in level flight, having approached from his 4 o'clock position. He was able to observe an orange glow from the jet tail pipes suggesting that after-burners may have been operating. The aircraft rapidly disappeared from sight. He noted that if the other pilot had seen him, he considered he passed far too close. If he had not seen him, then he believed the risk of collision was very high. He noted that, from the information provided in the NOTAM, he could not have been expected to be at the incident location. THE ALPHA JET PILOT reports being vectored for a PAR approach at Boscombe Down. The black ac had HISL selected on, as was the SSR transponder with Modes A and C. He was operating under IFR in VMC with a TS from Boscombe APR [ MHz]. About 10nm SW of Boscombe Down, 1000ft above cloud heading 110 at 300kt, he received TI from APR and at the same time saw a white glider disappear under the L wing, about 100m below, on what appeared to be a reciprocal course. He assessed the risk of collision as Low. THE BOSCOMBE DOWN (BDN) RAD CONTROLLER reports he had the Alpha Jet on his frequency and that the pilot had asked for recovery. As another ac was conducting a trial to the NW of Boscombe, he called the traffic and turned the Alpha Jet onto a heading of 180 in preparation for handover to APR. He rang APR to hand-over and was asked to turn the aircraft L onto a heading of 110. He then transferred the Alpha Jet pilot to APR. At that time he saw no conflicting traffic to effect. [UKAB Note(1): The BDN RAD/APR RT was transcribed as follows: 1

34 From To Speech Transcription Time APR RAD Approach 14:45:22 RAD APR Radar inbound radar [Alpha Jet C/S] 14:45:23 APR RAD Approach 14:45:30 RAD Alpha Jet [Alpha Jet C/S] previously called [other ac type] now south east three miles tracking west flight level 77 climbing 14:45:30 Alpha Jet RAD garbled 14:45:39 RAD Alpha Jet [Alpha Jet C/S] coughing [Alpha Jet C/S] continue right turn to head 180 degrees Alpha Jet RAD 180 degrees [Alpha Jet C/S] and [other ac type] in sight [Alpha Jet C/S] 14:45:45 14:45:52 RAD Alpha Jet [Alpha Jet C/S] 14:45:57 RAD APR Got your [other ac type] in sight 14:45:58 APR RAD OK visual, visual with you go ahead 14:46:00 RAD APR Compton Abbas north north east 8 miles tracking correction heading 180 squawking [Alpha Jet C/S] 14:46:02 APR RAD Contact 14:46:09 RAD APR I haven t descended him yet because I wasn t sure what you wanted me to do with your guy 14:46:10 APR RAD OK err OK turn left 110 degrees identified stud 4 14:46:14 RAD APR Left 100 do you want to descend him? 14:46:18 APR RAD 50 please 14:46:20 RAD APR Roger 14:46:21 APR RAD Approach 14:46:22 RAD Alpha Jet [Alpha Jet C/S] turn left heading 110 degrees descend flight level 50 14:46:23 Alpha Jet RAD Left heading 110 degrees and.. garbled.. 14:46:29 RAD Alpha Jet [Alpha Jet C/S] contact Boscombe Radar stud 4 14:46:34 Alpha Jet RAD Stud 4 [Alpha Jet C/S] 14:46:38] THE BDN APR CONTROLLER reports working 2 aircraft on a BS. RAD called with a hand-over for a radar recovery on the Alpha Jet, which had been turned S to avoid another ac at a similar FL. There were Primary Surveillance Returns (PSR) to the S, between Salisbury and Fordingbridge, all of which he believed to be gliders. The PSR were spaced quite widely apart and at no point were they a factor to the Alpha Jet for a radar feed in from the S. There was a sufficient amount of space to vector the Alpha Jet between the returns and sufficient time to call any relevant traffic. During the hand-over he turned the Alpha Jet onto 110 to vector him through the space. At this time another ac called up for recovery. He identified it, placed the pilot under a service and turned him to the NE. He called DIR to control this other ac. The Alpha Jet pilot, who was still high at about FL75-80 descending, then called up on APR. The controller noted that the Alpha Jet pilot seemed to take a while to establish contact, possibly due to the other ac calling for recovery. As the Alpha Jet pilot called on APR a PSR was 2

35 seen in his 12 o clock and TI was passed on initial contact. The Alpha Jet pilot reported visual and continued with his recovery. He perceived the severity of the incident as Low. [UKAB Note(2): The BDN APR/Alpha Jet RT was transcribed as follows: From To Speech Transcription Time Other ac RT traffic Alpha Jet APR [Alpha Jet C/S] with you on heading 110 descending flight level five zero for a PAR. squelch.par approach for overshoot then visual join APR Alpha Jet [Alpha Jet C/S] roger Boscombe Approach roger traffic twelve o clock half a mile crossing left to right slow moving no height possible glider 14:47:00 14:47:08 Alpha Jet APR Just passed [Alpha Jet C/S] 14:47:14 APR Alpha Jet [Alpha Jet C/S] Boscombe Approach identified descending flight level five zero traffic service. 14:47:16 Alpha Jet APR Flight level five zero [Alpha Jet C/S] 14:47:20] THE BDN ZONE CONTROLLER reports he was controlling on a busy afternoon when he received a free-call from the Ventus pilot who wanted to report an Airprox as a fast jet had just flown above him. He reported he was 17.5 miles East of Shaftsbury at about 7300ft on QNH 1019hPa when the incident occurred. He was in a non-transponding ac, however, he did state that he believed the other pilot was visual with him. The controller asked whether he required a LARS service but he declined. He asked him to confirm his position, level, and registration, informed him he was potentially flying above the Boscombe MATZ and advised that a service would be beneficial for air safety. However, he again declined and free-called en route. The controller spoke to the Alpha Jet pilot later in the day to inform him that a civilian glider had filed an Airprox. [UKAB Note(3): The BDN ZONE/Ventus RT was transcribed as follows: From To Speech Transcription Time Ventus ZONE Boscombe Golf, Boscombe [Ventus C/S]. 14:48:06 ZONE Ventus [Ventus C/S] Boscombe Zone pass your message 14:48:13 Ventus ZONE [Ventus C/S] would like to report an Airprox with a fast jet that just passed over me about 50ft above. I m 17km west err of Shafts correction 17km east of Shaftesbury at 7300ft 14:48:16 ZONE Ventus [Ventus C/S] roger do you require a service from Boscombe as well 14:48:38 Ventus ZONE Negative, I m VMC and err happy to continue but I think the jet saw me, I think he waggled his wings as he crossed over but I guess he ll report an Airprox ZONE Ventus [Ventus C/S] roger, can I take your details your registration and your where you were at the time Ventus ZONE Roger you may be able to see me on radar it [Ventus registration], my position I can give you as latitude and longitude, I haven t moved significantly from the airmiss 14:48:42 14:48:57 14:49:05 3

36 From To Speech Transcription Time ZONE Ventus [Ventus C/S] or just your approximate position at the time of the Airprox and height Ventus ZONE Roger height about 7300ft err on 1019 and I m 17.5km east of Shaftesbury ZONE Ventus [Ventus C/S] Roger, I think or believe I can see you nine miles South West of Boscombe in the inbound lane. Would you like a service err to keep you safe? 14:49:24 14:49:30 14:49:54 Ventus ZONE Negative no service required 14:50:05 ZONE Ventus [Ventus C/S] 14:50:09 THE BDN SUPERVISOR reports RAD was working 3 frequencies. When the Alpha Jet pilot called for recovery the SUP asked RAD if he wanted to hand-off to DIR but he indicated he was happy to continue with one in the pattern. Moments later, another ac free-called RAD for recovery so the SUP directed that it should be given to DIR as the workload was becoming too high for RAD to maintain SA. The Alpha Jet pilot then contacted APR and TI was passed to which the pilot replied that he was visual. Factual Background The Boscombe Down weather was recorded as follows: METAR EGDM Z 32011KT 9999 SCT035 18/09 Q1017 BLU NOSIG The event occurred within the Boscombe Down Advisory Radio Area (ARA). The CAA VFR chart, Edition 39, at Note 19 states: BOSCOMBE DOWN ADVISORY RADIO AREA FL50-FL195. Pilots entering the area are strongly advised to call Boscombe Down on MHz to obtain information on test flight activity and if requested, advice on arranging a detour of the test area. For full details see UK AIP ENR 5.6. ARA details for Boscombe Down in the current UK AIP are at ENR 5.2-8, dated 27 Jun 2013: ARA BOSCOMBE DOWN N W N W N W N W N W N W - BUT excludes Controlled Airspace. Upper limit: FL195 Lower limit: FL50 Hours: Mon to Fri 0930 to 1730 Winter (Summer 1hr earlier). Remarks: Considerable test flight activity. Test flight activity often requires the pilots to fly profiles which limit their ability to manoeuvre their aircraft in compliance with the Rules of the Air. Such flights will receive a radar service from Boscombe Down or the Swanwick Military Special Tasks Cell. Advisory Measures: Pilots entering the area are advised to call Boscombe Down on MHz to obtain information on test flight activity. The Ventus pilot was flying in a competition notified by the following NOTAM: H2373/13 NOTAMN Q) EGTT/QWGLW/IV/M /W /000/100/5051N00317W010 A) EGTT B) C) D) SR-SS E) MAJOR GLIDING COMPETITION INCLUDING CROSS-COUNTRY RTE. INTENSE ACTIVITY WI 10NM RADIUS N W (NORTH HILL, DEVON). UP TO 50 GLIDERS AND 7 TUG ACFT MAY PARTICIPATE. GLIDERS WILL NORMALLY OPR BLW THE INVERSION LVL OR BTN TOPS OF ANY CU 4

