Assessment Summary Sheet for UKAB Meeting on 14Th Oct 2015

Assessment Summary Sheet for UKAB Meeting on 14th Oct 2015

Total Risk A Risk B Risk C Risk D Risk E 18 3 8 6 0 1

Aircraft 1 Aircraft 2 Airspace ICAO Airprox Cause (Type) (Type) (Class) Risk

Ikarus C42 Cessna 152 ATZ The C42 pilot flew into conflict 2015083 B (Civ Pte) (Civ Trg) (G) with the C152.

A late sighting by the C182 pilot and a non-sighting by the PA28 pilot. C182 PA28 London FIR 2015088 Contributory Factor: Oxford ATC C (Civ Trg) (Civ Pte) (G) did not give TI to the C182 pilot despite him being in receipt of a Traffic Service.

AA5 PA28 London FIR A late sighting by both pilots. 2015091 B (Civ Pte) (Civ Pte) (G)

C182 Eurofox London FIR A non-sighting by both pilots. 2015092 B (Civ Club) (Civ Pte) (G)

The ADC cleared the Gazelle pilot to depart into conflict with the over-shooting Tutor. Contributory Factor: The complex ATC circuit with multiple aircraft types and runways overloaded the Gazelle Tutor (A) Boscombe ATZ Tower controller. 2015093 A (MoD ATEC) (HQ Air Trg) (G) Recommendations: 1.HQ Air Command considers the value of having a Supervisor in both the VCR and the ACR. 2. HQ Air Command reviews the simultaneous use of both runways with inexperienced pilots.

Effectively a non-sighting by the Tornado Paramotor London FIR 2015098 Tornado crew and a non-sighting A (HQ Air Ops) (Civ Pte) (G) by the paramotor pilot.

Cabri G2 DR400 Leicester ATZ The DR400 pilot flew into conflict 2015099 B (Civ Trg) (Civ Club) (G) with the Cabri.

Coningsby ATC allowed the Tornado Sentinel Coningsby MATZ 2015100 Tornado to depart into conflict with C (HQ Air Ops) (HQ Air Ops) (G) the Sentinel.

The Tutor B pilot flew close Tutor (A) Tutor (B) London FIR 2015101 enough to cause the Tutor A pilot E (HQ Air Trg) (HQ Air Trg) (G) concern. Aircraft 1 Aircraft 2 Airspace ICAO Airprox Cause (Type) (Type) (Class) Risk

EC135 Cessna 172 FIR A late sighting by both pilots. 2015105 C (HEMS) (Civ Club) (G)

Tutor King Air Cranwell ATZ The student Tutor pilot turned into 2015107 B (HQ Air Trg) (HQ Air Trg) (G) conflict with the King Air.

B737 LBA CTR The drone was flown into conflict 2015109 Drone B (CAT) (D) with the B737.

The Tornado A pilot flew into conflict with Tornado B during the formation join. Tornado Tornado London FIR 2015110 Contributory Factor: The Tornado A (HQ Air Ops) (HQ Air Ops) (G) B pilot instructed Tornado A pilot to close up in conditions that were not suitable.

The Hawk B pilot flew close enough to Hawk A to cause its pilot concern. Contributory Factors: 1. Loss of Hawk Hawk LFA7 2015112 situational awareness by the C (HQ Air Trg) (HQ Air Trg) (G) Hawk B pilot. 2. The back-up deconfliction plan between Jester and Mustang was not robust enough.

The EC225 pilot was concerned by the proximity of the BA146. Contributory Factors: 1. Aberdeen did not give TI to the EC225 pilot EC225 BA146 Scottish FIR regarding the BA146. 2015116 C (Civ Comm) (Civ Comm) (G) 2. Aberdeen did not give TI to the BA146 pilot despite being aware of the proximity of the EC225. 3. The BA146 NOTAM did not provide useful information.

EC135 London FIR A conflict in Class G resolved by 2015120 Light Aircraft C (HEMS) (G) the EC135 pilot.

Non-sighting by the F15 pilot and SHK-1 Glider F15 London FIR/LFA7 2015123 effectively a non-sighting by the B (Civ Pte) (Foreign Mil) (G) glider pilot.

