Jet and Turkish Airlines 777 in 'near-miss' over London

[ba038]

A business jet came close to a mid-air collision with a Turkish Airlines passenger plane after taking off from London City Airport, a report has said.
The Air Accidents Investigation Branch (AAIB) study described the near-miss over London as a "serious incident".
The Citation 525 jet was about 100ft to 200ft below and half a mile away from the Boeing 777 passenger plane, heading to Heathrow with 232 people on board.
The near-miss happened on 27 July when both aircraft were at about 4,000ft.
The report said the control tower at London City Airport had cleared the German-owned business jet to climb to 3,000ft but when the flight crew acknowledged the instruction, they said they would be climbing to 4,000ft.
This instruction from the plane - a "readback" mistake - was not noticed by the controller at the tower, the AAIB said.
'Commands not followed'
Meanwhile, the Turkish flight had been cleared to descend to 4,000ft as it approached Heathrow Airport in west London.
If the planes had come close during bad weather "the only barrier to a potential mid-air collision" would have been built-in collision-avoidance systems as the aircraft would not have been able to see each other, the AAIB said.
But the report said that when the aircraft came close the Turkish flight crew had not "followed the commands" of three on-board collision-avoidance warnings and the Citation jet did not even have the equipment, known as TCAS II.
It was a pilot sitting on the observer seat of the passenger plane who saw the business jet, carrying two crew members and one passenger, "pass west of them at an estimated 100 to 200ft below", the report said.
In its account the Citation's captain said he had the passenger plane in sight "all the time" and at first thought his jet would be "well above" it.
The AAIB suggested authorities should consider making the TCAS II equipment mandatory for planes flying in the London area.



FULL REPORT - BBC News - Jet and Turkish Airlines 777 in 'near-miss' over London (http://www.bbc.co.uk/news/uk-england-london-11237496)

[AeroMad]

Just tried searching for the AAIB report on their website and I'm getting nothing. :confused:
Any idea where the Citation was going?

[stepwilk]

A "passenger plane," eh? Like those "fighter jets," as though there are "fighter props." I love it.

[A4]

I thought TCAS was mandatory? Or is the Citation too small :hmm:

Of course the bigger question is why the Turkish didn't "follow the commands" of its TCAS. Obviously the lessons of Uberlingen (sp?) have not been learned by everyone.

Controversial, and I've not read the report yet, and I appreciate the errors by the controller and Citation crew were the first two holes in the cheese .... but why are crews of a MAJOR airline still disregarding TCAS? I share this airspace with them - I expect them to abide by the rules.

Tin hat on.


A4

Ok, I've skimmed the report - not a nice scenario to be presented with. A "crossing descend" followed by "increase descent", followed by "climb" with a controller request thrown in for good measure but it does seem the increase descent was as a result of not following an initial TCAS instruction.

Link to report: Air Accidents Investigation: Citation 525, D-ITAN and Boeing 777 300ER, TC-JJA (http://www.aaib.gov.uk/publications/bulletins/september_2010/citation_525__d_itan_and_boeing_777_300er__tc_jja.cfm)

[potkettleblack]

Ok, I've skimmed the report - not a nice scenario to be presented with. A "crossing descend" followed by "increase descent", followed by "climb" with a controller request thrown in for good measure but it does seem the increase descent was as a result of not following an initial TCAS instruction.

Yep but yet again the fundamentals get missed.

"London, Turkish 1991 TCAS RA standby". Followed smartly by following the TCAS instructions.

Another Turkish training flight with an observer on the jumpseat and they are getting themselves into a pickle. The skipper must be Turkeys answer to Chuck Yeager to be in the LHS of a 777 and a TRI or TRE with only 4300hrs.

[infrequentflyer789]

Another Turkish training flight with an observer on the jumpseat and they are getting themselves into a pickle. The skipper must be Turkeys answer to Chuck Yeager to be in the LHS of a 777 and a TRI or TRE with only 4300hrs.

