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N° 1

January 2005

Putting Safety First in Air Traffic Management

By Tzvetomir Blajev “Hindsight”
Coordinator - Safety Improvement Initiatives, The ability or opportunity to understand and judge
and Editor in Chief of HindSight. an event or experience after it has occured.

“With the benefit of hindsight I would

have done it differently”.

How often do we hear responsible people If we learn the right lessons we will stand with your colleagues - think what you
saying these words? Often, it is an attempt a much better chance of reacting correct- would do if you had a similar experience.
to disguise the fact that they had not ly when we are faced with new situations We hope that you too will join in this
prepared themselves for some unusual where a quick, correct decision is essen- information sharing experience. Let us
situation. Yet hindsight is a wonderful tial. This magazine is intended for you, the know about any unusual experiences
thing and can be of great benefit if used controller on the front line, to make you you have had – we promise to preserve
intelligently to prepare ourselves for the know of these lessons. It contains many your confidentiality if that is what you
unexpected. There is much to be learnt examples of actual incidents which raise wish. Working together with the benefit
from a study of other peoples’ actions - some interesting questions for discussion. of HindSight we can make a real contribu-
good and bad. Read them carefully - talk about them tion to improved aviation safety.

The Briefing Room

Editorial 121.5 - Safety Alerts
Learning from Experience

HindSight is a Wonderful Thing 1 Avoiding Action Phraseology 4 Runway Incursion 7

EUROCONTROL Safety New Clearance Related Loss of Separation 10

Enhancement Business Division 2 to Levels 4
Controlled Flight Into Terrain 12
About HindSight 3 Aircraft Turn Performance
Early Turns 5 Unauthorised Penetration
Acronyms used in This Issue 23 of Airspace 14
Undetected Simultaneous
The Editorial Team 25 Transmission 5 Wake Vortex Turbulence 16

Contact Us 26 Hand-over/Take-over of Runway Excursion 18

Operational Position 6
Disclaimer 27 Level Bust 20

Feedback 21

European Air Traffic Management - EATM



By Tzvetomir Blajev, Coordinator - Safety Improvement Initiatives, and Editor in Chief of HindSight.

The Safety Enhancement The SAForum

Business Division

Within the EUROCONTROL Directorate Safety information exchange is a key

of ATM Systems (DAP), the role of the enabler for safety improvements.
Safety Enhancement Business Division Safety information, notably on cause,
(SAF) is to lead the implementation of lessons learned and remedial actions
safety management in the Air Navigation must be shared.
Service Providers (ANSPs) of the ECAC
states as well as in the EUROCONTROL To facilitate this sharring the Safety
Agency. Enhancement Business Division, has
launched a web-based Safety Forum
This purpose is achieved by means of called "SAForum". The SAForum is avai-
Safety enhancement programmes such lable via One Sky Online.
as the European Strategic Safety Action
Plan (SSAP). The SSAP aims to provide Web portal:
a common minimum level of Safety
Regulation and Safety Management
throughout the ECAC area.
This is achieved through collaborative
actions between State ATM Regulators,

Consensus is essential to achieve har-

monised implementation. Consultation
is achieved at all levels through Working
Groups, the EATM Safety Team, the
Safety Regulation Commission (SRC)
and ultimately the Provisional Council
of EUROCONTROL. In addition to State
Regulators and ANSPs, the operators
(airlines, general aviation, etc.), equipment
and software suppliers are also involved.

The SSAP covers a range of high priority

safety requirements and is a joint Safety
Management/Safety Regulation pro-
gramme, which ensures that there is close
coordination between the regulatory
requirements and the implementation of
safety management systems. In the
emerging environment of the Single
European Sky the European Commission
plays an increasingly important role in
providing a legal framework for safety

European Air Traffic Management - EATM

EUROCONTROL Page 2 January 2005


The main function of the HindSight magazine is to help operational air traffic controllers to share in the experiences of other controllers who
have been involved in ATM-related safety occurrences. In this way, they will have an opportunity to broaden their experience of the problems
that may be encountered; to consider the available solutions; and so to be better prepared should they meet similar occurrences themselves.

Material contained in HindSight falls into The incidents fall into several categories: Coding of Subject Matter
three distinct classes:
z Summaries of accident and To aid identification of subject matter,
z Editorial; serious incident reports each article is coded as follows:
z 121.5 - Safety Alerts; and The full report usually runs to many
z The Briefing Room - Learning pages, so these reports must be Each article is marked by a coloured icon
from Experience. summarised and simplified, concen- which appears on the contents list and
trating on the ATM-related aspects also at the head of each item.
On page 1, you will find a table of and passing quickly over other issues
contents listing articles under these three which have no direct relevance to
headings. Editorial material, such as this ATCOs. A reference to the original
article, needs no explanation but a few report is always supplied.
words on the other two classes may
prevent any misunderstanding. z Dis-identified accounts of other
Loss of
ATM-related incidents Separation
Typically, the original reports are not
121.5 in the public domain; however there
Safety Alerts are important lessons to be learned
from them. The identifying features of
Level Bust
From time to time EUROCONTROL issues the reports are altered without
Early Warning Messages and Safety changing the substance of the
Reminder Messages to draw the attention reports in order to preserve the
of the ATM community to emerging confidentiality of the reporter.
safety issues. The messages are inten- Runway
ded to encourage discussion on the z Feedback Incursion
prevalence and seriousness of the issue Edition 1 contains a number of items
and on the most appropriate reaction taken from recent editions of
to them. A summary of recent messages Feedback, the journal of the UK
are included, coded to reflect the subject Confidential Human Factors Incident Controlled Flight
into Terrain
material. Reporting Programme (CHIRP). These
items consist of incident reports and
comments by ATCOs and pilots. We
The Briefing Room hope that in future editions we may .. . .
.. . . .
. . .. .

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


Learning From Experience be able to produce a similar feature

of Airspace ..
.. .

. .. . . . .. .
based on letters and reports received
The majority of HindSight is taken up from readers of HindSight.
with articles concentrating on specific
safety issues. These usually comprise a
study of an actual accident or incident Knowledge Base Wake Vortex Turbulence
together with a summary of lessons
learned. Again, these articles are coded to We intend to compile a Knowledge Base
reflect the subject material. of all types of ATM-related safety reports,
which may be accessed by persons carry-
Some incidents relate to the performance ing out research on particular subjects. Other
of ATCOs or the ATM system, while others This is a long-term project but we plan
illustrate pilot errors which can arise that the HindSight magazine should be
from incorrect interpretation of ATC integrated with it from the outset.

European Air Traffic Management - EATM

EUROCONTROL Page 3 January 2005

121.5 Safety Alerts

MESSAGE SUMMARY Recent safety occurrences have shown AT (bearing by clock-reference and
that the correct Avoiding Action Phrase- distance)”.
ology is not always used by controllers.

AVOIDING ACTION The BFU Uberlingen Investigation Report PANS-ATM also states that when a pilot
emphasised the importance of the proper reports a manoeuvre induced by an ACAS
PHRASEOLOGY use of the avoiding action phraseology. Resolution Advisory (RA), the controller
shall not attempt to modify the aircraft
Origin: EUROCONTROL Agency flight path until the pilot reports return-
Issued: 16 October 2004 ICAO Procedure ing to the terms of the current air traffic
control instruction or clearance but shall
ICAO PANS ATM provides two formats provide traffic information as appropriate.
for the avoiding action message which
specify manoeuvres in the horizontal The tone of transmitting the avoiding
plane: action message contributes to conveying
to the pilot the urgency of the situation.
HEADING (three digits) TO AVOID No doubt, the importance of this
[UNIDENTIFIED] TRAFFIC (bearing by subject will be reflected in increased
clock-reference and distance)”; and, emphasis on avoiding action messages
“TURN LEFT (or RIGHT) (number of during training.

EARLY WARNING The Problem ICAO Procedures

MESSAGE SUMMARY Climbing through a previously restricted In response to a request for clarification,
level, and particularly through the First ICAO confirmed that "A level restriction
Stop Altitude (FSA), has been identified as will need to be repeated in order to
a causal factor for level busts. If a new continue to be in effect after a new
NEW CLEARANCE clearance is issued relating to levels, the clearance related to levels has been
pilot may assume that the previous issued.....this issue will be addressed in an
RELATED TO LEVELS restriction no longer applies. amendment proposal to PANS-ATM which
is currently being prepared...."
Origin: EUROCONTROL Level Bust For example, an aircraft on a Standard
Safety Improvement Initiative Instrument Departure (SID) has a height
Issued: 13 February 2004 restriction of 3,000ft until passing
way-point ABC. If the controller clears the
aircraft to FL240 after passing point ABC
without repeating the SID height restric-
tion the pilot may assume he is clear to
climb immediately to FL240.

