Meridiana MD82 and Avanti AT42 near Pantelleria on Aug 26th 2011, loss of separation
Last Update: June 15, 2017 / 16:02:02 GMT/Zulu time
Incident Facts
Date of incident
Aug 26, 2011
Classification
Incident
Airline
Meridiana
Flight number
IG-1825
Departure
Palermo, Italy
Destination
Pantelleria, Italy
Aircraft Registration
I-SMEZ
Aircraft Type
McDonnell Douglas MD-82
ICAO Type Designator
MD82
An Avanti Air Avion de Transport Regional ATR-42-300, registration D-BCRN performing a charter flight from Pantelleria to Palermo (Italy), was departing Pantelleria and was cleared to and climbed towards FL110.
The Italian ANSV reported on Sep 6th 2011 that a loss of separation had occurred between the two aircraft about 4nm north of Pantelleria which was resolved by TCAS resolution advisories, an investigation has been opened.
On Oct 26th 2011 the German BFU reported that the minium separation between the aircraft on opposite tracks reduced to 200 feet vertical and 1nm horizontal.
On Jun 15th 2017 the ANSV released their brief final report in Italian in the middle of a lot of other general aviation final reports concluding on pages 4 and 5:
The cause of the event is to be attributed to human factors. The event was in fact triggered by the erroneous conviction of the tower of Pantelleria as well as the area center control of Rome, that D-BRCN would level off at FL100, when in fact the crew had read back their clearance to climb to FL110.
In addition to the false conviction Rome area control center added an oversight fault not detecting in time that D-BRCN had climbed above the cleared flight level.
The ANSV reported that TCAS resolution advisories activated in both aircraft, I-SMEZ was instructed to descend and D-BRCN was instructed to climb. The minimum separation between the aircraft reduced to 200 feet vertical and 0.99nm horizontal while both aircraft responded to their TCAS advisories, the aircraft subsequently passed each other with a lateral distance of 0.39nm.
The ANSV analysed that Pantelleria Tower did not pay attention to the readback by D-BRCN in identifying the incorrect readback by the crew, while on re-listening the tapes the controller immediately detected the false readback.
Conincidentally Rome Area Control had instructed I-SMEZ to descend to FL110, but received a read back of FL100 and corrected (correctly) to FL110.
However, when D-BRCN reported on the Area Control frequency reporting they were climbing to FL110 while climbing through FL094, the controller did not pick up on the false flight level reported and continued the conviction based on the previous coordination with tower, that the aircraft was at FL100. The controller did not detect the aircraft had climbed through FL100 until the aircraft levelled off at FL110 and then recognized the conflict of the two aircraft in opposite directions.
Incident Facts
Date of incident
Aug 26, 2011
Classification
Incident
Airline
Meridiana
Flight number
IG-1825
Departure
Palermo, Italy
Destination
Pantelleria, Italy
Aircraft Registration
I-SMEZ
Aircraft Type
McDonnell Douglas MD-82
ICAO Type Designator
MD82
This article is published under license from Avherald.com. © of text by Avherald.com.
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