Think you've mis-read:

1) Citation 525, D-ITAN
2) Boeing 777 300ER, TC-JJA
[...]
1) 4,300 hours (of which 1,250 hours were on type)
Last 90 days - 60 hours
Last 28 days - 30 hours
2) Not known
Last 90 days - not known
Last 28 days - not known

So the worry now is not that the Turkish skipper is low hours, but that Turkish don't know how many hours... or they aren't co-operating with AAIB investigations. :confused:

[BOAC]

3300fpm with 1000' to go seems to be vastly excessive and poor airmanship. I assume the min climb gradient is required for noise/low level obstacles out of LCY?

Leaving aside the THY crew errors, I wonder what would have happened if they HAD followed the initial 'descend' RA - presumably the kit thought the Citation was going through their level (based on R of C) but in fact was apparently going to level off (quite a bunt I would have thought!).

Nearly a very big bang.:eek:

[Monde]

This happened over a year ago - its known as the D-ITAN incident.LCY SID's to change in the next couple of weeks as a result of this.

[DutchBird-757]

I believe this incident was the trigger for the 3000 feet cleared altitude seperate readback when you get your clearance from LCY ground. The procedure nowadays at LCY is that you get the clearance and read that back. Then you get your stop altitude and QNH and you have to read that back as well. Before this we'd never had this. It's on the plates anyway.

It's annoying for us regulars in LCY but I can totally see the point why they implemented this. Loads of business jets at LCY and you could be turning and nearly leveling off at 3000ft with LHR inbounds only 1000ft above. Sometimes quite impressive. The other week we ljust evelled off at 3000ft and had 2x A380's above us at 4000ft inbound for 27R at LHR. :ok:

[Shore Guy]

With "Enhanced Surveillance", doesn't the controller see the altitude set in the window?

[Weirdo Earthtorch]

With "Enhanced Surveillance", doesn't the controller see the altitude set in the window?

Usually, yes. However there are some types which do not or cannot downlink MCP-selected level. From the report:

There was no downlink from D-ITAN of the flight level selected on the autopilot and so the level-bust could not be anticipated by the controller. D-ITAN did not report on the Thames radar frequency until so close to the point of minimum separation that the controller did not have time to take effective action to resolve the situation.

[Cyrano]

A "passenger plane," eh? Like those "fighter jets," as though there are "fighter props." I love it.

Believe it or not, some planes don't carry passengers. They're called "cargo planes". I don't see any tautology in the term "passenger plane". ;)

[Telstar]

Airprox with 777 sparks London City procedure revision (http://www.flightglobal.com/articles/2010/09/09/347151/airprox-with-777-sparks-london-city-procedure-revision.html)

Airprox with 777 sparks London City procedure revision
By David Kaminski-Morrow

London City Airport has revised its procedures following a serious airprox incident involving a Turkish Airlines Boeing 777-300ER and an executive jet which mistakenly climbed above its cleared level on departure.

Investigators have highlighted 21 occasions in the past six years in which aircraft departing City have exceeded the 3,000ft altitude 'step' contained in the airport's standard outbound tracks - a third of them resulting in loss-of-separation events.

As a result of the incident with between the 777 and a Cessna Citation 525 jet, on 27 July last year, the UK's Air Accidents Investigation Branch recommended that the airport remove all 'step climb' procedures and, to avoid confusion, fix all departure tracks to terminate at 3,000ft.

New communications procedures have been implemented at City, the AAIB says, which are designed to ensure that crews understand the requirement to level off at 3,000ft.

In a statement London City's operator says that it has "thoroughly reviewed" the incident report and instigated procedural changes which "comply" with the AAIB's safety recommendations.

While the Citation had been cleared to climb to 3,000ft on departure, the crew erroneously read back a clearance to 4,000ft, which went uncorrected by air traffic control.

As the aircraft took off to the west, and turned north, it came into conflict with the 777 which had been cleared to turn south and descend also to 4,000ft.

While the 777's collision-avoidance system transmitted resolution advisories to descend, the crew "did not respond to [the advisories] in time to affect the geometry of the incident".

The AAIB stresses that, as a result, the conflict was not resolved by the collision-avoidance system, and has recommended that Turkish Airlines improve its training.

Investigators state that the aircraft were on a near-reciprocal heading, at about 0.5nm distance, with a vertical separation of 100-200ft. Weather conditions were clear enough to allow the Citation crew to obtain visual contact with the 777 and adjust the jet's flightpath to resolve the conflict.

