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ASN Wikibase Occurrence # 200977
Last updated: 19 November 2017
This record is based on the official accident investigation report. It has been locked for editing.

Date:28-SEP-2016
Time:11:05 LT
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different
Boeing 737-4Q8
Owner/operator:Enter Air
Registration: SP-ENA
C/n / msn: 26320/2563
Fatalities:Fatalities: 0 / Occupants: 6
Other fatalities:0
Airplane damage: None
Category:Incident
Location:near Girona-Costa Brava Airport (GRO/LEGE) -   Spain
Phase: Approach
Nature:Ferry/positioning
Departure airport:Warszawa-Frédéric Chopin Airport (WAW/EPWA)
Destination airport:Girona-Costa Brava Airport (GRO/LEGE)
Investigating agency: CIAIAC
Narrative:
A Boeing 737-400 registration SP-ENA, operated by Enter Air, was making a flight with callsign ENT1237 from the Warsaw-Chopin Airport (Poland) to the Girona Airport (Spain). A Cessna 172 aircraft, registration EC-JOB, operated by Barcelona Flight School, was on an instruction flight from the Sabadell Airport (Spain) to the Girona Airport. Runway 02 was in use at the Girona Airport and the approach control service was being provided by the Barcelona ACC.
According to the information provided, the REDAN Air navigation data network went off-line at 10:44 hours local time for 26 minutes, which resulted in a loss of the Girona radar signal, of the communications between Girona Airport and the Barcelona ACC and of the SACTA system (Automated air traffic control system).
At 10:50, there was a configuration change at the Barcelona TMA, which went from a west to an east configuration. After this, a new control sector was opened, going from sector T1E to sectors D1E and TGR. The controllers in charge of T1E went on to handle D1E, and two new controllers went on duty, assigned to sector TGR.
At 10:59:23, aircraft EC-JOB was instructed by the D1E sector of the Barcelona ACC to make an approach to runway 02 at Girona without sector TGR being informed of the transfer of said traffic. Following this, at 11:00, the aircraft operated by Enter Air was cleared by the sector TGR controllers to make an approach to runway 02 at Girona. As a result, there was a loss of separation between the two aircraft at the intermediate fix of the TISGO approach. According to data from the radar track, the separation at the closest point of approach was 0.4 NM horizontally and 200 ft vertically, which caused a TCAS RA on the aircraft operated by Enter Air.
The two aircraft were in visual contact at all times. Aircraft EC-JOB made a 360º turn to the left and SP-ENA continued its approach and landed on runway 02.

Causes/contributing factors:
The main cause of the incident was the loss of situation awareness of the controllers in sectors D1E and TGR after the sectors were opened. Aircraft EC-JOB, which was inbound from the Calella VOR and should have been under the control of sector TGR, was cleared by sector D1E to complete its approach to runway 02 at the Girona Airport. After this, sector TGR instructed aircraft SP-ENA to also approach inbound from OKETA, which caused a loss of separation between the two aircraft in the vicinity of the intermediate approach fix TISGO.
The following factors contributed to the incident:
- Sectors were opened at a time when there was a high workload for the controllers in sector T1E.
- There were several aircraft doing aerial work, and when the TMA configuration change occurred, these aircraft conflicted with operations at LEBL, which forced the controllers in sector D1E to focus their attention on managing these aircraft, a task that was not properly coordinated with the newly-opened sector TGR.
- The temporary outage of the air navigation data network, which caused the radar display for traffic below 3200 ft to be lost, along with the updated flight plans and communications between LEGE and the Barcelona ACC, requiring the use of telephone communications. All of this contributed to having the sector TGR controllers focus their attention on determining the position of aircraft EC-GGF, inbound to LEGE. This, combined with the loss of coordination with sector D1E, made them become unaware of other traffic affecting them.

Sources:


Accident investigation:
cover
Investigating agency: CIAIAC
Status: Investigation completed
Duration: 1 year
Accident number: IN-038/2016
Download report: Final report

Revision history:

Date/timeContributorUpdates
05-Nov-2017 20:02 harro Added
05-Nov-2017 20:11 harro Updated [Source]