Aer Lingus A320 at Malaga on Nov 7th 2013, loss of separation with Piper

Last Update: September 16, 2015 / 14:54:54 GMT/Zulu time

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Incident Facts

Date of incident
Nov 7, 2013

Classification
Incident

Airline
Aer Lingus

Flight number
EI-583

Departure
Malaga, Spain

Destination
Dublin, Ireland

Aircraft Registration
EI-DEA

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A private Piper PA28 with two occupants had departed Malaga's runway 31. Shortly after an Aer Lingus Airbus A320-200, registration EI-DEA performing flight EI-583 from Malaga,SP (Spain) to Dublin (Ireland) with 149 passengers and 6 crew, departed from runway 31, too.

Spain's CIAIAC reported that both aircraft had been cleared for departure and were being vectored. Following the departure of the A320 the separation between the two aircraft progressively reduced reaching a minimum of 250 feet vertically at 0.6nm horizontally about 5nm from the aerodrome. When the Piper turned left by 30 degrees the Airbus "was overpassing it by its right".

After being clear of conflict both aircraft continued to their destinations for safe landings.

The CIAIAC have opened an investigation into the loss of separation.

11 days earlier another loss of separation occurred at Malaga, see Incident: TAP B190 at Malaga on Oct 27th 2013, near collision with private aircraft.

On Jan 12th 2015 Spain's CIAIAC reported in an interim report, that the final report is already being drafted, the investigation identified the non-adherence to procedures by tower and approach controllers as factor into the occurrence, research is still on going whether the recent introduction of new procedures had an influence into the occurrence. The CIAIAC reported that the Piper had been cleared for takeoff from runway 31, 57 seconds later the aircraft began its departure roll and was handed off to Malaga Approach. 2:47 after the Piper began the departure roll the Aer Lingus A320 received takeoff clearance from runway 31 and was handed off to Malaga Approach. While following vectors issued by approach separation between the aircraft reduced to 100 feet vertical and 0.6nm horizontal.

On Sep 16th 2015 Spain's CIAIAC released their final report in Spanish concluding the probable causes into the incident were:

The main cause of the incident was the non-adherence of the tower controller at Malaga with the procedures to apply separation between two departing aircraft, the second of which exceeded the performance of the aircraft ahead.

Following contributing factors are being considered:

- the disappearance of the tag and the flight progress strip of the first departure from the tower's radar console once the approach controller had accepted the hand off of the first aircraft
- the fact that the tower controller under supervision as well as the instructor did not detect the conflict, either by display of the radar screen or time elapsed between departures, as well as the fact that tower did not respond to calls by Malaga Approach to stop the climb of the second departure

The CIAIAC reported that at the time of occurrence the tower of Malaga was staffed by a trainee controller under supervision and the instructor.

The CIAIAC reported that the tower of Malaga cleared the PA28 for takeoff from runway 31 and handed the aircraft off to Malaga APP (handling departures, too), 2 minutes and 47 seconds later the A320 was cleared for takeoff from runway 31. However, due to the performance differences between the aircraft procedures required a minimum time of 5 minutes between the departures unless approach released the next departure.

The approach controller, after the A320 had become airborne, recognized the developing conflict, immediately instructed the PA28 to turn left pulling the aircraft off the standard instrument departure route, and repeatedly phoned Malaga tower to stop the climb of the A320, however, without response. The PA28 followed the instruction to turn left, however the separation between the aircraft eroded to 100 feet vertical and 0.6nm horizontally, when the PA28 was at 3300 feet MSL and the A320 had already climbed to 3400 feet MSL, both aircraft still in the initial climb.

The CIAIAC reported that the crew of the A320 observed the PA28 on their TCAS display and had visual contact with the aircraft. No TCAS traffic or resolution advisory activated. The crew advised tower that they had the aircraft in sight and were prepared to take an evasive maneouver to the right if necessary.

The CIAIAC analysed it is being understood that errors in the controller's training procedures were the cause of the loss of separation between the aircraft. However, the instructor should have recognized the conflict, had he adequately monitored the trainee controller, and should have coordinated the departure of both aircraft with the approach controller ensuring proper release of the second faster aircraft.

The CIAIAC analysed that the instruction to the PA28 to turn left was aimed to achieve maximum lateral separation possible after the approach controller had recognized the developing conflict. The lack of TCAS resolution advisory on board of the A320 supports the hypothesis that the instruction indeed managed to increase the separation as intended. However, the instruction caused the PA28 to leave the protected departure corridor and to fly below minimum safe altitude. The transcript revealed that the approach controller did not check with the PA28 prior to that instruction, whether the PA28 had the ground in sight and was able to maintain visual separation with terrain. The PA28 crew in post occurrence interviews stated that they did have the ground in sight and were able to maneouver clear of terrain visually.

The CIAIAC analysed that on the tower's radar console flight progress strips were electronically managed. The flight progress strips were removed from the console as soon as the next controller had assumed control of the aircraft. Malaga APP assumed control of the PA28 52 seconds prior to the A320 receiving takeoff clearance. At the same time the flight progress strip was removed from the screen, the tag indicating the PA28 aircraft on the radar display was also removed from the display. As immediate action the software of the system was modified to keep the flight progress strip and tag active for a minimum of 5 minutes after takeoff regardless of whether another controller already assumed control of the aircraft.

The CIAIAC analysed that both trainee and instructor obviously had forgotten the previous departure had been a light aircraft when they cleared the A320 for takeoff and a minimum of 5 minutes had to pass unless approach actively released the next departure. It was also obvious, that approach control had not activated the option "hold release".

The CIAIAC analysed that the A320 was handed off to approach 109 seconds after takeoff clearance, when the aircraft climbed through 1500 feet MSL at a climb rate 1000 fpm above and a ground speed of 100 knots above the PA28, 2.8nm behind the PA28. The A320 reported on approach 135 seconds after takeoff clearance. When approach finally managed to alert the tower of the pending conflict, the instructor took control of the frequency and instructed the A320 to stop the climb at 2500 feet, however, the aircraft had already been handed off and was no longer on frequency.
Incident Facts

Date of incident
Nov 7, 2013

Classification
Incident

Airline
Aer Lingus

Flight number
EI-583

Departure
Malaga, Spain

Destination
Dublin, Ireland

Aircraft Registration
EI-DEA

Aircraft Type
Airbus A320

ICAO Type Designator
A320

This article is published under license from Avherald.com. © of text by Avherald.com.
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