Fedex B752 at Tel Aviv on Jan 30th 2018, on final approach near collision with UN aircraft
Last Update: March 8, 2018 / 18:50:01 GMT/Zulu time
A Beech 200 King Air operated on behalf of the United Nations departed Tel Aviv Sde Dov Airport's runway 21 and was climbing out, but did not follow the assigned departure route and instead continued south.
As result the separation between the Beech 200 and the Boeing 757 reduced to about 200 feet vertical with no lateral separation. The Boeing went around, positioned for another approach and landed safely on runway 12 about 15 minutes later.
Israel's Ministry of Transport reported the closure speed of the two aircraft was about 700 kph (377 knots), the separation eroded to about 200 feet vertically. An investigation has been opened into the serious incident. The Beech 200 King Air was supposed to turn north immediately after becoming airborne and later turn south, however, continued south after becoming airborne and thus got into the final approach path of Ben Gurion's runway 12.
On Mar 7th 2018 Israel's AIAI released their final report in Hebrew (Editorial note: why does the AIAI not release their reports in English, also by recommendation of ICAO Annex 13, for the benefit of global aviation so that the same mistakes can be avoided all around the planet - the AIAI so far did not react/respond to repeated mails to that regard) reporting the minimum separation between the two aircraft reduced to 300 feet vertically and 0,4nm laterally and releasing following findings:
1. There was a critical misunderstanding by the crew departing in a visual departure of the design of the SDE Dov tracon area, which limited the height the aircraft was permitted to climb to in the area of the ILS approach path to Ben Gurion's runway 12. The crew misinterpreted the departure clearance as an unrestricted climb to 5000 feet MSL.
2. The departure clearance by SDE Dov was legal. The continued communication however contributed to the misinterpretation of their departure clearance by the crew.
3. The lack of briefing of SDE Dov's Air Space, the unique procedures and "arrangments" by the two pilots in the King Air, contributed to the incident. The issue was discussed with Israel's Ministry of Industry and Trade who implemented a binding requirement for authorization of pilots to operate in that air space.
4. The misunderstanding as well as the fact that the two aircraft were communicating on different frequencies with different air control units, created the conflict during which the King Air continued to climb in front of the Fedex 757 on a path nearly parallel and in opposite direction to the 757 while the separation reduced resulting in a TCAS Traffic Advisory followed by TCAS Resolution Advisories issued in both aircraft. Both flight crews established visual contact with each other.
5. The occurrence was correctly reported and rated as a serious incident due to the significant loss of separation between the two aircraft. However, considering the circumstances of the occurrence including visibility, TCAS Advisories and visual contact established between the flight crews, it became clear the actual risk of a collision was very low. Consequently the severity of the occurrence was reduced to incident.
Note: the image of an alleged evasive maneouver by the 757 shown by a flight radar site misled the media.
6. The existing procedures to coordinate between the air traffic control units together with the existing infrastructure contributed to delays in providing real time guidance and thus development of a situational awareness scenario. Lack of standardized phraseology may result in use of wording that can not be unambiguously interpreted and thus does not result in proper action.
7. A number of points in the departure procedure for SDE Dov need clarification and better definition. As a matter of fact the King Air crew used Jeppesen standard instrument departure charts that were not contained in the Israel Aircraft Information Bulletins.
The AIAI reported the King Air was cleared for the ADLOD ONE BRAVO departure, ATC applied an altitude restriction to 5000 feet (the chart is not included with the report, we include the chart current in March 2018 with our coverage). The general instructions' text of the March 2018 version of the SIDs (at the right hand side of the chart) reads for departure: "When accepting a visual departure, climb straight ahead, maintain VMC and own terrain separation until turning to YAMIT." The specific instruction for runway 21 at the bottom of the page reads: "Climb straight ahead, at 500 ft turn RIGHT to YAMIT.Remain below 1 000 ft until passing RDL 310 BGN northbound." The ADLOD 1B departure route requires to pass waypoint YAMIT at 3000 feet or above, waypoint MATRA at 5500 feet or above and waypoint KANER at 7000 feet or above.
The AIAI analysed that the height restrictions to turn right at 500 feet and to remain below 1000 feet until passing radial 310 of BGN VOR while tracking northbound are needed to maintain separation to landing traffic on Ben Gurion's runway 12 by providing a vertical separation of at least 1500 feet. The AIAI further analysed that the aircraft would remain with SDE Dov ATC until climbing through 2500 feet while about passing YAMIT waypoint and would only then be handed off to Ben Gurion control which assumes responsibility at 3000 feet MSL. The SDE Dov control zone is limited to 1200 feet MSL in the area underneath the approach path to runway 12 at Ben Gurion.
However, the King Air climbed straight on runway 21 heading through 1600 feet MSL before turning right towards YAMIT. At that time the Fedex 757 was maintaining 3000 feet while intercepting the glide slope for runway 12 at Ben Gurion. Just when the King Air climbed through 2000 feet the Fedex intercepted the glidepath and began their final descent towards runway 12. Ben Gurion Tower recognized the threat and instructed the 757 to go around. Both crews established visual contact with each other, the King Air continued their flight path and climb rate. TCAS Traffic Advisories followed by TCAS resolution advisories activated in both aircraft.
The sketch below shows the standard instrument departure flight path (green), the actual flight path flown by the King Air (gray) and the actual flight path of the B752 in red.
Aircraft Registration Data New!
This article is published under license from Avherald.com. © of text by Avherald.com.
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