European Air Traffic Management - EATM

January 2005 Page 4 EUROCONTROL

121.5 Safety Alerts

manoeuvre, at least 5/8 nm before the that has been reported. The effect is most
MESSAGE SUMMARY waypoint, and even more in case of a wide noticeable where the track change is
angle. However, in some circumstances considerable, e.g. greater than 40°.
turns are commenced earlier than is strict- This behaviour depends in part on the
ly necessary in order to provide a safe and design of FMS in use, so the performance
AIRCRAFT TURN comfortable transition. of two aircraft of the same type will not
necessarily be the same.
PERFORMANCE - The way in which the Flight Management
System (FMS) calculates the turn point Circumstances can also cause aircraft
EARLY TURNS depends on the expected altitude when to turn late, e.g. if the groundspeed at
the aircraft passes the waypoint. If the the start of the turn is low and increases
Origin: EUROCONTROL Agency expected altitude is below FL 200, a as the turn proceeds, or if the FMS is
Issued: 8 September 2004 higher bank angle is assumed than if the inaccurately programmed.
aircraft is above FL 200. Above FL 200 the
lower permitted bank angle results in an In extreme cases this early turn behaviour
The Problem increase in the turn anticipation distance can result in penetration of restricted
up to as maximum of 20 nm. However, an airspace.
En-route operations now demand the aircraft below FL 200 may start the turn at
use of RNAV. These systems initiate the up to 20 nm before the waypoint as ATCOs operating in such areas should be
turning manoeuvre without over-flying though it were above FL 200, and the aware of this possibility and if necessary,
the prescribed waypoint or VOR. increased bank angle below FL 200 will issue instructions to the pilot to overfly
For example, for a medium turning give rise to the early turn phenomenon the designated waypoint or issue vectors.

EARLY WARNING Other agencies have reported similar z ANSPs, Aircraft Operators and
occurrences. Regulators should continue to pro-
MESSAGE SUMMARY mote strict RTF discipline, including
The following Safety Recommendations rigorous read back - hear back
are made to reduce the risk of (Undetec- process;
ted) Simultaneous Transmis-sions:
UNDETECTED z Third parties on a communication
z ANSPs, Regulators, Aircraft Operators channel should be encouraged to call
SIMULTANEOUS and the EUROCONTROL Agency out “blocked” if they detect simulta-
should continue the work on redu- neous transmission;
TRANSMISSIONS cing the risk associated with similar
callsigns; z ANSPs and Regulators should monitor
Origin: ANSP the incidence of (Undetected) Simul-
Issued 12 December 2003 z ANSPs should provide their control- taneous Transmissions Events;
lers with detailed information on RTF
cross-coupling and Best Signal Selec- z The originator ANSP, and the
The Problem tion functionality if used, including EUROCONTROL Agency will investi-
the process itself, how it should be gate further the operational and
Several cases of AIRPROX have been used and the problems inherent in technical aspects of the Swiss
reported by an ANSP due to pilots reading the system; occurrences;
back a clearance not intended for them at
the same time as the pilot for whom the z When multiple RTF channels are z ANSPs, Regulators, Equipment Manu-
clearance was intended. The ATCO did not coupled, priority should be given to facturers and the EUROCONTROL
detect the error because the transmission duplex coupling (allowing audible Agency will investigate the possibility
was hidden (technical systems transmit- simultaneous transmission) rather of a technological solution.
ting best signal only). than simplex coupling

European Air Traffic Management - EATM

January 2005 Page 5 EUROCONTROL

121.5 Safety Alerts

Before Hand-over:
z A hand-over produces a workload of z The taking-over controller should
its own. Careful consideration to the ensure that he/she has been able to
timing should be given; assimilate all information relevant to a
HAND-OVER / safe hand-over and should accept
z If it is likely that the sector will be split responsibility only after he/she is
TAKE-OVER OF shortly after the hand-over consider completely satisfied that he/she has a
splitting it before the hand-over; total awareness of the situation;
z Simultaneous take-over of all the z Use mnemonic reminders within the
Origin: EUROCONTROL Agency sector positions (for example both checklist like “check REST before
Issued: 15 October 2003 radar and planner) should be avoided; going to rest”. (See table below.)

z Do not short cut the existing good z Please, note that there is an important
The Problem practice during low vigilance periods; logic behind the REST sequence,
building consecutively the situational
A number of ANSPs have expressed z The handing-over controller should awareness for (1) environment frame-
concerns about safety occurrences tidy up the working position prior to work (2) environment of operations
associated with the hand-over/take-over the hand-over; (3) operations.
process of operational ATC positions.
z A hand-over should be commenced
It is acknowledged that the vast majority only after all the initiated actions for After a Hand-over:
of hand-overs take place without any resolving the potential conflicts or
problems, and only a very small propor- recoverings from actual conflicts are z It is specifically important that the
tion are flawed. Therefore, the level of accomplished handing-over controller should
normal human reliability has already remain available for few minutes
been reached and potential mitigations following the hand-over, particula-
should be targeted at the other system During Hand-over: ly in dynamic traffic situations, to
elements procedures (checklists) and/or provide clarifications / assistance
equipment. z Avoid distracting controllers during regarding any points which may sub-
hand-over; sequently arise;
The SISG secretariat has investigated,
analysed and summarised the existing z Use checklists with the sequence z Other controllers on the sector should
good practice approaches used by some of actions to be performed by both only impart additional information
ANSPs. Some recommendations are handing-over and taking-over con- after a hand-over is complete.
provided below: trollers;

R Restrictions Examples: Flow restrictions, TSA, Danger, Prohibited and other special status airspace.

Examples: Status, maintenance, ground-ground communications, air-ground

E Equipment communications, navigation, surveillance, radar filters, radar source, type of surveillance
sources integration if multiple, strip printers, workstations, information systems.

Examples: Weather (fog, snow, hail, visibility, low/high pressure, CB, turbulence, CAT,
S Situation winds etc.), Staffing, Configurations (Sectors, Runways, Taxiways, Adjacent sectors etc.),
Strips, Holding.

Examples: All under control, expected, military, VIP, Aerial activity, non compliant with ATM
T Traffic
regulations (RVSM, RNAV, 8.33, ACAS etc.), VFR flights, Clearances and instructions given

European Air Traffic Management - EATM

January 2005 Page 6 EUROCONTROL

The Briefing Room

The crew of the Shorts 3-30 aircraft believed they had been cleared to line up for take-off from an intermediate point on Runway 27 at Paris-
Charles de Gaulle Airport. As they entered the runway the aircraft was struck by the wing of an MD 83 aircraft which was taking off, using the
full runway length. A recent survey of pilots involved in Runway Incursion incidents revealed that 50% believed they had permission to be on
the runway when the incident took place.

Important Notice Factual Information

The complex factors relating to this IIt was dark and rain was falling when Air Three seconds later, SSW200 was instruct-
accident are difficult to summarise in the Liberté MD 83,“IJ8807” began to taxi from ed to go to Local frequency.
space available. The Probable Causes, and Terminal 1 to the holding point of RWY 27
Recommendations listed below use the at 02:12:40 local time. The aircraft At 02:50:45 the B737 vacated RWY 27,
precise wording employed in the English stopped on the way to the runway to deal having passed in front of SSW200. IJ8807
language version of the final report. with a technical problem. was then cleared for take off.
In some cases, the precise meaning is not
clear without reference to the full text. At 02:38:25, Streamline Shorts 330, Five seconds later at 02:50:50 SSW200 was
It is therefore recommended that readers “SSW200”, was cleared to taxi from the cleared to “line up runway 27 and wait,
refer to the full text of the report, cargo ramp to RWY 27. At this point both number two.” SSW200 taxied forward and
published in French and in English aircraft were under control of the Ground entered the runway, all the time looking
translation at the web-site of the Bureau Controller (GRD). for the No 1.
Enquêtes-Accidents (BEA)
At 02:44:25 SSW200 was offered depar- Shortly before impact, the Shorts 330
ture from an intermediate point on RWY Captain noticed the MD 83 beacon lights
27 and proceeded towards this point via and braked. About the same time, the MD
Taxiway 16. Shortly afterwards, IJ8807 83 crew noticed the Shorts 330 on the
resumed taxiing for RWY 27 and then edge of the runway. The aircraft had by
changed frequency to the Local then passed V1.
Controller (TWR).
At 02:52:01 the left wing of the MD 83 col-
At 02:48:37 IJ8807 was told to line-up and lided with the right propeller and cut
wait on RWY 27 after a landing B737. through the Shorts 330 cockpit.

