Canada A333 at Madrid on Jul 13th 2022, TCAS RA on final approach
Last Update: February 17, 2023 / 17:11:04 GMT/Zulu time
Date of incident
Jul 13, 2022
ICAO Type Designator
The Canadian TSB reported the aircraft was "landing runway 32L on short final at 1500ft when the crew received a TCAS RA to monitor vertical speed. They kicked off the autopilot and hand flew the descent when they were told by ATC about an aircraft heading towards them in the opposite direction. The crew reported missing the traffic by 200ft. No evasive maneuver reported and the aircraft landed safely."
On Oct 26th 2022 Spain's CIAIAC reported a military Cessna Citation 550 departed from runway 22 at Madrid's Torrejon Air Base. A loss of separation (no more specific information provided) between the Citation and the A333 on final approach to Barajas' runway 32L 5nm before the runway threshold occurred. The occurrence is being investigated by the CIAIAC.
On Feb 17th 2023 the CIAIAC released their final report concluding the probable cause of the incident was:
The investigation has determined that the loss of separation occurred as a result of a failure to adhere to the authorised departure procedures (SID NANDO 3H) by the crew of the military aircraft.
The CIAIAC stated: "At their closest point, the aircraft were separated by 400 ft vertically and 0.6 NM horizontally."
The CIAIAC analysed:
The fact that five control units were involved, two of them civilian (TWR LEMD and Madrid ACC with 2 sectors: LEMDAPN and LEMDEDN) and three military (LETO GCA, TLCL LETO and GND LETO) necessitates an analysis of the coordination between them.
On two occasions, the military LETO GCA controller coordinated with the civilian LEMDEDN controller to indicate that the two military aircraft would remain under their control in order to separate them from civilian traffic.
The crews of the two military aircraft were given the same instructions, i.e. to perform the NANDO3H departure and then to take a heading of 80º and climb to 8,000 ft.
The crew of the first military aircraft (not involved in the incident) proceeded as instructed, was transferred to GCA LETO and turned before reaching mile 2.5 DME of the TJZ VOR.
By contrast, the crew of the second aircraft did not follow these instructions and continued on the take-off heading, first crossing the runway 32 R localiser and then coming close to crossing the runway 32 L approach path, resulting in the loss of separation with the ACA824 aircraft positioned on the runway 32 L localiser.
At 11:02:32 h, the crew of the ORCA03D aircraft contacted the LEMDEDN controller to say that they had been assigned the NANDO3H departure, and the controller authorised them to climb to flight level FL 160. The crew requested that the instruction be repeated, but the LEMDEDN controller did not repeat the climb clearance, instructing them instead to turn to their left on a heading of 80º without requiring them to do so immediately and without traffic information.
This was probably the critical moment because everything seems to indicate that the ORCA03D crew not assimilating the take-off instructions they had given and failing to make the assigned turn.
For the DUNA95 aircraft (not involved in the incident), the LEMDEDN controller transmitted the coordination with the military LETO GCA controller to the LEMDAPN controller. However, as this did not happen for the ORCA03D aircraft, the LEMDAPN controller in charge of approaches probably wasn’t aware of the existence of the ORCA03D aircraft before the incident occurred.
Another relevant issue is that the ORCA3D aircraft was transferred directly by the LCL LETO tower controller to the LEMDEDN controller without the GCA LETO controller providing information on the heading and altitude previously agreed with the LEMDEDN controller.
This was the second critical moment; the lack of coordination between GCA LETO and LCL LETO led to the ORCA03D crew failing to follow the procedure that GCA LETO and LEMDDEN had agreed on, ultimately resulting in the loss of separation.
Both military units coordinated with LEMDDEN: LCL LETO to arrange that the ORCA3D aircraft would perform the SID NANDO3H, and GCA LETO to indicate that it would keep control of the aircraft and transfer it on a 080 heading and 8,000 ft. When GCA LETO called LCL LETO to coordinate the departure of the ORCA3D aircraft, their coordination was ineffective.
The ORDA03D crew continued on their take-off heading, did not follow the NANDO3H departure and did not turn to a heading of 80º as instructed by the LEMDEDN controller, who neglected to immediately provide the traffic information that would have helped the ORCA03D crew increase their situational awareness.
At 11:02:49 h, the LEMDAPN controller transferred the ACA824 aircraft to the tower local controller for runway 32 L, TWR LEMD LCL 32L.
At 11:03:07 h, the LEMDEDN controller called the LEMDAPN controller to say that he did not know what ORCA03D was doing and suggested that ACA824 be instructed to climb to prevent the two aircraft from getting any closer. LEMDAPN replied that the ACA824 aircraft was already in contact with the Madrid-Barajas tower controller.
At this point, the ORCA03D aircraft was climbing through 3,300 ft and turning to its left between the localisers for the two runways (32 R and 32 L) while the ACA824 aircraft was positioned on the localiser for runway 32 L, descending through 3,900 ft.
At 11:03:16 h, aircraft ACA824 reported to the LEMD LCL TWR controller for 32 L that it had traffic in sight, referring to the ORCA03D aircraft, with the distance between them being 2.3 NM and 200 ft on converging headings.
In the moments that followed, the ORCA03D aircraft continued to turn to its left, encroaching on the 32 R and 32 L runway localisers and decreasing the distance between the two aircraft both vertically and horizontally.
At 11:03:22, the distance between the aircraft was 1.4 NM horizontally, and they were at the same level. By 11:03:31, the distance had reduced to 0.6 NM horizontally and 400 ft vertically, this being the point of least separation.
At 11:03:34 h, after the loss of separation had occurred, the crew of the ORCA03D aircraft called the LEMDEDN controller to confirm the course they had been instructed to fly and were once again instructed to immediately turn to 80º and climb to flight level FL 160.
Subsequently, the LEMDEDN controller called the LCL LETO tower controller to ask what had happened with the ORCA03D aircraft. TWR LETO replied by asking if the aircraft was on their frequency and the LEMDEDN controller stated that it had crossed the runway 32 R localiser.
The LCL LETO tower controller replied that it had been pilot error.
At 11:04:29 h, the LEMDEDN controller cleared the crew of the ORCA3D aircraft to climb to flight level FL 160 but did not receive a response.
Almost one (1) minute later, at 11:05:12 h, the LEMDEDN controller contacted the ORCA03D crew to ask them why they had prolonged their initial heading to the point of crossing the localisers for both runways, and they replied that they had turned at 1 NM but that the aircraft’s turn radius was quite wide.
The respective internal investigations by ENAIRE and the Spanish Air and Space Force agreed that the loss of separation occurred because the crew of the ORCA03D military aircraft failed to comply with the instructions issued by the control services.
Aircraft Registration Data
Aircraft registration data reproduced and distributed with the permission of the Government of Canada.
Date of incident
Jul 13, 2022
ICAO Type Designator
This article is published under license from Avherald.com. © of text by Avherald.com.
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