Jet2 B738 at Reus on May 12th 2019, TCAS RA during missed approach

Last Update: March 18, 2020 / 20:35:31 GMT/Zulu time

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Photo of Jet2.com G-GDFS, Boeing 737-800 — Jet2.com G-GDFS, Boeing 737-800 (Photo credit: Support your local Air Museum! (HawkeyeUK) / Flickr / License: CC by-sa)

Incident Facts

Date of incident
May 12, 2019

Classification
Incident

Airline
Jet2.com

Flight number
LS-929

Departure
Manchester, United Kingdom

Destination
Reus, Spain

Aircraft Registration
G-GDFS

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Jet2.com Boeing 737-800, registration G-GDFS performing flight LS-929 from Manchester,EN (UK) to Reus,SP (Spain) with 186 passengers and 6 crew, had gone around from about 1300 feet MSL while on approach to Reus' runway 25 and was performing a missed approach similiar to the missed approach procedures defined in VOR/DME or ILS Z approaches. The aircraft climbed to 4000 feet and was inbound to the RES VOR when the crew received a TCAS resolution advisory and complied with the resolution advisory. The aircraft subsequently positioned for another approach to runway 25 and landed safely about 20 minutes after the go around and about 10 minutes after the TCAS RA.

Spain's CIAIAC reported a private aircraft, a Diamond DA20, had entered the control zone of Reuss and had been instructed to maintain 3500 feet or above due to an exhibition of aerobatic flights in the Tarragona (Reus) area. The trajectories of the DA20 and the B738 converged, the crew of the Boeing received a TCAS RA and complied performing the evasive maneouver. The separation between the two aircraft reduced to 100 feet vertical and 0.9nm horizontal. The occurrence is being investigated by the CIAIAC.

On Mar 18th 2020 the CIAIAC released their final report concluding the probable cause of the serious incident was:

The investigation has determined that this incident occurred because the controller under instruction and the instructor controller lost situational awareness of the traffic under their control.

The following factors contributed to the incident:

- Providing an inadequate clearance to the visual traffic EC-KMH, in terms of the altitude to maintain, as the lower clearance limit (3500 ft) conflicted with the ILS approach maneuver cleared to aircraft G-GDFS

- Not using the surveillance radar.

- The placement of the strips in the holder, as well as the use of various fixes (runway, pattern, approach), differed from those normally used by the instructor controller.

- AESA’s assignment, in coordination with ENAIRE, of an area very close to the Reus Airport for exhibition flights.

The CIAIAC summarized the sequence of events:

On Sunday, 12 May 2019, a Boeing 737-86N aircraft, registration G-GDFS, inbound from Manchester, was on approach to the Reus Airport. It had missed its previous landing maneuver and, at the time of the incident, it was on the outbound leg at 3800 ft in preparation to make a new ILS Y approach to runway 25. (The instrument approach chart published in the AIP states that the outbound leg should be flown descending from an altitude of 5000 ft to 3800 ft at DME mile 13 on the ILS. On the outbound leg, DME mile 13 on the ILS practically coincides with reporting point E).

The Diamond DA20-C1, registration EC-KMH, was preparing to enter the Reus Airport CTR via reporting point E. The visual approach chart published in the AIP states that arrivals via point E of the CTR must be made at a maximum altitude of 2000 ft; however, this aircraft had been instructed by the controller to maintain 3,500 ft or higher due to an aerobatic air show over Tarragona. At the time of the incident, the aircraft was flying at 3,800 ft.

The controller in the Reus control tower was receiving on-the-job instruction and was being supervised by the instructor controller. The instructor controller decided to set up the control tower radar to show only the Reus ATZ airspace since the Unit Training Plan states that the approach control service provided is procedural.

Neither the controller under instruction nor the instructor was aware of the potential conflict. The flight paths of both aircraft converged and G-GDFS received a TCAS RA, as a result of which it executed an avoidance maneuver that cleared the conflict.

The minimum horizontal distance between the two aircraft was 0.6 NM, and the vertical distance 200 ft.

There were no injuries and the aircraft were not damaged.

The CIAIAC analysed the controllers' actions:

The conflict was not identified by the controller under instruction or by the instructor controller, neither of whom reacted to it. In fact, before the conflict, no traffic information was provided to either of the two aircraft involved in this incident.

When the aircraft with callsign EXS929 informed him that there was an aircraft 200 ft below, the controller replied to stand by. In other words, the controller lacked the situational awareness needed to give the traffic an effective response.

Sixteen seconds later, when the crew of EXS929 told him they had started an avoidance maneuver, the controller instructed the other aircraft to descend to an altitude of 2000 ft, infringing the area reserved for the acrobatic air show that reached up to 3,300 feet, and informed EXS929 of the instruction given to the latter.

Although this instruction by the controller did not conflict with the TCAS resolution advisories, he did not follow the procedure established by ENAIRE for these situations, which calls for radio silence from ATC until the TCAS itself clears the conflict. Therefore, given the gravity of this event, it is recommended that ENAIRE provide refresher training to controllers at the unit on the procedure to follow in the event of a TCAS RA.