Runway 27

RWY 27
Impact holding
point Taxiway 16 point

Runway 27

Route followed by SSW200 along Taxiway 16 to RWY 27

Route followed by IJ8807 onto RWY 27 and up to the impact point

Work in progress between taxiway 16 and the runway threshold

European Air Traffic Management - EATM

January 2005 Page 7 EUROCONTROL

The Briefing Room


All the exchanges between ATC and The crew of the Shorts had not under- z The use of two languages for radio
IJ8807 were conducted in French while all stood the clearance given to IJ 8807, communications, which meant that
communication with SSW200 were in which was in French. They could not see the Shorts crew were not conscious
English. the MD83 on the runway, and assumed that the MD 83 was going to take off.
that the landing B737 which passed in
There was work in progress at various front of them was the aircraft taking off z The angle between access taxiway 16
points between taxiway 16 and the before them. Therefore they taxied onto and the runway which made it impos-
runway threshold involving some 10 the runway, as they thought, in accor- sible for the Shorts crew to perform
vehicles equipped with orange flashing dance with their clearance. a visual check before entering the
lights, while the work itself was illuminat- runway.
ed by halogen lamps (see diagram). The MD83 crew understood the clearance
given to the Shorts but were unaware that z The lack of co-ordination between the
There were no fixed obstacles blocking it was at the intersection. As they GRD and TWR controllers when
the view of the runway threshold from the commenced their takeoff there were no managing the Shorts, exacerbated by
cockpit of SSW200. The field of view from obstacles visible ahead of them. the presence of a third party whose
the Shorts 330 right hand pilots seat role was not defined.
extended 120° to the right of the aircraft
axis; however, the pilot was unable to see Probable Causes z A feedback system which was recent
the threshold of RWY 27 while the aircraft and still underdeveloped.
was on taxiway 16 because of the The investigation determined that the
extremely acute angle between taxiway accident was caused:
and runway. The UK Representative to the investiga-
z Firstly, by the TWR controller’s tion commented that the report would
It was normal practice for the Streamline erroneous perception of the position more accurately reflect the true position
aircraft to depart RWY 27 from a runway of the aircraft, this being reinforced by as represented by the evidence if the
intersection; however on the night in the context and the working third causal factor was deleted because
question the TWR position was manned methods, which led him to clear the the Shorts 330 crew complied with their
by an instructor who was re-familiarising Shorts to line up, clearance which they read back to ATC.
himself with the airport and had formed
the erroneous perception that all traffic z Secondly, by the inadequacy of
departing RWY 27 did so via the runway systematic verification procedures in
threshold. ATC which made it impossible for the
error to be corrected,
The aircraft strips were passed from GRD
to TWR by a third party. In doing so, no z Finally, by the Shorts’ crew not
mention was made of the position of the dispelling any doubts they had as to
Shorts, although this was indicated on the the position of the “number one”
strip. As he had not noticed the indication aircraft before entering the runway.
of the taxiway on the strip and nothing
had drawn his attention to the peculiari-
ties of the Shorts’ situation, TWR believed Contributory factors include:
that the aircraft was taxiing behind the
MD 83. z Light pollution in the area of RWY 27,
which made a direct view difficult for
A direct visual check was difficult to the TWR controller.
perform because of the works and the
light pollution, and radar verification was z Difficulty for the TWR controller in
difficult because of the screen’s character- accessing radar information: the
istics. In radio communication with ASTRE* image was difficult to read *ASTRE and AVISO are radar systems used
SSW200, there was no reference to the and the AVISO* image was not to identify the location of aircraft on the
aircraft’s position. displayed at his control position. airfield .

European Air Traffic Management - EATM

January 2005 Page 8 EUROCONTROL

The Briefing Room

Recommendations Lessons Learned

The investigation showed the importance RUNWAY INCURSION - From several

for safety of great precision in runway safety occurrances we recommend:
usage and the grave risks created by any
misunderstanding, especially when the Recommendations contained in this and z Assess any existing visibility restri-
aerodrome’s procedures allow for the other runway collision accident reports, tions from the tower which have a
occasional presence of more than one and data obtained following the analysis potential impact on the ability to see
aircraft on the runway. Accordingly the of many runway incursions were fully the runway, and disseminate this
investigation made recommendations to taken into account when developing the information as appropriate;
guarantee in all circumstances the same recommendations for the European
level of safety when such procedures are Action Plan for the Prevention of Runway z Ensure that runway safety issues are
in force. Incursions*. included in training and briefing for
ATC staff especially at shift hand over;
Several recommendations were also The recommendations appropriate to ATC
made concerning the organisation of Air are as follows: z When using multiple line-ups, do not
Traffic Control. use oblique or angled taxiways that
limit the ability of the flight crew to
In addition, the investigation recommen- z Use a clear and unambiguous see the runway threshold or the final
ded in the light of the analysis of this method to indicate that a runway is approach area;
accident and previously acquired temporarily obstructed;
experience, that the DGAC study the z To avoid the possibility of call sign
expediency and methods of implementa- z Do not instruct or imply that an confusion, use the full aircraft or
tion for the systematic use of the English aircraft should cross an illuminated vehicle call signs for all communic-
language for air traffic control at Paris red stop bar when entering or tions associated with runway oper-
Charles de Gaulle aerodrome, as well as crossing a runway. For situations tions;
the extension of this measure to other where the stop bars or controls are
aerodromes with significant international unserviceable contingency procedu- z Use only standard ICAO RTF
traffic. In making this recommendation, it res should be used to guide the phraseology;
was stressed that the investigation did aircraft across the stop bars. Stop bars
not aim to evaluate the advantages and that protect the runway must be z Always use the ICAO read-back proce-
disadvantages of the systematic use of a controllable by the runway controller; dure (including Drivers and other
single language. personnel who operate on the
z Ensure that ATC communication mes- manoeuvring area);
sages are not over long or complex;
z Improve situational awareness by
z Ensure that ATC procedures contain a conducting all communications
requirement for an explicit clearance associated with runway operations on
to cross any runway. This includes a common frequency;
non-active runways; (note - aerodromes with multiple
runways may use a different frequen-
z Use standard taxi routes when cy for each runway.)
practical to minimise the potential for
pilot confusion and allow pre-
planning by aircrew;

z In situations where a long and

complex taxi route is required, the
use of progressive taxi instructions is
recommended to reduce pilot worK- *A copy of the European Action Plan for the
load and the potential for any Prevention of Runway Incursions can be
confusion. Each element of the taxi obtained from the following e-mail address:
clearance should contain a clearance

European Air Traffic Management - EATM

January 2005 Page 9 EUROCONTROL

The Briefing Room

The incident which is described below took place in the middle of the day in the terminal area near a major European airport. The three air-
craft involved were operated by major European airlines. The details of the incident have been changed to protect confidentiality but the facts
are very much as they happened.

Factual Information

AirB123 is a Boeing 737 which is intend- But CAir035 had already passed FL90. Five The pilots of CAir035 were expecting
ing to land at the airport and is descend- seconds later he reports “We have a TCAS further climb clearance and accepted the
ing to FL100 under control of the Initial TA. Traffic is in sight.” clearance as being intended for them.
Approach Controller (INI). At 1200.00, INI The DEP controller did not detect the
instructs the pilot of AirB123 to “proceed DEP responds: “CAir035 descend immedi- error on readback. The fact that the pilot
PQR, for radar to ILS RWY 25R”. ately FL90, turn immediately left heading of CAir035 abbreviated his callsign at
090.” 1205.16 may have contributed to this
Two minutes later at 1202, the pilot of error.
CAir035, an Airbus A340 departing from At the same time, CAir035 receives a TCAS
the airport, informs Departure Control “climb” RA. He replies: “Descending FL90, The pilot of CAir035 received a TCAS
(DEP) that he is climbing to FL90 left 150 degrees, following TCAS.” “climb” RA and reported to ATC that he
and proceeding to LMN. DEP instructs was following it however he apparently
him to continue towards LMN and report In fact the pilot continued to descend, continued to descend in accordance with
reaching FL90. contrary to his “climb” RA. ATC avoiding instructions.

