SAX CRJ2 and SAA A320 at Port Elizabeth on Jul 10th 2014, ATC instructions and go-around lead to loss of separation
Last Update: April 13, 2015 / 20:51:59 GMT/Zulu time
Incident Facts
Date of incident
Jul 10, 2014
Classification
Incident
Flight number
SA-1336
Departure
Durban, South Africa
Destination
Port Elizabeth, South Africa
Aircraft Registration
ZS-NMF
Aircraft Type
Canadair Corporate Jetliner
ICAO Type Designator
CRJ2
A SAA South African Airways Airbus A320-200, registration ZS-SZZ performing flight SA-410 from Port Elizabeth to Johannesburg (South Africa) with 133 passengers and 7 crew, not yet lined up received clearance for an immediate takeoff from runway 26 with the addition "no stopping on the runway".
The crew of the CRJ2 decided to initiate a go-around at 500 feet AGL offsetting their aircraft to the right of the runway.
The French BEA reported in their weekly bulletin released on Nov 12th 2014, that both aircraft received TCAS resolution advisories during the climb out.
After the conflict was resolved the A320 continued to Johannesburg for a landing without further incident, the CRJ2 positioned for another approach to Port Elizabeth and landed safely.
The French BEA added, that the occurrence has been rated a serious incident by South Africa's Accident Investigation Board, who have opened an investigation into the occurrence.
In Apr 2015 the SACAA released their final report reporting the minimum separation between the aircraft reduced to 263 feet vertical and 0.2nm horizontally concluding the probable cause of the serious incident was:
The controller did not effectively monitor the flight progress of the aircraft on final approach, which resulted in a loss in separation, resulting in evasive action being taken by the crew of EXY336.
The SACAA reported the controller issued an immediate takeoff clearance from runway 26, no stopping on runway, when the aircraft on final approach to runway 26 was 3nm before touch down. The controller advised the arriving aircraft "continue with the approach, landing assured".
Following an assessment 32 seconds later with the departing aircraft still on the runway the arriving crew decided that separation was insufficient and initiated a go-around, almost simultaneously tower instructed the crew to go around.
The SACAA stated in summarizing testimony by the first officer of SA-1336, pilot flying of arriving aircraft: "The PF stated that he had SAA410 in sight, which was approximately 5° to 10° to the left of them and slightly below them. He then banked the aircraft to the right, and at the same time the TCAS RA commanded a descent of approximately 1 000 feet/minute. Due to visual meteorological conditions (VMC) prevailing, the PF elected to continue with the right turn and not to directly follow the RA, which would have put the aircraft in close proximity to the ground with the possibility of an enhanced ground proximity warning system (EGPWS) activation. Having the traffic visual, the safer option was not to follow the RA. They then positioned the aircraft on a right downwind for runway 26."
The SACAA reported that a student controller was also at the control tower receiving training by the controller on duty. In addition a calibration flight was being performed at the aerodrome.
The SACAA analysed: "The controller workload was regarded as high from the time he commenced with duty. He became preoccupied (diverted attention) and in doing so he most probably did not monitor the aircraft on final approach effectively, resulting in a loss in separation between the approaching and the departing aircraft. It was noted that a period of thirty-two (32) seconds had passed between the controller telling the crew “continue approach landing assured” until he instructed them to perform a goaround. This indicates that in a short space of time, the status quo had changed significantly, which necessitated evasive action by the crew on final approach."
The SACAA released three safety recommendations requesting that a controller should not provide training while a calibration flight is in progress, that no training should be provided to controller unless 2 or more fully licensed controllers are on duty and to develop standards and recommended practise for ATC operation.
Incident Facts
Date of incident
Jul 10, 2014
Classification
Incident
Flight number
SA-1336
Departure
Durban, South Africa
Destination
Port Elizabeth, South Africa
Aircraft Registration
ZS-NMF
Aircraft Type
Canadair Corporate Jetliner
ICAO Type Designator
CRJ2
This article is published under license from Avherald.com. © of text by Avherald.com.
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