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N° 2

January 2006

The ability or opportunity to understand and judge
an event or experience after it has occured.

Win a free trip for two to Paris:

See page 26

Front Line Report

by Bert Ruitenberg

The Phonological WHAT?

See page 25




z Communication 3
z About Hindsight 4
z Getting the Message Across 5
z Cognitive Fixation 6
z Contact Us 26
z Disclaimer 27

121.5 Safety Alerts

z Changes to the indication of VHF channels in radiotelephony 8

z Inadvertent transition to STANDBY mode of the Honeywell PRIMUS II transponder 9
z Safety Occurrences during On-the-Job Training 10
z Rate of Climb within last 1000ft before Cleared Level 11

The Briefing Room - Learning From Experience

z Loss of Separation 12
z Controlled Flight Into Terrain 14
z Unauthorised Penetration of Airspace 16
z Wake Vortex Turbulence 18
z Runway Excursion 21
z Level Bust 22
z Human Factors 25

Editorial Team

Editor in Chief
z Tzvetomir Blajev

Editorial Secretary
z Ian Wigmore

Editorial Committee
z John Barrass; Dominique Van Damme; Yvonne Page; Jacques Beaufays; Max Bezzina;
Alexander Krastev; Gilles Le Galo; Philip Marien; Antoine Vidal; Stanislaw Drozdowski;
Charlie Goovarts; Francois Cervo

Cover picture: © DFS Deutsche Flugsicherung

January 2006 EUROCONTROL


By Tzvetomir Blajev
Co-ordinator Safety Inprovement Initiatives
and Editor in Chief of HindSight

“I communicate hence I exist” - this might not be exactly the same as the famous for-
mula of Rene Descartes, but it very well reflects the nature of air traffic control.

Indeed air-ground communications serve as the main media for co-ordinating inten-
tions and delivering instructions and important information. More than that - voice
communication is currently the main mitigation against its own failures. This is the
read-back / hear-back / confirmation process.

Losing something one normally has really makes you appreciate it. Losing air-ground communications shows how critical
it is for aviation safety. But the hazardous scenarios in communications are not restricted only to the loss of communications
- there is also call sign confusions, hearing what we expect to hear, undetected simultaneous transmissions, meaning different
things by one and the same phrases, to name but a few.

There are fewer “safety nets” available after the communication is complete and therefore, not surprisingly, when the commu-
nication fails the outcome is very often a serious incident or an accident. This is also one of the reasons why, based on statis-
tics, communication is very often found to be one of the contributors to safety occurrences. Yet recent studies show that com-
munication is a very reliable process, functioning thousands of times perfectly, correcting itself most of the time, but
when it fails it “hurts”.

The road to improving safety in ATM, therefore, definitely passes through the area of air-ground communications safety. There
is little to be gained by simply trying to make the current, already very reliable, processes more reliable. There is no point in
simply repeating to the practitioners that they must be more careful with the hear-back process - their current performance
is already exceeding the normal human reliability of hearing correctly. The solutions that need to addressed are in the area of
formulating extra protection.

In 2004, in trying to protect this major “Achilles Heel” of the current air traffic control system, EUROCONTROL Safety Enhancement
Business Division started a number of activities. A series of briefing notes is in the course of preparation; a workshop on
the subject was held in Brussels during September; and a fully developed toolkit will become available in 2007.

This second edition of HindSight builds on the success of the first edition and the many useful comments made by you, the
users, following its publication last year. Its content is broadly similar to the first edition, but there is a definite bias towards
discussion of aspects of communication in this issue. HindSight highlights many valuable learning points; we hope that you
will select those points which are particularly relevant to your organisation and give them wide circulation.

Most of all, we hope that you will enjoy reading HindSight; that you will find it useful; and that you, in your turn, will commu-
nicate to us your comments and experiences so that the next edition will be even better.

EUROCONTROL Page 3 January 2006


The main function of the HindSight Some incidents relate to the perform- Coding of Subject Matter
magazine is to help operational air traf- ance of ATCOs or the ATM system, while
fic controllers to share in the experi- others illustrate pilot errors which can To aid identification of subject matter,
ences of other controllers who have arise from incorrect interpretation of each article is coded and marked by a
been involved in ATM-related safety ATC instructions, or other unpre- coloured icon which appears at its
occurrences. In this way, they will have dictable situations. head.
an opportunity to broaden their expe-
rience of the problems that may be The incidents fall into two categories:
encountered; to consider the available
solutions; and so to be better prepared z Summaries of accident and seri-
should they meet similar occurrences ous incident reports
The full report usually runs to many
Material contained in HindSight falls pages, so these reports must be sum-
into three distinct classes: marised and simplified, concentrating
on the ATM-related aspects and pass- Loss of
z Editorial ing quickly over (or even ignoring) Separation
z 121.5 - Safety Alerts and other issues which have no direct rele-
z The Briefing Room - Learning from vance to ATCOs. A reference to the orig-
Experience. inal report is always supplied.
Level Bust
On page 2, you will find a table of con- z Dis-identified accounts of other
tents listing articles under these three ATM-related incidents
headings. Editorial material, such as this
article, needs no explanation but a few Typically, the original reports are not in
words on the other two classes may the public domain; however there are Runway
prevent any misunderstanding. important lessons to be learned from
them. The identifying features of the
121.5 Safety Alerts reports are altered without changing
the substance of the reports in order to
Controlled Flight
From time to time EUROCONTROL preserve the confidentiality of the into Terrain
issues Early Warning Messages and reporter.
Safety Reminder Messages to draw the
attention of the ATM community to Lessons Learned
.. . .
emerging safety issues. The messages
.. . . .
. . .. .

Unauthorised Penetration ..
.. . . . . . . . . . .


are intended to encourage discussion In the articles that follow, only the les- of Airspace ..
.. .

. . . . . . .. .
on the prevalence and seriousness of sons learned from the featured acci-
the issue and on the most appropriate dents and incidents are listed. Posters
reaction to them. Summaries of some listing all relevant learning points are in
recent messages are included. the course of preparation.
Wake Vortex Turbulence

The Briefing Room - Learning Knowledge Base

From Experience
We intend to compile a Knowledge
The majority of HindSight is taken up Base of all types of ATM-related safety
Human Factors
with articles concentrating on specific reports, which may be accessed by per-
safety issues. These usually comprise a sons carrying out research on particu-
study of an actual accident or inci- lar subjects. This is a long-term project
dent(s) together with a summary of les- but we plan that the HindSight maga-
sons learned. These articles are coded zine should be integrated with it from Other
to reflect the subject material. the outset.

January 2006 Page 4 EUROCONTROL



by Bert Ruitenberg

Bert Ruitenberg is a TWR/APP controller, supervisor and ATC safety officer at Schiphol
Airport, Amsterdam, The Netherlands. He is the Human Factors Specialist for IFATCA
and also a consultant to the ICAO Flight Safety and Human Factors Programme.