CAir3365 is an Airbus A320 at FL90 on the At 1206.30, AirB123 informs INI that he
same route as CD035 but 10 miles ahead, has the traffic in sight on his right hand
also under control of DEP. side. The aircraft pass 1.5nm apart, both at
FL096, descending.
At 1205.00, CAir035 advises levelling at
FL90 and requests further climb.
Unfortunately, the callsign is corrupt and
DEP believes the message came from CAir Analysis
3365. He issues the instruction:“CAir 3365
climb report level FL200”. Two aircraft with callsigns CAir035 and
CAir3365 departed from the same airfield
CAir 035 does not notice the incorrect call on similar initial tracks within a few
sign and replies:“Climbing to 200, 035”. minutes of each other. The potential for
call sign confusion (same prefix, two digits
DEP does not notice that the wrong in each suffix the same, final digit in each
aircraft has responded to the clearance. suffix the same) was apparently not
detected by the airline callsign deconflic-
A few seconds later, INI detects the tion programme nor was it noticed by the
conflict and instructs AirB 123 to turn left controllers or the pilots of either aircraft.
heading 300. He advises AirB 123 that he
has “traffic at 11 o’clock 5 miles same level, The request from CAir035 for further
climbing”. He then instructs AirB 123 to climb was corrupt and the call sign was
“descend immediately to FL70”. unclear. The DEP controller was expecting
a climb request from CAir3365 and so
At 1205.50, DEP issues the instruction: assumed the call was from that aircraft
“CAir035 maintain FL90, traffic crossing and issued it with a clearance to climb to
right to left, turn left heading 120.” FL200 without first checking the call sign.

European Air Traffic Management - EATM

January 2005 Page 10 EUROCONTROL

The Briefing Room



300° 090° This schematic diagram shows the approximate relationship of the aircraft.
The diagram is not drawn to scale.

Track of AirB123
Track of CAir035
The position of CAir3365 at the time of the incidant is also
shown on the diagram

Lessons Learned


safety occurrances we recommend:

Communication &
Similar Callsigns TCAS

z Use correct RTF phraseology, proce- z A transmission could be blocked z Where a collision risk exists, ACAS
dures and discipline at all times; when two or more aircraft are provides the most effective means of
responding to the same clearance. collision avoidance.
z Insist on readback. Listen carefully to Typically the controller would hear a
readback. Always correct errors and partial or garbled readback. z When a controller is informed that a
insist on correct readback following If a blocked transmission is suspected, pilot is following an RA, he should not
an error for as many times as is neces- ensure that both aircraft retransmit attempt to modify the aircraft flight
sary to ensure that the correct their messages and confirm that a path until the pilot reports returning
clearance has been understood; clearance has not been taken by an to the clearance. He should provide
aircraft for which it was not intended; traffic information as appropriate.
z Monitor flight crew compliance with
RTF callsign use; z Where an actual or potential callsign
confusion incident is observed, file a The EUROCONTROL Level Bust Toolkit
z Take extra care when language report using the national mandatory contains further information to reduce
difficulties may exist; incident reporting system or volun- the potential for loss of separation.
tary incident reporting system as See page 20.
z Recognise and understand the pilots’ appropriate;
working environments and
constraints; z Advise adjacent sectors/airports if it is
felt that potential confusion may exist
z Warn the pilots of aircraft on the same between aircraft likely to enter their
RTF frequency having similar callsigns airspace;
that callsignconfusion may occur.
If necessary, instruct one or both z Ensure that aircraft operators are
aircraft to use alternative callsigns made aware of any actual or potential
while they are on the frequency; callsign confusion reported by air
traffic controllers.

European Air Traffic Management - EATM

January 2005 Page 11 EUROCONTROL

The Briefing Room

In spite of concerted action throughout the industry, Controlled Flight Into Terrain (CFIT) remains a major accident cause.

According to the IATA Safety Report for focused on traffic flow. Both are balancing in emergency and non-standard situa-
2003 there were eight fatal Controlled safety and efficiency. tions.
Flight Into Terrain (CFIT) accidents world-
wide during 2003, which accounted for Airline operators sometimes push flight The results of these sessions were very
136 fatalities. crews with schedule pressures, shorten- encouraging and resulted in positive
ing turn-around times and demanding advances in mutual understanding being
Sadly, it would appear that three of these greater productivity of aircraft and flight reported by pilots and controllers.
accidents involved European operators crews. They also push the ATC system
and took place within the European geo- to increase capacity of landing/takeoff During the 1990s, international collabora-
graphical area - two in Turkey and one in runways, reduce landing intervals, reduce tion led by the Flight Safety Foundation
France. radar separation minimums, and use (FSF) resulted in the development of the
complex multiple-runway combinations. FSF Approach and Landing Accident
It will be some time before the full details In this demanding environment, flight Reduction (ALAR) Toolkit.
of the accident investigations are safety depends on spoken communi-
available and it is possible that the initial cation. For more information, refer to
classification as CFIT proves to be
inappropriate. The known facts of the Although pilots and controllers work
three European accidents are summarised together, sometimes they don’t under-
briefly on page 13. stand each other’s problems.

CFIT occurs when an airworthy aircraft A programme on pilot-controller commu-

under the control of the flight crew is nication should involve pilots and
flown unintentionally into terrain, obsta- controllers in joint meetings and in joint
cles or water, usually with no prior aware- flight/ATC simulator sessions to promote
ness by the crew. a mutual understanding of each other’s
working environment.
Pilots and controllers are involved equally
in the ATC system, and their responsibili- Discussions, for example, could include
ties overlap in many areas and provide problems caused by late clearances and
backup. last-minute runway changes. In the end,
these are problems for pilots AND
The pilot-controller confirmation/correc- controllers.
tion process is a loop that ensures
effective communication. An example of a successful programme
that provided real-world experience and
Whenever adverse factors are likely to proved the value of mutual understand-
affect communication, adherence to the ing between pilots and controllers was
confirmation/correction process is a line that between KLM and Amsterdam ATC.
of defence against communication errors.
Controllers participated in Flight Simu-
Controllers and pilots must work lator sessions, acting as co-pilot and
together, but there is a gap in their under- reading the check-list; on the command
standing of each other’s challenges. of the pilot they operated the flaps,
The pilot is focused on a very complex landing gear and other systems; they
aeroplane in the demanding environment conducted communications with ATC;
of approach and landing. The controller is and they contributed to decision making

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January 2005 Page 12 EUROCONTROL

The Briefing Room

Date: 8 January 2003 270°/11kt variable between 230° and

Location: Diyarbakir, Turkey 300°, visibility better than 10km in light
Operator: THY Turkish Airlines rain showers, and scattered cloud at
Aircraft Type: Avro RJ100 Regional Jet 1,200ft. However, it is thought likely
Fatalities: Passengers - 70 / Crew - 5 that the mountains where the accident
happened would have been shrouded in
The aircraft undershot during the final cloud.
stage of a VOR/DME approach to RWY 34
at Diyarbakir, impacting the ground
slightly to the side of the extended
centreline of the runway, about 500m Date: 22 June 2003
short of the runway threshold and 100ft Location: Brest, France
below the airfield elevation. The aircraft Operator: Brit Air
broke up during the crash sequence and Aircraft Type: Canadair Regional Jet
was destroyed by fire after eventually CRJ-100
coming to rest. It is understood that, at Fatalities: Passengers nil / Crew 1
the MDA, the pilots did not have visual
contact with the runway. The aircraft undershot during the final The earlier part of the approach had
stage of an ILS approach to RWY 26L at appeared normal but it is reported that
The accident happened in darkness Brest, touching down about 2,300m the captain, who was handling the air-
(2020L) and in poor weather. The report- before the threshold of the runway and craft, apparently failed to respond to the
ed weather at 1950L was: wind calm, about 450m. to the left of the extended warnings or noticeably react as the air-
visibility 3.5km, RWY 34 RVR 3,500m and centreline. After coming to rest the craft descended through the Glide Slope
falling, and scattered cloud at 4,000ft. aircraft caught fire and was destroyed. and continued below it. The co-pilot is
However, at the accident location there is reported as saying that, following the first
a small stream and it is reported that the The accident happened in darkness ‘Glide Slope’ warning, he had looked at
fog was considerably thicker in this (2351L) and in poor weather: wind the captain who appeared to be sitting in
region. 320°/9kts variable between 280° and 360°, a normal position, looking towards his
visibility 800m in fog, RWY 26 RVR variable instruments, with both hands on the con-
The Turkish authorities recently ruled that between 1,400m and 1,500m, and cloud trol column. The co-pilot appears not to
the probable cause of this accident was broken at 200ft and scattered at 2,000ft. have commented on the aircraft's contin-
pilot error. More specifically, they stated The aircraft was operating a flight ued deviation below the Glide Slope but,
that ‘the crew was insistent on landing (AF5672) from Nantes. reportedly, he put his hand on the TOGA
despite the fact that neither the approach button. The captain apparently still did
lights nor the runway was visible.’ The aircraft was cleared to descend to not respond. The co-pilot then reportedly
2,000ft and reached that altitude by increased power and attempted to pull
about 7DME, continuing at 2,000ft until back on the control column, which ‘felt as
reaching the Outer Marker (4DME). if it was blocked.’ A few seconds later, the
Date: 26 May 2003 A further descent was then made to inter- aircraft impacted the ground.
Location: near Macka, Turkey cept the Glide Slope. However, this
Operator: UM Air (Ukraine) descent was continued, through the Glide
Aircraft Type: Yakolev YAK-42 Slope, which was crossed at a height of
Fatalities: Passengers 62 / Crew 13 above 1,000ft, and seems to have contin-
ued at more or less the same rate until
The aircraft was destroyed when it flew shortly before impact. The GPWS warning
into a steep hillside near Macka during its ‘Glide Slope’ had commenced, as the
second approach to RWY 29 at Trabzon. aircraft descended below it, 23 seconds
The accident happened shortly after the before impact. The ‘Glide Slope’ and ‘Sink
crew advised ATC that they were Rate’ warnings continued for the rest of
'inbound' towards the Trabzon VOR. the approach. Meanwhile, the aircraft had
The point of impact was at the 4,300ft been slightly left of the localiser and
level some 25km. south of the Trabzon continued to diverge, steadily, further to
VOR, which is located on Trabzon Airport. the left during most of the rest of
The accident happened in darkness the approach.
(0413L). The reported weather was: wind