PA28 DA40 London FIR The PA28 pilot flew into conflict 2015125 B (Civ Pte) (Civ Trg) (G) with the DA40. AIRPROX REPORT No 2015083

Date: 8 Jun 2015 Time: 1105Z Position: 5153N 00210W Location: Gloucestershire Airport

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Ikarus C42 Cessna 152 Operator Civ Pte Civ Trg Airspace ATZ ATZ Class G G Rules VFR VFR Service Aerodrome Aerodrome Provider Gloucester Gloucester Altitude/FL 1100ft 1100ft Transponder A, C, S A,C Reported Colours White/red White/red/blue Lighting Strobe on Anti rudder collision/landing Conditions VMC VMC Visibility >10km N/K Altitude/FL 1300ft N/K Altimeter QFE (1031hPa) NK Heading 310° N/K Speed 80kt N/K ACAS/TAS Not fitted Not fitted Separation Reported 10ft V/<100 H N/K V/N/K H Recorded 0 V/<0.1nm H

THE IKARUS C-42 PILOT reports joining the Gloucestershire circuit via the overhead at 2200ft for a left-hand circuit for RWY04. He was aware that an aircraft had been told to abandon its approach because it had lined up on RW09 rather than RW04. After descending to 1300ft on the deadside and then turning to cross the upwind end of RW04, he saw a Cessna about 100 ft away, slightly lower but in a climbing attitude left to right. He banked steeply to the left and the Cessna passed down his right side underneath him.

He assessed the risk of collision as ‘High’.

THE CESSNA 152 PILOT reports being on a first solo cross-country flight. He joined the overhead for RW04 left hand and descended on the deadside. Unfortunately he became disorientated and lined up on final for RW09 rather than RW04. He discontinued the approach and climbed to 2000ft to reorientate himself and then reposition in the circuit for RW04. He did not see the other aircraft; therefore he did not have an assessment of risk.

THE GLOSTER CONTROLLER reports operating the circuit 04 left hand. The Ikarus C42 was joining deadside to join the circuit. The Cessna 152 pilot reported final RW04 to land. He noticed that the Cessna was lined up with RW09 so he instructed the pilot to go around as a helicopter was blocking that runway. The Cessna 152 pilot elected to climb back into the overhead rather than join downwind left hand. Traffic Information was given to both pilots.

He did not rate the risk of collision.

1 Airprox 2015083

Factual Background

The Gloucestershire weather at the time was:

EGBJ 081050Z 01007KT 9999 SCT040 16/05 Q1035

Analysis and Investigation

CAA ATSI

ATSI had access to both pilot reports, the controller report, the Swanwick Area Radar recording and recordings of the Gloster Tower and Approach frequencies. The C152 was a student pilot. The C42 was approaching Gloucester from the south. Both aircraft initially contacted Gloster Approach and received a Basic Service.

Just prior to the radio recording (which started at 1053:00) the C152 made contact with Gloster Approach on 128.55. At 1053:04 a Basic Service was agreed with the C152 and the pilot was advised that the runway had just changed to RW04 (from RW09). The C152 was cleared for a standard overhead join and told to report at 3nm from Gloucester.

At 1056:50 the C42 contacted Gloster Approach and a Basic Service was agreed. The C42 was cleared for a standard overhead join and told to report at 3nm from Gloucester. At 1059:30 the C152 reported 3nm and was instructed to contact Gloster Tower.

At 1100:18 the C152 contacted Gloster Tower and was instructed to report downwind left for RW04. The pilot replied “report downwind”. At 1100:31 the C42 reported at 4nm from Gloster and was instructed to contact Gloster Tower. At 1102:40 the C42 reported 2nm to run to the overhead and was instructed to join downwind left for RW04.

At 1102:52 the C152 pilot reported downwind and then, at 1103:58, reported finals. The controller then advised the C152 to Go-around because the pilot was on finals for RW09 and there was helicopter traffic in the circuit. The controller – knowing that the pilot was a student – offered the pilot a choice of returning to the overhead for a deadside join again, or positioning downwind for RW04. The pilot elected to climb back into the overhead. At 1104:47 the controller passed traffic information to the C42 about the C152. The C42 reported descending on the deadside. The controller immediately gave traffic information to the C152 about the C42.

CPA occurred between 1105:30 (Figure 1) and 1105:34 (Figure 2).

Figure 1 – (Swanwick MRT at 1105:30) The C152 was heading east and indicating 1000ft, the C42 was in a left turn and indicating 1200ft.

Airprox 2015083

Figure 2 - (Swanwick MRT 1105:34) The C152 was the easterly of the two contacts.

