Jazz DH8A at Sault Ste Marie on Sep 3rd 2014, near collision with training aircraft

Last Update: October 19, 2015 / 15:08:48 GMT/Zulu time

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Incident Facts

Date of incident
Sep 3, 2014

Classification
Report

Flight number
QK-7794

Destination
Toronto, Canada

Aircraft Registration
C-GJMI

ICAO Type Designator
DH8A

A Jazz de Havilland Dash 8-100, registration C-GJMI performing flight QK-7794 from Sault Ste Marie,ON to Toronto,ON (Canada) with 34 passengers and 3 crew, was climbing through 4000 feet out of Sault Ste Marie's runway 22 being cleared to track direct to DARID waypoint, when the crew observed a light aircraft, later identified by the Canadian TSB as tailnumber C-FANU, about 1000 feet above them and about 3nm ahead. The captain, pilot flying, eased the climb and stopped the climb at 4500 feet, when the crew observed the light aircraft to enter a steep descending turn towards them. The captain banked the aircraft 30 degrees to the left in order to evade the pending collision, the separation reduced to 0 feet vertical and 350-450 feet of horizontal separation, the Dhas 8 passed to the right of the light aircraft Clear of conflict the Dash continued the climb and landed safely in Toronto, the light aircraft returned to the home base for a safe landing, too.

The Canadian TSB released their final report concluding the probable causes of the serious incident involving the risk of collision were:

- The altitude portion of the radar target representing C-FANU went unnoticed when the Toronto area control centre (CZYZ) controller cleared JZA7794 direct to the DARID intersection, possibly due to a combination of clutter between radar targets, dimness of display, and expectation of a lower altitude for the training aircraft.

- The conflicting traffic was not seen by the C-FANU flight crew during their visual scan prior to the spin, possibly due to its position below the aircraft nose or wing, or due to a lack of anticipation.

- The JZA7794 flight crew was unaware of the possibility that there were training aircraft in the vicinity and, lacking this information, had no reason to anticipate that the opposing traffic would initiate a rapidly descending turn. As a result, their initial action of levelling off the aircraft at 4500 feet was insufficient to resolve the risk of collision once C-FANU initiated the spin.

- The irregular flight path of the spin put the 2 aircraft on a collision course before an evasive turn by JZA7794 caused the aircraft to pass each other, separated by 350–450 feet laterally.

Findings as to risk

- If manoeuvres related to flight training take place in controlled airspace that is not specifically designated for such training or known to air traffic control, there is an increased risk of collision, as these types of manoeuvres can be difficult for controllers or the crews of conflicting traffic to anticipate.

C-FANU belongs to a flight school "Sault College", a student and a flight instructor were on board the aircraft. The student was to undergo lessons involving spin recovery. The aircraft therefore positioned to an area about 6-12nm south of Sault Ste Marie in an area that had been frequently used for such lessons, both student and instructor engaged in a lookout to verify they were not in conflict with any other traffic, the aircraft climbed to 5700 feet, both checked again that they were clear of conflict, the aircraft entered a spin, the student recovered the aircraft at 5000 feet. The student was to perform a second spin recovery, again both student pilot and instructor checked the airspace around them observing no other traffic, the aircraft climbed again and entered the second spin at 5200 feet MSL, the student recovered the aircraft at 4500 feet MSL. Just as the rotation stopped both student and flight instructor noticed the Dash 8 very close to them and the student banked sharply to the left.

The TSB wrote: "The large aircraft (JZA7794) passed to the right of C-FANU at the same altitude, separated laterally by approximately 350–450 feet."

The TSB described the events at Toronto Area Control Center (CZYZ) responsible for QK-7794 at the time:

At 1554:30, the crew of JZA7794 contacted CZYZ and stated that they were climbing through 2000 feet. Around this time, the controller was controlling 3 other IFR aircraft nearby in the sector. Noticing no imminent conflicts with these aircraft, the controller cleared JZA7794 direct to the DARID intersection and to continue a climb to FL210.

As JZA7794 turned toward DARID, the controller returned attention to ensuring that the other IFR targets did not conflict with this new flight path, and issued one minor adjustment to the flight path of an IFR aircraft 35 nm to the southeast, to ensure continued separation.

When the controller’s attention returned to JZA7794, it was noticed that the aircraft was no longer headed directly toward DARID but, rather, was in a left turn. Shortly thereafter, the JZA7794 flight crew informed the controller that the deviation was due to a TCAS RA.