European Air Traffic Management - EATM

January 2005 Page 13 EUROCONTROL

The Briefing Room

. .. .

.. . . .
. . .. .

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


.. . . . . . ..

Airspace Infringements are a potentially serious aviation hazard and occur when an aircraft enters Controlled Airspace (CAS) without clear-
ance. This article summarises the findings of the recent “On Track” project conducted by the UK CAA. The full report may be viewed at the UK
CAA website at

The “On Track” project was established in account the actual utilisation of the air- The advances of modern technology now
2001: ‘To identify the causal factors space concerned. Minor adjustments to being employed in the production of
behind airspace infringements, and to CAS would produce significant benefits downloadable on-line charts for the more
make recommendations for safety for all users. congested areas was very impressive.
improvements.’ A non-CAA project team Further opportunities are available to
was appointed to collect detailed confi- There is overwhelming support for Lower produce low cost interactive CD-ROM
dential data on why infringements Airspace Radar Service (LARS), especially based charts, which could be marketed
occurred and to make recommendations in the most congested areas, which for individual printing of selectable data
based on comments and suggestions should receive priority allocation of a on a home PC.
from pilots and controllers. specific GA radar facility, and early action
should be taken to achieve this aim.
“On Track” represented a completely fresh
approach to the infringement problem, Pilots reported difficulty in understanding AICs and NOTAMS
by directly inviting Pilots and Controllers why zone crossing clearances were so
to give their individual views. The General often refused without explanation. A for- Infringements in this category were the
Aviation (GA) community, Aviation Press mal procedure for pilots to register a result of misunderstanding or failing to
and many controllers welcomed this refusal of service would quantify this read an Aeronautical Information Circular
approach as long overdue, but cautioned problem, and provide feedback. (AIC) or NOTAM, particularly where a
that its success would be judged solely on Temporary Restricted Area (TRA) is estab-
tangible results, and that the follow-up An additional level of service - Flight lished.
process would be closely monitored. Following or Listening Out/Monitoring -
based on the US model, would enhance Emphasis should be placed on the use of
During the 18 month data collection safety when a full LARS may not be common English and clarity of presenta-
period, 165 infringement reports were required by the pilot or available from tion, avoiding the use of abbreviations
researched by the project. Of these, 144 ATC. This would employ nominated where plain language would be more
were ‘infringements’ and 21 were ‘almost transponder codes matched to RTF easily understood.
infringements’. In addition, the project frequencies.
team gathered further detail from pilots On-line versions should be widely publi-
who had no infringement to discuss but There is a perceived attitude of mistrust cised and make full use of the improved
wished to contribute their views. between GA pilots and controllers. graphics and presentation available.
Airspace policy and procedures are not Downloadable full colour maps and pub-
well understood by GA pilots who would licity material should be available on-line
benefit from a focussed education where applicable.
Airspace Issues & Lower Airspace programme and improved publicity.
Radar Service

Infringements often occur in areas where

the amount of free airspace available to Maps and Charts
GA aircraft is restricted. Airspace constric-
tions or “choke points” are particularly GA pilots were generally very satisfied
prone to infringement. with the current Maps and Charts follow-
ing recent improvements, although prob-
GA pilots should be invited to participate lems still arise from misreading CAS
in review of CAS allocation, taking into boundaries.

European Air Traffic Management - EATM

January 2005 Page 14 EUROCONTROL

The Briefing Room

Global Positioning Transponders CAA Investigation and Follow-up

Systems (GPS) Procedure

GPS is used by a large number of GA pilots Pre-allocated squawks associated with A more constructive attitude towards the
who report that its accuracy, performance assigned frequencies, especially in known GA community would facilitate the free
and reliability are excellent. Unfortunately “hot-spots”, in support of a varied LARS or exchange of information and ideas
there is little official recognition of GPS Flight Following/Monitoring service required to reduce infringements.
use by GA within UK Airspace, and no should be introduced. As a minimum
compliance requirements exist. benefit, controllers would then be able to Paradoxically, the most serious infringe-
contact an aircraft on the listening out ments that should attract the highest
A wide-ranging formal compliance proce- frequency allied with its squawk. level of safety scrutiny and comment are
dure would reduce infringements by lost to any safety follow up system when
improving the effectiveness and applica- An education and publicity programme they are passed for investigation.
tion of GPS. should issue clear guidance on the most Historically, all details of an infringement
effective use of transponders in the have been withheld where prosecution is
Formal recognition of GPS use would modern ATC environment. likely, due to legal constraints. However, it
further enhance the benefits for GA pilots, is unlikely that such secrecy is necessary
for example, by including GPS co-ordi- after the event.
nates whenever possible in navigation Licensing Issues
information. Safety expertise should be included at the
Infringements would be reduced if more earliest stage of every investigation, with
pilots had some form of Instrument the specific aim of identifying infringe-
Training Rating (I/R). The more comprehensive use ment safety issues. Only limited infringe-
of radio navaids would confer a higher ment data is currently available.
Poor training contributes to infringe- level of navigation accuracy. Whenever possible, causal factors should
ments, and the specific areas of be identified and effectively recorded to
Navigation, GPS and RTF training attract- A modular I/R should be introduced to promote safety analysis.‘Infringers’ should
ed particular criticism. focus on GA requirements. be encouraged to contribute preventative
suggestions as part of a “no blame ”
A comprehensive review of all aspects of Greater credit for foreign I/R training and culture when closing reports.
navigation training is required to produce qualification should be given to encour-
a well-structured syllabus, detailed in- age participation and increase levels of There was strong support for heavy fines
structor guidance and an effective expertise. where blatant, irresponsible infringe-
standardisation scheme. ments had occurred; publicity should be
given to all such awards.
There is currently no formal guidance or Communication
training in the use of GPS, and many pilots Periodic detailed feedback should be
are unaware of the most effective GPS Lack of knowledge and poor understand- available to promote infringement
navigation techniques. ing of procedures contributes to infringe- awareness and ‘lessons learned’ with
ments. More resources and ingenuity are appropriate expert discussion and
Although controllers reported that a high required to identify and implement comment.
standard of pilot RTF was more likely to practical means of disseminating useful,
produce a service, it was noticeable that relevant safety information, which could
RTF training had a low priority. help reduce infringements.

Some pilots operate their radios with no The use of an independent “open forum ”
RTF licence at all. They view the RTF style website by “On Track ” was universal-
Manual as too complex for their basic VFR ly viewed as a very significant, inclusive
flying requirement, and choose to opt out move forward. The clear GA view was in
of the licence altogether. favour of widening the forum.

European Air Traffic Management - EATM

January 2005 Page 15 EUROCONTROL

The Briefing Room


With the world airline fleet expected to double in size over the next 15 years and the giant A380 entering service in 2006, solutions to the
wake-vortex problem cannot come too soon for the European aerospace industry.