Aerodrome Control shall issue information and instructions to aircraft under its control to achieve a safe orderly and expeditious flow of air traffic….1 Aerodrome Control is not solely responsible for the prevention of collisions. Pilots and vehicle drivers must also fulfil their own responsibilities in accordance with the Rules of the Air.2

UKAB Secretariat

Both pilots shared an equal responsibility for not flying into such proximity as to create a collision hazard3. An aircraft operated on or in the vicinity of an aerodrome shall4:

(a) observe other aerodrome traffic for the purpose of avoiding collision; (b) conform with or avoid the pattern of traffic formed by other aircraft in operation;

Summary

An Airprox was reported on Monday 8th June 2015 when a Cessna 152 and an Ikarus C42 flew into proximity in the circuit at Gloucestershire Airport. Both aircraft were operating VFR in VMC under an Aerodrome Control Service from Gloucester Tower. The C152 was going around and climbing into the overhead having made an approach to RW09 by mistake; the C42 was approaching the upwind threshold whilst conducting an overhead join for RW04.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft, transcripts of the relevant RT frequencies, radar photographs/video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities.

The Board first turned their attention to the actions of the pilots concerned. They noted that the C152 pilot had joined the circuit from an overhead join just after the runways had been changed from 09 to 04. He was correctly using a ‘Student’ callsign to alert others of his status, and ATC were aware. Members commented that it was unfortunate that he made an error by positioning on final for the wrong runway, but they agreed that he complied quickly with ATC instructions to commence a go- around and, when given the choice, made a sound decision to climb back into the overhead and reorientate himself as to the runway layout of an airfield unfamiliar. GA members commented that at this stage the student would no doubt have been flustered, and they speculated that his lookout and

1 CAP 493 Section 2 Chapter 1 2.1 2 CAP 493 Section 2 Chapter 1 2.1(Note) 3 SERA 3205, Proximity. 4 SERA.3225, Operation on and in the vicinity of an aerodrome.

Airprox 2015083 ability to gain situational awareness from others making radio calls would no doubt have deteriorated as he concentrated on positioning himself correctly for the overhead and working out why he had made the mistake. They also commented that as he climbed out the C42, descending from his high 3 o’clock position would likely have been obscured by the high wing of his aircraft.

As for the Ikarus C42 pilot, several Board members commented that, although technically keeping to CAA guidelines regarding an overhead join, the track he had chosen to fly was a little tight and this would also have increased his rate of descent on the deadside, exacerbating the visibility problem for the C152 high-wing aircraft pilot. Members thought that, bearing in mind the C42 pilot had been told the Cessna was repositioning, it may have been more prudent to fly a wider pattern in order to give more time to spot the conflicting traffic. One Board member commented that the overhead join the C42 pilot had flown seemed more appropriate in its dimensions to RW09 than to RW04; they wondered whether the C42 pilot had also been somewhat caught out by the runway change and been forced into a tighter pattern than normal [Post Board comment: The C42 pilot commented that he was familiar with Gloucester, had been passed RW04 on joining and that the P2, also a pilot, had a flight guide open at the Gloucester entry. He also stated that, after consideration of events, he should have remained in the overhead, maintaining sight of the student pilot, until the student had at least positioned himself on the downwind for RW04. The C42 pilot noted that he had used precisely this technique at another airfield a few weeks after the Airprox event, keeping the other aircraft in sight and descending behind it].

Turning to ATC, members complimented the controller for giving the student pilot the option of turning downwind or climbing above the circuit to re-orientate himself. They also noted that Traffic Information had been given to both pilots by ATC, and so both were made aware of each other at an early juncture. They commented that it was unfortunate that the C42 had then tracked almost directly overhead the control tower thus obscuring the view of the controller and compromising any chance he might have had to provide further warnings to each pilot.

It was agreed that although both pilots shared an equal responsibility to avoid each other, the C42 pilot, who was joining the circuit, had a duty to integrate with those who were already established within. As a result, they determined that the cause of the incident had been that the Ikarus C42 pilot had flown into conflict with the C152. When considering the risk, it was agreed that action had been taken by the C42 pilot to avoid the aircraft colliding, but that safety margins had been much reduced below the normal.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The Ikarus C42 pilot flew into conflict with the C152.

Degree of Risk: B.

AIRPROX REPORT No 2015088

Date: 10 Jun 2015 Time: 1520Z Position: 5151N 00129W Location: 5nm W Oxford Airport

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft C182 PA28 Operator Civ Trg Civ Pte Airspace London FIR London FIR Class G G Rules IFR VFR Service Traffic Basic Provider Oxford Radar Brize Radar Altitude/FL 1900ft 2100ft Transponder A/C/S A/C/S Reported Colours White/maroon White/green Lighting HISL, strobe, Strobes, nav nav, landing, taxi Conditions VMC VMC Visibility >10km 20nm Altitude/FL 1900ft 2200ft Altimeter QNH NK (1030hPa) Heading 099° 180° Speed 100kt 115kt ACAS/TAS Not fitted Not fitted Separation Reported 100ft V/0.5nm H 200ftV/500m H Recorded 200ft V/0.2nm H

