Airprox Serious incident Boeing 737 MAX 8 A6-FME, Tuesday 9 January 2024
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Date:Tuesday 9 January 2024
Time:11:26
Type:Silhouette image of generic B38M model; specific model in this crash may look slightly different    
Boeing 737 MAX 8
Owner/operator:flydubai
Registration: A6-FME
MSN: 60970/6699
Year of manufacture:2017
Engine model:CFMI CFM LEAP-1B
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:near Colombo-Bandaranaike International Airport (CMB/VCBI) -   Sri Lanka
Phase: Initial climb
Nature:Passenger - Scheduled
Departure airport:Colombo-Bandaranaike International Airport (CMB/VCBI)
Destination airport:Malé-Velana International Airport (MLE/VRMM)
Investigating agency: CAASL
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A Boeing 737 MAX 8 (A6-FME) operating as flydubai flight FZ1026, a scheduled flight from Colombo, Sri Lanka to Malé, Maldives was issued clear instructions by Colombo Approach Control to follow the Standard Instrument Departure (SID) procedure. These instructions were communicated twice. The Pilot in Command of FZ1026 confirmed receipt of these instructions by reading back the clearance to the controller. However, the aircraft subsequently failed to comply with the vertical restrictions mandated by the SID, resulting in a reduced separation from another aircraft, SriLankan Airlines flight UL122, an Airbus A330-243 (4R-ALS) which was operating under Instrument Flight Rules (IFR) which had originated from Chennai, India to Colombo, Sri Lanka. As the loss of separation developed, the air traffic controller responded by providing traffic information to both aircraft. FZ1026 acknowledged the information; however, the aircraft had already
climbed to an altitude of 4,300 feet, triggering the Short-Term Conflict Alert (STCA) in the Air Traffic Management (ATM) system. At the same time, UL122 maintained an altitude of 5,000 feet marking the point where the separation breach occurred.

Causes
1. Pilot Non-Compliance: The failure of the PIC of FDB1026 to adhere to ATC instructions raises questions about decision-making authority and situational awareness in high-pressure environments. As outlined in aviation regulations, the PIC holds ultimate responsibility for flight safety and must comply with operational procedures unless safety dictates otherwise.
2. Judgmental Error- The perceived expectation of the ATC that FDB1026 would continue to adhere to the vertical profile of the SID, despite the data depicted on the actual vertical profile of the aircraft predicted otherwise. Further, expecting the required minimum separation would be achieved through the spatial profile displacement of the aircraft which would not warrant the ATC intervention to resolve.
3. ATC Communication Dynamics: The effectiveness of communication between ATC and pilots is crucial for maintaining safe separation. In this incident, distractions within the ATCenvironment have compromised the controller’s ability to manage traffic effectively.

Accident investigation:
cover
  
Investigating agency: CAASL
Report number: 
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report

Sources:

https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-airbus-a330-registered-4r-als-operated-by-srilankan-airlines-and-the-boeing-737-registered-a6-fme-operated-by-flydubai-on-09-01-2024-near-bandaranaike/
CAASL

Location

Revision history:

Date/timeContributorUpdates
28-Feb-2024 13:15 ASN Added
26-May-2024 06:02 Prometheus Updated [Operator, Location, ]
24-Feb-2025 10:37 Prometheus Updated [Phase, Source, Narrative, ]
24-Feb-2025 10:39 ASN Updated [Narrative, Accident report, ]
12-May-2025 07:46 Prometheus Updated [Location, ]
13-May-2025 11:47 Prometheus Updated [Location, ]

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