[WHBM]

As one who lives pretty much underneath this point, and so observes things from the ground, I have a bit of an interest.

It's not only the LCY departures that have bust their level here; the last AAIB report I recall at the same point, it was the Heathrow arrival which had descended below their assigned level.

Don't think that going up at 3,300 fpm out of LCY is somehow necessary for obstacle clearance, there are plenty of F50s climbing much more sedately out of LCY which comply with the limits perfectly well.

I wonder why inbound Heathrows are sometimes descended to 4,000 feet at this exact point; again from observation they pass overhead at a range of heights, and why an extra 1,000 feet as a buffer cannot be allowed at this point I will leave for others to comment on. Certainly on the odd occasions when LCY is on easterlies and Heathrow is on westerlies, inbounds to LCY are turning finals over the Houses of Parliament at 3,000 feet, and the Heathrow inbound traffic is obviously all still at 4,000 or more, so quite why they have to be down to 4,000 some 6 miles to the east is something I would be interested to know the reason for.

Did I miss in the report that the LCY ATIS also emphasises the 3,000 feet limitation, or did this not get put on until after this incident ?

[Defruiter]

If City is on Easterlies, the City arrivals will be at 2000ft when turning finals, not 3.

[stepwilk]

"A passenger plane": Yes, I understand that there are aircraft that carry cargo, and even some that carry weapons, for that matter, but it's basically just that I have never, ever heard an actual pilot refer to an aircraft as "a passenger plane." In fact few pilots refer to an aircraft of any sort as "a plane," that being a carpenter's tool.

Ultimately, my gripe is having to wade through so much trash from simplayers and the people who at best ride in "passenger planes." There are plenty of enthusiast sites out there, and that's not what I come here for.

[Skipness One Echo]

Similar current thread here:
http://www.pprune.org/atc-issues/426875-heathrow-inbounds-descending-over-top-london-city-outbounds.html

Previous incident in the same area here :
http://www.pprune.org/tech-log/288199-near-miss-over-east-london.html

Forgive me but this airspace is as near as damn over my old home so I do have an interest, having watched this aerial ballet more than a few times. So many "planes".......

Anyhoo....for the educated non pilots who enjoy reading the boards, can someone give us top level explanation of what the new SIDs mean in practical terms and whether they are likely to solve this issue.

Given that the current procedure is :
SID clearnace delivery and readback
3000 ft climb limit and readback

What's the practical fix over and above this check I guess is my question?
Thanks

[fireflybob]

What's the practical fix over and above this check I guess is my question?

Ground all the a/c! You will never completely eliminate the possibility of human error. Make sure your procedures are as water tight as they can be and train pilots accordingly. The final line of defence is TCAS.

As regards rate of climb/descent most operators require max rate 1,000 ft a minute when within 1,000 ft of a cleared level to avoid nuisance TCAS alerts.

[JW411]

Rates of climb or descent in excess of 1,000 fpm or more during the last 1,000feet before assigned altitude/flight level either in the climb or descent was a mandatory SAFETY call from the PNF when I joined Laker at the end of 1978.

Needless to say, this was long before TCAS had even been invented.

Surely the 1,000 fpm safety call is still normal SOP?

It certainly was in every company that I ever worked for.

[Sable Knight]

Am i missing something here. The german business jet mis-read the flight level, the controller did not correct them. The German aircraft continued to climb beyond its assigned altitude. Yet we have having a bash at the Turkish pilot who was doing what he was suppose to.

Can someone correct me if i am being thick please

[BOAC]

Yet we have having a bash at the Turkish pilot who was doing what he was suppose to. - the comments have been that THY did not follow the initial RA.

[Locked door]

In fact the Turkish jet failed to respond to three RA's. The Citation didn't have TCAS so it was up to the Turkish to do the avoiding. Yes it was the final error in a list, but it's a biggie.

They lost a jet because the autothrottle failed, now they're not responding to RA's. Not impressive.

LD

[fireflybob]

Lots of holes in the Swiss cheese here methinks - a lucky escape for all. But one would expect professionals to respond to an RA.