THE CESSNA 182 PILOT reports that he was performing an NDB DME 099 procedure at Oxford with an approach time of around 1515. They were in good VMC but under a Traffic Service for the instrument approach for RW01. The controllers were under a reasonably high workload vectoring an AirMed aircraft onto a final approach RW01 through Brize, and he found out later that they were also coordinating other instrument traffic from London. He had completed his base turn inbound on 099° and was just beginning the descent at around 1900ft on the QNH. It was at this point that they saw a PA28 in his 10 o’clock, 1nm, which flew straight across within 1nm of his path, at a very similar level, heading south into the Brize Zone. He did not report that he had taken any avoiding action, but he did comment that he passed just behind the other aircraft. He noted that he had just transferred from Radar to the Tower, which he opined was another possible reason why the controllers may not have been able to tell him about the other aircraft after they had switched frequency. They informed ATC of the aircraft, and they reported it to Radar. He had received no call that he could remember, and the radar controllers said they could not remember if they had given him the information due to the high workload and would have to listen to the RTF tapes to find out. They also mentioned that they had had no communication from Brize radar regarding the traffic. When they looked at the screen they believed the aircraft to be at 2000ft. The C182 pilot commented that there may have been a little confusion in the Oxford Controllers’ minds about whether he was on a Traffic or a Basic service because they had departed initially on a Traffic Service then ‘downgraded’ this to a Basic Service for a general handling phase of the flight before requesting a further Traffic Service as they headed back towards the OX NDB at a time when the controllers were handing over. He recalled he was given a reduced Traffic Service on entering the radar overhead so this may also have added to the issue. However, at the time of the incident he recalled being about 5nm to the west of the airport.

He assessed the risk of collision as ‘None’.

1 Airprox 2015088

THE PIPER PA28 PILOT reports that he was first alerted to the Airprox some 2 weeks after the event. He was flying more or less due south and routing via Popham’s overhead. He was on autopilot, linked to GPS, and maintaining a steady heading. It was a busy flying day with lots of aircraft around but excellent visibility; his front-seat passenger and he were keeping a good look-out. There were several encounters with other traffic on the day, although he did not consider any of them significant. His GPS log showed he held a steady altitude of around 2200ft for most of the journey, with a straight track between waypoints. He was receiving a Basic Service from Brize Radar. He did recall a Cessna type aircraft coming in at a similar altitude, or perhaps a little lower, on a converging course from his left at about his 9 o'clock (i.e. from the direction of Oxford). Even as he saw it, the aircraft’s pilot took avoiding action he thought, and turned sharply away. At the time he considered this was not an especially close encounter but was grateful for the positive avoiding response of the other pilot; he would have been ready to take action himself if necessary. He remembered thinking at the time that possibly this was a trainee pilot with an instructor out of Oxford, and that the instructor had taken control to make a positive response to the developing situation. He did not think anything more of it until he was advised about the Airprox. [UKAB Note: this sighting was in fact before the Airprox that was reported by the C182 pilot, and is likely to have been when they initially crossed over a minute or so prior.]

He assessed the risk of collision as ‘None’.

THE BRIZE ZONE CONTROLLER states that the Airprox was reported to him some time after the event and, as such, he had a very limited recollection. The aircraft that he was working was believed to be the subject PA28 because the pilot was on the frequency at the time of the reported Airprox, and his flight profile would place the aircraft in the correct location. The pilot was operating under a Basic Service and was given permission to transit Brize Norton Class D controlled airspace at 2200ft. The aircraft was displaying mode 3A and C. No conflicting Oxford traffic was observed or called to the PA28 pilot as far as he can remember. Nothing was declared on frequency by the aircraft’s pilot at the time. Traffic Information regarding the profile would have been available to adjacent units as the aircraft was displaying a BZN Zone transponder code. No such information was requested.

THE BRIZE SUPERVISOR stated that this Airprox has been brought to his attention a significant amount of time after the incident has taken place. He was unable to recall whether he witnessed the transit in question as nothing was reported on frequency or notified to him by the controller. He therefore had no further comment to add.

Factual Background

The Oxford weather was:

EGTK 101450Z 05014KT 020V080 9999 SCT038 15/07 Q1027=

Analysis and Investigation

CAA ATSI

ATSI had access to both pilot reports, the Swanwick Radar recording and recordings of the relevant radio frequencies. The C182 pilot had taken off from Oxford on a training flight. Initially the C182 pilot had departed to the east on a Traffic Service from Oxford Radar. After announcing an intention to carry out general manouevring to the east for approximately 10 minutes, the service was changed to a Basic Service. At 1459:10, the C182 (code 4506) pilot called Oxford for a rejoin to hold, followed by an instrument approach. A Traffic Service was agreed although the C182 pilot was advised that Traffic Information in the overhead would be limited. At 1515:10, the C182 pilot commenced an NDB/DME 099 approach which involved tracking to the west before making a base turn and returning to Oxford (Figure 1).

