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ASN Wikibase Occurrence # 239132
Last updated: 30 November 2021
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Date:01-NOV-2018
Time:23:52 UTC
Type:Silhouette image of generic B788 model; specific model in this crash may look slightly different
Boeing 787-8 Dreamliner
Owner/operator:Royal Brunei Airlines
Registration: V8-DLB
MSN: 34786/130
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:position "D I Khan" (DI) -   Pakistan
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Bandar Seri Begawan-Brunei International Airport (BWN/WBSB)
Destination airport:London-Heathrow Airport (LHR/EGLL)
Investigating agency: CAA Pakistan
Narrative:
Turkish Airlines Flight THY714E (Airbus 330-300, TC-LOE) was involved in a serious airprox incident with
Royal Brunei Flight RBA003 (Boeing 787-8, V8-DLB) over Pakistan.
THY714E was maintaining FL390 and operating from Istanbul to Lahore on route N644/A466. At position D I Khan (DI) the aircraft requested descent clearance. The Area Radar Controller West cleared the flight down to FL370 and traffic information was given about Singapore Airline Flight SIA346 which was maintaining FL360.
The Area Radar Controller West subsequently realized that there was another potential conflict with reciprocal traffic at FL380: Royal Brunei Flight RBA003, operating from Brunei to London.

The controller tried to take evasive action by assigning radar vectors and headings to both flights, however both
THY714E and RBA003 already received Resolution Advisores from their Traffic Collision Avoidance Systems and initiated climb and descend respectively.
At the time of minimum vertical separation of about 300 ft, both aircraft were about 5 Nautical miles laterally separated. They crossed each other with a vertical separation of about 1500ft approximately, as both had initiated
TCAS–RA climb and descend respectively.

Cause(s) of Occurrence
1 Lack of situational awareness on part of Duty Air Traffic Controller (Area Radar Controller West) who missed out the immediate reciprocal traffic RBA003 (maintaining FL380) while issuing descent clearance to THY714E and putting more emphasis on another reciprocal traffic (SIA346 maintaining FL360). Whereas this was comparatively
at a larger distance than RBA003 and was not causing immediate concern.
2 Due to lack of situational awareness on part of Duty Air Traffic Controller (Area Radar Controller West) the recommended evasive maneuver was too late and incorrect.
3 Lack of coordination / assistance on the part of Duty Air Traffic Controller (Area Procedure Controller West) for not been able to anticipate the traffic conflict, contributed to the occurrence. This was because he was busy in coordination for another flight (ETD54N) diverting due to medical emergency.

Sources:

CAA Pakistan

Accident investigation:
cover
  
Investigating agency: CAA Pakistan
Status: Investigation completed
Duration: 1 year and 9 months
Download report: Final report


Images:

Photo of V8-DLB courtesy AirHistory.net


London - Heathrow (EGLL / LHR)
6 June 2019; (c) Streep

Revision history:

Date/timeContributorUpdates
05-Aug-2020 17:24 harro Added

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