Ryanair B738 and Vueling A320 near Sevilla on Oct 30th 2014, near collision

Last Update: February 13, 2017 / 18:36:54 GMT/Zulu time

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Incident Facts

Date of incident
Oct 30, 2014

Classification
Incident

Cause
Near collision

Airline
Ryanair

Flight number
FR-2848

Departure
Shannon, Ireland

Destination
Malaga, Spain

Aircraft Registration
EI-EKS

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Ryanair Boeing 737-800, registration EI-EKS performing flight FR-2848 from Shannon (Ireland) to Malaga,SP (Spain) with 36 passengers and 7 crew, was descending towards Malaga in contact with Sevilla air traffic control and had been cleared to descend to FL150 at 2000 feet per minute or more.

A Vueling Airbus A320-200, registration EC-KCU performing flight VY-2226 from Barcelona,SP to Sevilla,SP (Spain) with 153 passengers and 6 crew, was descending towards Sevilla planning for an approach to runway 09. The crew noticed however that westerly winds prevailed and requested runway 27, which was approved by ATC. The aircraft was cleared to descend to FL170 at 2000 feet per minute or less.

On Jan 28th 2015 Spain's CIAIAC reported that the two aircraft were descending through FL220 when the separation between the aircraft reduced to 100 feet vertical and 1.4nm lateral and TCAS issued resolution advisories in both aircraft. The CIAIAC concluded their report: "The conflict was resolved satisfactorily."

The CIAIAC is investigating the occurrence.

On Dec 16th 2015 the CIAIAC reported in an interim statement (indicating the investigation is continuing), that for reasons unknown so far the Vueling crew did not follow the TCAS resolution advisory instructions ("Adjust Vertical Speed") until the TCAS reversed its instructions to "Climb! Climb now!", which was promptly followed by the crew. All factual information has already been compiled and is being analysed, in particular operational aspects as well as system properties of both TCAS and "automated air traffic control system" (SACTA) are being analysed.

On Feb 13th 2017 the CIAIAC released their final report in Spanish concluding the probable causes of the incident were:

the incident occurred because the crew of VLG-2226 failed to comply with the descent instructions by ATC. The crew was instructed to maintain a rate of descent of 2000 feet per minute or less, however, increased the rate which created a conflict with RYR314Q on a converging path, who were descending below and a rate of descent of 2000 fpm or more.

Contributing factors were:

- The controller instructed VLG-2226 to proceed direct to waypoint ROTAX adding, that speed restrictions were still in effect. This last part of the transmission was not read back nor did the controller require a read back.

- Subsequently the controller cleared the aircraft to descend to another flight level, however, without adding that the restriction on the rate of descent remained in effect. This led the crew to mistakenly select a higher rate of descent.

- The controller did not have a display of the rate of descents available on his screen and remained unaware that VLG-2226 did not comply with the restrictions on vertical speed

The incident was aggravated by following factors:

- the crew of VLG-2226 did not obey the TCAS resolution advisory "Adjust vertical speed, adjust" but increased the rate of descent instead of reducing it as required. It was not possible to determine whether this was an incorrect crew response or whether it was a fault in the VSI system displaying the TCAS indications.

- although the crew rest and activity times were in agreement with EU-OPS regulations and it has not been possible to demonstrate the crew was fatigued, it could not be ruled out that the crew was in a period of activity that adversely affected how they managed the situation.

The CIAIAC analysed that RYR314Q had been instructed to descend at 2000 fpm or more. VLG2226 was cleared to descend to FL250 at 2000 fpm or less. The instructions were transmitted in English so that both crews were able to understand and develop situational awareness. The instructions were legal although RYR314Q had not yet cleared FL250 by that time because the restrictions on the rate of descent would have ensured vertical separation at the crossing point. VLG2226 adopted a rate of descent at 1800 fpm.

About 40 seconds later the controller instructed VLG2226 to proceed directly to ROTAX stating that the speed restrictions remained in effect. The crew acknowledged direct to ROTAX but did not acknowledge the speed restrictions remaining in effect, the controller did not request that readback.

Shortly before reaching FL250 the vertical rate of VLG2226 changed to 2400 fpm, the crew reported they were levelling off at FL250. The controller in response cleared the flight to FL170, without mentioning any vertical speed restriction, and the crew selected a rate of descent of 5000 fpm. The vertical separation, which was 3600 feet at that point, began to erode.

According to regulations vertical speed restrictions remain in effect until lifted, hence VLG2226 should have continued to descend at 2000 fpm or less. However, upon issuing a clearance involving a different flight level/altitude the controller is supposed to re-iterate vertical speed restrictions in order to avoid misunderstandings or forgetfulness.

The controller received a prediction of conflict alert, the controller therefore issued a traffic information to VLG2226 indicating traffic 9nm ahead and 2000 feet below. At that point VLG2226 was descending at 4400 fpm which increased to 5025 fpm a few seconds later.

The controller did not have indications of the vertical speeds of either aircraft on his screen, hence it was difficult for him to find out which aircraft did not comply with the instructions.

A TCAS resolution advisory activated, VLG2226 issued "Monitor Vertical Speed" restricting the descent to 1000 fpm or less, the VSI was supposed to indication a green area for vertical speed of less than 1000 fpm descent and marking the area 1000 fpm descent to maximum descent red. The first officer, pilot flying, disengaged the autopilot and increased the descent. In interviews with the crew it was not possible to identify whether the crew misinterpreted the VSI display or whether the color markings on the display were reversed.

When the TCAS reversed its resolution advisory to "Climb! Climb Now!" both crew (dual input without one activating the priority button) pulled their sticks resulting in a vertical G-load of +2.03G. Dual input continued for about 10 seconds (no aural warning "dual input" occurred however). The descent was arrested at 21340 feet, the minium separation was found 100 feet vertical and 1.4nm horizontally. When VLG2226 climbed through FL220 TCAS announced "Clear of Conflict".

The CIAIAC analysed that Ryanair crew reported their TCAS RA as well as being clear of conflict, the Vueling crew however did not report the TCAS resolution advisory nor did the report when they were clear of conflict.

The CIAIAC therefore analysed that the performance of the crew did not adequately managed the resources, did not coordinate properly and did not correctly apply operator and manufacturer procedures. The crew was performing their 4th leg of the day, indicating the possibility of fatigue, and had already concluded 10:02 hours of activity with a total of activity at 10:42 hours for that day. The crew had not shown any deficiencies in cockpit resource management during previous simulator session.
Aircraft Registration Data
Registration mark
EI-EKS
Country of Registration
Ireland
Date of Registration
Iceebmfkeppbn Subscribe to unlock
Manufacturer
THE BOEING COMPANY
Aircraft Model / Type
BOEING 737-8AS
ICAO Aircraft Type
B738
Year of Manufacture
Pi A Subscribe to unlock
Serial Number
NkbdA Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
GA AA Subscribe to unlock
Engine Count
E Subscribe to unlock
Engine
Npdhk bcckcfihlmpingiih e Subscribe to unlock
Main Owner
DjhhcknpbhbehhAcjdjpc gAbj mAlpfmhfbnqiqfp Ajkpljcfjbqeblfgkfeeg Subscribe to unlock
Incident Facts

Date of incident
Oct 30, 2014

Classification
Incident

Cause
Near collision

Airline
Ryanair

Flight number
FR-2848

Departure
Shannon, Ireland

Destination
Malaga, Spain

Aircraft Registration
EI-EKS

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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