2 Airprox 2015088

Figure 1 NDB(L)/DME 099.

The PA28 was observed on radar approaching from the north indicating 2000ft (code 3702 – Brize Radar). At 1519:42, as the C182 pilot commenced the base turn (to the left), the C182 crossed the path of the PA28 from east to west at a range of approximately 0.5nm and 100ft below (Figure 2). [UKAB Note: this was probably when the PA28 pilot saw the C182].

Figure 2 (Swanwick MRT 1519:42).

At 1520:26 the C182 pilot reported base turn complete and was transferred to Oxford Tower. At 1520:45 the C182 pilot reported the PA28 to Oxford Tower.

At 1520:49 CPA occurred – 0.2nm and 200ft (Figure 3).

Figure 3 (Swanwick MRT at 1520:49).

No Traffic Information was passed to the C182 pilot and no coordination with Brize Radar took place. The controller at Oxford was under training and the workload was moderate to busy.

In relation to the provision of a Traffic Service, CAP493, Section 1, Chapter 12 states:

3 Airprox 2015088

‘A Traffic Service is a surveillance-based type of UK FIS where, in addition to the provisions of Basic Service, the controller provides specific surveillance-derived traffic information to assist the pilot in avoiding other traffic.

A controller shall pass traffic information on relevant traffic, and shall update the traffic information if it continues to constitute a definite hazard, or if requested by the pilot.

Traffic is normally considered to be relevant when, in the judgement of the controller, the conflicting aircraft’s observed trajectory indicates that it will pass within 3 NM and, where level information is available, 3,000 ft of the aircraft in receipt of the Traffic Service or its level-band if manoeuvring within a level block. However, the controller is not required to achieve defined de-confliction minima and pilots remain responsible for collision avoidance even when being provided with headings/levels by ATC.’

Military ATM

The Radar Analysis Cell captured the incident based upon the London QNH of 1026 hPa.

The PA28 pilot was provided with a Zone transit at 1518:41 with no altitude restriction. The geometry at Figure 4 at 1520:25 demonstrates that the Cessna 182 had previously crossed the path of the PA28 prior to turning left, closing the geometry with the PA28.

Figure 4: Geometry at 1520:25 (Cessna squawk 4506; PA28 squawk 3702).

The CPA was at 1520:42 (Figure 2) with 200ft vertical and 0.2nm horizontal separation.

Figure 5: CPA at 1520:42.

At 1521:15, Brize informed the PA28 pilot that he was entering Brize controlled airspace for a Radar Control Service, remaining VMC.

4 Airprox 2015088

No Traffic Information was provided by Brize; the PA28 pilot was placed on a discrete SSR code for the zone transit and, at the time of the Airprox, the aircraft was under a Basic Service. The PA28 was not fitted with ACAS/TAS so the remaining barrier to prevent an Airprox was the principle of ‘see-and-avoid’. The PA28 pilot had seen the Cessna and had noticed the pilot’s avoiding action [UKAB Note: but this was likely to have been on the first crossing of paths, not the reported Airprox]; the PA28 pilot felt that the separation distance was acceptable at this point in time and that he would have taken action himself had the other aircraft continued on a collision course.

UKAB Secretariat

Both pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard.1 Because the geometry was converging, the PA28 pilot was required to give way to the C182.2

Summary

The Airprox occurred in Class G airspace of the London FIR. At the time, the C182 pilot was in receipt of a Traffic Service from Oxford Radar and the PA28 pilot was in receipt of a Basic Service from Brize. Neither pilot received Traffic Information about the other aircraft. The PA28 pilot reported seeing a Cessna aircraft on a converging course from his left at about his 9 o'clock. The radar recordings show that the C182 did cross in front of the PA28 from left to right at a range of about 0.5nm. However, the actual Airprox occurred approximately one minute later, after the C182 pilot had made a turn back towards the airport, with a CPA of 0.2nm horizontally and 200ft vertically. The PA28 pilot did not report seeing the C182 at this time. The C182 pilot reported seeing the PA28 in his 10 o’clock, 1nm, which then flew straight across within 1nm of his path at a similar level.

PART B: SUMMARY OF THE BOARD’S DISCUSSIONS

Information available included reports from both pilots, the Brize controller, area radar and RTF recordings and reports from the appropriate ATC and operating authorities.

