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Accident and Serious Incident Reports: LOS

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

Contents

Definition

Reports relating to accidents and incidents which involved Loss of Separation.

The accident and serious incident reports are grouped together below in subcategories.

TCAS RA Mis-flown

  • C525 / B773, vicinity London City UK, 2009 (LB LOS AGC HF) (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • T154 / B752, en-route, Uberlingen Germany, 2002 (LOS HF) (On 1st July 2002, a Tu-154 collided with a B757 over Überlingen, Germany, following an ATC control lapse and failure of the TU154 to follow the coordinated TCAS RA guidance.)
  • A310 / B736, en-route, Southern Norway, 2001 (LB LOS HF) (On 21 February 2001, a level bust 10 nm north of Oslo Airport by a climbing PIA A310 led to loss of separation with an SAS B736 in which response to a TCAS RA by the A310 not being in accordance with its likely activation (descend). The B736 received and correctly actioned a Climb RA.)
  • GLF5 / A319, south-eastern France, 2004 (LB LOS HF) (On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.)


Accepted ATC Clearance Not Followed

  • A310 / B736, en-route, Southern Norway, 2001 (LB LOS HF) (On 21 February 2001, a level bust 10 nm north of Oslo Airport by a climbing PIA A310 led to loss of separation with an SAS B736 in which response to a TCAS RA by the A310 not being in accordance with its likely activation (descend). The B736 received and correctly actioned a Climb RA.)
  • F15 / E145, en-route, Bedford UK, 2005 (LB AI LOS AGC HF) (On 27 January 2005, two USAF-operated McDonald Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • C525 / B773, vicinity London City UK, 2009 (LB LOS AGC HF) (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • F50 / T6, vicinity Maastrict Netherlands, 2007 (HF LOS) (On 2 August 2007, a Fokker F50 being operated by KLM Cityhopper making a daylight ILS approach in IMC to Maastricht came into close proximity inside the CTZ with a privately operated North American T6 Harvard which had failed to follow its clearance to enter the CTZ.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (AI LOS AGC HF) (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • … further results


"See and Avoid" Ineffective

  • DH8D / TOR, en-route, North Sea UK, 2008 (AI LOS) (On 13 October 2008, a DHC-8 Q400 executed ATC instructions, followed by TCAS TA and RA to avoid unknown traffic. Recorded minimum lateral separation was 2.5 NM.)
  • H500 / D150, en-route, North of London UK, 2007 (LOS HF) (On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.)
  • AT72 / B732, vicinity Queenstown New Zealand, 1999 (AI LOS AGC HF) (On 26 July 1999, an ATR 72-200 being operated by Mount Cook Airlines on a scheduled passenger flight from Christchurch to Queenstown entered the destination CTR without the required ATC clearance after earlier cancelling IFR and in marginal day VMC due to snow showers, separation was then lost against a Boeing 737-200 being operated IFR by Air New Zealand on a scheduled passenger flight from Auckland to Queenstown which was manoeuvring visually (circling) after making an offset VOR/DME approach in accordance with a valid ATC clearance.)
  • AS50 / PA32, en-route, Hudson River NJ USA, 2009 (LOS HF) (On August 8, 2009 a privately operated PA32 and a Eurocopter AS350BA helicopter being operated by Liberty Helicopters on a public transport sightseeing flight collided in VMC over the Hudson River near Hoboken, New Jersey whilst both operating under VFR. The three occupants of the PA32, which was en route from Wings Field PA to Ocean City NJ, and the six occupants of the helicopter, which had just left the West 30th Street Heliport, were killed and both aircraft received substantially damaged.)
  • SH36 / SH36, en-route, Watertown WI USA, 2006 (LOS LOC RE HF) (On 5 February 2006, two Shorts SD-360-300 aircraft collided in mid air while in formation near Watertown, WI, USA; both aircraft suffered damage. One aircraft experienced loss of control and impacted terrain while the other made an emergency landing, overunning the runway, at a nearby airport.)
  • … further results