37 CLOUDS AND 500FT AGL. RTF MHZ. FOR INFO ON DAILY TASK RTE CTC GLIDER COMPETITION CTL TEL OR /AS 3 F) SFC G) FL100 Analysis and Investigation Military ATM All heights/altitudes quoted are based upon SSR Mode C from the radar replay unless otherwise stated; however, the incident was not visible on the NATS radar replay and, although there was an intermittent primary contact in the incident area, it has not been possible to determine whether this corresponded with the Ventus. Moreover, APR s description of the surveillance picture at the time was that there were multiple primary returns in the area, that he believed to be gliders, and thus the radar replay does not fully depict the situation. APR described his workload and task complexity as moderate, providing BS to 2 pilots in addition to the Alpha Jet pilot. RAD did not assess his workload or task complexity but seemed to have been providing an ATS to the Alpha Jet pilot only; the unit has subsequently determined that RAD s workload was low and that he was indeed providing an ATS to the Alpha Jet pilot only. The incident sequence commenced at 1446:02 as RAD commenced the handover of the Alpha Jet pilot to APR. APR requested that RAD descend the Alpha Jet to FL50 and turn it onto hdg 110 ; the handover was completed at 1446:22. APR reported that RAD had vectored the Alpha Jet initially to the S of BDN to avoid a Gazelle that was operating at a similar level to the Alpha Jet. They further stated that there were primary returns to the south, between Salisbury and Fordingbridge, all of which [he] believed to be gliders. The primary returns were spaced quite widely apart and at no point were they a factor to [the Alpha Jet] for a radar feed in from the S. There was [a] sufficient amount of space to vector [the Alpha Jet] between the returns and sufficient time to call any relevant traffic to [the Alpha Jet] post handover. Based on subsequent conversation with APR, the hdg of 110 passed by APR to RAD for the Alpha Jet was designed to allow the Alpha Jet to pass between 2 distinct groups of primary returns on their surveillance display. UK Mil AIP entry for MOD Boscombe Down states that radar services within 15nm of Boscombe Down are automatically limited due to high traffic density and local airspace restrictions; standard separation may not be achieved on recovery profiles. Thus BDN ATC will not re-iterate this reduction to the ATS to station-based aircraft. At 1446:23, RAD instructed the Alpha Jet pilot to, turn left heading degrees, descend Flight Level 5-0 which was read-back. Immediately after, at 1446:34, RAD instructed the Alpha Jet pilot to contact APR which was acknowledged, the Alpha Jet pilot leaving RAD s freq at about 1446:40. RAD reported that at the point at which he transferred the Alpha Jet pilot to APR, he saw no conflicting traffic to effect and no TI was passed to the Alpha Jet pilot on the 2 groups of PSR. The Alpha Jet pilot commenced the L turn onto 110 at 1446:42, steadying on hdg at 1446:59. At 1446:44, one of the pilots of the 2 ac being provided with a BS by APR called for a SRA recovery; APR was then engaged in an RT exchange with this pilot until 1446:59. At the point that this pilot called APR for recovery, 3.4nm lateral separation existed between the Alpha Jet and the incident location. This separation was the basis for APR s assertion that sufficient time to call any relevant traffic to [the Alpha Jet] existed post handover. At 1447:00, the Alpha Jet pilot made initial contact with APR stating that they were on heading 1-1-0, descending Flight Level 5-0 for a PAR [squelch] PAR approach for overshoot then visual join. APR replied [Alpha Jet C/S] roger, Boscombe Approach, Roger, traffic 12 o clock, half a mile, crossing left to right, slow moving, no height, possible glider. The Alpha Jet pilot replied that he d just passed [the Ventus] ; thus the CPA occurred at approximately 1447:14. 5

38 CAP 774 Chapter 3 Para 5 states that the controller shall pass traffic information on relevant traffic However, high controller workload and RTF loading may reduce the ability of the controller to pass traffic information, and the timeliness of such information. The guidance material to this paragraph states: Traffic is normally considered to be relevant when, in the judgement of the controller, the conflicting aircraft s observed flight profile indicates that it will pass within 3nm and, where level information is available, 3000ft of the aircraft in receipt of the TS. However, controllers may also use their judgement to decide on occasions when such traffic is not relevant, e.g. passing behind or within the parameters but diverging. Controllers shall aim to pass information on relevant traffic before the conflicting aircraft is within 5nm, in order to give the pilot sufficient time to meet his collision avoidance responsibilities and to allow for an update in traffic information if considered necessary. At 1447:26, a PSR becomes visible on the radar replay, directly within the trail of the Alpha Jet, indicating that the contact was in the vicinity of the Alpha Jet at 1447:16 and thus it is reasonable to argue that this contact was the Ventus. Extrapolation of the available radar data together with the Alpha Jet s radar estimated ground speed, suggests that APR passed TI to the Alpha Jet pilot with approximately 1.1nm lateral separation between it and the Ventus. The situation was aggravated by the delay experienced in establishing 2-way RT between the Alpha Jet pilot and APR, due to the unrelated ac calling APR for a SRA recovery and, potentially, by the delay between the Alpha Jet pilot being issued the vector and commencing the turn. Consequently, whilst cognisant that controllers may use their judgement to decide when not to pass TI, given the proximity of the PSR to the Alpha Jet s projected track and that their intentions were unknown, it is reasonable to argue that the Alpha Jet pilot could have received TI prior to being transferred to APR. Comments HQ Air Command This incident highlights the risk inherent in any aviation activity, even when all parties are complying with their respective best practice. Whilst the crew might have received TI earlier and they might have spotted the glider earlier in any case, the steady flight profile and colour scheme made sighting much less likely. It is unfortunate that APR did not assimilate that the multiple contacts he could see, and which he assumed to be gliders, were part of a wider grouping on a competition route, and that a generic warning to the Alpha Jet pilot was not issued as a result. Had any of the competition organisers communicated their route for the day to Boscombe Down, or other airfields whose local traffic might be affected, such a warning may have been possible. Equally, a call from any one of the gliders involved, in advance of an Airprox occurring, would have served the same purpose. Of note, pilots entering the area are strongly advised to call Boscombe Down to obtain information on test flight activity and, if requested, advice on arranging a detour of the test area. Summary A Ventus and an Alpha Jet, both operating in Class G airspace under VFR and IFR respectively, came into close proximity at about 1447 on 1 st July 2013, 10nm SW of Boscombe Down. The Ventus pilot was listening out on the BGA cloud-flying frequency and the Alpha Jet pilot was in receipt of a reduced TS, having just transferred from Boscombe RAD to APR for an instrument recovery. Both pilots had equal responsibility for collision avoidance, and the Ventus pilot had right of way. 6