The Board was disappointed that the Oxford controller had been unable to file a report as he had been unaware, until about two weeks after the event, that an Airprox had been filed. They commented that this reinforced the need for pilots to notify ATC of Airprox incidents on the RT so that valuable information could be retained, and notes could be made by ATC (and the other pilot if on frequency), in order to assist in assessing the incident.

The Board first discussed the actions of the Oxford Radar controller. The Board noted that, although the controller had been providing a Traffic Service to the C182 pilot, Traffic Information had not been passed with regard to the presence of the PA28 despite it being present on the radar display and displaying a Brize SSR conspicuity code. In debating the reason for this absence of Traffic Information, members speculated that it would only likely have happened if the Oxford controller was not closely monitoring the C182; they noted that, leading up to the incident, the service being provided to the C182 pilot had changed from a Traffic Service to a Basic Service and then back to a Traffic Service, which had been restricted whilst the C182 had been in the Oxford overhead. Some members wondered whether these numerous changes of service had led to the controller losing track of what he was providing at the time, and mentally reverting to the application of a Basic Service which would not have required him to track the C182. The Board also noted that the Airprox had occurred when the C182 was 5nm west of the airport, which was judged to have been outside the radar overhead, and so the PA28 and the C182 tracks should have been visible; the CAA ATSI advisor confirmed that the recording of the Oxford radar had shown both aircraft at the time of the Airprox. Finally, although the Airprox occurred just after the C182 pilot had been transferred to the Tower frequency, Civil ATC members confirmed that it was still the Radar controller’s responsibility to

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way (c) (2) Converging.

5 Airprox 2015088 issue Traffic Information about conflicting traffic before transferring the C182 pilot to the Tower frequency.

The Board then discussed the actions of the Brize controller. Although recognising that the PA28 pilot had been in receipt of a Basic Service, some members wondered if the controller could have done more by passing Traffic Information to the pilot, or could have transferred him to Oxford’s frequency on noting that his routeing was taking him through Oxford’s instrument approach. The Board were informed that the Oxford approach track was not displayed on the Brize radar display, and so he would not necessarily have been aware that the PA28 was likely to fly through. The Military ATC member then went on to explain that, to assist the movement of traffic within the vicinity of Brize and Oxford, a Letter of Agreement (LOA) had been established , which was reviewed annually; this review had taken place about two months previously. He confirmed that, in accordance with the current LOA, it was Oxford’s responsibility to coordinate any traffic seen to be conflicting with their traffic. To assist Oxford ATC, pilots are instructed to squawk a Brize conspicuity code, and this had occurred on this occasion. He also considered that the option of transferring the pilot to the Oxford frequency was not practical because the aircraft had been about to enter the Brize CTR, where Brize would need to be in control of the PA28.

Some Board members wondered whether the PA28 pilot should have requested a Traffic Service, especially because his route would be taking him through an instrument approach to Oxford. A Civil Pilot member commented that it was equally possible that he had not realised that his flight would cross through the Oxford instrument procedure because it was not displayed on the CAA charts; the fact that it was not aligned with Oxford’s runways might have understandably meant that the PA28 pilot could have thought he was doing his best to avoid Oxford’s ATZ and instrument patterns when in fact he might be unaware that he was flying through one. Members recalled previous recommendations, both made in November 2014 (Airprox 2014097 and 2014126), that had called for the CAA to consider producing a chart of UK Airfield holding pattern positions, and expressed their concern that the recommendations had not been resolved to date. Ultimately, most members agreed that the pilot had been in communication with the correct ATC unit (Brize is notified as the LARS unit for the area), and had done all that was required of him in ATC terms given his likely knowledge of the airspace structure.

The Board then considered the cause of the Airprox. They noted that the tracks of the two aircraft had crossed twice. On the first occasion, approximately one minute before the Airprox had occurred, the pilot of the PA28 had seen the C182 pass ahead and turn away in what he had thought had been avoiding action; however, given that the C182 pilot did not report seeing the PA28 at this time, members opined that this was probably simply the C182 pilot following the instrument approach procedure’s left turn. After his turn back towards Oxford, the C182 pilot had then observed the PA28 crossing from left to right in close proximity. Although assessing the risk of a collision as none, the Board noted that he had nevertheless elected to file an Airprox report, and they wondered if he had done so as a result of being startled by suddenly seeing an aircraft when he would justifiably have expected to have been warned of any conflicting traffic under his agreed Traffic Service. The Board agreed that, although pilots in Class G are ultimately responsible for seeing and avoiding other traffic, the C182 pilot should have been assisted with Traffic Information from the Oxford controller before he changed frequency; although it was agreed that this lack of Traffic Information was a contributory factor, the root cause of the Airprox was, nevertheless, determined to be because of a late sighting by the C182 pilot and a non-sighting by the PA28 pilot. The C182 pilot’s own assessment of no risk, combined with the 200ft/0.2nm measured separation at CPA, led the Board to consider that here had, in the end, been little risk of collision, and that the risk should therefore be classified as Category C.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: A late sighting by the C182 pilot and a non-sighting by the PA28 pilot.