It happened in the early hours of what airborne, so the path of the inbound
promised to become another fine sum- aircraft was clear by the time the ILS
mer's day. A twin propeller commuter was intercepted. A short but interest-
flight was just beginning to taxi to the ing discussion followed with the crew
departure runway, an activity that of the commuter aircraft, about topics
would take close to 10 minutes such as compass headings and runway
because of the remote location of the directions, and suffice it to say that the
runway, when the tower controller content of ICAO approved phraseology
realised that there was an opportunity in that discussion was less than
to let this flight use the main landing average.
runway for take-off since there were
few inbounds at that moment. What may have played a role in the fessionals is about the same as when
event is that although it is perfectly telling car drivers to "drive carefully" in
The controller passed the offer to use legal and within published procedures the hope that the number of road traf-
the nearby runway to the commuter's to use the runway for departures in the fic accidents will go down, i.e. the value
crew, duly using standard ICAO phrase- direction assigned to the commuter, is little to zero. If these or similar rec-
ology of course, and the crew was only most departures from that runway are ommendations are the best the indus-
too happy to accept this option for it done in the opposite direction (with try can come up with to resolve air-
meant a saving of some 10 minutes of landings then obviously taking place ground communication problems,
taxi time. When the crew reported on another runway). The point of this we've not come very far since the radio
ready for departure at the assigned story however is to demonstrate that was invented by Marconi over a
intersection near the middle of the serious communication errors can century ago.
runway, the controller gave the take-off occur even when perfect ICAO phrase-
clearance and again duly included the ology is used by both the controller Instead of addressing human behav-
runway designator in his call. Now try and the pilots. iour I'd put my money on other draft
to imagine the controller's surprise recommendations, that were also dis-
when he saw the aircraft accelerate on This is why I'm not terribly impressed cussed in the workshop, like the sys-
the runway in the opposite direction of with some of the draft recommenda- temic deconflicting of similar call signs,
what had been correctly acknowl- tions that were proposed in the Air the use of data link, and the applica-
edged by the crew several times when Ground Communications workshop tion of a technical device that would
accepting the offer and when reading that was held at the Eurocontrol head- not just alert users that a simultaneous
back their take-off clearance… quarters in Brussels on 30 September transmission takes place but that
2005. In particular I'm referring to those would prevent simultaneous transmis-
When analysing this event - hang on! recommendations that say things like sions altogether. (Where I suggest
Before I go there you probably want to "use standard phraseology", "take extra "data link" this is not meant to imply
know the outcome of the event, right? care where language difficulties could that it should replace voice communi-
Well, the controller considered instruct- exist" and "always listen carefully to cations. I'm a fan of data link as an extra
ing the aircraft to stop its take-off roll readbacks". means of air-ground communications.
but since the first inbound aircraft was Send information by data link, and use
still far enough away from the runway Don't get me wrong, I don't question voice for instructions - it can be as sim-
he decided to just let the rolling aircraft that the advice contained in these rec- ple as that.)
continue its take-off, and resolve the ommendations is sound. It's just that I
situation in the air. The commuter was think that the practical value of giving Having said this, it is interesting to note
turned away from the centreline once that advice to seasoned aviation pro- how none of those proposed

EUROCONTROL Page 5 January 2006


recommendations or solutions would our customers. But I think we should work that is being advocated by ICAO
have made any difference in the event start asking ourselves whether we and other bodies, I recommend going
described at the beginning of this text. really are doing the pilots a favour, or over the event described above again
In that event the problem wasn't the whether we're merely giving them an from a TEM perspective to see what
technique nor the technology used for extra opportunity to make a mistake. I Threats, Errors and Undesired States
the communication, rather it was the submit that in today's environment the can be identified from the ATC and the
content and the related interpretation potential gains of the former are often pilots' viewpoints. If you're not yet
of the message that resulted in a take- outweighed by the potential for risk in familiar with the TEM framework I
off in the wrong direction. the latter. recommend an internet search or a
dedicated visit to the website of ICAO
Air Traffic Controllers are a service-ori- Bert Ruitenberg (
ented breed. When we see a possibility tors/) where a text on TEM for ATC can
for a direct routing, a taxi shortcut or a PS - If you're familiar with the Threat be downloaded.
more optimal runway we'll offer it to and Error Management (TEM) frame-

by Professor Sidney Dekker

Sidney Dekker is Professor of Human Factors & Aviation Safety at Lund University in Sweden. He gained his PhD in Cognitive
Systems Engineering at The Ohio State University in the US. His books include "The Field Guide to Human Error Investigations"
and "Ten Questions about Human Error".

People always think they know what is

going on, what the world around them
looks like. Of course, these ideas may
be incomplete or even wrong (com-
pared to what they discover the world
to have been), but saying that some-
thing has been lost is not helpful. It is
better to try to understand how this
picture may have made sense, or felt
complete or accurate, to people at the

Making sense of a situation, or “sense-

making”, is an ongoing process.
People's actions and assessments of
what is going on are deeply inter-
twined. By doing something, people
learn more about the world.This in turn
helps them decide what to do next.The Handbooks and checklist are of lit- controllers to a particular interpre-
dynamics of sensemaking in unfolding tle help tation
situations can, however, create interest- z Controllers have to make provi- z A side effect of taking action is that
ing side effects. sional assessments of what is going controllers build an explanation
on based on partial and uncertain that justifies their action. This
Some important aspects of sensemak- data explanation may persist and can
ing may arise, especially when con- z Controllers' situation assessment get transformed into an assump-
trollers are faced with an unfamiliar or and corrective actions are tightly tion that is then taken for granted.
unexpected problem, for example: interwoven. One constrains and
informs the other From an emerging mass of uncertain,
z A well-formulated diagnosis of the z Taking action simplifies the diag- incomplete and contradictory data,
problem is often impossible. nostic problem. It commits controllers have to come up with a

January 2006 Page 6 EUROCONTROL


plausible explanation. In this situation, the latest clue. To understand human

their judgement may be biased in a performance from the point of view of
particular direction (e.g.“this is an indi- the controller on the job, you have to
cation problem”). A preliminary inter- acknowledge the existence and impor-
pretation allows them to settle on at tance of this balancing act. Thematic
least a plausible explanation that cov- vagabonding and getting cognitively
ers the data observed. But it can acti- locked up are opposite extremes, cre-
vate certain kinds of knowledge and ated by uncertain, dynamic situations
trouble-shooting activities at the in which we ask controllers to solve dif-
expense of others. ficult, unclear problems.

The danger is that controllers might

hold on to an assessment of a situation
in spite of new contradictory evidence
- psychologists call this “cognitive fixa-
tion”. The assessment may actually be
wrong in the first place, with more and
more evidence contradicting the
assessment coming in over time.
Alternatively, the assessment, while ini-
tially right, can grow increasingly at
odds with the way the situation is
really developing.

Whether or not to abandon an initial

interpretation has nothing to do with
a controller's motivation. They are very
interested in getting it right-in under-
standing what is going on. Instead, it is
about a cognitive balancing act. When
trying to understand and simultane-
ously manage a changing, uncertain
situation the questions arise:

z Should you change your explana-

tion of what is going on with every
new piece of data that comes in?
This is called “thematic vagabond-
ing”, a jumping around from expla-
nation to explanation, driven by the
loudest or latest indication or
alarm. No coherent picture of what
is going on can emerge
z Or should you keep your explana-
tion stable despite newly emerging
data that could suggest other plau-
sible scenarios? Not revising your
assessment (cognitive fixation) can
lead to an obsolete understanding.

There is no right or wrong here. Only

hindsight can show you whether con-
trollers should have abandoned one
explanation in favour of another, or
should have finally settled on a stable
interpretation instead of just pursuing

EUROCONTROL Page 7 January 2006

121.5 Safety Alerts

EARLY WARNING Changes to Procedures { 118,005 specified as "ONE ONE
MESSAGE SUMMARY Amendment 80 to ICAO Annex 10, FIVE"
Volume II - Aeronautical Tele- { 118,025 specified as "ONE ONE
CHANGES TO THE communications - takes effect on 24 EIGHT DECIMAL ZERO TWO
November 2005; FIVE"
INDICATION OF VHF { 118,100 specified as "ONE ONE
CHANNELS IN z It introduces a procedure for VHF EIGHT DECIMAL ONE"
communication channels to be z Use of the term "CHANNEL" for 8.33
RADIOTELEPHONY indicated in 6 and 4 digits irrespec- kHz channels is discontinued
Origin: EUROCONTROL 8.33 kHz tive of whether 25 or 8.33 kHz
Programme Manager channel spacing is used, e.g EUROCONTROL 8.33 kHz Programme
Issued: 16 November 2005
z The EUROCONTROL Agency has
prepared a poster to increase
awareness on a revised procedure
for the indication of VHF channels
in radiotelephony
z The widespread distribution and
display of this poster, especially to
flight crews and air traffic con-
trollers, is strongly encouraged
z Further information, and a copy of
the poster, is available at