39 PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both ac, transcripts of the relevant RT frequencies, radar video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities. The Board first considered the regulations pertaining to the occurrence location. The pilots were both in Class G airspace, albeit within the BDN ARA. The Board noted that there was no requirement for pilots to contact BDN when within the lateral and vertical boundaries of the ARA but that they were strongly advised to do so. Board glider pilot members also noted that there was no requirement for a glider pilot to be in receipt of an ATS from BDN and that most gliders lack SSR, which would obviate a radar-based service. The issue of glider pilot radio usage was discussed with members pointing out that whilst increasing numbers of gliders were equipped with a radio, many were not. Additionally, many glider pilots were not in possession of an RT license and so could not use the radio on a non- BGA allocated frequency. Notwithstanding these limitations, the Board felt that those glider pilots who were able, would be well served by contacting busy local airfields when in the vicinity with a simple call to pass routeing information. Equally, it was felt that a more comprehensive notification system would increase all pilots SA. Board members opined that non-powered aircraft competitions, organised under the auspices of a parent organisations, could be more pro-active in promulgating their task routeing in a timely fashion to airspace users on or near the task track before the event. The Board spent some time discussing how this could be accomplished and ultimately decided that promulgation by the competition organisers through the NOTAM system would help achieve the desired coverage. It was recognised that this code of practice would have to be incorporated into parent organisations procedures so the Board decided to make a recommendation that the CAA investigate how this could best be achieved. The Board then turned to the pilots actions. They were both entitled airspace users; the glider pilot operating under VFR and the Alpha Jet pilot operating under IFR. The Board noted that the glider pilot contacted BDN by RT to file the Airprox, and commended him for doing so; they also noted that he would have been well-served by planning to do so before he entered the ARA, iaw the CAA VFR chart. A Board adviser stated that on this occasion the gliding competition was not using task routeing but rather, enterprising tasks, consisting of flexible routeing between a selection of way-points in Devon and Dorset. Nonetheless, Board members remained of the opinion that prior promulgation would have been of assistance. The Alpha Jet pilot received TI, most probably on the subject glider, very shortly before CPA, but was not able to obtain visual contact until after the last opportunity to affect the outcome, as the glider disappeared under his left wing. The Board was somewhat perplexed by his risk assessment of Low. The Ventus pilot did not see the Alpha Jet until after it had passed and, given his detailed description of the receding Alpha Jet s engine exhaust glow, the Board decided that the situation had stopped just short of an actual collision and that chance had played a major part in events where nothing more could have been done to improve matters. PART C: ASSESSMENT OF CAUSE AND RISK Cause: An effective non-sighting by the Alpha Jet pilot in Class G airspace. Degree of Risk: A. ERC Score: Recommendation: CAA GA unit consult with non-powered aircraft parent organisations to review prior promulgation of task routeing and way-points to Airspace Information Service and airfields close to task track. 1 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

40 AIRPROX REPORT No Date/Time: 30 May Z Position: 5432N 00303W (Thirlmere) Airspace: LFA 17 Lon FIR (Class: G) Reporting Ac Reported Ac Type: Tornado GR4 Ikarus C42 Operator: HQ Air (Ops) Civ Pte Alt/FL: 350ft agl ft agl (RPS 1006hPa) NK Weather: VMC CLBC VMC CLBC Visibility: 20km 10km Reported Separation: 500ft V/0m H Recorded Separation: NK NK PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE TORNADO PILOT reports conducting a low-level sortie as part of a 3-aircraft formation. The grey camouflaged aircraft had navigation lights and HISL selected on, as was the SSR transponder with Modes A, C and S. The aircraft was not fitted with an ACAS. They were operating autonomously under VFR in VMC with the radios selected to the low-level common frequency and an intra-formation frequency. Whilst flying at low-level through the Lake District 2nm NW of Keswick, heading 355 at 420kt, the crew observed a white, high-wing, single-engine, light aircraft about 0.5nm ahead, flying in the opposite direction, about 500ft above. The crew informed the other formation aircraft, a pair following at low-level about 5min behind, using the intra-formation frequency and put out an information call on the low-level common frequency. The following pair subsequently saw the light aircraft heading S overhead Thirlmere; they assessed it to be 300ft above them under a cloud-base that gradually lowered from N to S. The Tornado crew also spoke to Carlisle A/D, who had no knowledge of a light aircraft transiting S through the Lake District. The Tornado pilot noted that military aircraft operating below 2000ft agl are required to transit from S to N if using the valleys that contain Thirlmere (S of Keswick) and Bassenthwaite Lake (NW of Keswick), which is denoted by a flow-arrow on military VFR charts, but that no such requirement exists for non-military aircraft. He assessed the risk of collision as Medium. THE IKARUS PILOT reports transiting S en-route to an A/D in France. The white and red aircraft had the SSR transponder selected on with Modes A, C and S and was not fitted with an ACAS. The lighting was not reported. He was operating under VFR in VMC and was not in receipt of an ATS. Overhead Thirlmere, heading S in level cruise at 75kt and an estimated height of ft in good visibility, he saw a pair of Tornados about 5nm ahead, at low-level. He was not concerned, rocked his wings to signal he had seen them as they approached, and watched as they passed out of sight below and to the R. He noted that he commented on what a great sight they were to the other pilot on board and thought nothing more of the incident. He assessed the risk of collision as Low. 1

41 Factual Background The weather at Carlisle was recorded as follows: METAR EGNC Z 04008KT 9999 FEW016 SCT022 13/09 Q1014 The Tornado formation was correctly authorised and booked in to the UK Low Flying System. Analysis and Investigation UKAB Secretariat The Ikarus and Tornado pilots were operating in Class G airspace and all had equal responsibility for collision avoidance 1. The pilots were required to manoeuvre their aircraft to the R if approaching head-on and there was a danger of collision 2. Whilst the Ikarus pilot was required to comply with Rules of the Air 2007, Rule 5(b) 3, the Tornado pilots were required to fly not lower than 250ft 4 agl and to maintain a minimum separation of 250ft from any object. Likewise, the Tornado crews were required to comply with the flow-arrow, to route S to N, but the Ikarus pilot was not. Military flow-arrows exist at many choke-points around the UK, the intent being to prevent fast-moving military low-level traffic routeing in opposite directions through constrained areas. Non-military traffic is not required to conform to the flow-arrow requirements and flowarrows are not printed on CAA VFR charts. Comments HQ Air Command Air Command commends the crew for their report of the sighting. It reminds crews that civilian aircraft may be found almost anywhere and at any time within what the military term the Low Flying System. The report also highlights some excellent practice such as the passing of specific warnings to the following Tornados as well as general warnings to other users of the Low Flying Area on the Low Flying Common frequency. Equally, it is an opportunity to remind GA traffic that they are most likely to encounter military fast jet traffic between 250ft and 1500ft across the majority of the UK; details are available at There may be some additional value in highlighting the existing flow arrows to GA traffic, but given the significant speed differences, there would be no benefit in requiring compliance with them. Whilst this would reduce closure speeds slightly, it would rob GA traffic of much of their ability to see and avoid. Summary An Ikarus C42 and members of a Tornado formation came in to close proximity in the Lake District at about 1016 and 1021 on 30 th May All the pilots were operating autonomously under VFR in VMC in Class G airspace. The Tornado crews were operating at low-level iaw military low-flying regulations. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both ac and a report from the appropriate operating authority. 1 Rules of the Air 2007, Rule 8 (Avoiding aerial collisions) 2 Rules of the Air 2007, Rule 10 (Approaching head-on) 3 The 500 feet rule: Except with the written permission of the CAA, an aircraft shall not be flown closer than 500 feet to any person, vessel, vehicle or structure. 4 UK Military Low Flying Handbook. 2

42 Given the reported circumstances of the incident, the Board surmised that the military crew had filed an Airprox in no small part due to their surprise at seeing opposite direction traffic in an area that was constrained by the surrounding high terrain, by the lowering cloud base and by the military low-flying requirement to follow the flow-arrow. After some discussion, Board members decided that the GA community could usefully be made more aware of aspects of flow-arrows such as their location, orientation and applicability, although they recognised that civilian pilots were not required to abide by their limitations. It was agreed that the CAA be recommended to review education of GA pilots in order to improve understanding of the implications of flow arrows and their choke-point implications with respect to military fast-jets at low-level. It was also noted that flow-arrows had previously been printed on CAA VFR charts but the Board was not convinced that their re-introduction would improve matters. Although the Ikarus pilot apparently only saw the second pair of Tornados, the Board were content that the separation was such that it did not cause him concern and that, by maintaining their flight paths, all the Tornado pilots had taken effective and timely action to prevent collision. The Board also commended the Tornado crew on their decision to file an Airprox. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Sighting report. Degree of Risk: C. ERC Score: 2 5 Recommendation(s): CAA to review education of GA pilots to improve understanding of implications of military low-flying flow arrows. 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. 3

43 AIRPROX REPORT No Date/Time: 3 Jul Z Position: 52 03N W (5nm west of Duxford) Airspace: London FIR (Class: G) Reporting Ac Reported Ac Type: Lynx Tiger Moth Operator: RN Civ Trg Alt/FL: RPS (1000hPa) QNH (1009hPa) Weather: VMC CLBC VMC CLBC Visibility: 20km >10km Reported Separation: 10ft V/80m H Recorded Separation: NR V/0.1nm H 75ft V/>200m H Diagram based on radar data and pilot reports 1455:38 NM Lynx 1500ft alt RPS 1000hPa 55:55 56:14 A16 A15 Tiger Moth 1500ft alt QNH 1009hPa PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE LYNX PILOT reports routeing VFR from Wittering to RNAS Yeovilton at 1500ft on the RPS of 1000hPa. The helicopter was grey with red anti-collision lights and navigation lights turned on, and was squawking transponder Modes A, C and S. The pilot reports heading 190, at 120kts, in receipt of a Basic Service from Cambridge Approach when he saw the Tiger Moth 150m away, in his left, 11 o clock position. He turned right and the Tiger Moth passed behind his aircraft with estimated minimum separation of 10ft vertically and 80m horizontally. He perceived the severity of the incident as Medium. THE TIGER MOTH PILOT reports carrying out a training flight, cruising VFR, heading 340, at 80kts, level at 1500ft on the Duxford QNH 1009hPa. The aircraft was bright RAF Training yellow and did not have an ancillary electrical system; consequently, it did not display any lights and was not equipped with a transponder. He was briefing the student on basic picture reference points whilst looking out for traffic, when he saw the Lynx 1200m away, slightly left of his 12 o clock position, around 10 or 11 seconds before the CPA. He made an avoiding action right turn and estimates the minimum separation to be 75ft vertically and over 200m horizontally. The pilot did not see the Lynx deviate from its course or altitude and felt confident that the Lynx crew would not have seen his aircraft until he had banked left back on to his track. He kept the Lynx in sight until the aircraft had passed clear of each other. He assessed the risk of collision as None. THE CAMBRIDGE APPROACH CONTROLLER reports providing a non-radar Basic Service to the Lynx when the pilot reported an Airprox with a yellow bi-plane; the Lynx pilot left his frequency shortly afterwards. Factual Background The Cambridge METAR at 1550 was: 1