Contributory Factor: Oxford ATC did not give Traffic Information to the C182 pilot despite him being in receipt of a Traffic Service.

6 Airprox 2015088

Degree of Risk: C.

7 AIRPROX REPORT No 2015091

Date: 21 Jun 2015 Time: 1019Z Position: 5207N 00028E Location: 2nm W Stradishall

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft AA5 PA28 Operator Civ Pte Civ Pte Airspace London FIR London FIR Class G G Rules VFR VFR Service Basic NK Provider Cambridge App N/A Altitude/FL 2800ft 3000ft Transponder A, C, S A, C, S Reported Colours White/blue White/blue Lighting Strobe, beacon NK Conditions VMC VMC Visibility >20km >10km Altitude/FL 2700ft 3000ft Altimeter QNH (1015hPa) QNH (1015hPa) Heading 270° 130° Speed 110kt 110kt ACAS/TAS Not fitted Not fitted Separation Reported 200ft V/75m H NK Recorded 200ft V/0nm H

THE AA5 PILOT reports that shortly after making contact with Cambridge Approach and turning west, he scanned outside and noticed a white and blue PA28 at a range of ¼nm approaching on a closing course from the north, heading south. He assessed that there was a chance of collision so took avoiding action by diving. The other pilot appeared not to have seen him, since there was no indication of any deviation in the other aircraft’s course or level.

He assessed the risk of collision as ‘Medium’.

THE PA28 PILOT reports that he could not recall the exact circumstances of this event and assumed that the information given regarding the date, time and position was correct. He stated that he may have been receiving a Basic Service from Cambridge, or may have just left their frequency. However, he did remember a very late sighting of another aircraft ahead and slightly below that seemed to be already taking avoiding action. The PA28 pilot thought he turned slightly but he didn't consider there was any risk of collision.

He assessed the risk of collision as ‘None’.

THE CAMBRIDGE CONTROLLER was not informed of the Airprox and did not file a report.

Factual Background

The weather at Cambridge was recorded as follows:

METAR EGSC 211020Z 27011KT 240V320 9999 SCT035 17/11 Q1015

1 Airprox 2015091

Analysis and Investigation

CAA ATSI

ATSI had access to both pilot reports, the Swanwick Radar recording and recordings of the relevant radio frequencies.

 At 1006:05 the PA28 pilot had established communication with Cambridge Approach and a Basic Service was agreed. Surveillance services were not available as Cambridge were operating procedurally.  At 1015:40 the PA28 pilot reported east abeam Cambridge, as previously requested by Cambridge Approach.  At 1017:50 the AA5 pilot made contact with Cambridge and a Basic Service was agreed.  At 1018:55 the PA28 pilot advised leaving the frequency but did not state the next agency.  At 1019:14 CPA occurred. It was not possible to measure the horizontal distance between the aircraft – for reference the picture shows a 0.1nm line. The vertical distance was 200ft (see Figure 1).

Neither pilot advised Cambridge of the Airprox, and the Controller would not have been aware. Under a Basic Service pilots are ultimately responsible for the provision of collision avoidance and controllers are not expected to monitor individual flights (CAP 774 Section 2.1 refers).

Figure 1: CPA. Swanwick MRT at 1019:14

UKAB Secretariat

The AA5 and PA28 pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. If the incident geometry is considered as head-on or nearly so then both pilots were required to turn to the right2. If the incident geometry is considered as converging then the AA5 pilot was required to give way to the PA283.

Summary

An Airprox was reported when an AA5 and a PA28 flew into proximity at 1019 on Sunday 21st June 2015. Both pilots were operating under VFR in VMC, the AA5 pilot in receipt of a Basic Service from Cambridge Approach, operating without radar, and the PA28 pilot having just left the Cambridge frequency and probably not in receipt of a service.

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way (c) (1) Approaching head-on. 3 SERA.3210 Right-of-way (c) (2) Converging.

2 Airprox 2015091

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft, radar photographs/video recordings and a report from the appropriate ATC authority.