January 2006 Page 8 EUROCONTROL

121.5 Safety Alerts

EARLY WARNING The Problem dated 9 December 2004 was

issued. It was sent to every
MESSAGE SUMMARY: z The Swiss ANSP, Skyguide, has aircraft operator of Honeywell
warned of several cases of radar Primus equipment with Mode S
track loss transponders. The TNL recom-
z With the help of some airlines, it mends a temporary solution by
INADVERTENT was discovered that an anomaly means of an operational proce-
TRANSITION TO STANDBY could exist due to an interface dure for the flight crew to
issue in the Honeywell Primus suite check, after every Mode-A code
MODE OF THE with Mode-S transponders. If the change, that the transponder
HONEYWELL PRIMUS II flight crew take longer than 5 sec- has not reverted to "Standby"
onds to complete a Mode-A code mode
TRANSPONDER change, the transponder will revert { A software change is being
to "Standby" mode. This will cause developed for release by
Origin: Skyguide the track to be dropped by radars, Service Bulletin.
Issued: 13 April 2005 and the TCAS II on board the air-
craft will fail Recent Experience
z The operational consequences are
high with a safety critical impact: z Incidents related to this problem
{ Temporary loss of radar contact which took place during April 2005
{ Degradation of the ACAS safety have shown that some flight crews
net - the aircraft's TCAS will fail, are not aware of the operational
and the aircraft will not be procedure proposed in the
acquired by other TCAS II Honeywell TNL
equipped aircraft in the vicinity z EUROCONTROL Mode-S & ACAS
since the transponder is in Programme:
"Standby" mode. { The Mode-S & ACAS
Programme is pressing for
NOTE THAT THIS PROBLEM COULD effective enforcement action
OCCUR IN ALL AIRSPACE ENVIRON- by Regulatory Authorities.
Action Required
Action Taken
z Increased vigilance is essential, to
z Skyguide took the following action: ensure that tracks are not dropped
{ Issue of company "Flash" note at times of Mode-A code change,
to the crew of the relevant air- pending rectification of this
lines problem
{ Increase awareness of the z Any occurrences should be
Skyguide ATCO at Geneva and reported to the Eurocontrol MSA
Zurich Airborne Monitoring Project (AMP)
{ Reminder to pilots by ATCOs in at
case of loss of radar contact
z Honeywell took the following
{ Honeywell Technical News-
letter (TNL) A23-1146-004

EUROCONTROL Page 9 January 2006

121.5 Safety Alerts

EARLY WARNING The Problem { Unrealistic simulation environ-

ment, including aircraft per-
MESSAGE SUMMARY z According to a recent report, 10% formance and coordination
of the analysed safety occurrences procedures
are associated with the “controller z In general, humans are not good at
under training” situation monitoring tasks and the OJT
SAFETY OCCURRENCES z This fact alone does not give suffi- instructor role demands a high
DURING ON-THE-JOB cient indication of the scale of the degree of monitoring.
problem, unless statistics are made
TRAINING available to establish the relation- Potential Solutions
ship between the total number of
Origin: EUROCONTROL Agency sector hours and the number of z The OJT instructor is responsible
Issued: 20 September 2005 sector/hours during on-the-job for the safety of the ATC service
training (OJT) for a specified time being provided under supervision.
period Therefore consider:
z Independent of the above argu- { Identifying needs for and
ment some ANSPs are concerned implement improvements in
by an increasing trend in such the selection and training of
events the OJT instructor
z While “Lack of attention from the { Clearly defining and docu-

instructor” was reported as “infre- menting the roles and respon-

quent to none” during the first 10 sibilities of the OJT instructor
minutes of an OJT session, it was and implementing them in
reported as “significant” during the the OJT instructor training
second hour in working position. programme
{ Limiting the time on the OJT

Potential Explanations position

{ Providing refresher training on

z Insufficient awareness by the coaching techniques and error

instructors of the level of compe- recovery to OJT instructors on a
tence of the student or trainee they regular basis
are supervising { Introducing a regular meeting

z The instructor allowing the situa- forum for the OJT instructors
tion to develop for the purpose of for exchanging lessons learned
training and good practices and for sup-
z Distraction of the instructor porting drafting the respective
z An unmanaged mismatch between Unit/ANSP Training Plan
simulator exercise timing (often { Making arrangements for shar-

between 45 minutes and 1 hour) ing situational awareness and

and the time on the position (often the plan of work between the
2 hours) OJT instructor and the trainee
z General inconsistency between the { Detailing when and how to

ab-initio and OJT programmes in take over control from the

terms of: trainee, including the take over
{ Level of knowledge and skills of communication by using the
required to start OJT appropriate switch/pedal to
z General inconsistency between the activate the transmitter
simulator and OJT process in terms { Detailing the procedure for the

of: hand-over/take-over of the

{ Change of instructors position, including introducing
{ Change in system support pro- appropriate checklists
vided by the simulator facility { Ensuring the OJT instructor is

and the operational system briefed on the level of profi-

{ Specific operational environ- ciency of the student/trainee
ment not known to the needed { Developing a competence
level of detail scheme for OJT instructors

January 2006 Page 10 EUROCONTROL

121.5 Safety Alerts

z Ensure that the ANSP has a pro- z Consider introducing the practice { Consider the possibility for
cedure to provide assurance that of briefings and de-briefings OJT instructor and student to
students and trainees are appro- between the OJT instructor and be able to use simulation
priately trained and licensed the trainee facilities during OJT so that
z Consider limiting the number of z Review the training programmes certain experiences occurring
permitted OJT instructors per to ensure that they reflect the with live traffic can be
trainee knowledge and skills required for: repeated in a simulated envi-
z Consider restricting simultaneous { Collision avoidance ronment in order to maximise
OJT on more than one position of { Emergency situations the lessons learned.
a sector or more than one adja- z Ensure smooth transition from
cent sectors simulator to OJT, including:
z Consider incremental increase of { Sufficient simulator time
complexity in the training pro- { Training in emergency and
gramme - defining training unusual situations
phases and communicating the { Identical system support
objectives and progress of the { Simulation environment as
phase, including strong and weak close as possible to the oper-
points ational environment

EARLY WARNING The Problem Many national authorities have

issued recommendations to this
MESSAGE SUMMARY: z In order to reduce the risk of effect within their flight rules and
ACAS/TCAS Resolution Advisories procedures
(RAs) which are subsequently shown z ATC may request different rates of
to have been operationally unneces- climb or descent at any time for the
RATE OF CLIMB WITHIN sary - so called “nuisance” RAs - many purpose of maintaining separation
LAST 1000FT BEFORE operators have standard operating of aircraft. In such cases, these rates
procedures requiring pilots to reduce shall be strictly complied with.
CLEARED LEVEL their rate of climb or descent to less Failure to do so could result in a
than 1500ft/min when in RVSM air- potentially serious loss of separa-
Origin: Airline
space or within the last 1000ft before tion. It should not be supposed
Issued: 03 October 2005 cleared level that there will “automatically” be an
z Some operators have expressed RA.
concern that when ATC controllers
specify a rate of climb or descent, Potential Solutions
they expect the pilots to maintain
the given rate until reaching the o Aircraft Operators will remind flight
cleared altitude. crews that, if able, they are expected
to comply with ATC instructions
Factual Information regarding rates of climb and descent
o Controllers must be aware of the
z RAs could occur when aircraft are possibility of “nuisance” RAs when
in close proximity and the vertical vertical speeds exceed 1500ft/min
speed of closure, which may be the when approaching a cleared level
sum of the vertical speeds of both and there are other aircraft in close
aircraft or the vertical speed of just proximity. (1500ft/min in itself does
one aircraft, exceeds 1500ft/min not mean that there will be an RA;
z Flight Crews can reduce the likeli- it depends whether there are other
hood of an RA by confining vertical aircraft in close proximity.)
speeds to less than 1000ft/min, and o Of course, a high rate of climb or
ideally between 500 and descent cannot be maintained
1000ft/min, within the last 1000ft right up to the cleared level or the
before reaching assigned level. aircraft will overshoot it!

EUROCONTROL Page 11 January 2006

The Briefing Room - Learning from Experience

Reproduced with permission of the Direction des Opérations de la DSNA, BP 155, 94541 ORLY AEROGARE CEDEX in translation
from the Bulletin Sécurité de la Circulation Aérienne N° 36.