44 METAR EGSC Z 27011KT 240V FEW032 BKN049 19/13 Q1011 Analysis and Investigation UKAB Secretariat Both pilots were operating under VFR in class G airspace and shared the responsibility to avoid each other 1. When aircraft are approaching each-other head-on, or approximately so, the pilots should each adjust their course to the right 2. Both pilots reported turning right; the Tiger Moth pilot submitted a cockpit video which clearly shows his turn and its effect but, whilst the Lynx can be seen, the image is not clear enough to assess any manoeuvres it may have made. Figures 1 and 2 are taken from the Tiger Moth s cockpit video and show the aircraft before and after the CPA. Figure 1. Before CPA Figure 2. After CPA The 9hPa difference between the altimeter pressure settings of the two aircraft indicates that, as both pilots reported flying at 1500ft, there was likely to have been around 243ft vertical separation between them. Navy Command This Airprox occurred between 2 aircraft flying VFR in VMC, with both crews seeing the other aircraft very late and manoeuvring correctly in accordance with the rules of the air. Lookout was the only MAC barrier in this instance and collision was avoided. It is noted that the human estimation of distance is subject to significant variation. Summary The Airprox occurred between a Lynx and a Tiger Moth operating VFR in Class G airspace 5nm to the west of Duxford. Both pilots reported seeing the other aircraft and manoeuvring to the right. Minimum horizontal separation of 0.1nm was recorded on radar. 1 Rules of the Air 2007, Rule 8, Avoiding aerial collisions 2 Rules of the Air 2007, Rule 10, Approaching head-on 2

45 PART B: SUMMARY OF THE BOARD S DISCUSSIONS Information available to the Board consisted of the reports from both crews and the radar recordings. The Chairman invited the GA and helicopter members to lead the discussions and they unanimously felt that this was a straightforward occurrence of two aircraft operating VFR in Class G airspace. Whilst it appeared that the Lynx pilot saw the Tiger-Moth later than the Tiger-Moth pilot saw the Lynx, nonetheless, both pilots took appropriate action by manoeuvring to the right and achieving lateral separation of 0.1nm. Because the Tiger-Moth did not have a transponder, it was not possible to provide a measured vertical separation but it was noted that the difference in the pressure settings that the aircraft were flying on was likely to have provided around 243ft of vertical separation; both pilots reported less than that, but very accurate judgement of distance and height is always challenging, and the Board concluded that the pilots reports were commensurate with that distance. The Board agreed that, whilst safety margins had been reduced, both pilots had seen the other aircraft in time to take effective and timely action to prevent a collision; the Board agreed on a Risk Grading of C. The safety barriers 3 pertinent to this Airprox were: aircrew rules and procedures, visual sighting and aircrew action. The Board concluded that, as both crews had seen the other aircraft in time to take effective avoiding action in accordance with Rule 10 4, the barriers had been effective ; The Lynx had 4 POB and the Tiger-Moth had 2 POB so an Event Risk Classification score of 10 was allocated. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Confliction of flight-paths resolved by both pilots. Degree of Risk: C. ERC Score: 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 Rules of the Air 2007, Rule 10, Approaching head-on: When two aircraft are approaching head-on, or approximately so, in the air and there is a danger of collision, each shall alter its course to the right. 3

46 AIRPROX REPORT No Date/Time: 3 Jul Z Position: 5409N 00116W (6nm NNW Linton-on-Ouse) Airspace: Vale of York AIAA (Class: G) Reporter: RAF Linton-on-Ouse Departures 1st Ac 2nd Ac Type: Tucano T1 2 x Hawk T1 Operator: HQ Air (Trg) HQ Air (Ops) Alt/FL: FL ft QFE (1010hPa) Weather: IMC KLWD VMC CLBL Visibility: N/A NK Reported Separation: Not seen Recorded Separation: 0ft V/2.1nm H 1200ft V/0.4nm H Not seen PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE RAF LINTON-ON-OUSE (LIN) DEPARTURES (DEP) CONTROLLER reports the Tucano pilot departed the A/D and levelled at FL45, approximately 5nm N of LIN, under a TS. DEP was in the process of ringing Leeming (LEE) ZONE to pass TI and hopefully hand the track to them for its onward journey to Durham Tees Valley (DTV) A/D, for a practice diversion (PD), when he noticed a fast moving contact approximately 15nm ENE of the Tucano, at about 15000ft, which turned onto a W ly heading, changed to a LEE RAD Squawk and begin descending. He decided to ask for TI on this contact, before commencing the handover. The LEE ZONE asked him to standby while they ascertained the intentions of the ac under RAD s control. They informed him it was descending to 3000ft. He emphasised that the Tucano was maintaining FL45 and that it appeared LEE s intention was to descend their ac through that level, whilst pointing at the Tucano, under a radar service. Whilst clarifying this, the conflicting ac noticeably increased speed, so he broke off from attempting coordination to give TI to the Tucano pilot. The LEE ac was 7 to 8nm E and 4000ft above the Tucano as he started to call the confliction. As he began transmitting, he heard LEE state their ac was expediting its descent to get below. This increased the velocity of their ac and by the time he had transmitted traffic, right 3 o clock the LEE ac had closed to 3 or 4nm and its Mode C was now indicating slightly above. He tried to paint as accurate a picture of what was happening as he could on RT, whilst becoming increasingly concerned by the rate at which the LEE ac was approaching the Tucano. The Tucano pilot asked for an upgrade to a DS; the DEP couldn't climb him, as the other ac was still indicating slightly above, he couldn't descend him as he knew the other ac was in a more rapid descent and he couldn't turn him R, as this would have closed the gap even quicker. He therefore gave an avoiding action turn onto W to slow the closure of the 2 ac as much as possible. As the Tucano started to turn, the conflicting ac's Mode C started to indicate it as below that of the Tucano. The LEE SUP now talked on the landline, over the top of the other LEE controller, to state they were below my ac by 1000ft'. It was difficult to hear this part of the conversation, so DEP asked for confirmation that they were 1000ft below my ac on Mode C. He turned the Tucano back onto N, to turn it further away from the LEE ac, and, ascertaining there were no further conflicting ac, he rang DTV and handed the Tucano over for the PD. He perceived the severity of the incident as High. 1

47 [UKAB Note(1): A combined transcript of the LIN DEP, LEE ZONE and LEE APR RTFs is reproduced below. Note that due to an inconsistency between the time-base of each recording, elapsed time from the landline opening is used: From To Speech Transcription Elapsed Time establishing comm 00:00 LIN DEP LEE ZONE Linton North 4 miles tracking north, squawking :05 LEE ZONE LIN DEP Contact 00:08 LIN DEP LEE ZONE Maintaining flight level 45 on route Durham for a PD 00:09 LEE ZONE LIN DEP Maintaining flight level 45 on route to Durham for a PD. 00:13 LIN DEP LEE ZONE.request traffic information please. 00:16 LEE ZONE LIN DEP Go ahead 00:18 LIN DEP LEE ZONE Linton miles tracking West squawking :19 LEE ZONE LIN DEP Erh, descending 3500ft QFE 1003 standby one just calling your traffic now. 00:23 LEE APR Hawk Ld {Hawk Ld C/S] flight traffic left 11 o clock range 5 miles crossing left right indicating 3000 feet below 00:26 LIN DEP LEE ZONE Thank you 00:31 LIN DEP Tucano [Tucano C/S] traffic right 3 o clock crossing right left fast moving in the descent currently indicating 2000ft above. 00:32 Hawk Ld LEE APR [Hawk Ld C/S] flight 00:36 Tucano LIN DEP [Tucano C/S] deconfliction service 00:38 LIN DEP Tucano [Tucano C/S] roger avoiding action turn left 270 degrees. Traffic was right 3 o clock 2 miles crossing right left, indicating slightly above. 00:41 Hawk Ld LEE APR Confirm height of that traffic please 00:41 LEE APR Hawk Ld Flight Level 45 00:43 Hawk Ld LEE APR [Hawk Ld C/S] flight 00:48 LEE APR Hawk Ld [Hawk Ld C/S] flight, stop descent 5000 feet 00:50 Tucano LIN DEP Left 270 degrees avoiding action Lima 64 00:51 Hawk Ld LEE APR [Hawk Ld C/S] flight, levelling 3500 feet now 00:53 LEE ZONE LIN DEP I ve expedited his descent now levelling 3500ft 00:54 LEE APR Hawk Ld [Hawk Ld C/S] flight, roger descend to height 2000 feet for Dishforth MATZ 00:55 LIN DEP Tucano [Tucano C/S] previously called aircraft is now descending through your level and is expediting. I m just co-ordinating it below you 00:57 Hawk Ld LEE APR 2000 feet [Hawk Ld C/S] flight 00:59 2

