Serious incident Diamond DA42 NG TwinStar A6-FTX,
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ASN Wikibase Occurrence # 224075
 
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Date:Monday 16 October 2017
Time:02:50 UTC
Type:Silhouette image of generic DA42 model; specific model in this crash may look slightly different    
Diamond DA42 NG TwinStar
Owner/operator:Etihad Flight College
Registration: A6-FTX
MSN: 42.363
Fatalities:Fatalities: 0 / Occupants: 2
Aircraft damage: None
Category:Serious incident
Location:3nm N of Al Ain International Airport -   United Arab Emirates
Phase: En route
Nature:Training
Departure airport:Al Ain Airport (AAN/OMAL)
Destination airport:Al Ain Airport (AAN/OMAL)
Investigating agency: GCAA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On 16 October 2017, Etihad Aviation Training (EAT) scheduled two aircraft with cadet pilots and instructor pilots to conduct training missions.
The first aircraft was a Diamond DA42, flight number EYT405, registration A6-FTX, which departed at approximately 00:29 UTC from runway 01, at Al Ain International Airport (OMAL). The DA42 training mission was to conduct instrument landing system (ILS), VOR approaches and missed approaches. Instructor pilot and cadet pilot were on-board. The other aircraft was an Embraer Phenom 100, registration A6-EFA, operating flight number EYT516. The aircraft departed at approximately 00:50 UTC from runway 01, at Al Ain International Airport (OMAL), with training mission to conduct ILS, VOR Z approaches, and missed approaches. Instructor pilot and two cadet pilot (one flying and second observer) were on-board.
Both aircraft were being flown by cadet pilots, the instructor pilots were the pilots monitoring (PM). After takeoff at 00:29 UTC, the DA42 was practicing IFR approaches including the published missed approach segments, which necessitated holding overhead Al Ain VOR/DME. At 02:39 UTC, during the final missed approach training, and while climbing at 2,500 feet, the pilot monitoring contacted Abu Dhabi Approach East (APPE) controller for the clearance to enter the hold, and the controller (ATCO) provided clearance to climb to 4,000 feet and enter the hold at ALN.
On the Phenom 100, which was also operating on the vicinity of the airport, the cadet pilot was the pilot flying. An additional cadet was at the time also observing the flight. While executing the first training task of the mission the cadet pilot, at 02:40 UTC, requested a missed approach after the execution of the approach as per the published procedures, and the APPE ATCO gave clearance and instructed the flight to descend according to the procedures, and to contact the Aerodrome Controller (ADC) at Al Ain Tower on radio frequency 119.85 MHz.
The Phenom 100 called the ADC at 6 nautical miles (NM) for a missed approach, and the ADC instructed to report at 3 NM DME runway 01. The Phenom 100 reported at 3 NM DME, and the ADC instructed to report going around. The Phenom 100 reported going around and the ADC acknowledged and transferred it to APPE.
After executing the missed approach, during climb at 3,700 feet at 02:46 UTC, the Phenom 100 instructor pilot reported to APPE that they are at 3,200 feet, and climbing to 5,000 feet.
The APPE ATCO instructed them to stop the climb at 3,000 feet, as there was company traffic at their 11 o’clock position at 4,000 feet in the hold ahead of them. The Phenom 100 instructor pilot announced that they are visual with traffic and he mentioned that he was in control of the aircraft and was executing a decent.
Meanwhile, the APPE ATCO contacted the DA42 and informed the crew that company traffic was passing behind them at 3,500 feet. The DA42 instructor pilot announced that the traffic was in sight and visual. The closest proximity of the two aircraft was less than 0.5 nautical miles (nm) lateral and 300 feet vertical. The Phenom 100 continued to climb straight ahead on the runway heading after passing the DA42 as per the requested radar vectors for the ILS RWY01. During this AIRPROX occurrence, a traffic collision avoidance system (TCAS) traffic advisory (TA) was displayed on the primary flight displays (PFD) of both aircraft. Simultaneously, the short-term conflict alert (STCA) activated on the APPE radar display.
Following the Incident, both aircraft continued on their intended training missions and later landed uneventfully.



Causes:
The Air Accident Investigation Sector determines that the cause of this AIRPROX Incident was the loss of minimum separation between the two aircraft, while following instructions provided by ATC.
Contributing factors to this Incident were:
(a) The LoA (letter of agreement) between APPE and OMAL does not contain clear instructions to manage IFR training flights nor does it state who was responsible for issuing the standard missed approach instructions.
(b) IFR arrivals and Phenom Jet trainer operations by Etihad Aviation Training was discussed exclusively in OMAL LATSI, Part 2, Section 1 – Unit Operation Procedures, but it was not mentioned in the APPE LATSI.
(c) The APPE ATCOs perception that the E50P flight was a VFR flight and not an IFR flight, which he interpreted to mean that the E50P would follow standard VFR missed approach instructions and he anticipated that the ADC would issue instructions (fly runway heading maintain A025), no coordination is required unless other than standard missed approach instructions are issued.
(d) The APPE ATCO did not notice that the E50P was an IFR flight, despite this information being correctly and clearly displayed on the Flight Strip for E50P

Accident investigation:
cover
  
Investigating agency: GCAA
Report number: 
Status: Investigation completed
Duration: 1 year and 6 months
Download report: Final report

Sources:

GCAA

Revision history:

Date/timeContributorUpdates
17-Apr-2019 09:37 harro Added

Corrections or additions? ... Edit this accident description

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