ASN Wikibase Occurrence # 180529
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| Date: | Saturday 15 November 2014 |
| Time: | |
| Type: |  ATR 72-500 (72-212A) |
| Owner/operator: | Flybe Nordic |
| Registration: | OH-ATP |
| MSN: | 1050 |
| Fatalities: | Fatalities: 0 / Occupants: |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Riga International Airport (RIX/EVRA) -
 Latvia
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Riga International Airport (RIX/EVRA) |
| Helsinki-Vantaa Airport (HEL/EFHK) | |
| Investigating agency: | TAIIB |
| Confidence Rating: |  Accident investigation report completed and information captured |
Flybe Nordic flight FCM72TX departed from Riga International Airport runway 18 on SID SOKVA 5E. The aircraft, an ATR-72, climbed to 4000 feet
with a rate of climb of 800 ft/min on true track 184 degrees. The crew then received a clearance to climb to FL190.
Meanwhile, Air Baltic flight BTI34H, a DHC-8-400, departed from the same runway on SID ERIVA 4E and began climbing to 4000 feet on true track 187 degrees. A further clearance was given to climb to FL170.
Initially after departure FCM72TX had high rate of climb but later the climb rate decreased. As a result the distance between both aircraft decreased and the Short Term Conflict Alert (STCA) signal triggered a warning about a potential conflict situation. The APP Controller, who was an instructor, tried to correct the potential conflict and stopped the climb of BTI34H at an altitude of 4000 feet. But due to late intervention and high rate of climb BTI34H stopped only at altitude 4400 feet. Notwithstanding that the SID's for traffic were on different directions, during the turn to the north the longitudinal separation betweeen FCM72TX and BTI34H decreased to less than 3NM and infringement of separation standards occurred. Horizontal distance between aircraft during the conflict was 2.7 NM, vertical 800 feet.
Causes
Proximate Cause:
The APP Controller-Student decision to clear succeeding aircraft BTI-34H to climb to FL170 without climb rate limit;
Root Cause:
The source or origin of an event that played the major role that caused this incident -infringement the separation minima between departing aircraft DH-8D and ATR-72-500 in the TMA was not strict complying the rules prescribed in the Approach Sector Operations Manual by the APP Controller-student, that lead to infringement of separation standards.
Contributing causes:
- Lack of Controller-student experience due to perform On-the-job training and starting initial phase of Practical Part, Sector Executive Position;
- Lack of procedures how to perform hand-over take over/take over of the position;
- Failure of the OJTI to communicate /coordinate Trainee actions in a timely manner;
- Late establishing first contact with APP controller after take-off to the contrary of requirements of the AIP Latvia.;
Primary cause:
The event after which incident became inevitable.
Decision of OJTI not to cancel wrong command by himself immediately upon recognizing students’ mistake- wrong command.
Sources:
Accident investigation:
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Images:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 19-Oct-2015 19:13 | harro | Added |
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