A serious incident occurred following a planning controller could see Paris - Hello?
misunderstanding in the course of tele- Speedbird 360 and therefore knew Brest - What about the Speedbird?
phone coordination. When the con- why I was calling. Nevertheless I con- Paris - 360 yes, he's above the clouds
trollers discovered the conflict, they firmed, adding “360” and I explained and it's getting rough apparently - he'd
issued avoiding instructions; however, why he wished to climb. I suggested like to climb.
both aircraft received TCAS RAs the next highest odd flight level, FL Brest - Yes, well, you can tell him to
instructing them to manoeuvre in the 290, since the aircraft was bound for climb to…
opposite direction. One of the two air- Lyon and was not expected to climb.” Paris - 29?
craft followed the controller's instruc- Brest - Yep, 29 is fine.
tion, which was the opposite of the For this part, the Brest controller was Paris - OK, I'll make the “MOD" and send
TCAS advisory, then belatedly manoeu- expecting coordination for BAW 2486 it to you.
vred in the manner requested by TCAS. and was certain he knew what the call Brest - OK, thanks.
This incident occurred between two was about. “I had in my hand the strip
centres with superimposed airspace: for BAW 2486 and was expecting a call
Paris controls airspace below FL 285 from the Paris to suggest climb clear- The climb was about to cause a
and Brest is responsible for airspace ance. The button for Paris lit up and I conflict with another aircraft
above that level. said, “Is it for the Speedbird?”
Two thousand feet above, DAL 27 was in
Both centres knew about BAW 2486, “Paris replied: “Yes, three six zero”. I level flight at FL 290. Only Brest was
which had taken off from London and thought that he was talking about a aware of this aircraft. BAW 360 climbed,
was to be coordinated by Paris to climb flight level, that BAW 2486 had asked having received clearance, and the cor-
to the airspace controlled by Brest.There for FL 360, or that he was answering responding “MOD” was made immedi-
was another Speedbird at FL 270, BAW someone else. I gave FL 290, thinking ately, causing the aircraft to be displayed
360, which was known and visible only that we were talking about BAW 2486, in the upper airspace (at Brest) and the
to Paris; and lastly a DAL 27 at FL 290, but Paris took this level for BAW 360, safety net alert to be triggered. The two
known and visible only to Brest. for which I had neither a strip nor a aircraft were at the same level, 10 nm
display.” apart, and converging.
BAW 360 asked Paris if it could climb
due to turbulence.

Brest could not see an aircraft,

call sign 360

For the Paris radar controller, there was

no ambiguity about which aircraft was
the subject of the coordination. He
commented afterwards, “Traffic was
very quiet so I decided to coordinate
this request myself. First of all I used the
“Display” function for the Brest sector
in order to help it identify the aircraft.
I was unaware that this function
depended on there being a flight plan
in the Flight Plan Processing System of
the receiving centre. “

“Then I called Brest but before I could

say anything, I heard, “what about the
Speedbird?” I assumed that the Brest

January 2006 Page 12 EUROCONTROL

The Briefing Room - Learning from Experience

other) were not rigorous enough to

enable the confusion to be resolved.
Furthermore the fact that the
“DISPLAY” seemed to be working prop-
erly no doubt reassured the Paris con-
troller as regards the way he proposed
coordination to the Brest controller.

Lessons Learned

z Controllers must be completely

familiar with the limitations as well
as the advantages of the technical
equipment they operate
z To avoid misunderstanding, con-
trollers must use full call signs and
avoid short-cuts when arranging
co-ordination with an adjacent
z Care must be taken when there is
Contradictory avoidance instruc- separation was measured at approxi- the possibility of confusion
tions and TCAS Resolution mately 1nm and 100 ft. between two numbers, to ensure
Advisories that, for example, a call sign is not
Contributory causes and factors mistaken for a level or a heading,
Paris asked BAW 360 to descend again or vice-versa
while at the same time Brest asked DAL The Local Safety Committee identified
27 to climb to FL 300 (using emergency the cause of this incident as: “confusion The EUROCONTROL Level Bust Toolkit
phraseology). between the radar controller for the contains further information to reduce
Paris sector and the planning controller the potential for loss of separation. The
But BAW 360 announced that it was for Brest sector at the time of telephone Toolkit may be obtained on CD ROM by
following a TCAS RA to climb. For its coordination as regards which aircraft contacting the Coordinator Safety
part the other aircraft climbed too, was the subject of the coordination.” Improvements Initiative, Mr Tzvetomir
reaching FL 300, then belatedly follows Blajev, on
the TCAS RA to descend. BAW 360 con- The two controllers were talking at tel: +32 (02) 729 3965
tinued its climb to FL 320 at 4,500 cross purposes and the exchanges on fax: +32 (02) 729 9082
ft/min, since the pilot was visual with the telephone concerning “BAW”
the approaching aircraft. Minimum (360 for one controller and 2486 for the

EUROCONTROL Page 13 January 2006

The Briefing Room - Learning from Experience

In spite of years of concentrated effort The flight crew of N304PA contacted Zulu at Palomar, and the SDNR con-
by the aviation community, Controlled the San Diego North Radar (SDNR) con- troller responded, “Seminole three zero
Flight into Terrain (CFIT) remains the troller at 2043:48, reporting level at four papa alpha thank you very much.”
No1 aviation killer. In most cases, CFIT 8,000. The SDNR controller instructed According to radar data, at that time
accidents are caused primarily by the the pilot to fly heading 260 after Julian N304PA was descending through
actions of the pilot, and there is little and intercept the (Palomar) localiser. about 6,600 feet.
scope for ATC intervention. However, The pilot read back the clearance.
there have been instances where con- At 2050:27, the SDNR controller again
troller action - or inaction - has been At 2045:47, the SDNR controller told the cleared N434PA to descend and main-
the direct cause, or where action by the pilot of N434PA, the Piper Seminole tain 5,200 feet. The pilot read back the
controller could have saved the day. ahead of N304PA and flying the same clearance, and the SDNR controller
The following report, based on the route, to descend to 6,000 feet. The pilot then transmitted, "Seminole four three
findings of the NTSB investigation2, of N434PA acknowledged the clearance. four papa alpha is five miles from
illustrates this point very well. The acci- ESCON. Cross ESCON three thousand
dent took place in USA, but perhaps it At 2047:55, the SDNR controller trans- five hundred or above cleared ILS 24 at
could have happened anywhere. mitted, “Seminole four papa alpha Palomar.” The pilot of N434PA acknowl-
descend and maintain five thousand edged.
Factual Information two hundred.” The pilot of N304PA
responded, “Down to five thousand The TRACON's MSAW system gener-
On 10th May 2004, at about 2051 two hundred for three zero four papa ated two predicted altitude alerts on
local time, a Piper Seminole aircraft, alpha.” According to information pro- the accident aircraft at 2050:46 and
N304PA, collided with mountainous vided by the approach controller, this 2050:51. According to FAA MSAW doc-
terrain at Julian, California. The air- clearance was intended for N434PA. umentation, two consecutive predicted
craft was operated by Pan Am The controller did not recognize that alerts will initiate an MSAW warning to
the clearance had been acknowledged the controller working the affected air-
by N304PA rather than N434PA. craft. Collectively, these alerts would
have caused a 5 second aural alert to
At 2048:19, the pilot of N434PA trans- the sector controller beginning at
mitted, “…for four three four papa 2050:51, along with a flashing red “LA”
alpha?” (The beginning of the transmis- in N304PA's data block from 2050:51
sion was blocked by another transmis- until about 2051:06.
sion from the SDNR controller to an
International Flight Academy. Both uninvolved aircraft.) The SDNR con- N304PA then descended below radar
private pilots were fatally injured troller replied, “No. Duke six romeo coverage and the alert terminated. The
and the aircraft was destroyed. Visual tango heading one nine zero maintain wreckage of N304PA was located on a
meteorological conditions prevailed eight thousand.” ridgeline 200 yards south of the Julian
and an instrument flight plan had VOR at 5,537 feet above sea level.
been filed. The flight originated at When, at 2049:03, N304PA descended
Deer Valley, Arizona. below 7,800 feet, the MSAW system Accident Cause
activated and provided a visual alert to
The aircraft was on an IFR flight from the controller. The alert continued until The NTSB determined the cause of this
Phoenix, Arizona, to Carlsbad, N304PA struck the terrain, although accident to be the incorrect use of an
California. N304PA was number four recorded automation data shows that abbreviated call sign by the sector con-
in a train of five company aircrafts the controller dropped the data block troller when issuing of a descent clear-
flying the same route. The time from the display when the aircraft ance to N434PA, and the sector con-
separation between each aircraft was descended through 6,800 feet. troller's failure to detect that the pilot
about 5 to 10 minutes. The aircraft of N304PA had read the clearance back
directly ahead of N304PA was At 2049:55, the pilot of N304PA with the full call sign.
N434PA. reported that he had ATIS information