[NigelOnDraft]

A lot of criticisms here (as usual :ugh: ) rather than saying "what can we learn" and "what can I now do to ensure this wouldn't happen to me"? For me:

The crew requested clearance to start engines from the Tower controller but were given both start and ATC clearances in the reply.We, and am sure other airlines, have strict rules about both pilots listening to, writing down, and checking the clearance. Some SOPs might get cut short, not this one by choice i.e. I doubt a P2 in my airlione would go and get the ATC Clnc when I was not aware. However, frequently one call to ATC and it is just given, unrequested, as here... So maybe one for ATCOs to think on?

faced a rapidly changing TCAS encounter with two RAs generated within six seconds and three in less than 10 secondsWhilst technically the crew did not follow the procedures here, it was a tough call IMHO. Training Flight, P2 handling, already half configured for landing, turning onto base, busy comms both ATC and in cockpit, and then 3 RAs, 2 trying to get a descent at low level. Can you really say a less than 100% correct response is "poor"? I reckon, not pre-warned / not in the Sim, a good % of crews would not have got it much more right :{ Particularly when it was a trainee as PF who maybe missed the initial RA, and the Capt had to take control to respond.

I remember doing a few Sims when I knew TCAS RAs were coming, and response from crews needing repeating. I don't remember any with 3 RAs in rapid succession, in the middle of RT calls and the intermediate approach.

Again, those who are firing criticism at the THY crew, maybe actually read the report His transmission and the subsequent reply from ATC were made at the same time as the first two RAs, which might have made the warnings more difficult to hear than otherwiseLesson to me seems TCAS is a great system, but it is still one part only of avoiding mid-airs. It did not resolve this airmiss for various reasons, and I think if replicated in future, the response could not be expected to be much better. So the more traditional means of avoiding midairs - clearances, RoC etc. still need careful adherence :ok: The number of P2s I fly with who disregard the RoC rule, and when challenged, point at the TCAS display and say "but there's nobody out there" :ugh: (which starts another topic)

NoD

[LayLoLay]

How does TCAS tackle the terrain?

If turkish was to follow the TCAS, started a steep descent, at the same time the other plane followed the ATC and descended back to 3000. As the turkish would already be in a descent would TCAS push him further down?

How for would this game continue and how far would a pilot follow TCAS descent with terrain?

What are the rules with ATC, non-TCAS aircraft and TCAS equipped aircraft that close to terrain?

[NigelOnDraft]

LayToLay

TCAS RAs in general are inhibited below ~1000R (the actual ruleset is quite complex), and become TAs.

Our QRH says to "respect GWPS warnings" during a TCAS RA, which to me seems sensible :ok:

That said, ~4000' over London in a widebody jet, low speed, half configured, I think it would be hard work to make oneself stuff the nose down to >2500'/m, almost certainly (but correctly) overspeeding the flaps in the process :confused: which will now set off various loud bells to add to the TCAS / ATC / Crew Comms / maybe GPWS symphony

NoD

[His dudeness]

Hmmm, as a german business jet pilot that visits LCY regularly, I´ve got to say I find it hard NOT to query the clearance to 4000ft - when you go upstairs to pay your fees and/or use the crewlounge, there is plenty of "avoid levelbusts" / "remember the stepped clib" / etc posters on the walls. Also LCY JetCentre sends out good info on the subject to all users.

Sometimes the handover to Thames is quite late and so the "gate" of the initial call with cleared level might not work always. If we go outta there, it usually comes together with level off and first turn...

Someone asked why some of us climb so hard when in LCY...most likely because we have been told of numerous noise monitoring stations. Thats what I try to avoid, getting a prob with these things (and adhere to climb gradient requirements of course)

[alpergokgoz]

here is the official interim report

http://www.aaib.gov.uk/cms_resources.cfm?file=/Citation%20525,%20D-ITAN%20and%20Boeing%20777%20300ER,%20TC-JJA%2009-10.pdf

[Globaliser]

Ultimately, my gripe is having to wade through so much trash from simplayers and the people who at best ride in "passenger planes." There are plenty of enthusiast sites out there, and that's not what I come here for.The phrase "passenger plane" was used by the BBC journalist who wrote the article quoted in the OP, so I think your gripe may be misplaced.here is the official interim reportI think that's the final report, already linked to in post #4 (http://www.pprune.org/rumours-news/426839-jet-turkish-airlines-777-near-miss-over-london.html#post5923550).