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ASN Wikibase Occurrence # 196316
Last updated: 26 July 2017
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Date:26-AUG-2011
Time:13:55 UTC
Type:Silhouette image of generic AT43 model; specific model in this crash may look slightly different
ATR 42-320
Owner/operator:Avanti Air, opf Meridiana
Registration: D-BCRN
C/n / msn: 329
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Airplane damage: None
Category:Serious incident
Location:26 NM N of isola di Pantelleria -   Italy
Phase: En route
Nature:Domestic Scheduled Passenger
Departure airport:Pantelleria Airport (PNL/LICG)
Destination airport:Palermo-Punta Raisi Airport (PMO/LICJ)
Investigating agency: Agenzia Nazionale per la Sicurezza del Volo (ANSV)
Narrative:
An MD-82 (I-SMEZ) and an ATR-42 (D-BCRN) experienced a TCAS/RA alert while flying in opposite directions at the same altitude. Both crew followed the advisories.
The ATR-42 was operating flight ISS1834 on behalf of Meridiana from Pantelleria to Palermo, Sicily, Italy. At 13:37 UTC the Pantelleria Tower controller cleared the flight to climb to FL100, but this was read back as FL110. The controller did not notice this incorrect read-back.
Subsequently the Pantelleria Tower controller coordinated with Rome ACC (South Sector) and stated ISS1834 had been cleared to FL100.
At 13:50 the flight switched frequencies to Rome ACC (South Sector), and reported: "Rome good afternoon ISS1834, passing FL 7-2, climbing 1-1-0, inbound ROBET". Again, the error in the cleared altitude was not noticed by the controller.
At 13:52 another Meridiana flight, ISS1825 from Palermo to Pantelleria, was being cleared to descend to FL100 by the Rome ACC (South Sector) controller. This clearance was immediately corrected to FL110.
At 13:55:05 both aircraft were at FL110 in opposite directions with a separation of 4.55 NM. Then the TCAS system on both aircraft issued a Resolution Advisory. ISS1825 (MD-82 I-SMEZ) was instructed to descend and ISS1834 (ATR-42 D-BCRN) was instructed to climb.
Separation at 13:55:30 was 0.99 NM horizontal and 200 feet vertical. The vertical separation increased to 1200 feet and both aircraft were able to continue to their respective destinations.

Causes (translated from Italian):
The cause of event is attributable to human factors. The CTA TWR in Pantelleria and CTA EXE SUD of Rome ACC had the false assumption that ISS1834 was actually climbing for the authorized level of FL100, while it was evident that the crew of the flight in question was executing a maneuver to climb up to FL110. Such a false belief caused a lack of vigilance by CTA EXE SUD in the exercise of the radar surveillance, which did not allow a quick detection of a climb beyond authorized limits.

Sources:

ANSV


Revision history:

Date/timeContributorUpdates
24-Jun-2017 16:16 harro Added
24-Jun-2017 16:34 harro Updated [Narrative]

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