48 From To Speech Transcription Elapsed Time LEE APR Hawk Ld [Hawk Ld C/S] flight, traffic s now 12 o clock, 1 mile, crossing left right, FL 45 01:02 Tucano LIN DEP Copied Lima 64 01:06 LIN DEP LEE ZONE Request co-ordination please maintaining flight level 45 confirm you are, you can take 1000ft below me on mode Charlie? 01:07 Hawk Ld LEE APR [Hawk Ld C/S] flight 01:08 LEE ZONE LIN DEP Standby another controller is working it 01:13 Hawk Ld LEE APR [Hawk Ld C/S] flight, request own navigation visual recovery 01:13 LEE APR Hawk Ld [Hawk Ld C/S] flight own navigation not below 2000 feet in the Dishforth MATZ, report visual with the aerodrome 01:15 LEE internal comm [name] they need co-ordination on that one 01:18 LIN DEP Tucano [Tucano C/S numbers only] you happy right turn now back North 01:23 LEE APR Hawk Ld [Hawk form n C/S] not below 2000 and visual to tower, [Hawk form n C/S] 01:23 LIN DEP Tucano Right turn heading North [Tucano C/S] 01:27 LEE APR Hawk Ld [Hawk form n C/S] standby 01:27 LEE SUP Unknown He did expedite descent called it in to traffic service, he s expedite descent to go underneath, remaining a thousand underneath 01:28 LEE ZONE LIN DEP.he s expediting 01:30] THE LIN SUPERVISOR reports, at the time of the Airprox, traffic levels on the Unit were medium to high but were low on DEP with only one ac on frequency. He was aware that the DEP was in contact with LEE in respect of their ac heading toward [the subject Tucano] but was confident that, with the lateral and vertical distance between the ac, a solution could be negotiated and, as a result, was conducting a handover between the LIN LARS and DIR, whose traffic levels were much higher. The DEP informed him of the situation once he had completed the handover of [the Tucano] to Durham radar. THE TUCANO PILOT reports conducting an instructional sortie en-route to a PD at DTV. He was in the rear seat (PM) with the student (PF) in the front. The black ac had HISL selected on, as was the SSR transponder with Modes A and C. The ac was fitted with TCAS I. They were operating under IFR in cloud with a TS from LIN DEP. On passing approximately 4000ft, with the student flying on instruments in the front seat, they entered cloud. He was aware of a TCAS contact in the 1-2 o'clock position at a range of about 4nm, but showing ft above. Seconds after they entered cloud they received a TCAS Traffic, Traffic warning. He could see that the contact, now displayed in the 1 o'clock position, was descending rapidly and was approximately 1-2nm range and closing. He requested a DS but by this point the TCAS contact was indicating almost co-height, still descending and approximately 1nm away. Due to the rapid descent profile of the conflicting traffic, he felt it would be counterproductive to descend, but due to its close proximity, and the lack of fidelity of TCAS azimuth representation, he felt that a climb might also have made matters worse. LIN DEP then informed him that the contact had been expedited through his level and was under a service from LEE. He assessed the risk of collision as Medium. 3

49 THE HAWK FORMATION LEADER PILOT reports recovering to LEE, leading a close formation pair of ac. The black ac had navigation lights, nose light and HISL selected on; the lead ac SSR transponder was selected on with Modes A, C and S. They were operating under VFR in VMC between cloud layers with a TS from LEE DIR. They were cleared to descend to 3500ft on LEE QFE. Passing 5600ft, TI was passed on a contact at 12 o clock, 5nm range and 3000ft below. As the formation was cleared to 1000ft above this height no action was taken. At about 4700ft, heading 270 at 360kt and approaching a layer of cloud, ATC was asked for the actual height of the contact which was passed as 4500ft. By this time, due to the rate of descent and the fact that the formation was briefly IMC, it was deemed safer to continue the descent rather than to attempt to climb above the traffic. As the formation was levelled at 3500ft, VMC again, ATC passed TI on the contact at 12 o clock, range 1nm at 4500ft. He assessed the risk of collision as Low. Factual Background The weather at Linton-on-Ouse was recorded as follows: METAR EGXU Z 26010KT 9999 FEW028 BKN035 20/11 Q1009 BLU NOSIG Analysis and Investigation Military ATM All heights/altitudes quoted are based upon SSR Mode C from the radar replay unless otherwise stated. A discrepancy of approx 3min 16sec was determined to exist between the LEE R/T and landline transcript and the radar replay; transcript times have been amended to reflect the radar replay timings. The Tucano pilot reported IMC with BKN cloud at 4000ft. The Hawk formation reported being briefly IMC as they passed through a 1000ft thick layer of cloud with tops around 4700ft but were VMC above and below the layer. LEE APR was manned by an instructor and a trainee, operating in the band-boxed DIR/APR position due to the paucity of traffic. The instructor described their workload as moderate to low with low task complexity, providing ATS to the Hawk formation only. They reported that they had been controlling for 90min since their last break. The trainee did not add a narrative to the DASOR, nor assess their perception of the task complexity and workload. Although traffic levels at LIN were assessed by the SUP as high, LIN DEP was only providing an ATS to the incident Tucano, and assessed his workload and task complexity as low. He reported that he had been controlling for 2hr since the last break. The guidance material to CAP774, Chapter 3, Para 3 states that pilots should be aware that a TS might not be appropriate for flight in IMC when other services are available. The incident sequence commenced at 1432:46, as LEE APR instructed the Hawk formation to, descend height 3500 ft. This was acknowledged by the formation leader who advised LEE APR that they were, coming left for the avoid [Sutton Bank glider site]. At this point, the Hawk formation was 15.3nm ENE of the Tucano, tracking WNW ly at FL160; the Tucano was in a RH turn onto a NE ly track, passing through N and indicating a climb through 2300ft. Figure 1 depicts the incident geometry; SSR 3A 4524 was the Tucano, SSR 3A 0410 was the Hawk formation. 4

50 Figure 1: Incident Geometry at 1432:46. LIN DEP reported that they had detected the Hawk formation prior to the start of the incident sequence, as it adopted a W ly track and began squawking an SSR 3A code assigned to LEE. At 1433:42, LIN DEP contacted LEE via landline; the call was answered by LEE ZONE but monitored by LEE APR. At this point, the Hawk formation was 8.5 nm ENE of the Tucano, tracking W ly, indicating descent through FL155; the Tucano was tracking NE ly at FL45. LIN DEP first passed TI to LEE on the Tucano, describing it as, maintaining FL4-5 en-route to Durham for a P-D, which was acknowledged by LEE ZONE; LIN DEP then requested TI on the descending Hawk formation, Linton miles, tracking west, squawking LEE APR clicked out of the conversation at about 1434:03 as LIN DEP was passing the bearing and range of the Hawk formation from LIN. LEE ZONE then continued the landline conversation with LIN DEP, replying at 1434:04, Err descending 3500ft Q-F-E , standby one just calling your traffic now..., which was acknowledged by LIN DEP. At this point, the Hawk formation was 5.9 nm ENE of the Tucano, tracking W ly, indicating descent through FL91; the Tucano was tracking NNE ly at FL45. Shortly after clicking out of the landline call, at 1434:07, LEE APR passed TI to the Hawk formation on the Tucano, advising them of, traffic left 11 o clock, range 5 miles, crossing left-right, indicating 3000 ft below which was acknowledged. At this point, the radar replay depicts 5.5 nm lateral separation, with the Hawk formation indicating descent through FL85, 4000ft above the Tucano. At 1434:14, LIN DEP passed TI to the Tucano on the Hawk formation, advising them, traffic right 3 o clock, crossing right-left, fast moving, in the descent, currently indicating 2000ft above. At this point, the Hawk formation was 4.5nm ENE of the Tucano, tracking W ly, indicating descent through FL72; the Tucano was tracking NNE ly at FL45. The Tucano instructor reported being aware of a TCAS contact in [their] 1-2 o clock at a range of approx 4nm but showing ft above. The guidance material to CAP774, Chapter 3, Para 5 states that, controllers shall aim to pass information on relevant traffic before the conflicting aircraft is within 5 NM, in order to give the pilot sufficient time to meet his collision avoidance responsibilities and to allow for an update in traffic information if considered necessary. CAP413, Chapter 5, Para states that whenever practicable, information regarding traffic on a possible conflicting path should [include the] distance from the conflicting traffic. The Tucano pilot immediately replied requesting a DS, Figure 2 depicts the incident geometry at this point at 1434:20, and was advised by LIN DEP, avoiding action, turn left degrees, traffic was right, 3 o clock, 2 miles, crossing right-left, indicating slightly above which was acknowledged. 5