January 2006 Page 14 EUROCONTROL

The Briefing Room - Learning from Experience

A contributing cause was the N304PA The missing words from the blocked The necessity to repeat the descent
pilot's failure to question a clearance transmission from N434PA at 2048:19 clearance for N434PA two minutes
that put them below the published are not known, but given the timing of after the first clearance, coupled with
minimum en route altitude. Another the message (immediately after the height loss depicted on N304PA's
contributing cause to the accident was N304PA wrongly accepted the other data block and the MSAW alert
the failure of both the Centre and aircraft's descent clearance), it is quite should have alerted the SDNR con-
TRACON controllers to properly probable that the full transmission was troller to the impending accident,
respond to the aural and visual MSAW “was that descent clearance… for four but appears to have overlooked all
alert. three four papa alpha?” If the controller these clues took no action. The TRA-
had asked N434PA to repeat his mes- CON controller also received two
Analysis sage he might have realised that the MSAW alerts but apparently took no
clearance had been taken by the action either.
The similarity of the aircraft call signs - wrong aircraft.
N434PA and N304PA - meant that there
was a high probability of confusion.
However, if this danger was appreci-
ated by the controllers involved, they
did not point it out either to the pilots
involved or to adjacent sector con-

This danger of call sign confusion

was increased when the SDNR con-
troller abbreviated the first aircraft's
call sign “Seminole four papa alpha”;
this abbreviated call sign could have
applied equally to N304PA or Lessons Learned
N434PA. It is legitimate for an aircraft
call sign of this type to be abbrevi- During the 1990s, international collab- z After satisfactory communication
ated “After satisfactory communica- oration led by the Flight Safety has been established, abbreviated
tion has been established… pro- Foundation (FSF) resulted in the devel- call signs may be used provided
vided that no confusion is likely to opment of the FSF Approach and that no confusion is likely to arise
arise2”; however, in this case, both Landing Accident Reduction (ALAR) z Advise adjacent sectors/airports if
aircraft had checked in on frequency Toolkit, which comprises a detailed it is felt that potential confusion
and it should have been obvious to study of CFIT together with much valu- may exist between aircraft likely to
the controller that confusion was able advice on accident avoidance. enter their airspace
extremely likely to arise. For more information, refer to z A transmission could be blocked when two or more aircraft are
The pilot of N304PA may have under- responding to the same clearance.
stood that this risk existed, for he used Specific lessons learned from the Typically the controller would hear
the full call sign in his response “Down above accident are listed below: a partial or garbled read-back. If a
to five thousand two hundred for three blocked transmission is suspected,
zero four papa alpha”; however, by z Place the aircraft call sign at the ensure that both aircraft retransmit
placing his call sign at the end of the beginning of a message. This allows their messages and confirm care-
message and preceding it by the word pilots to identify messages fully that a clearance has not been
“for” (which may have been misunder- intended for them quickly and taken by an aircraft for which it was
stood as the figure “four”) the chance reduces the chance of a message not intended.
of the controller detecting the mistake being acted on by the wrong pilot;
was reduced.

3 See ICAO Annex 10 Volume II Section

EUROCONTROL Page 15 January 2006

The Briefing Room - Learning from Experience

. .. .

.. . . .
. . .. .

... . . . . .. . ..



.. . . . . . ..

Almost invariably, unauthorised pene- problem; when, where and how it is due to early turns. An example of this
tration of airspace occurs due to pilot most likely to occur; and constant vig- is reproduced below.
error. In many cases, unauthorised pen- ilance, especially when unidentified
etration involves GA aircraft which radar returns are observed approach- Early Turns
accidentally stray into controlled or ing controlled airspace from outside.
restricted airspace, often due to inaccu- Usually, the only action the ATCO can Introduction
rate navigation, lack of awareness of take is to issue avoiding action to air- Occasionally, control staff report air-
the location of the airspace, lack of craft under control. craft turning (very) early before an en-
knowledge of the procedures for route point, in some cases flying on the
edge or even within military areas. In
modern aircraft, this seems to be a “fea-
ture” of the state-of-the-art navigation
system. According to aircraft manufac-
turers, it “smoothens” the turn,
increases passenger comfort and min-
imises the mileage flown.

As it introduces some uncertainty to

what the aircraft is doing, this aircraft
behaviour can be annoying for ATC.
The early turn should result in the air-
craft exactly over-flying the corner
edge of the two crossing airways. In the
example from the NICKY sector, it is the
crossing of the dotted blue lines in the

The Problem
However, if you modify the routing of
the aircraft, e.g. by clearing the aircraft
from NIK direct to DIK in the example,
the FMS will aim for the corner edge of
the new, non-existing route NIK-DIK,
obtaining clearance to enter the air- The ATCO should always report air- which is almost, but not quite the same
space, or poor communication tech- space infringement, even when no as NIK-BUB-DIK. By omitting the 3° left
nique. danger (e.g. loss of separation) results, turn in BUB, the corner which the air-
and regardless of whether the culprit is craft aims for shifts slightly. As a result
Military aircraft too, are often responsi- identified. Reporting action, the subse- in the aircraft briefly enters the
ble for airspace infringement. The quent investigation process and detec- restricted airspace, in this case the
cause may be sudden deterioration of tion of the intruder help raise aware- TRA-North.
weather, particularly when low flying is ness of the issue.
being undertaken, coupled with inabil- Technically, the early turns are within
ity to communicate with civil air traffic The nature of commercial airline oper- the RNAV specification and there's lit-
authorities due to incompatibility of ation is such that airliners usually con- tle to prevent aircraft from “optimizing”
RTF equipment (many military aircraft duct the whole of their flight within the space available in an airway. In this
are equipped with UHF radios only). controlled airspace; therefore, unautho- particular case, controllers are advised
rised penetration seldom occurs. not to clear aircraft from NIK direct to
In the cases cited above, the ATCO's However, there have been examples of DIK when the TRA-North is active. If
best defence is awareness of the penetration of military danger areas similar situations exist in your area of

January 2006 Page 16 EUROCONTROL

The Briefing Room - Learning from Experience

operation, you might consider recom- close to military areas etc. But keep in
mending similar advice. mind that even when there is no
restricted area, the issue can still affect
Conclusion conflict geometry and how you solve
These situations are of course not lim- them. If you really need the aircraft to
ited to the TRA North corner. Some air- stay on a route to avoid TRA's or other
ways have “do-not-turn-before” points aircraft, the surest way is to lock them
defined in the AIP to avoid coming too on headings.

EUROCONTROL Page 17 January 2006

The Briefing Room - Learning from Experience


Throughout the world, many thou- danger of wake vortices where pilot ICAO regulations specify minimum
sands of wake vortex incidents occur response is sub-optimal. separation standards for aircraft arriv-
every year. Thankfully, these incidents ing at and departing from airports. In
are seldom serious, although they are The Role Of The Air Traffic some cases, these standards have been
often very frightening to passengers Controller increased by ANSPs in the light of
and crew and may result in injuries to actual experience.
persons who are not strapped in, or if The role of the air traffic controller is
loose articles are thrown about the crucial in reducing the number and
cabin. IFALPA4 considers Wake Vortex seriousness of wake vortex turbulence.
to be a seriously under-reported issue. The ATCO has to walk the fine dividing
line between optimizing traffic flow at
A few fatal accidents have been his/her airport and maintaining a high
attributed, directly or indirectly, to level of safety.
wake turbulence. The most recent of
these involved the loss of American
Airlines Flight 587, a summary of
which follows.