Crash follows encounter with

Boing 757 Wake Vortex

The pilot-in-command's failure to They are experienced as a buffeting of

maintain adequate separation behind the the aircraft. While of little concern to
Boeing 757 and/or remain above its passengers and crew who are wearing
flight path during the approach, which seat belts at this stage, pilots regularly
resulted in an encounter with wake report minor injuries to crew members
vortices from the 757. Factors related to standing up or moving around the
the accident were: an inadequacy in the cabin. However, thanks to ICAO regula-
On 15 December 1993 a Boeing 757 & an ATC procedure related to visual approach- tions on separations, there have been
Israel Aircraft Industries Westwind (WW) es and VFR operations behind heavier no serious accidents reported with
were vectored for landings on RWY 19R at airplanes, and the resultant lack of passenger airliners.
Santa Ana—John Wayne Airport, USA.The information to the Westwind pilots for
757 & WW were sequenced for visual them to determine the relative flight path The above statement was made in the
approaches. Before being cleared for of their airplane with respect to the European Commission on-line research
visual approach, the WW was closing Boeing 757’s flight path. magazine “Growth” dated 14th July 2000*.
3.5nm behind the 757 on a converging
course. Wake vortices are normally invisible
and pilots have no warning that they
The 757 & WW crews were told to slow to are flying into one. For this reason, the
170kt due to a preceding aircraft. The 757 International Civil Aviation Organisa-
slowed below 150kt and was high on final tion (ICAO) lays down strict rules about
approach with a 5.6° descent. The WW the permitted spacing between
continued to converge to about 2.1nm aircraft, based on their size. In instru-
behind the 757 on a 3° approach. ment flying conditions aircraft may
follow no closer than three nautical
ATC did not specifically advise, nor was it miles (5.56km) [Between medium
required to advise the WW pilots that they aircraft]*, and a small aircraft must
were behind a Boeing 757. The WW follow at least six nautical miles
captain discussed possible wake turbu- (11.12km) behind a heavy jet such as a
lence, flew the ILS one dot high, noted Boeing 747.
their closeness to the 757 & indicated
there should be no problem. While These separations are conservative:
descending through approximately they do not completely avoid the
1,100ft AMSL the WW encountered wake effects of wake vortices, but they are
turbulence from the 757, rolled into a sufficient to be safe in most meteoro-
steep descent & crashed. logical conditions.
The National Transportation Safety Board Nearly all airline pilots will have had growth/gcc/projects/in actionvortex.html
determined the probable causes of this encounters with vortices, usually on
accident as follows: the final approach to airports. * Editorial remark

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January 2005 Page 16 EUROCONTROL

The Briefing Room

While this statement is true, there have Finally, it has been observed that the wake
been a number of fatal accidents involv- vortex characteristics of certain aircraft Lessons Learned
ing smaller aircraft, and the example types, particularly the Boeing 757, seem to
quoted bellow serves to demonstrate the differ from what would be expected
power of wake vortices. based on their size. Because of this, some WAKE VORTEX TURBULENCE - From
national authorities specify greater sepa- several safety
A number of research projects have been ration for aircraft following these aircraft occurrances we recommend:
undertaken on both sides of the Atlantic types.
ever since the problem of Wake Vortex
Turbulence was identified. Indeed, the While there have been rare instances z Departing aircraft must be separated
passage quoted above comes from an where wake turbulence caused structural by at least the minimum spacing spe-
article which refers to the work done to damage, the greatest hazard is induced cified in ICAO or national regulations.
date and emphasises the need for more roll and yaw. This is especially dangerous
research. during takeoff and landing when there is z Arriving aircraft must be separated
little altitude for recovery. from preceding aircraft by at least the
To quote again from “Growth”: minimum spacing specified in ICAO
During takeoff and landing, the vortices or national regulations and must be
The impetus for further study of wake sink toward the ground and move lateral- routed so as to avoid the wake vortex
vortices, now a major concern in North ly away from the runway centreline, when turbulence from departing aircraft.
America as well as in Europe, is twofold: the wind is calm. A 3kt—5kt crosswind
will tend to keep the upwind vortex in z In light or calm wind conditions, pilots
1. A new generation of very large the runway area and may cause the of aircraft following other aircraft at
aircraft (VLA), such as the A380, is due downwind vortex to drift toward another near the minimum specified spacing
to come into operation from 2007. runway. should be warned that turbulent
These are expected to generate conditions may persist.
even larger wake vortices and if no Minimum separation distances are speci-
action is taken will cause severe fied in ICAO Doc 4444 (PANS-ATM). This z Pilots of aircraft reporting wake
problems for ATM. may be supplemented by national regula- vortex turbulence should be encour-
tions. The heavier the aircraft and the aged to submit a formal report using
2. Many busy airports in the USA and slower it is flying, the stronger the vortex. the standard Wake Vortex Reporting
Europe are already working near form.
capacity limits, at least during peak Aircraft should be spaced so that aircraft
hours. A better understanding of the of a lower weight category do not fly z ATCOs controlling aircraft operating
wake-vortex phenomenon would through the wake of aircraft of a higher under VFR should remain alert to the
permit aircraft to fly closer together category within the area of maximum danger of wake vortex turbulence
when local weather conditions were vortices. Therefore, different separation and warn pilots if they approach the
suitable and so ease congestion. distances are applied depending on the minimum recommended separation.
Increasing capacity in this way would runway configuration (single, parallel,
be a better solution than building crossing or diverging runways) and the
new runways. departure route being flown.

A third potential area for concern is RVSM

airspace, and several studies of wake
vortex incidents have been carried out on
behalf of EUROCONTROL. These indicate
that the majority of wake vortex encoun-
ters occur with climbing or descending
aircraft. It is too early to tell if the introduc-
tion of RVSM has had an impact on the
probability of wake vortex encounter and
so there is a continuing need to keep up
the momentum of reporting so that any ``
significant trends can be identified.

European Air Traffic Management - EATM

January 2005 Page 17 EUROCONTROL

The Briefing Room

This article contains a brief summary of the full accident report, which may be viewed on the US National Transportation Safety Board (NTSB)

Factual Information

On 5th March 2000, at about 1811 local Descend 6,000 ft

time, Southwest Airlines flight 1455, a Minimum speed 230 kt
Boeing 737-300, overran the departure
end of RWY 8 after landing at Burbank
Airport, California (BUR). The aircraft
touched down at approximately 182 kt 6,000 ft
and about 20 seconds later, at approxi-
mately 32 kt, collided with a metal blast
fence and an airport perimeter wall. The
aircraft came to rest on a city street near a Cross Van Nuys at or above 3,000 ft
petrol station. 44 of the 142 persons on Clear visual approach RWY 08
board were injured and the aircraft was Descend 3,000
extensively damaged. Van Nuys
Apparently the takeoff and en route
portions of the flight to BUR were normal 220-230 kt
and uneventful. The flight crew was
advised by the terminal radar approach
control controller that the current ATIS At 18:08:19 the flight was cleared to “cross the speed was 180kt even though the
was information Papa and that they Van Nuys at or above three thousand, limit speed for this setting is 158kt.
should expect an ILS landing on RWY 8. cleared visual approach runway eight.”
This clearance effectively removed the For the last 35 seconds of the flight GPWS
When the aircraft was about 20 miles speed restriction and the captain then alerts were continuously broadcast, first
north of the outer marker at an altitude of commenced reducing speed. After the as “sink rate” and later switching to
about 8,000 ft, the controller instructed accident the captain stated that as the “whoop, whoop, pull up.”
the flight to turn left to a heading of 190° flight passed about 2 miles west of Van
and to descend to 6,000 ft. At 18:04:02, the Nuys at 3,000 ft at approximately 220 kt to The aircraft touched down with flaps
controller imposed a minimum speed 230 kt, he deployed the speed brakes. extended to 30° at about 182kt. Thrusts
restriction of 230 kt, apparently in order to reversers were deployed about 4 seconds
sequence the flight between two other Van Nuys VOR is north of the Outer Marker later and the captain braked hard before
flights. and about 6nm from touchdown. the aircraft had decelerated to 80kt. As
At 18:08:36, as the aircraft was descending the aircraft neared the end of the runway,
The first officer obtained information through about 3,800ft, the captain began the captain initiated a right turn.
Papa, and informed the captain that the turning to the left for the final approach.
target airspeed for the approach would The aircraft departed the right side of the
be 138 kt. The captain thereafter called for flaps and runway, penetrated a metal blast fence
landing gear to be lowered progressively and an airport perimeter wall, and came
Vectoring for the approach continued as he attempted to reduce the aircraft to a stop on a city street off the airport
with progressive descent clearances until speed and establish the aircraft on the ILS property. An emergency evacuation
18:07:43 when the aircraft was cleared to glide path. The first officer stated later ensued, and all crewmembers and pas-
3,000 ft. that the captain asked for 40° flap when sengers successfully exited the aircraft.

