Western SF34 and private aircraft at Nassau on Sep 22nd 2018, near midair collision over runway, aircraft took off in opposite directions at the same time
Last Update: June 11, 2019 / 15:53:36 GMT/Zulu time
Incident Facts
Date of incident
Sep 22, 2018
Classification
Report
Airline
Western Air
Flight number
WST-701
Departure
Nassau, Bahamas
Destination
Freeport, Bahamas
Aircraft Registration
C6-KID
Aircraft Type
SAAB 340
ICAO Type Designator
SF34
About 6 seconds prior to issuing the takeoff clearance to WST-701 tower cleared a private Aztec aircraft for takeoff from runway 27. The crew however taxied their aircraft onto runway 32 and commenced takeoff becoming airborne prior to the Saab, a surveillance camera showed the aircraft half way between taxiways B and D at a height of about 50 feet when it came into sight of the camera. About 12 seconds later C6-KID was observed passing taxiway E, rotated just ahead of taxiway D. By the time C6-KID became airborne the Aztec had already left the camera view, the Saab passed underneath the Aztec.
Bahama's Air Accident Investigation Department (AAID) released their Short Investigation Final Report reporting it could not be determined what vertical separation existed between the two aircraft, however, both crews remained unaware of the proximity of the other aircraft. The AAID concluded the probable causes of the serious incident, a near midair collision, were:
The poor decision making exercised by the pilot of aircraft Aztec in not following directions issued by ATC, despite advising he understood the instructions given, has been determined as the probable cause of the near mid-air collision.
- Also contributing to this near mid-air collision was the actions of the air traffic controller by losing visual on the aircraft he issued instructions to, and the failure on the part of the crew of C6-KID for not observing that another aircraft was on the same runway at the same time before commencing their take-off roll.
- The AAID believes this loss of visual contact on the aircraft by the controller, may have been as a result of distraction due to the ongoing shift change at the time, and the fact that the controller was manning two separate radio frequencies3 during a time of high traffic volume, while using a system that required additional training and frequent data input so that all systems can function properly with adequate current information.
- The AAID also believes the failure to notice the aircraft by the crew of C6-KID may be the result of distractions or preoccupation with completing final checks while on the runway, before takeoff.
- Pilot training, qualification and air traffic controller training, licensing and record keeping practices has been investigated and while not directly contributing to the incident were noteworthy and required action.
Additional Findings of Significance
Air Traffic Controller
- Medical Certificate had expired
- ATC license was not issued
Bahamas Air Navigation Services Division
At the time of this incident and commencement of this investigation it was noted that BANSD had;
- No documented process to track medical status of Air Traffic Controllers
- No ATC personnel in possession of required ATC licenses.
- Several ATC personnel were operating without the required current medical certificates.
3 ATC management advised this practice is not unusual having one controller manning more than one frequency at a time.
However, the internal review conducted have concluded that this practice is unsafe (especially at periods of high traffic volume) and have made recommendations to address this unsafe condition.
NOTE: An Air Traffic Control license with associated endorsed ratings, as well as a current medical certificate is required by Bahamas Civil Aviation General Regulations (CAGR) Schedule 8, Subpart B and Subdivision IX, when exercising the privileges of any required certificate.
Pilot Aztec
- No record of required annual recurrent training as required by CAGR was documented.
Crew C6-KID
- Failed to observe other aircraft on the runway in time to abort. Possibly due to distractions or pilot duties, crew did not realize another aircraft was taking off toward them until it had passed directly overhead.
- Crew continued to their destination and only after returning did they advise they needed to be relieved of duty due to the near mid-air collision incident.
The AAID described the weather at the time of the occurrence: "The weather at Lynden Pindling Int’l Airport at the time of the occurrence was Visual Meteorological Conditions (VMC). Bahamas Meteorological Department METAR Report indicated that the wind direction was 090 degrees with speeds at 04 knots. Visibility was reported at 7 nautical miles (nm). Clouds were reported as scattered at 2,000 and 22,000 feet. Temperature was reported as 81°F and Dewpoint 73°F. Altimeter was reported as 29.98 inches of Mercury (“Hg)."
The AAID released following safety message:
Security video footage retrieved documented the takeoff and flight path of both aircraft. The exact takeoff point of the Aztec on Runway 32 was out of camera range and the aircraft came into view at approximately 50 feet above the runway heading northwest. C6-KID subsequently became airborne from Runway 14 at approximately Delta intersection, abeam the fire station. By the time C6-KID became airborne, the Aztec had already crossed over his path and was out of camera view.
While the incident investigated did not find that both aircraft were airborne at the same time that would create a conflict of a mid-air collision, the seriousness of two aircraft on opposite ends on the same runway, headed in opposite directions toward each other, cannot be understated.
While it was clear the pilot of the Aztec did not follow instructions as issued by ATC, and acknowledged by him, it is still incumbent on all pilots entering an active runway to be cognizant and vigilant of traffic that may be crossing a runway, exiting a runway or in this case departing from a runway.
It is recommended that all traffic entering an active runway ensure all required checks are done prior to lining up for takeoff or ensure one crewmember (if multi-crew operation) is always vigilant and looking outside.
Based on the investigation of this incident, it appears the crew of C6-KID may have been pre-occupied, possibly with before takeoff checks, or may have been distracted, for whatever reason, and not raising the alarm with ATC when the aircraft was lining up on the opposite end of the same runway and departing toward them.
The Aztec was airborne prior to the takeoff roll of C6-KID and therefore it is unlikely that the crew would not have seen the aircraft in time to abort the takeoff, had they been vigilant and focus was outside the aircraft once on the runway in position for takeoff.
Transcript of the incident reviewed confirmed the instructions issued by ATC for the Aztec to depart runway 27, the pilot acknowledged the instructions, but still failed to follow them and created a conflict that could have dire consequences had both aircraft become airborne at the same time, toward each other.
It is also recommended that greater vigilance be exercised by all ATC personnel when issuing instruction to aircraft while using simultaneous runways for departure or landings, to ensure aircraft are following instructions given. It is also recommended that BANSD either increase its manpower or institute a system whereby the workload is reduced for controllers or eliminate the dual positions or frequencies by a single controller during high traffic periods.
Incident Facts
Date of incident
Sep 22, 2018
Classification
Report
Airline
Western Air
Flight number
WST-701
Departure
Nassau, Bahamas
Destination
Freeport, Bahamas
Aircraft Registration
C6-KID
Aircraft Type
SAAB 340
ICAO Type Designator
SF34
This article is published under license from Avherald.com. © of text by Avherald.com.
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