American Airlines Flight 587

On November 12, 2001, American

Airlines flight 587, an Airbus A300,
crashed into a residential area of Belle Radar Separation
Harbour, New York, shortly after takeoff
from John F. Kennedy International Leading Following Separation
Airport New York. Flight 587 was a Aircraft Aircraft Distance
scheduled passenger flight with 2
Heavy Heavy 4nm
flight crew members, 7 flight atten-
dants, and 251 passengers on board. Heavy Medium 5nm
The airplane's vertical stabilizer and
Heavy Light 6nm
rudder separated in flight and were
found in Jamaica Bay, about 1 mile Medium Light 5nm
north of the main wreckage site. The
airplane's engines subsequently sepa-
rated in flight and were found several
blocks north and east of the main
wreckage site. All 260 people aboard
the airplane and 5 people on the Non-radar Separation
ground were killed.
Leading Following Separation Separation
The accident report5 finds that the air- Aircraft Aircraft Time Time
craft encountered two wake turbu- Arriving Departing
lence events and that the first officer
responded to these with excessive rud- Heavy Medium 2 minutes 2 minutes*
der pedal inputs which resulted in the Heavy Light 3 minutes 2 minutes*
fracture of the vertical stabilizer from
the fuselage. This accident was not Medium Light 3 minutes 2 minutes*
caused by the wake turbulence itself,
but by the pilot's reaction to it;
however, it demonstrates the potential * 3 minutes if taking off from an intermediate position

4 IFALPA - International Federation of Air Line pilots’ Associations

5 See http: //

January 2006 Page 18 EUROCONTROL

The Briefing Room - Learning from Experience

In practice, these standards are a crude reach the ground). Decay is usually If the vortex is entered at right
tool, for the circumstances which may sudden and occurs more quickly in angles to its axis, rapid vertical and
give rise to wake turbulence are windy conditions. Cross-winds can pitch displacements with airspeed
extremely complex. The following para- carry a vortex away from the flight changes are likely. An oblique entry,
graphs, which explain some of these path of the aircraft. For each nautical the most likely event, will have symp-
circumstances, are intended to help the mile behind an aircraft, the vortex toms of both.
ATCO apply the minimum separation the aircraft generates will typically
standards intelligently. have descended between 100 and A significant proportion of the wake
vortex incidents occur below 200 feet
i.e. just before landing where there may
not be room to recover. An accident in
the UK badly damaged a light aircraft,
which it appears got too close behind
a landing turboprop. At 100-150 ft the
right wing and nose dropped and the
aircraft did not respond to control
inputs, descended rapidly and hit a
hedge. Estimated separation was about
3 nm. The wind speed was reported as
2kt. Incidents including fatal accidents
have also occurred shortly after take-
off, which is when the affected aircraft
is most likely to be directly behind a
larger aircraft.

Close to the ground where their effect

is most hazardous, vortices generally
persist for about 80 seconds. They tend
to move apart at about 5 knots in still
air, so a crosswind component of 5
All aircraft generate vortices at the wing knots can keep the upwind vortex sta-
tips as a consequence of producing lift. tionary on or near the runway while
The heavier the aircraft and the slower it the downwind vortex moves away at
is flying, the stronger the vortex. about 10 knots. In crosswinds of more
than 5 knots, the area of hazard is not
Among other factors, the size of the 200 ft. Some pilots have reported necessarily aligned with the flight path
vortex is proportional to the span of encountering wake turbulence as of the aircraft ahead. At airfields where
the aircraft which generates it, for much as 20 miles behind and 1000ft intersecting runways are both in use,
instance a Boeing 747, with a span of below a preceding aircraft. the location of the vortex may be dif-
65metres trails a vortex from both ficult to predict.
wingtips each with a diameter of Generally, the lighter the aircraft, the
around 65 metres. greater the degree of upset if a wake Some Recent Wake Vortex
vortex is encountered. Thus, a light air- Turbulence Incidents
Some aircraft, notably the Boeing 757, craft will be vulnerable to the vortices
have particularly strong wake turbu- of a similar sized aircraft ahead of it, The following incidents occurred
lence characteristics which can be and microlight aircraft will be even recently at various airports throughout
experienced at much greater distances more vulnerable. Europe. Some of the reports are very
than would be expected, given the air- brief, but they serve to indicate the
craft's weight. A light aircraft penetrating a vortex type of problem that may be experi-
from a larger aircraft on a similar tra- enced.
At low altitudes, vortices generally jectory and axis can experience a
persist for as long as 80 seconds, but severe roll. In the worst cases it may Turbulence may be experienced even
in very light or calm wind conditions, be beyond the power of the ailerons when separation from the preceding
they can last for up to two and a half to counteract the roll. Even execu- aircraft is greater than the minimum
minutes. Once formed, vortices con- tive jets have been rolled upside standards specified.
tinue to descend until they decay (or down.

EUROCONTROL Page 19 January 2006

The Briefing Room - Learning from Experience

1. While an A319 (A) was making an was lost when a following a/c The crew thought they were fol-
ILS approach on Rwy 07L, ATC began to catch up the B737. The lowing a B747 and in order to pre-
cleared another aircraft (B) to cross B737 was repositioned for vent another vortex encounter, the
the 07L localiser and join the 07R approach. The operator has stated crew reduced speed to approxi-
localiser when less than 2nm ahead that approximately 2nms before mately 140 kts without notifying
of the A319. This caused severe they were instructed to reduce to ATC. The crew admitted that their
wake turbulence which adversely 160 kts, the a/c experienced wake actions caused this incident.
affected the stability of the A319's turbulence and the autopilot was
approach. disengaged.

2. An EMB145 on ILS at 3000ft

encountered wake turbulence from Lessons Learned
a B757 3nms ahead. The EMB145
rolled 45 degrees left and the The first three items below are speci- encouraged to submit a formal
autopilot failed. With the approach fied in ICAO Doc 4444 (PANS ATM). report using the standard Wake
stabilised, the autopilot was recon- Vortex Reporting form
nected. Analysis of the radar z Departing aircraft must be sepa- z ATCOs controlling aircraft operat-
recording shows that the EMB145 rated by at least the minimum ing under VFR should remain alert
was vectored onto final approach spacing specified in ICAO or to the danger of wake vortex
approximately 4.2nm behind the national regulations turbulence and warn pilots if they
B757. The required vortex separa- z Arriving aircraft must be separated appear to be approaching too
tion is 4nm. As the EMB145 estab- from preceding aircraft by at least close to the preceding aircraft
lished on the localiser just inside the minimum spacing specified in z Separation distances should take
10nm range, the two aircraft were ICAO or national regulations and into account expected manoeu-
exactly 4nm apart. Once the B757 must be routed so as to avoid the vring, e.g. slowing down or speed-
reached 4nm from touchdown the wake vortex turbulence from ing up on approach or departure
crew reduced speed, as is normal, departing aircraft z Turbulence may be experienced
and so there was a normal and z In light or calm wind conditions, even when aircraft are separated
acceptable 'catch up'. When the pilots of aircraft following other by the minimum distance; there-
B757 was at a range of 1nm and an aircraft at near the minimum spec- fore, if traffic circumstances
altitude of 400 feet, the EMB145 ified spacing must be warned that permit, the separation should be
was 3nm behind at an altitude of turbulent conditions may persist increased when wake turbulence
1400 feet. z Pilots of aircraft reporting wake is likely.
3. A B737 on approach did not com- vortex turbulence should be
ply with speed control. Separation