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January 2005 Page 18 EUROCONTROL

The Briefing Room


The speed throughout the approach was Further, the controller’s instruction to
high and was 182kt at touch down, “cross Van Nuys at or above three
compared with a target speed of 138kt. thousand” was ambiguous because the
The flight path angle during the Van Nuys VOR is not on the aircraft’s flight
approach was 7°, more than twice the path. This ambiguous clearance may have
standard flight path angle of 3°. The first caused the flight crew to delay descent
officer did not make any altitude callouts longer than necessary.
nor did he draw the captain’s attention to
the high speed and sink rate, as required In summary, the NTSB concluded that the
by Southwest Airlines SOPs. If he had actions of the controller positioned the
made these callouts, both he and the aircraft too fast, too high, and too close to
captain and might have been further the runway threshold to leave any safe
alerted to the fact that the aircraft’s air- options other than a go-around manoeu-
speed and sink rate were excessive. vre.

Because of the high speed and sink rate The NTSB determines the probable causes
the approach was unstabilised and the of this accident as follows:
aircraft was not in the proper position to
land; therefore, in accordance with “… the flight crew's excessive airspeed
Southwest Airlines SOPs, a go-around and flight path angle during the approach
manoeuvre should have been performed. and landing and its failure to abort the
Furthermore, the Flight Operations approach when stabilized approach crite-
Manual indicates that touchdown should ria were not met.
occur between 1,000ft and 1,500ft from
the landing threshold. The aircraft landed Contributing to the accident was the con-
about 2,150ft from the threshold, further troller's positioning of the aircraft in such
indicating that it was not in the proper a manner as to leave no safe options for
position to land. the flight crew other than a go-around
At 1804:02 the controller instructed the
flight to “maintain two thirty or greater Lessons Learned
‘till advised”. At 1808:19, the controller
issued a clearance to commence the RUNWAY EXCURSION - From several
approach, thereby cancelling the earlier safety occurrances we recommend:
speed assignment. At 1807:43, traffic con-
ditions no longer warranted the speed
limitation; cancelling the speed limitation z Controllers must recognise and
then would have permitted the captain to understand the pilots’ working envi
begin to reduce his speed about 37 ronments and constraints;
seconds sooner, thereby giving him more
time to properly execute his approach to z Controllers have a primary responsi-
land. bility for safety, therefore the requir-
ment to position aircraft so that a safe
The flight was given vectors that resulted approach and landing is possible is
in interception of the final approach overriding;
course about 8 nm west of the runway
threshold.This vector put the aircraft in an z Altitude or speed restrictions should
unfavourable position for final approach, be clear and unambiguous and must
complicated the flight crew’s approach be removed as soon as they cease to
planning and execution, and contributed be necessary.
to the unstabilised approach.

European Air Traffic Management - EATM

January 2005 Page 19 EUROCONTROL

The Briefing Room

The EUROCONTROL level Bust Toolkit contains much advice to help
reduce the threat of level busts

The Eurocontrol HEIDI* definition of a Lessons Learned

Level Bust is “any unauthorised deviation
of more than 300 ft from an ATC flight LEVEL BUST - From several safety
clearance”. In RVSM airspace this limit is occurrances we recommend:
reduced to 200 ft.
z Issue clearances in good time, if z Insist on full readback after issuing a
Level busts occur frequently throughout possible avoiding periods of high clearance - “Roger” is not a satisfacto-
the world, and may result in serious harm, pilot workload; ry alternative;
either from a mid-air collision or from
collision with the ground (controlled z Control the speed of transmission z Listen carefully to the read-back and
flight into terrain [CFIT]). Occasionally, a especially when pilots are unfamiliar correct any error or apparent misu-
rapid avoidance manoeuvre may be with the area or may have language derstanding of an instruction;
necessary, which may result in injuries to difficulties;
passengers, flight crewmembers, and z Do not use readback time to carry out
particularly to cabin crewmembers. z Take care not to clip transmissions; other tasks;

By definition, level busts are always the z Use standard phraseology to ensure z When circumstances permit, monitor
result of pilot action or incorrect action. clear and unambiguous pilot-con- the actions of aircraft after a clearance
However, the actions of ATCOs, and of ATM troller communications; has been passed, especially if there is
in general, can reduce or increase the reason to believe the clearance may
chances of a level bust occurring and can z Limit the number of items of infor- have been misunderstood;
have an important effect on the outcome. mation in a clearance to a maximum
of three; z Notify the pilots involved whenever
The EUROCONTROL Level Bust Toolkit† two aircraft with similar call-signs are
has been developed as a result of the z Never combine a frequency change on frequency—always report such
EUROCONTROL Level Bust Initiative. with any other clearance; occurrences and any confusion that
It contains much important information results;
and advice to help combat the level bust z Take care to avoid confusion between
threat. The following is a brief summary of different items of information, z If a blocked transmission is suspected,
advice for ATCOs. especially heading, speed and flight ensure that both aircraft retransmit
level; their messages and confirm carefully
that a clearance has not been taken
z Never omit call-signs in a by an aircraft for which it was not
transmission; intended;

* HEIDI—Harmonisation of European z Use of full call-signs reduces the z Do not issue avoiding action
Incident Definitions Initiative for ATM potential for call-sign confusion; following notification that an aircraft
is responding to a TCAS RA;
† The EUROCONTROL Level Bust Toolkit may z Take particular care when issuing a
be obtained on CD ROM by contacting the clearance to FL 100 or FL 110; z In an emergency, use clear and
Coordinator Safety Improvements Initiative, concise communications, allow the
Mr Tzvetomir Blajev, on tel: +32 (02) 729 z When two different languages are in pilots time and airspace to deal with
3965 fax: +32 (02) 729 9082 use on the same frequency, pilots the emergency, and when possible, who do not understand one language reduce distraction by clearing other
may lose situational awareness; aircraft from the frequency.

European Air Traffic Management - EATM

January 2005 Page 20 EUROCONTROL

The Briefing Room

The following reports were made by pilots and air traffic controllers and were published in recent editions of Feedback, the journal of the UK
Confidential Human Factors Incident Reporting Programme (CHIRP). Back numbers of Feedback may be viewed at
Where applicable, the editorial response that appeared in Feedback is shown after the incident report.
The items themselves are self-explanatory and require no additional editorial comment from HindSight. But ask yourself,“What action do we
take to prevent similar incidents happening at my location?” Pilots are certainly fallible but it is our job to help them avoid error. Are we doing
our best?

Changes to ATIS information are normally I think to myself, what would have hap- services to the airport.
broadcast or passed to aircraft in the pened if the weather had been such that
approach sequence as a matter of course. we couldn't have seen the other aircraft It is my belief that careful and particular
However, this is not always the case at ahead...?? attention must be given to the callsigns
some European destinations: that companies allocate at this airfield,
Feedback Issue 67 – Summer 2003 otherwise it would easily become a factor
in any future incident that may occur!
Pilot’s Report

Arriving at ### (N. European International FEWER AIRLINES - MORE Editorial response
Airport), weather CAVOK, at about
midnight UTC, the ATIS says Runway ## CALL SIGN CONFUSION More than 100 Mandatory Occurrence
Left is in use for Landing, Runway ## Right Reports relating to callsign confusion
for take-off. have been submitted this year. It is impor-
ATCO’s Comment tant that all incidents of this type that are
We set up for ## Left. Air Traffic barely assessed as being potentially dangerous
speak to us, just a couple of vectors from Unfortunately this is not the first time I've are reported to permit follow up action to
the STAR and then the instruction to: felt the need to report on the occurrence be taken, where this is deemed to be
'Report fully established on the ILS' (no of similar callsigns. Within the space of appropriate.
confirmation of runway included). ATC several days we've not only had several
adds that we are 'following a heavy at 7 similar callsign incidents but now a multi- Feedback Issue 67 – Summer 2003
miles'. We see the lights of the heavy and ple of similar callsigns together!
confirm we have him in sight, and a little
later confirm fully established on I work at LTCC providing radar services for
approach. Then we notice that the jumbo the London TMA airfields. The problem
we are following is on approach to the would seem to have arisen from the
Right runway. merger of the "low cost" airlines into two
big companies AAA and BBB.
We make an RTF call to check it is the Left
Runway for Landing: 'Negative, Runway Just this week we've seen AAA123/
##Right' (!!) I reply we will be reposition- BBB123 together, AAA5AB/BBB9AB also.
ing for ## Right, adding that the ATIS My colleague had four inbound aircraft at
reported landing Left, take off Right. the same time all displaying worryingly
similar callsigns, again from the same
We reposition visually on to the approach companies.
to the other runway, quickly re-setting the
navaids in case of a go-round (the With the increasing levels of traffic, cou-
controller helps by passing the ILS pled with the complexity of airspace
frequency). around the airfields, there is very little
margin of error in providing air traffic