Required Separation not Maintained

  • B712, En route, Western Australia, 2006 (LOC AW LOS HF) (On 28 February 2006, a Boeing 717-200 being operated by National Jet for Qantas Link on a domestic scheduled passenger flight from Paraburdoo to Perth, Western Australia in day IMC experienced an activation of the stall protection system just after the aircraft had levelled at a cruise altitude of FL340. The response of the flight crew was to initiate an immediate descent without either declaring an emergency or obtaining ATC clearance and, as a result, procedural separation against opposite direction traffic at FL320 was lost. The 72 occupants were uninjured and the aircraft was undamaged.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (AI LOS AGC HF) (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • T154 / B752, en-route, Uberlingen Germany, 2002 (LOS HF) (On 1st July 2002, a Tu-154 collided with a B757 over Überlingen, Germany, following an ATC control lapse and failure of the TU154 to follow the coordinated TCAS RA guidance.)
  • GLF5 / A319, south-eastern France, 2004 (LB LOS HF) (On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.)
  • B737 / B737, vicinity Geneva Switzerland, 2006 (LOS HF) (On 11 May 2006, loss of separation occurred between a B737 taking off from Geneva and a Boeing Business Jet (BBJ) which had commenced a go around from the same runway following an unstabilised approach. The speed of the BBJ was such that it rapidly caught up with the departing B737.)
  • … further results


Released to Own Separation

  • G115 / G115, near Porthcawl South Wales UK, 2009 (LOS HF FIRE) (On 11 February 2009, two civil registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and based at RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers in uncontrolled airspace near Porthcawl in day VMC when they collided.)
  • D150 / H500, London UK, 2007 (LOS HF) (On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.)
  • A320 / B738, vicinity Launceston Australia, 2008 (LOS HF) (On 1 May 2008 an Airbus A320-200 being operated by JetStar on a scheduled passenger flight from Melbourne to Launceston, Tasmania was making a missed approach from runway 32L when it came into close proximity in night VMC with a Boeing 737-800 being operated by Virgin Blue and also inbound to Launceston from Melbourne which was manoeuvring about 5nm north west of the airport after carrying out a similar missed approach. Minimum separation was 3 nm at the same altitude and the situation was fully resolved by the A320 climbing to 4000 feet.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (LOS HF) (On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.)


Level Bust

  • B734 / MD81, en-route, Romford UK, 1996 (LB LOS HF) (On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow, in IMC, to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level. Neither aircraft was fitted with ACAS.)
  • GLF5 / A319, south-eastern France, 2004 (LB LOS HF) (On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.)
  • C525 / B773, vicinity London City UK, 2009 (LB LOS AGC HF) (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • B712, En route, Western Australia, 2006 (LOC AW LOS HF) (On 28 February 2006, a Boeing 717-200 being operated by National Jet for Qantas Link on a domestic scheduled passenger flight from Paraburdoo to Perth, Western Australia in day IMC experienced an activation of the stall protection system just after the aircraft had levelled at a cruise altitude of FL340. The response of the flight crew was to initiate an immediate descent without either declaring an emergency or obtaining ATC clearance and, as a result, procedural separation against opposite direction traffic at FL320 was lost. The 72 occupants were uninjured and the aircraft was undamaged.)
  • F15 / E145, en-route, Bedford UK, 2005 (LB AI LOS AGC HF) (On 27 January 2005, two USAF-operated McDonald Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • … further results


Lateral Navigation Error

  • F50 / T6, vicinity Maastrict Netherlands, 2007 (HF LOS) (On 2 August 2007, a Fokker F50 being operated by KLM Cityhopper making a daylight ILS approach in IMC to Maastricht came into close proximity inside the CTZ with a privately operated North American T6 Harvard which had failed to follow its clearance to enter the CTZ.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (AI LOS AGC HF) (On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • A320, en-route, Sydney Australia, 2007 (LOS HF AW) (On 11 January 2007, an Air New Zealand Airbus A320 which had just departed Sydney Australia for Auckland, New Zealand was observed to have turned onto a heading contrary to the ATC-issued radar heading. When so advised by ATC, the crew checked the aircraft compasses and found that they were reading approximately 40 degrees off the correct heading.)