The TSB annotated: "The CZYZ controller was used to seeing VFR targets surrounding CYAM and preferred to have the PPSs associated with these targets dimmed to the lowest available setting to ensure that the IFR PPSs stood out. In the controller’s experience, these VFR targets were most often at low altitudes (less than 5000 feet) and generally didn’t conflict with IFR traffic."

The airspace C-FANU operated in was a Class E airspace. The TSB stated: "In Class E airspace, ATC is required by regulation to provide separation between all IFR aircraft,9 and all IFR aircraft must have a clearance from the associated ATC unit to enter the airspace. There are no special entry or communication requirements for VFR aircraft in Class E, and no ATC separation is provided. ... The Air Traffic Control Manual of Operations (ATC MANOPS) requires that in Class E airspace, workload permitting, controllers provide traffic information to radar-identified IFR aircraft if the radar target appears likely to merge with another radar-observed target." The TSB stated, that the controller was in charge of 8 aircraft in his sector communicating with 4-5 of them at the time of the occurrence, the workload was considered light to moderate.

The TSB wrote: "Over the past 10 years, there have been several recorded risk-of-collision events near CYAM. A search of the Civil Aviation Daily Occurrence Reporting System (CADORS) identified 15 similar occurrences of TCAS RAs resulting from a risk of collision between an IFR and a VFR aircraft. At least 7 of those occurrences involved aircraft operated by Sault College."

The TSB analysed that there neither aircraft, crew qualification or weather contributed to the risk of collision and stated: "the analysis will focus on the underlying reasons why the crew of C-FANU was not aware of the traffic, why the initial action by JZA7794 was insufficient to avoid the conflict, and why the conflict situation was not recognized by the Toronto area control centre (CZYZ) controller."

The TSB analysed: "When C-FANU departed CYAM and cleared the control zone, its crew switched communications to the school’s dispatch frequency in order to monitor other school aircraft in the general area and ensure that their intentions didn’t conflict. Outside of the control zone, C-FANU entered Class E airspace, where there is no requirement to contact air traffic control (ATC)—in this case, Toronto area control centre (CZYZ)—or to monitor the frequency for instrument flight rules (IFR) traffic. As a result, the clearance issued by CZYZ to JZA7794 was not heard by the C-FANU flight crew. Hearing the clearance may have alerted C-FANU to the possible conflict. Given their experience with previously completing upper airwork in this area without conflict, the student and instructor did not anticipate spotting a departing IFR aircraft during their scan of traffic in the area prior to the spin. In preparation for the second spin, the student executed a climbing turn to scan for traffic and gain altitude. This would have placed C-FANU in a nose-high attitude, with JZA7794 approaching from below. As a result, the conflicting traffic was not seen by the C-FANU flight crew during their visual scan prior to the spin, possibly due to its position below the aircraft nose or wing, or due to a lack of anticipation."

The TSB continued analysis with respect to CZYZ: "When the controller issued the clearance to JZA7794, the radar target on the controller’s screen associated with C-FANU was directly in line between JZA7794 and DARID, and displayed an altitude of 5600 feet. The controller was familiar with seeing VFR targets in the area of CYAM, and was aware of the busy flight school in the area. In the controller’s experience, the targets in close proximity to the airport were much lower than 5000 feet. This expectation may have resulted in the aircraft target’s altitude going unnoticed. This may also have occurred due to the fact that the brightness of the target—and all other VFR targets—was set to the minimum setting, or potentially due to the clutter of the targets in the CYAM area, given the large scale of the display for the Sault Low sector."

With respect to the Dash the TSB analysed: "When the traffic alert and collision avoidance system (TCAS) on board JZA7794 initially alerted the flight crew to the traffic, the action taken to level off the aircraft and pass beneath C-FANU should have provided a safe margin, given that the traffic was also slightly to the right of their flight path. The flight crew was unaware of the possibility that there were training aircraft in the vicinity and, lacking this information, had no reason to anticipate that the opposing traffic would initiate a rapidly descending turn. As a result, their initial action of levelling off the aircraft at 4500 feet was insufficient to resolve the risk of collision once C-FANU initiated the spin. The irregular flight path of the spin put the 2 aircraft on a collision course before an evasive turn by JZA7794 caused the aircraft to pass each other, separated by 350–450 feet laterally."

The TSB reported that a number of safety actions were taken as result of the occurrence and investigation, Sault College notifying towers of intended spin works, the training area moved away from the arrival/departure pathes of the surrounding airports. In addition a request was filed to declare the now chosen training areas officially as training areas also on the aeronautics charts.
Incident Facts

Date of incident
Sep 3, 2014

Classification
Report

Flight number
QK-7794

Destination
Toronto, Canada

Aircraft Registration
C-GJMI

ICAO Type Designator
DH8A

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