Qantas A332 and Qantas A332 near Adelaide on Sep 20th 2013, loss of separation
Last Update: March 6, 2015 / 15:47:23 GMT/Zulu time
Incident Facts
Date of incident
Sep 20, 2013
Classification
Incident
Airline
Qantas
Flight number
QF-576
Departure
Perth, Australia
Destination
Sydney, Australia
Aircraft Registration
VH-EBS
Aircraft Type
Airbus A330-200
ICAO Type Designator
A332
A Qantas Airbus A330-200, registration VH-EBO performing flight QF-581 from Sydney,NS to Perth,WA (Australia), was enroute at FL380 westbound and about to reach a point 10nm west of Adelaide Airport,SA, when air traffic control cleared the flight to climb to FL400. ATC soon recognized the error, cancelled the clearance and instructed QF-581 to descend back to FL380. The aircraft had reached about FL383 in the meantime and descended back to FL380.
QF-576 received a TCAS resolution advisory to climb and reached at least FL392 before returning to FL390.
After being clear of conflict VH-EBO was cleared to FL400 again. Both aircraft reached their destinations for safe landings.
The Australian TSB opened an investigation into the occurrence rated a loss of separation reporting VH-EBS received a TCAS resolution advisory. The ATSB have not yet stated a remaining minimum separation. The ATSB rated the occurrence a serious incident and opened an investigation estimated to conclude in September 2014.
Radar data suggest minimum separation reduced to 700 feet vertical and 5.6nm lateral at 02:13:55Z.
On Oct 10th 2013 Australia's TSB reported in a first preliminary brief that VH-EBO reached a maximum of 38,350 feet on standard pressure setting, minimal vertical separation remained at 650 feet, at that point the aircraft were 4.1nm apart. The aircraft reached a minimum horizontal separation of 1.6nm at 870 feet vertical separation. While the crew of VH-EBS could see VH-EBO on their TCAS display and received TCAS traffic and resolution advisories, the crew of VH-EBO could not see VH-EBS on their TCAS display and did not receive any TCAS advisories. A preliminary check after arrival at Perth did not reveal any malfunction, the aircraft was released under minimum equipment list requirements without TCAS for the return flight. A further examination in Sydney revealed a malfunction between #2 transponder, TCAS computer and TCAS antenna. The crew of VH-EBS had acquired visual contact with VH-EBO before receiving a TCAS traffic advisory and saw the aircraft climbing. The crew of VH-EBO was not aware of the presence of VH-EBS, neither by seeing the aircraft on TCAS nor by establishing visual contact.
The ATSB also stated in the first preliminary brief that the air traffic controller in question had monitored the outgoing controller in training for a while before taking the sector over when the aircraft were 140nm west and 80nm east of Adelaide. The sector west of Adelaide indicated they had no altitude restriction of VH-EBO. At that time VH-EBS was already on frequency. About 10 minutes after the controller took over VH-EBO reported on frequency and a minute later requested to climb to FL400 which was immediately approved by the controller. 24 seconds after VH-EBO began the climb the short term collision alert at the radar console activated prompting the controller to instruct VH-EBO to descend to FL380 again, which the crew complied with. Nonetheless, VH-EBS received a TCAS resolution advisory to climb and complied with.
On Mar 5th 2015 the ATSB released their final report concluding:
Contributing factors
- At least partly due to some task-related factors specific to this occasion, the controller did not assess the traffic for potential conflicts before issuing the climb instruction to the flight crew of VH-EBO.
Other factors that increased risk
- The traffic collision avoidance system in the A330 aircraft registered VH-EBO malfunctioned and did not provide the flight crew with traffic information or generate any safety alerts.
- The convergence of many published air routes overhead Adelaide, combined with the convergence point being positioned on the sector boundary of the Augusta and Tailem Bend sectors, reduced the separation assurance provided by strategically separated one-way air routes and increased the potential requirement for controller intervention to assure separation. [Safety issue]
Other findings
- The reason for the malfunction of the traffic collision avoidance system in the A330 aircraft registered VH-EBO could not be determined and the equipment manufacturer considered it to be a unique event.
Aircraft Registration Data
Incident Facts
Date of incident
Sep 20, 2013
Classification
Incident
Airline
Qantas
Flight number
QF-576
Departure
Perth, Australia
Destination
Sydney, Australia
Aircraft Registration
VH-EBS
Aircraft Type
Airbus A330-200
ICAO Type Designator
A332
This article is published under license from Avherald.com. © of text by Avherald.com.
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