January 2006 Page 20 EUROCONTROL

The Briefing Room - Learning from Experience

Each year we hear of many runway z Inadequate weather information previous aircraft? Did we... do
excursion accidents and incidents. (out of date or inaccurate weather everything we could?
Some of these result in tragic loss of reports, meteorological equipment
life and untold misery for the families failure).
and friends of those involved. In other
cases, heavy financial losses may result, Ultimately, it is the pilot's decision to
from the damage to aircraft and the land, but he/she has to base that deci-
buildings or other items struck by the sion on known facts. Of course, he/she
aircraft, as well as the consequential may make the wrong decision even
financial costs, which may be very when the facts presented to him/her
large. Even when there is no injury and suggest that a go-around would be the
damage is slight, the effect on the air- right decision - that is beyond our con-
line may be considerable due to loss of trol. But we can try to create an envi-
passenger confidence etc. The effect of ronment which will help the pilot to
closing a busy airport, even for a short reach the right decision.
time while the aircraft is cleared from Lessons Learned
the manoeuvring area, must also be Our training and experience guides us
taken into account. in the right direction by telling us how From several safety occurrences we
to line up an aircraft for a successful recommend:
Runway excursions have many causes, approach and landing. Our standard
including the following: operating procedures (SOPs) tell us z Controllers must recognise and
under what conditions we may refuse understand the pilots' working
z Technical malfunction (brakes, permission to land or order a go- environments and constraints;
landing gear, nose-wheel steering, around, how often we must pass z Controllers have a primary respon-
power units, flaps, speed brakes, weather reports, when we must allow sibility for safety, therefore the
etc.) the pilot to adjust his/her speed for the requirement to position aircraft so
z Extreme weather (wet or slippery landing, and so on. that a safe approach and landing is
runway, strong or gusting winds, possible is overriding;
wind shear, turbulence, etc.) If we follow our training and the z Altitude or speed restrictions
z Pilot error (e.g. unstabilised SOPs we will have a clear conscience should be clear and unambiguous
approach, or decision to land when if the aircraft goes off the runway on and must be removed as soon as
a go-around or diversion would be landing - or will we? Did the pilot they cease to be necessary;
more appropriate) know about unusual conditions at z In bad weather conditions, pass the
z Controller error (poor positioning our airport? Did we tell the pilot that pilots any additional information
for the approach - alignment, the last ten aircraft had diverted due that will help them to make the
height, speed, distance from pre- to extreme weather? Did we pass on correct landing decision.
ceding aircraft, etc.) the landing report made by the

EUROCONTROL Page 21 January 2006

The Briefing Room - Learning from Experience

The chart below is taken from the UK incident described below was indeed a The DC-10 had two pilots on the flight
CAA “Level Best” web-site6. It depicts near miss for the 677 passengers and deck: the FO, who was receiving train-
the number of level bust incidents crew of the aircraft involved. The ing for upgrade to captain, was in the
reported annually to UK CAA. At first account of the incident is based on LH seat; the captain was in the RH seat;
a flight engineer was also positioned
on the flight deck.

The Tokyo Area Control Centre (ACC)

was controlled by three ATCOs: the
radar controller (the ATCO), who was
receiving familiarisation training on the
sector; the watch supervisor and an
ATC coordinator.

At 1541, the B747 reported that they

were passing 11,000 feet for FL390.
The ATCO cleared them direct to the
YAIZU NDB and to stop their climb at
Loss of Separation FL350. The altitude restriction was
due to another aircraft, American
Airlines 157, which was cruising at
FL390, and was being controlled by
another sector.

The B747 captain told investigators

that at this time he could see a con-
trail at 11 o'clock: “it was at a higher
sight, it seems that the number of level article which appeared in the Flight altitude and approximately 40nm
busts is falling, but unfortunately, that Safety Foundation Digest for March from our position,” the captain said,
is not the case, for the data for 2005 20047. The incident demonstrates the “I talked with the trainee pilot about
represents only the first 6 months of importance of pilots following TCAS how close the traffic would become
that year. In fact, there was a 40% Resolution Advisories (RAs), but it also before being displayed on the navi-
increase in the number of incidents emphasises the important role of the gational display. The traffic was
reported in 2005 compared with the ATCO in preventing dangerous situa- displayed when it reached 25nm.
same period for 2004, and a 100% tions from developing in the first place. From the TCAS the altitude was
increase compared with the same determined FL370. The cockpit crew
period in 2003. Factual Information discussed that we should keep an
eye on the traffic.”
In spite of the first impression given, Boeing 747 JA8904, call sign Japan Air
this chart does not necessarily indicate 907, was climbing to cruising level en Between 1543 and 1552 the ATCO han-
that the number of level busts is rising. route from Tokyo to Okinawa. dled 14 aircraft and made 37 radio
But it does demonstrate the success of McDonnell-Douglas DC-10 JA8546, call transmissions under the guidance of
efforts made in encouraging pilots and sign Japan Air 958 was cruising at the watch supervisor. The ATCO told
ATCOs to report level busts, even if no FL370 en route to Tokyo from Korea. the investigation that, “the traffic vol-
loss of separation resulted, even if no ume at the time of the on-the-job
one else knew about them. There were four pilots on the B747 training was at about the level I could
flight deck: the captain was in the LH handle.”
Japanese Near Miss seat; the First Officer (FO) was on the
jump seat behind the captain; and two At 1546, the B747 was on a westerly
The term “near miss” has now been trainee pilots receiving training for track, east of YAIZU climbing through
replaced by the more accurately upgrade to FO occupied the RH seat 21,600 feet. The flight was cleared to
descriptive term “AIRPROX” but the and the RH jump seat. climb to FL390.

7 Bracing the Last Line of Defense Against Midar Collisions. See

January 2006 Page 22 EUROCONTROL

The Briefing Room - Learning from Experience

At 1547, the ATCO instructed Flight 157 The ATCO, however, instructed the B747 altitude to some extent using this air-
to descend to FL350, but as the aircraft to descend to FL350. The B747 crew speed margin for climb by transform-
was not yet on frequency he received acknowledged the instruction giving ing kinetic energy into potential
no response. also their call sign and told the ATCO, energy.”
“Traffic in sight.” Even so, neither the
At 1548, the DC-10 checked in at FL370. ATCO nor the watch supervisor noticed Observing that the DC-10 was not
At that time it was on an easterly track, that it was the B747, not the DC-10 that descending, during the next few sec-
west of YAIZU. acknowledged the descent instruction; onds the ATCO twice instructed the
indeed, the watch supervisor stated crew to turn right for separation; how-
Shortly afterwards, Flight 157 checked that she was convinced at the time that ever, the crew did not respond to either
in at FL390 and was cleared to FL350. the ATCO had issued the instruction to instruction, and probably did not hear
This instruction was acknowledged the DC-10. them due to the cockpit workload at
and the aircraft began to descend. that time. The watch controller then
As the B747 crew had been instructed took over radio communications and
Near YAIZU, the B747 began a climbing to descend during a climb, the captain instructed “JAL957” to begin a descent;
left turn from a heading of 270º to disengaged the autopilot and at that time, there was no aircraft with
207º. At about the same time the DC- autothrottles and reduced power to that call sign in the sector's airspace.
10 was heading 095º and the FO told idle while commencing the descent.
the captain that he could see traffic at The aircraft climbed to around FL371 At 1554:49 as the DC-10 was descend-
10 o'clock to 11 o'clock position. At that due to its inertia before beginning to ing through FL369, the crew received
time the B747 was displayed on the descend. an “increase descent” RA, calling for a
DC-10's TCAS, climbing. descent of 2,500 fpm. To achieve this,
At 1554:34, just 16 seconds after the the captain extended the speed brakes
“The traffic was displayed on the TCAS conflict alert was displayed on the while the FO lowered the nose further.
screen beyond the 10-mile arc at ATCO's screen, the DC-10 received an The FO told the investigators, “I felt as
between 12 and 13 nm,” the DC-10 cap- RA calling for descent at 1,500 ft/min. if the other aircraft was rapidly rushing
tain said. “As we saw the other aircraft One second later, the B747 received an towards us and I wondered why, since
turning over YAIZU a TCAS 'Traffic, Traffic' RA calling for a 1,500 ft/min climb. our aircraft was following the TCAS
Traffic Advisory (TA) sounded while we descent command.”
were about 10nm distant at FL370. From On the DC-10, the autopilot was disen-
the TCAS the other aircraft's altitude was gaged, idle power was set, and the Between 1554:51 and 1555:11 the B747
determined to be also FL370. The Pilot nose was lowered to increase the rate descended from 36,900 feet to 35,500
Flying (PF) disengaged the autothrottles of descent. feet and the DC-10 descended from
in anticipation of an RA. 36,900 feet to 35,700 feet.
On the B747, the aircraft had begun
The ATC watch supervisor was providing to descend when the climb RA was At 1555:06 the B-747 crew received an
comments to the ATCO about the tasks received, and the captain decided to “increase climb” RA calling for 2,500
he had to perform and was discussing continue the descent. “At that time, I fpm climb but the captain continued
the traffic situation with the ATCO at observed the other aircraft approach- the descent.
1554:18, when a conflict alert was dis- ing from the forward right at about
played on the ATCO's radar screen. the same altitude, but I had already The DC-10 captain could see the top of
initiated the descent and, judging the B747's fuselage and judged that it
The ATCO could not remember at what that the best way to avoid a collision was increasing its descent rate. The
time he received the hand-off of the at that altitude would be to continue pilots had no time to communicate
DC-10 from the adjacent sector, but he descending contrary to the TCAS and both pulled back on the yokes
first became aware of its presence command, I continued descending to together. The B-747 passed beneath
when the conflict alert operated and FL350, the captain said.“Further, I also them.
the letters 'CNF' flashed in the data considered the risk of stalling if we
blocks of the DC-10 and the B747. pitched up, given the insufficient Analysis of recorded data indicates that
thrust, leading to an even more dan- the aircraft passed within horizontally
The ATC watch supervisor said,“I was in gerous sitation.” 135 metres (443 feet) of each other. If the
a flurry because I had forgotten about B747 had climbed in response to the ini-
the presence of [the DC-10]. At that Investigators calculated that the B747 tial RA, and had continued to climb, it is
time I deemed that the best action was had a margin of about 65kt over the estimated that the aircraft would have
to [issue an instruction to the DC-10 stall speed, and considered that the air- been separated by 1,600 feet vertically
crew to] descend.” craft, “would have been able to gain when they passed each other.