51 Figure 2: Incident Geometry at 1434:20. LIN DEP provided a detailed report on their decision to issue deconfliction advice to the W, relating that they felt that they couldn t climb, as the other ac was still indicating slightly above. [They] couldn t descend as [they] knew the other ac was in a more rapid descent. [They] couldn t go right, as this would have closed the gap even quicker, so [they] gave an avoiding action onto west to slow the closure of the 2 ac as much as [they] could. The Tucano instructor reported that, based upon their analysis of the information displayed by TCAS and due to the rapid descent profile of the conflicting traffic [they] felt it would be counter-productive to descend but due to [the Hawk formation s] close proximity and the lack of fidelity in the TCAS azimuth representation, [they] felt that a climb might also have made matters worse. Extrapolation of the radar data demonstrated that, had the Tucano maintained its heading, the Hawk formation would have passed about 0.5nm behind, as it descended through 3600ft. At 1434:22, as LIN DEP began to pass deconfliction advice to the Tucano, the Hawk formation asked LEE APR to confirm height of that traffic please?. It is noteworthy that this request occurred only 5sec after acknowledging the earlier TI. LEE APR advised the Hawk formation that the Tucano was at FL45 which was acknowledged 5sec later. The Hawk formation reported that, due to their rate of descent and the fact that the formation was briefly IMC, it was deemed safer to continue the descent below, rather than to abruptly arrest the descent in an attempt to climb above the traffic ; this intention was not communicated to LEE APR. The LEE APR instructor prompted the trainee to issue an instruction [to the Hawk formation] to stop descent at 5000 ft which was passed to the Hawk formation at 1434:31; however, the Hawk formation leader replied that they were, levelling 3500 ft now. Based upon the report of the LEE SUP, this was the point at which they moved to interject with the trainee [APR] controller ; the screen [APR] controller instructed the trainee to issue an instruction to stop descent at 5000ft. The unit s subsequent investigation determined that the SUP was aware of the developing situation but was waiting to determine whether either the trainee or instructor would act to resolve the situation. Figure 3 depicts the incident geometry at the point at which LEE APR instructed the Hawk formation to stop descent; the next sweep of the radar at 1434:34 depicted the Hawk formation indicating descent through FL46, 2.1nm ENE of the Tucano. 6

52 Figure 3: Incident Geometry at 1434:31. At 1434:37, LEE ZONE advised LIN DEP, I ve expedited his descent, now levelling 3500 ft. LIN DEP then immediately advised the Tucano that the, previously called aircraft is now descending through your level and is expediting. I m just coordinating it below you, which was acknowledged. It is at this point that the Tucano pilot s response to the avoiding action became visible on the radar replay, as depicted in Figure 4, about 14sec after the deconfliction advice was issued. Figure 4: Incident Geometry at 1434:40. Vertical CPA occurred at 1434:34 as the Hawk formation descended through the Tucano s level, 2.1nm ENE of the Tucano. Lateral separation then continued to close, whilst vertical separation increased, as depicted in Figs 5 and 6. However, the situation was effectively resolved by 1434:50 (see Fig 5) and coordination agreed shortly after that between LEE SUP and LIN DEP. Figure 5: Incident Geometry at 1434:50. Figure 6: Incident Geometry at 1434:55. 7

53 The issue over the dividing line between the responsibilities of both controllers and pilots whilst operating under a TS has received wide discussion at the UKAB and was the subject of a meeting at Aviation House on 19 Sep 13 to discuss ATSOCAS Duty of Care. However, given the steady relative bearing between the Hawk formation and the Tucano throughout the incident sequence and LEE APR s low workload, BM SPA contends that good practice would have been for LEE APR to have re-assessed the situation and provided the Hawk formation with an intermediate level, stopping their descent above the Tucano. Whilst the timing of the TI by LEE APR to the Hawk formation appears to have been prompted by the landline call from LIN DEP, suggesting that they had not detected the Tucano prior to that point, given the vertical separation that existed at the point that TI was passed, an opportunity did exist for an intermediate stop level to be applied. Moreover, whilst the TI was passed before the Hawk formation was within 5nm of the Tucano, given the relative speeds and flight profiles involved, BM SPA agrees with the contention in LEE ATC s investigation that good practice would have been for LEE APR to have provided earlier TI to the Hawk formation. The crux of this incident from LEE ATC s perspective was that the trainee on the APR control position was not adequately supervised. Whilst both the instructor and the SUP acted to intercede with the trainee, the intervention was too late to prevent the Hawk formation descending through the Tucano s level, on a conflicting flight path. That said, given the low traffic levels on the unit and on the APR position specifically, it is reasonable to argue that the LEE SUP should not have been expected to intervene. It is also worth highlighting that LEE APR s description of the Tucano s level as 3000 ft below was not the best way to present this information, given that the Hawk formation was descending, and probably prompted the formation leader to request confirmation of the Tucano s height. A better course of action would have been to state that the Tucano was at FL 45 in the TI, thus providing a definitive datum for the Hawk formation to base their assessment of the confliction upon. LIN DEP was aware from an early stage of the potential for conflict between the Tucano and the Hawk formation and it was commendable that he contacted LEE to pass TI on the ac and to seek TI on the Hawk formation whilst providing a TS. However, whilst LIN DEP decision to describe their traffic first during that landline call was understandable given the situation, the purpose was frustrated when the landline was answered by LEE ZONE, who would not have been immediately aware of the LIN DEP intent in making the call. Thus the landline liaison became protracted, serving to distract LIN DEP such that the TI to the Tucano was provided later than is required by Regulation. Given the low workload, a better solution would have been for LIN DEP to have prioritised the provision of TI to the Tucano prior to initiating the landline liaison with LEE. This may also have prompted the Tucano crew to advise LIN DEP earlier that they were operating in IMC and, possibly, to seek an upgrade to DS earlier. That said, subsequent to completing their report, LIN DEP has related that they prioritised contacting LEE over passing TI, as they did not believe that the Hawk formation would have been instructed to descend through the Tucano s level, given their conflicting flight paths. In terms of the LIN DEP decision to offer the Tucano deconfliction advice onto W, the situation posed to LIN DEP following the later than ideal TI and subsequent timing of the Tucano pilot s request for upgrade to DS, coupled with the incident geometry, was distinctly unenviable. BM SPA contends that LIN DEP decision, based upon the information available to them at the time, was both understandable and sound. UKAB Secretariat It is worthy of note that Section 4 (General Flight Rules) of the Rules of the Air 2007 makes no distinction as to the applicability of the rules contained therein to flight under VFR or under IFR. The responsibility for collision avoidance rested solely, and equally, with the aircraft captains, whether VMC or IMC, and the Hawk formation had right of way. The point of closest lateral separation occurred about 1min after vertical CPA, after the Tucano had turned W, as the Hawk formation overtook, also on a W ly heading, S of and below the Tucano. 8

