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ASN Wikibase Occurrence # 216666
Last updated: 13 October 2020
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Date:02-OCT-2018
Time:14:57 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8AS (WL)
Owner/operator:Ryanair
Registration: EI-FRY
C/n / msn: 44750/6087
Fatalities:Fatalities: 0 / Occupants: 184
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:near Pamplona -   Spain
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Santiago de Compostela Airport (SCQ/LEST)
Destination airport:Palma de Mallorca Airport (PMI/LEPA)
Investigating agency: CIAIAC
Narrative:
On Tuesday, 2 October 2018 at 14:57:09, an aircraft proximity event occurred involving aircraft EI-FRY and EI-DWW as they were flying level at FL340. Both aircraft were in the airspace of Madrid ACC sector PAL, although one of them had been transferred 3 minutes earlier to adjacent sector ZGZ. This means that during the conflict, each aircraft was in radio contact with a different controller.
Aircraft 1, EI-FRY, callsign RYR55CB (FR724), was heading southeast en route from Santiago de Compostela (Spain) to Palma de Mallorca (Spain). Aircraft 2, EI-DWW, callsign FR1192, was heading northeast en route from Seville (Spain) to Toulouse (France).
Both aircraft were at the same flight level (FL340) on converging headings.
At 14:54:36, an Short Term Conflict Alert (STCA) alert should have appeared for the two aircraft. This alert, which is displayed about 2 minutes before the minimum required separation is breached, was not generated due to operational problems.
At 14:55:42 the Bordeaux ACC controller notified the PAL sector controller of the conflict between the two aircraft. Judging by his reply, the PAL controller had not detected it. At this time, the aircraft were still level at FL340 and 8.7 NM away. Immediately after finishing the conversation, the PAL controller called ZGZ to correct the situation. The ZGZ controller also had not identified it. The PAL controller said "Do you want me to lower my RYR (aircraft 1) to 33 (FL330) just in case?",to which the ZGZ controller replied: "Yes, please!"
The PAL controller then radioed aircraft 1: "Would you be so kind to descend to level 330 for a while? Iím afraid thereís some other traffic at 34 (FL340) by your right". This new cleared flight level was not entered into the label.
Just a few seconds later the ZGZ instructed aircraft 2 to "descend immediately level 320". The controller changed the label to reflect the new cleared level.
Aircraft 1 the contacted the PAL controller again, requesting confirmation of the instruction after seeing the other traffic descending on the TCAS display.
Both controllers then concluded they were both requesting their flights to descend. At that time, they were within 5 NM and 1000 ft, meaning the minimum separation was being violated.
A confusing situation developed in which both controllers then requested aircraft 1 and 2 to maintain FL340.
At 14:56:47 a TCAS Traffic Advisory (TA) appeared in aircraft 2. Separated at that time was 3.9 NM and 278 ft. Aircraft 2 acknowledged ATCís instruction to maintain FL340 while changing its selected flight level from FL320 to FL340. At 14:56:57, the controller informed the crew of the presence of traffic to the left, and the crew confirmed it had it on the TCAS.
As a result of the ATC instructions issued at 14:56:41 and 14:56:46 to maintain FL340, aircraft 1 maintained its altitude and aircraft 2, which was descending, stopped doing so and began climbing again, reaching a positive climb rate of +544 fpm.
Their flight paths, which were once again converging, meant that 13 s after the TCAS TA was received, both TCAS Resolution Advisories (RA) were generated, at 14:57:00, which remained active for 43 s.
Aircraft 1 received a "CLIMB" RA, while aircraft 2 received a "DESCEND" RA.
At 14:57:09: the crew reported the TCAS RA to ATC just as the aircraft were at their closest point of approach: 2.3 NM and 334 ft.
After being clear of conflict, both flights were recleared to new altitudes and continued their respective flights.

Causes/Contributing factors:
The incident involving aircraft 1 (EI-FRY) and 2 (EI-DWW) was caused by the failure of the PAL sector controller to identify the conflict, and the subsequent transfer of aircraft 2 (EI-DWW) to the adjacent sector, ZGZ, without being clear of the conflict. Contributing to the incident is the improper handling of the conflict by the controllers in both sectors, who issued similar instructions to the two aircraft, contrary to what had been agreed previously.

Sources:

https://www.fomento.es/organos-colegiados/ciaiac/investigacion/2018/in-039-2018

Accident investigation:
cover
  
Investigating agency: CIAIAC
Status: Investigation completed
Duration: 1 year and 11 months
Download report: Final report


Images:

Photo of EI-FRY courtesy AirHistory.net


Edinburgh (EGPH / EDI)
18 November 2018; (c) Ian Howat


Figure: CIAIAC

Revision history:

Date/timeContributorUpdates
20-Sep-2020 17:49 harro Updated [Time, Total occupants, Narrative, Accident report, ]

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