EUROCONTROL Page 23 January 2006

The Briefing Room - Learning from Experience

Analysis the fact that the ATCO and supervisor

were in discussion may have distracted Lessons Learned
The decision of the B747 captain to their attention from the approaching
follow ATC instructions instead of the confliction, which should have been z In high-pressure situations, take
TCAS RA was a major cause of this evident from the indications on the time to ensure that instructions
incident. ATC were not informed by radar screen. issued are appropriate. Three obvi-
either crew that they had received an ous errors of this type occurred:
RA, nor did the DC-10 crew inform Both the ATCO and the watch super- { A clearance was passed to an

ATC that they were following their visor were taken by surprise when aircraft which was not on fre-
{ A clearance was twice passed
to aircraft using the wrong call
z Avoid distractions, especially in
high-pressure situations. Sound
briefing before and de-briefing
after a period of duty is usually
more effective and less distracting
than discussion during the duty
z Always take time to up-date your
situational model when a new air-
craft comes under your control.
Attempt to visualise any conflict
that may arise with other traffic in
the future before moving on to
other tasks
RA. This omission increased the the conflict alert was signalled. z See also 121.5 Safety Alerts - Safety
uncertainty on the part of the con- Having decided to descend the DC- Occurrences during On-the-Job
trollers, and the ATCO continued to 10, the ATCO accidentally issued the Training on Page 10.
issue instructions which contradicted descent instruction to the B747.
the TCAS (although they could not Neither the ATCO nor the supervisor The EUROCONTROL Level Bust Toolkit
have known that). noticed this error, nor did they notice has been developed as a result of the
that the B747 accepted the clear- EUROCONTROL Level Bust Initiative. It
Subsequently, ICAO ruled8 that pilots ance. In spite of subsequent events, contains much important information
must follow TCAS RAs regardless of neither controller suspected that this and advice to help combat the level
contrary ATC instructions; if for any rea- error had occurred. bust threat. The EUROCONTROL Level
son it is not possible to follow the RA, Bust Toolkit may be obtained on CD
aircraft must remain level rather than When the watch supervisor took ROM by contacting the Coordinator
take action in the opposite direction to over control, she issued an instruc- Safety Improvements Initiative, Mr
that indicated by the RA. ICAO also tion to JAL957, even though there Tzvetomir Blajev, on
requires pilots to notify ATC as soon as was no aircraft with that call sign on tel: +32 (02) 729 3965
possible. frequency. This may have been a fax: +32 (02) 729 9082
sub-conscious combination of the
American Airlines 157 was cleared to call signs “907” and “958” which
descend before the aircraft was on fre- belonged to the B747 and the DC-
quency. This error had no direct influ- 10, resulting from the obvious pres-
ence on subsequent events. sure of the situation. This event was
probably too late to have any effect
Both the ATCO and the watch supervi- on the outcome of the situation;
sor 'forgot' the presence of the DC-10, nevertheless, it is worth noting that
even though it had checked in on fre- this was the second occasion when
quency only a few minutes before. a controller used an unintended call
These two events may indicate that the
ATCO was overloaded at the time. Also,

8 See ICAO Doc 8168 - Procedures for Air Navigation Services - Operations (PANS-OPS)

January 2006 Page 24 EUROCONTROL



Provided by Airservices Australia

A little known aural memory concept, information, you can hear things and This is just one example of a mix-up
known as the phonological loop has respond without consciously pro- that can occur without the controller
been identified as contributing to cessing the information also. realising it. We must not rely on those
last ditch safety nets, such as STCA and
TCAS to save the day - they usually will,
but not without leaving a trail of fright-
ened pilots and controllers (and
perhaps passengers too). The best
defence lies in good team work,
encouraging members of the team to
look out for errors, especially when the
pressure is on. This in turn relies on
strong leadership and a sound safety
culture, reinforced by regular Team
Resource Management training.

many communication breakdowns, It is important that controllers under-

especially information delivery errors. stand the perils associated with antici-
For example: pating read-backs and accept the logic
behind the memory prompts and
z Flight data record says aircraft checks that have been incorporated
squawk code 1234 into the air traffic control system to
z The controller erroneously instructs mitigate these types of risks.
squawk code 1243
z The pilot correctly reads back code
z The controller compares the pilot's
read-back to his incorrect instruc-
tion (1243 =1243)
z The controller detects a match and
the error goes unnoticed.

The error occurs because the con-

troller can detect the match [instruc-
tion code = read-back code] without
ever having to process the informa-
tion. The controller's instruction and
the pilot's read-back are both stored
in the phonological loop, which is an
aural processing area of the brain
that does not require conscious
effort to store information. Just as
you see things and respond without
ever consciously processing the

EUROCONTROL Page 25 January 2006


The success of this publication

CONTACT depends very much on you. We need
to know what you think of HindSight.

US Do you find the contents interesting or

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We wish to encourage controllers to give us proposals for safety improvements based on their experience. All proposals
received by the Editor in Chief by the end of April 2006 will be assessed by an independent Jury. The controller which
submits the best proposal will receive a free weekend for two in Paris. Proposals should be supported by argument and
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January 2006 Page 26 EUROCONTROL

© European Organisation for Safety of
Air Navigation (EUROCONTROL)
January 2006

This publication has been prepared by

the Safety Improvement Sub-Group
(SISG) of EUROCONTROL. The authors
acknowledge the assistance given by
many sources in the preparation of this

The information contained herein may

be copied in whole or in part, provid-
ing that the copyright notice and
disclaimer are included.

The information contained in this doc-

ument may not be modified without
prior permission from EUROCONTROL.

The views expressed in this document

are not necessarily those of EURO-

EUROCONTROL makes no warranty,

either implied or expressed, for the
information contained in this
document; neither does it assume any
legal liability or responsibility for the
accuracy completeness and usefulness
of this information.
Putting Safety First in
Air Traffic Management

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