European Air Traffic Management - EATM

January 2005 Page 21 EUROCONTROL

The Briefing Room


Comment by Air Traffic Controller

The incidence of weather avoidance z Pilots to notify ATC as early as possible we thought we should hear, thus confus-
appears to be on the increase and this is of the need to turn and to request a ing heading and cleared level.
highlighting a concern that many of us heading, rather than "Request turn
working in the London TMA have started left/right twenty degrees" to assist As vulnerable as one can be on a
to see. the ATCO's tactical planning. new type, it could have happened on my
previous type (23 years 13,000hrs)
The "problem" is occurring AFTER aircraft z ATCOs to consider including the .
are clear of weather. Many flight crews are phrase "Report when clear" when Also, I had a good First Officer.
now taking it as their right to return to issuing the subsequent clearance to
whatever heading or navigation route change heading.
they were on before they requested a turn
for weather avoidance. Quite often this z Pilots to report "Clear" and maintain Editorial Response
occurs without telling ATC of the change heading until further cleared by ATC.
of course. This is a good example of how easily an
Feedback Issue 71 – Summer 2004 ATC instruction can be misinterpreted,
It is the considered view of the controller when it sounds similar to one that you are
that any heading given for weather expecting.
avoidance is a radar heading i.e. an
instruction to turn. MISHEARD CLEARANCE – In an attempt to reduce errors of this type,
NATS has mandated that when an ATC
In many cases there are two or more air- LEVEL BUST heading instruction ending in a zero is
craft in close proximity turning towards given the word "DEGREES" is to be added.
the same piece of "blue" sky, hence any Interestingly, current evidence is that
unexpected turn by an aircraft could have Pilot’s Report many pilots do not include this term in
serious separation consequences. their readback; it is recommended that
On arrival at AAA (a major UK airport), we this be done.
I wonder whether the higher authorities entered a hold at FL150 with approx
should clarify this to the flying communi- 30mins delay due to strong winds. In a situation like that reported, the impor-
ty - weather avoidance is an extreme Stepped down in the holding pattern tance of both pilots listening to ATC, and
situation for BOTH ATC and crew and 1000ft each hold (approx) i.e., 150, 140, also the clearance being read back to the
uncertainty like this needs to be removed. 130, 120, 110, 100, 90. ATCO to close the information loop is
We transferred to AAA Director at around
FL100. Next clearance understood as Feedback Issue 70 – Spring 2004
Editorial Response descend FL80 (next lower level). At or
near FL80 ATC ask if we have TURNED
There appears to be no 'best practice' onto heading 080!
guidance to either pilots or ATCOs for the
communication of weather avoidance Need I describe that dreadful feeling?
manoeuvres and, given the multiplicity of Mortified! I apologised on the RTF, ATC
circumstances faced by flight crews when responded, "No problem", gave updated
in the vicinity of adverse weather, simple heading and further descent. However,
guidelines might not be possible. AAA is not the place to be at the wrong
level and heading on a busy, rough
Notwithstanding this, the matter has Sunday night!
been referred to CAA (SRG) for considera-
tion, as the reporter suggests. Having given the incident much thought
in the days following the incident, I
In the absence of formal advice, the fol- believe that a major contributing factor
lowing might be of assistance in address- was the expectation, quite reasonably, of
ing the reporter's concern. further descent to FL80 and hearing what

European Air Traffic Management - EATM

January 2005 Page 22 EUROCONTROL



ACAS ............................... Airborne Collision Avoidance Systems
AIC ............................... Aeronautical Information Circular
AIRPROX ............................... Aircraft Proximity
ALAR ............................... Approach and Landing Accident Reduction
AMSL ............................... Above Mean Sea Level
ANSP ............................... Air Navigation Service Provider
ATC ............................... Air Traffic Control
ATCO ............................... Air Traffic Control Officer
ATIS ............................... Automated Terminal Information Service
ATM ............................... Air Transport Management
ATSU ............................... Air Traffic Service Unit
BEA ............................... French Accident Investigation Bureau
CAA(SRG)............................... Civil Aviation Authority (Safety Regulation Group) (UK)
CAS ............................... Controlled Airspace
CAT ............................... Clear Air Turbulence
CAVOK ............................... Cloud and Visibility OK
CB ............................... Cumulonimbus (cloud)
CFIT ............................... Controlled Flight Into Terrain
CHIRP ............................... Confidential Human Factors Incident Reporting Programme (UK)
DAP ............................... EUROCONTROL Directorate of ATM Programmes
DEP ............................... Departure Controller
DGAC ............................... French Civil Aviation Authority
DME ............................... Distance Measuring Equipment
EATM ............................... European Air Traffic Management
ECAC ............................... European Civil Aviation Conference
FAA ............................... Federal Aviation Administration (US)
FL ............................... Flight Level
FMS ............................... Flight Management System
FSA ............................... First Stop Altitude
FSF ............................... Flight Safety Foundation
ft ............................... Feet
GA ............................... General Aviation
GPS ............................... Global Positioning System
GPWS ............................... Ground Proximity Warning System
GRD ............................... Aerodrome Ground Controller
HEIDI ............................... Harmonisation of European Incident Definitions Initiative for ATM
I/R ............................... Instrument Rating
IATA ............................... International Air Transport Association
ICAO ............................... International Civil Aviation Organisation
ILS ............................... Instrument Landing System
INI ............................... Initial Approach Controller
JAA ............................... Joint Aviation Authorities

European Air Traffic Management - EATM

EUROCONTROL Page 23 January 2005


km ............................... Kilometre
kt ............................... Knot(s)
LARS ............................... Lower Airspace Radar Service
LTCC ............................... London Terminal Control Centre
m ............................... Metre
MDA ............................... Minimum Descent Altitude
NATS ............................... National Air Traffic Service (UK)
NOTAM ............................... Notice to Airmen
Nm ............................... Nautical Mile
NTSB ............................... National Transportation Safety Board (US)
The Southwest Airlines Boeing 737 which
PANS ............................... Procedures for Air Navigation Services overran the runway at Burbank California.
RA ............................... Resolution Advisory (ACAS) See page 18
RNAV ............................... Area Navigation
RTF ............................... Radio Telephony
RVR ............................... Runway Visual Range
RVSM ............................... Reduced Vertical Separation Minima
RWY ............................... Runway
SAF ............................... Safety Enhancement Business Division—a division of DAP
SID ............................... Standard Instrument Departure (Route)
SRC ............................... Safety Regulation Commission
SSAP ............................... Strategic Safety Action Plan
STAR ............................... Standard Terminal Arrival Route
TA ............................... Traffic Advisory (ACAS)
TCAS ............................... Traffic Alert and Collision Avoidance System
TOGA ............................... Take-Off/Go-Around
TMA ............................... Terminal Control Area
TRA ............................... Temporary Restricted Airspace
TSA ............................... Temporary Segregated Area
TWR ............................... Aerodrome Local (Tower) Controller
UTC ............................... Coordinated Universal Time
V1 ............................... Take-off Decision Speed
VFR ............................... Visual Flight Rules
VIP ............................... Very Important Person
VLA ............................... Very Large Aircraft
VOR ............................... Very High Frequency Omni-Range

European Air Traffic Management - EATM

EUROCONTROL Page 24 January 2005


Editor in Chief

z Tzvetomir Blajev

Editorial Secretary

z Ian Wigmore

Editorial Committee

z Dominique Van Damme

z Yvonne Page

z Jacques Beaufays

z Max Bezzina

z Alexander Krastev

z Gilles Le Galo

z Philip Marien

z Antoine Vidal

European Air Traffic Management - EATM

EUROCONTROL Page 25 January 2005


CONTACT The success of this publication depends

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European Air Traffic Management - EATM

EUROCONTROL Page 26 January 2005


DISCLAIMER © European Organisation for Safety of Air

Navigation (EUROCONTROL)
October 2004.

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, providing that
the copyright notice and disclaimer are

The information contained in this

document may not be modified without
prior permission from EUROCONTROL.

The views expressed in this document are

not necessarily those of EUROCONTROL.
EUROCONTROL makes no warranty, either
implied or expressed, for the information
contained in this document, neither does
it assume any legal liability or responsibil-
ity for the accuracy completeness and
usefulness of this information.

European Air Traffic Management - EATM

EUROCONTROL Page 27 January 2005

Putting Safety First in
Air Traffic Management

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