Airprox Serious incident Embraer EMB-505 Phenom 300 CS-PHM, Friday 10 February 2023
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Date:Friday 10 February 2023
Time:14:27 LT
Type:Silhouette image of generic E55P model; specific model in this crash may look slightly different    
Embraer EMB-505 Phenom 300
Owner/operator:NetJets Europe
Registration: CS-PHM
MSN: 50500471
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:3 NM W of St. Gallen-Altenrhein -   Switzerland
Phase: Approach
Nature:Private
Departure airport:Bad Windsheim Airfield (EDQB)
Destination airport:St. Gallen-Altenrhein Airport (ACH/LSZR)
Investigating agency: STSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
An Embraer EMB-505 Phenom 300 (CS-PHM) and a Diamond DA 40 (HB-SHB) were involved in a serious airprox incident 3 NM west of St. Gallen-Altenrhein Airport.
The Phenom jet was on an instrument approach to runway 10 and the DA 40 aircraft had taken off from runway 28 under visual flight rules.

In Class D airspace, in which the aircraft were located, collision avoidance is fundamentally ensured by the principle of "see and avoid." The operational procedures applied at St. Gallen-Altenrhein (LSZR) can lead to conflict situations depending on the sequence of events between IFR approaches to runway 10 and aircraft taking off from runway 28 in the opposite direction. In this case, there was a potential conflict between the HB-SHB departing westward from runway 28 and the CS-PHM approaching runway 10.

After taking off, the pilot of the HB-SHB was absorbed with aircraft control procedures and continued to fly straight ahead, contrary to the procedures published on the visual flight chart, thus putting himself on a collision course with the oncoming Phenom jet, leading to an airprox. The fact that the pilot responded to the repeated calls of the air traffic controller (ATC) with only his call sign or not at all suggests a severely limited capacity to respond during this phase.

The crew of the CS-PHM was informed by the ATC about the aircraft taking off from runway 28. After sighting the other aircraft, they performed an evasive maneuver. Simultaneously, the TCAS (Traffic Collision Avoidance System) acted as a safety net as intended.

The serious incident, in which a single-engine aircraft flying by visual flight rules from runway 28 came dangerously close to a business travel aircraft approaching runway 10 by instrument flight rules, was caused by the pilot of the light aircraft maintaining his course after takeoff and not initiating a right turn into the cross-departure route as published.

The operational procedures applied at St. Gallen-Altenrhein (LSZR), which regularly lead to take-offs and landings in opposite directions, contributed to the occurrence of the serious incident and thus represent a safety deficit.

Accident investigation:
cover
  
Investigating agency: STSB
Report number: 
Status: Preliminary report
Duration: 1 year and 11 months
Download report: Preliminary report

Sources:

STSB

Revision history:

Date/timeContributorUpdates
01-May-2023 09:02 harro Added

Corrections or additions? ... Edit this accident description

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