ATC Error


Near Miss

  • A332 / RJ1H, vicinity Zurich Switzerland, 2004 (LOS HF) (On 31 October 2004, a Loss of Separation occurred between an A330-200, on a low go-around from Rwy 14 at Zurich Switzerland, and an Avro RJ100 which had been cleared for take-off on Rwy 10 and was on a convergent flight path.)
  • TBM8, Birmingham UK, 2011 (AGC LOS HF) (On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non procedural approach to runway 15 prior to the issue of a landing clearance and prior to checking in on the ATC TWR frequency. It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take off in accordance with ATC instructions. No damage or personal injury resulted from the close proximity.)
  • B737 / F100, Geneva Switzerland, 2006 (HF LOS) (On 29 December 2006, take off clearance for an Easyjet B737-700 which had been lined up ready for a night departure from Geneva was delayed whilst a business jet which had just landed cleared the runway. Take off clearance was given when further landing traffic, A KLM Cityhopper F100, was at IMC at a range from touchdown of 2nm finals. When the F100 became visual at 350 ft agl, the flight crew did not notice the accelerating B737 on the runway. As the B737 was nearing V1, ATC cancelled the take off clearance and instructed the F100 to make a non standard missed approach involving a turn off the runway extended centreline. The B737 continued the take off, subsequently advising that it had been considered inappropriate to make the high speed rejected take off which would have been required.)
  • B734 / MD81, en-route, Romford UK, 1996 (LB LOS HF) (On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow, in IMC, to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level. Neither aircraft was fitted with ACAS.)
  • C525 / B773, vicinity London City UK, 2009 (LB LOS AGC HF) (On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • … further results


Lateral Offset in Use

None on SKYbrary

Mid-Air Collision

  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (LOS HF) (On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.)
  • SH36 / SH36, en-route, Watertown WI USA, 2006 (LOS LOC RE HF) (On 5 February 2006, two Shorts SD-360-300 aircraft collided in mid air while in formation near Watertown, WI, USA; both aircraft suffered damage. One aircraft experienced loss of control and impacted terrain while the other made an emergency landing, overunning the runway, at a nearby airport.)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (LOS HF FIRE) (On 11 February 2009, two civil registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and based at RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers in uncontrolled airspace near Porthcawl in day VMC when they collided.)
  • AS50 / PA32, en-route, Hudson River NJ USA, 2009 (LOS HF) (On August 8, 2009 a privately operated PA32 and a Eurocopter AS350BA helicopter being operated by Liberty Helicopters on a public transport sightseeing flight collided in VMC over the Hudson River near Hoboken, New Jersey whilst both operating under VFR. The three occupants of the PA32, which was en route from Wings Field PA to Ocean City NJ, and the six occupants of the helicopter, which had just left the West 30th Street Heliport, were killed and both aircraft received substantially damaged.)
  • E135 / B738, en-route, Amazon Brazil, 2006 (HF AGC LOS) (On 29 September 2006, a B737-800, operated by the Brazilian airline Gol, collided head-on with a US owned and operated EMB135 Legacy at FL370 over the Amazon, Brazil. The aircraft were flying at the same altitude in opposite directions along the same airway.)
  • … further results


Uncommanded AP disconnect

None on SKYbrary

Military Aircraft Involved

  • F15 / B752, en-route, South East of Birmingham UK, 2000 (LOS AGC HF) (On 22 November 2000, near Birmingham UK, a dangerous loss of vertical and lateral separation occurred between a Boeing B757-200 being operated by Britannia Airways on a passenger flight and a formation flight of two F-15Es being operated by the United States Air Force (USAF).)
  • G115 / G115, near Porthcawl South Wales UK, 2009 (LOS HF FIRE) (On 11 February 2009, two civil registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and based at RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers in uncontrolled airspace near Porthcawl in day VMC when they collided.)
  • G115 / GLID, en-route Oxfordshire UK, 2009 (LOS HF AW) (On 14 June 2009, a Grob 115E Tutor being operated by the UK Royal Air Force (RAF) and based at RAF Benson was conducting aerobatics in uncontrolled airspace near Drayton, Oxfordshire in day VMC when it collided with a Standard Cirrus Glider on a cross country detail from Lasham. The glider was sufficiently damaged that it could no longer be controlled and the glider pilot parachuted to safety. The Tutor entered a spin or spiral manoeuvre which it exited in a steep dive from which it did not recover prior to a ground impact which killed both occupants.)
  • DH8D / TOR, en-route, North Sea UK, 2008 (AI LOS) (On 13 October 2008, a DHC-8 Q400 executed ATC instructions, followed by TCAS TA and RA to avoid unknown traffic. Recorded minimum lateral separation was 2.5 NM.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (LOS HF) (On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.)
  • … further results


Related Articles

Further Reading

Bureau d’Enquêtes et d’Analyses (BEA)

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