54 Comments HQ Air Command Current guidance for MAA Regulations, which is anticipated to be upgraded to Acceptable Means of Compliance shortly, states, with some caveats, that aircraft in IMC should be under a Radar Service. It is considered best practice to take a DS, where practicable, in accordance with advice contained in CAP774. This incident highlights the avoidable predicament a controller may be presented with following an immediate upgrade to a DS on receipt of TI; controllers need time to arrange coordination. A number of minor issues combined to make the event more alarming for all involved; an earlier call of the Tucano s level, earlier provision of an intermediate descent level to the Hawk formation, or an earlier TI call to the Tucano pilot may each have prompted different pilot actions. In the event, the Hawk leader s reaction when eventually appraised of the Tucano s level was appropriate. That said, best practice for any descent through cloud should be to request a DS early. Summary The incident occurred 6.6nm NNW of LIN at 1430:50 on 3 Jul 13, between a Tucano and a formation of 2 Hawks. The Tucano pilot had departed LIN en-route to DTV, heading NNW and level at FL45, in receipt of a TS from LIN DEP. The Hawk formation was recovering to LEE, heading W in a rapid descent, in receipt of a TS from LEE APR. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both ac, transcripts of the relevant RT frequencies, radar video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities. The Board first considered the pilots actions. The Tucano pilot had levelled at FL45 on his transit to DTV. This level happened to put him in cloud and he maintained his TS. As the Hawk formation got closer he requested an upgrade to a DS but the Board opined that this reactive response to the impending conflict did not allow the controller time to implement the service and hence did not ameliorate the situation. It was further opined that, since the Tucano captain was responsible for collision avoidance outside CAS, he would have been better served by levelling off below or above cloud, in VMC, or by requesting a DS once in IMC. The Board was advised that LIN Tucano crews were now required to use a DS if in persistent IMC. The Hawk formation leader was equally responsible for collision avoidance and, given the impending cloud layer, the Board felt that a DS would have been justified. It was felt appropriate to recommend that the MAA consider giving additional guidance on the benefits of a DS in IMC. The formation leader s decision to continue the descent, despite the proximity of the Tucano, was understandable, and the Board opined that he would have been much better served by the LEE APR stating the Tucano s level when passing TI, rather than a snapshot of the rapidly changing altitude difference. Turning to the controllers, the Board commended the LIN DEP on his proactive attempt to gain some degree of cooperation with LEE, despite the fact he was providing a TS and was not required to do so under the terms of that ATS. It was unfortunate that LEE ZONE answered the phone but it was acknowledged that LEE APR had also initially monitored the call. The Board were not able to ascertain why the LEE APR clicked out of the call but it did appear that he had been prompted to pass TI to the Hawk formation. Board members opined that he would have been much better advised to pass an intermediate level-off request before the TI but recognised he was not required to do so under the terms of a TS. Some members opined that the LEE APR was entitled, and required, to pass a level-off instruction to the Hawk formation under the general responsibility of duty of care. After some time discussing the cause of the Airprox, the Board decided by a majority that it was due to the Hawk formation being allowed to descend into conflict. The Board also decided that there were a number of contributory factors: inappropriate ATS for the flight conditions; lack of effective 9

55 cooperation between LIN DEP and LEE APR; and lack of supervision of the LEE trainee (APR) controller. The Board also spent some time discussing the risk, with many members opining that effective and timely action had been taken to prevent collision. Ultimately, the Board voted by a narrow majority that in this case safety margins had been much reduced below the normal. PART C: ASSESSMENT OF CAUSE AND RISK Cause: Contributory Factors: Leeming APR allowed the Hawk formation to descend into conflict with the Tucano. 1. Inappropriate ATS for the flight conditions. 2. Lack of effective ATC cooperation. 3. Lack of effective supervision of the Leeming APR trainee. Degree of Risk: B. ERC Score: 21 1 Recommendations: The MAA consider giving additional guidance on the benefits of a DS in IMC. 1 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. 10

56 AIRPROX REPORT No Date/Time: 6 Jul Z (Saturday) Position: 5047N 00114W (2nm SW Lee-on-Solent G/S) Airspace: Lon FIR (Class: G) Reporting Ac Type: Chipmunk PA24 Reported Ac Operator: Civ Club Civ Pte Alt/FL: 2220ft 2100ft QFE (NK hpa) QNH (1029hPa) Weather: VMC CLBC VMC CLBC Visibility: 10km >10km Reported Separation: 15ft V/35ft H Recorded Separation: NK V/<0.1nm H 100ft V/75m H Diagram based on radar data and pilot reports CPA 1204:11 NK V < 0.1nm H PA ft alt 1202:42 03:00 03:18 03:36 03:54 Lee-on-Solent G/S Chipmunk Glider PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE CHIPMUNK PILOT reports glider towing, just a little offshore from Lee-on-Solent A/D. The white and blue aircraft had navigation and landing lights selected on; it was not fitted with an SSR transponder or ACAS. The pilot was operating under VFR in VMC with an A/G Service from Lee Radio. As he was climbing through about 2,200ft he heard another pilot call Lee Radio on RT, pass his details and and inform them of his routeing intentions; he was just leaving the Southampton zone, passing Calshot and heading E at 2500ft. He thought the pilot may have added that he was inbound to Bembridge. Lee Radio advised him of the runway in use (RW23), the RH circuit direction, and that there was intensive gliding activity in the area. He couldn t recall if Lee Radio stated an aerotow was in progress. The Chipmunk pilot thought initially that the other aircraft was a couple of miles behind him, and potentially at the same height, heading in roughly the same direction. He then heard the other pilot add they were visual with the combination. The glider released about 5-10sec afterwards, at 2500ft, and the Chipmunk pilot immediately made a descending right turn, making a specially good lookout, in preparation for a return to the airfield. Visibility had improved through the day, but was hazy, with bright sun, and little cloud. He called directly to the other pilot that the combination had now separated, but that he did not have the other aircraft in visual contact. The other pilot acknowledged. The Chipmunk pilot s intention was for the other pilot to maintain visual contact with him. He completed a 180 turn to the R, maintaining an intensive lookout scan, in the belief that the other aircraft was about ft above him. Passing 315 at 100kt he suddenly, and without warning, saw a white and blue, low-wing, single-engine aircraft about yards in-front, on an almost reciprocal course, about 10-15ft lower and to the RH side. It was travelling slightly towards him and closed as it flashed by, about 1sec after he first saw it. There was no time to react and he did not observe any avoiding action from the other aircraft. He assessed the risk of collision as High. THE PA24 PILOT reports transiting to Sandown, Isle of White, routing via Southampton. He was operating under VFR in VMC with an A/G Service from Lee Radio. The white and maroon aircraft had strobe lights and beacon selected on, as was the SSR transponder with Mode A and C. On contact with Solent he requested zone clearance and a BS but Solent could not accommodate overhead routeing so he was routed via Bishops Waltham VRP [Southampton 090 /5.1nm]. On reaching, the controller suggested he contact Lee-on-Solent as their ATZ was busy. Heading 180 at 1

57 135kt and level at 2100ft, he called Lee Radio and passed his details. The radio operator acknowledged and informed him there was a lot of traffic and to keep a good look out. He acknowledged and reported that he was in visual contact with a glider and, he thought, a tug over the Solent, near Ryde IOW. He then saw the tug release the glider and turn back towards Lee-on-Solent. A male voice on RT almost immediately said I have that plane visual. He did not hear a call sign but assumed that it was the tug pilot. He didn't remember noticing anything untoward regarding the tug aircraft s approach until it descended rapidly towards him. It looked initially like it was going to pass to his L side, but instead it crossed in front and passed to his R side, still descending. His biggest concern was to avoid the tow cable. He assessed the risk of collision as High. Factual Background The Southampton weather was recorded as follows: METAR EGBJ Z 19004KT 130V FEW032 21/14 Q1029 Analysis and Investigation CAA ATSI The PA24 pilot was operating on a VFR flight to Sandown, in communication with Lee Radio (A/G), but not in receipt of an ATS. The Chipmunk was operating from Lee-on-Solent under VFR as a glider tug, also in communication with Lee Radio and not in receipt of an ATS. The Chipmunk pilot had released a glider just prior to the incident. Lee-on-Solent is a non-licensed A/D, which is promulgated in the UK AIP ENR (dated 27 Jun 2013) as a gliding site (Winch and Tow), with an upper limit of 2000ft and site elevation of 32ft amsl. CAA ATSI had access to area and Southampton radar recording together with written reports from both pilots. Lee-on-Solent are not required to record their RTF and consequently no RTF recording was available. The PA24 pilot had been cleared to transit the Solent CTA, routeing via Bishop Waltham. The Solent ATSU reported that he was instructed to contact Lee Radio for traffic information on their busy ATZ. The PA24 pilot s written report indicated that, after passing abeam Bishop Waltham, he contacted Lee Radio and passed his flight details. In response, the A/G operator reported that there was a lot of traffic in the area and suggested that the pilot keep a good lookout. The PA24 pilot indicated he had visual contact with a glider and tug (he thought) which were over the Solent. At 1202:30, radar showed the PA24, 2.7nm NW of Lee-on-Solent with the tug and glider in its half past 12 at a range of 3nm (see Figure 1). Figure 1 Southampton radar at 1202:30 2

58 The Chipmunk pilot reported being aware of the transit aircraft [the PA24] talking to Lee Radio and of hearing Lee Radio advise the PA24 pilot of intense glider activity in the area. The PA24 pilot indicated that he sighted the Chipmunk release the glider and then observed the Chipmunk turn towards Lee-on-Solent. At 1204:02, radar showed the Chipmunk in the PA24 s 12 o clock at a range of 0.7nm and the glider in its 10 o clock at 0.5nm (see Figure 2). Figure 2 Southampton radar at 1204:02 The PA24 pilot indicated that he heard a transmission, I have that plane visual, which he presumed was from the Chipmunk pilot. Radar showed the Chipmunk track prior to the incident. The Chipmunk pilot had initially rolled out onto a NE ly track, followed by a turn onto a NW ly track as it passed abeam the PA24. At 1204:11, the PA24 and Chipmunk are shown in close proximity as the Chipmunk passed down the RH side of the PA24 (see Figure 3). Figure 3 Southampton radar at 1204:11 Both the PA24 and Chipmunk pilots were in communication with Lee Radio, which provided information to the PA24 pilot about the traffic in the area and of intense gliding activity. Neither aircraft were in receipt of an ATS and both pilots were ultimately responsible for their own collision avoidance. CAP774, Chapter 1, Page1, Paragraph 2, states: Within Class F and G airspace, regardless of the service being provided, pilots are ultimately responsible for collision avoidance and terrain clearance, and they should consider service provision to be constrained by the unpredictable nature of this environment. 3

59 Summary The incident occurred when a PA24 and Chipmunk came into close proximity whilst operating within Class G airspace and not in receipt of an ATS. The Lee Radio operator provided appropriate information to the PA24 pilot to aid his situation awareness and both pilots were ultimately responsible for their own collision avoidance. PART B: SUMMARY OF THE BOARD'S DISCUSSIONS Information available included reports from the pilots of both aircraft, radar photographs and video recordings and a report from the appropriate ATC authority. The Board first considered the actions of the Chipmunk tug pilot. He had built a mental model of the PA24 s position and intentions from the RT and, having just released the glider, he was no doubt intent on returning to Lee-on-Solent. He was satisfied that the PA24 pilot was visual with him but then made 2 flawed assumptions; firstly that the PA24 pilot would maintain visual and therefore the ability to avoid him, and secondly that an immediate R turn would not take him in to confliction, in the belief that the other ac was above him. It transpired that the immediate R turn did not afford the Chipmunk pilot the opportunity to visually acquire the PA24 before CPA and the Board therefore opined that he would have been better served by a more thorough clearing lookout before commencing the turn. Turning to the PA24 pilot, he had seen the glider release from the Chipmunk towing aircraft and hence was visual with both. The Board were unable to ascertain why the PA24 pilot then allowed the Chipmunk to fly into such close proximity and opined that he would have been well advised to change his flight path earlier such that he gave both the glider and tug a wider berth. A gliding member noted that tug aircraft pilots almost invariably make a dynamic manoeuvre after glider release in order to commence expeditious recovery to the launch airfield and therefore that it was always advisable to avoid such a combination by a wide margin. The Board considered the cause and decided unanimously that the Chipmunk pilot had flown into confliction with the PA24 during his turn back to Lee-on-Solent. Given the reported separation at CPA, the Chipmunk pilot s very late sighting, and the PA24 pilot s concern with avoiding the tow rope, Board members were also unanimous in their opinion that separation had been reduced to the minimum and that chance had played a major part in events. PART C: ASSESSMENT OF CAUSE AND RISK Cause: The Chipmunk pilot turned into conflict with the PA24. Degree of Risk: A. ERC Score: 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

60 AIRPROX REPORT No Date/Time: 12 Jul Z Position: 5049N 00113W (Lee-on-Solent Airfieldelevation 32ft) Ikarus Fleetlands ATZ Airspace: London FIR (Class: G) Reporting Ac Reported Ac Type: Ikarus C42 PA-28 CPA 1628 Operator: Civ Trg Civ Pte Alt/FL: ft 300ft NK NK (1021hPa) Weather: VMC NK VMC NK Visibility: 25km >10km Reported Separation: PA ft V/NK H 200ft V/500ft H Recorded Separation: Diagram based on pilot reports NK PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE C42 PILOT reports he was conducting cct training with a student on RW23 RH at Lee-on-Solent and was in receipt of an A/G service. He had just rotated from his second touch-and-go of the sortie, with the student as the handling pilot, when he observed an ac on final approach to RW05, coming straight towards his ac. He took control immediately and as he was sitting in the right-hand seat, he banked L, in order to maintain visual contact with the ac. He positioned the C42 on the dead-side of the RW and continued to climb on RW heading. He asked the A/G operator if she was aware of the ac making an approach to RW05. She confirmed she was not aware of any other traffic in the cct. The other ac continued its approach to RW05 and as he passed through about ft, it passed down his R side in the opposite direction at an estimated height of ft. He identified the ac s registration and informed the A/G operator, who repeatedly tried to contact the ac without success. The other ac was seen to land on RW05. THE PA28 PILOT reports operating solo on a VFR flight from Jersey to Lee-on-Solent. Navigation and landing lights were illuminated and SSR Mode C Code 7000 was selected. He obtained a briefing from Jersey on weather and operational procedures at Lee-on-Solent, which informed him that A/G shuts at 1700L. He, therefore, did not expect A/G to be manned. Because the wind conditions from the nearest official MET (Southampton) showed a light northerly wind, he expected the RW in use to RW05. He explained that when he checked the Southampton ATIS as he passed KATHY, it confirmed that the wind was still northerly. When 6nm S of Lee-on-Solent he advised London Information that he was changing to Lee Radio on frequency MHz (correct frequency MHz). This was acknowledged and BS was terminated. On contacting frequency MHz with his C/S there was no reply. Approximately 15 seconds later he blind called his registration, position and intention to land on RW05, as he was fully under the assumption that A/G was closed. Once established for RW05, he called again, advising his registration, position, distance from RW and his intention of making a straight-in approach. He repeated the same call 1

61 approximately 1nm from the airfield. During his scan for cct traffic, at about 300ft above the RW height, he noticed a C42 approximately 200ft above his ac, but some distance to the R. He considered that this ac did not appear to pose a risk due to its distance and direction. However, he was concerned that traffic could be taking off from the grass glider strip (RW23L) as the wind might have allowed landing/take off from RW23 or 05. He evaluated the situation and noted the wind sock was limp, suggesting light and variable wind. With a further scan of the airfield, which had no further traffic, he decided it was appropriate to land on RW05. THE LEE-ON-SOLENT A/G OPERATOR reports that RW23 with a RH cct was in use and at the time of the incident, 1628Z (1728L) there was one ac in the cct, a C42 carrying out touch-and-goes. The C42 reported on final for a touch-and-go and shortly afterwards reported an ac coming directly towards him, looking to land on RW05. The C42 took avoiding action by turning R (she thought) and from her perspective in the tower, which overlooks the RW05 threshold, the ac were in close proximity. She made numerous attempts to contact the landing ac, a PA28, but none were returned and after landing the ac proceeded to taxi to B Hangar on the NE side of the airfield. She closed the radio watch and went to B Hangar to speak to the pilot, who did not appear to realise he had been in close proximity to another ac. He stated he was given the frequency (incorrect frequency) by London Information and had this frequency confirmed by his GPS. In addition, the pilot also reported he had read a weather report from Southampton EGHI at approximately 1200 GMT that stated the wind direction as 040. He landed on RW05 based solely on this piece of information, despite the fact that two windsocks at Lee on Solent clearly showed wind favouring RW23 and there was another ac, the C42, in the circuit using RW23RH. She asked the pilot whether he was visual with the C42 on final for RW23, to which he stated he was when the C42 was to the R of him (after the avoiding action). He commented that it was his first visit to Lee-on-Solent airfield. Factual Background Lee-on-Solent airfield is situated within the Portsmouth/Fleetlands (Government Aerodrome) ATZ. The ATZ is a circle, 2nm radius centred at N W, with an upper limit of 2000ft. There is a LOA on Flight Operations within the MOD Fleetlands Heliport ATZ, agreed between Fleetlands and Lee-on-Solent. The ATZ is notified in accordance with Rule 45 of the Rules of the Air and Air Traffic Regulations, for which an ATS is provided by an AFISO at Fleetlands Heliport. Lee-on-Solent Airfield is designated as a civil, unlicensed aerodrome. It is therefore, not required to establish its own ATZ and is not required to provide an ATC service. Under Rule 45, pilots of ac wishing to enter the Fleetlands ATZ are required to obtain sufficient information to enable them to safely conduct their flight through the zone during the notified hours. Pilots of ac approaching or landing at Lee-on-Solent and who intend to transit the western sector of the ATZ, bounded by the disused railway line to the E of Lee-on-Solent, are not required to contact Fleetlands if in contact with Lee Radio. The UK AIP 1 promulgates Lee-on-Solent as a gliding site (Winch and Tow) with an upper limit of 2000ft, operating from Sunrise to Sunset. The official Lee-on-Solent Visitor Guide and the Aerodrome Manual, both of which can be accessed on the internet, state the Lee Radio frequency as MHz (also shown on the CAA/NATS Aeronautical Charts 1:500,000 and 1:250,000). The airfield operating hours, effective from 4 th July 2011, are Monday-Friday, L or sunset. The procedures for joining RW05 state that the RW uses a LH cct. When joining from the S it is advisable to join on a L base giving way to any traffic already in the cct. It requests that joins overhead and use of the dead-side is avoided due to intense 1 Page ENR (27 Jun 2013) 2