Members discussed the pilots’ actions and first considered the AA5 pilot’s narrative. It was apparent that he had seen the PA28 at fairly close range and that he had perceived a possibility of collision. Consequently he had dived below the other aircraft. Members agreed that, from the radar picture, it appeared the AA5 pilot had commenced the dive close to CPA, and that he had probably not significantly further increased separation. Turning to the PA28 pilot, it was clear that he had, by his own account, seen the AA5 also at a late stage. Neither pilot should have expected to obtain Traffic Information from Cambridge due to the Air Traffic Service they had requested, and, in any case, the PA28 pilot had left the frequency some 20sec before CPA. Therefore, it was agreed that the cause of the Airprox was a late sighting by both pilots.

Turning to risk, the PA28 pilot reported ‘a very late sighting of another aircraft ahead and slightly below that seemed to be already taking avoiding action’; he consequently felt there was no risk of collision. Members discussed his perception of collision risk; on the one hand he had quite rightly assessed that the AA5 would miss him, on the other, members felt that the close proximity of the two aircraft denoted an inherent increased risk. It was suggested that the PA28 pilot’s view of risk of collision was based on his perception of the instantaneous trajectories of each aircraft at or close to CPA, whereas the Board felt this picture was too limiting and dealt purely with the outcome rather than a complete assessment of events surrounding the Airprox. Some members felt that timely action had been taken to prevent a collision, not least because the aircraft were separated by some 200ft vertically in the first place; however, by a close majority, it was felt that although avoiding action had been taken, it appeared to have been too late to have materially affected separation and that safety margins had been reduced below the normal.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: A late sighting by both pilots.

Degree of Risk: B.

3 AIRPROX REPORT No 2015092

Date: 23 Jun 2015 Time: 1729Z Position: 5311N 00236W Location: Oulton Park

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft C182 Eurofox Operator Civ Club Civ Pte Airspace FIR FIR Class G G Rules VFR VFR Service Basic A/G Provider Liverpool Ashcroft Altitude/FL 1200ft 1100ft Transponder A,C,S A,C,S Reported Colours White White Lighting HISL HISL Conditions VMC VMC Visibility >10km >10km Altitude/FL 1400ft 700ft Altimeter QNH QFE (1018hPa) Heading 360° 180 Speed 127kt 60kts ACAS/TAS Other TAS Not fitted Alert TA N/A Separation Reported 200ft V/100m H NK Recorded 100ft V/0.1nm H

THE C182 PILOT reports approaching Oulton Park from the south receiving a Basic Service from Liverpool. He was listening out on the frequency some 5 minutes before calling Liverpool in order to build situational awareness and was aware of a helicopter flying into Hawarden from the east, and so was maintaining a good lookout for this aircraft. He was using a portable PCAS unit which seemed to give indications which correlated with the helicopter traffic which he had in sight, and he was not aware of any other threats. On playback of the cockpit video the next day, he noticed an unknown and unseen aircraft passing beneath him almost head-on from right to left. He assumed this aircraft was flying south down the low-level route.

He assessed the risk of collision as ‘High’.

THE EUROFOX PILOT reports returning to Ashcroft after a short (50min) local flight. He approached the airfield from the southwest having made an announcement on the designated frequency 5 miles out and joined overhead at 1500ft. He assessed the windsock and elected to land on RW09. He announced his position overhead and in descent to the north for a left hand on RW09. He descended to the north joining downwind, flew out to Oulton lake and turned onto base. As he was turning onto final his passenger commented on another aircraft in close proximity, but because he was looking towards the runway he did not see the aircraft, however he did instinctively tighten his turn slightly. The aircraft landed normally and he took no reporting action.

THE LIVERPOOL CONTROLLER reports providing a Basic Service to the C182 outside controlled airspace. He was given a standard joining clearance, together with a squawk of 5050. He questioned the pilot whether he was approaching Oulton Park and, after an affirmative answer, warned of traffic in the vicinity on a 7000 squawk. The pilot replied he had the Hawarden traffic in

Airprox 2015092 sight, although this was not the traffic in question. The next day the pilot called to state he would be filing an Airprox on an unknown aircraft.

Factual Background

The Liverpool weather at the time of the incident was:

METAR EGGP 231720Z 30007KT 270V340 CAVOK 17/10 Q1018

The C182 pilot provided a screen grab of his cockpit video, showing the other aircraft at bottom right, apparently in a left turn:

Analysis and Investigation

CAA ATSI

ATSI had access to one pilot report, the Swanwick Radar recording and recordings of the relevant radio frequencies. The pilot of the C182 reports listening in to the Liverpool frequency for 5 minutes prior to establishing contact. At 1724:50 a clearance to join controlled airspace via Oulton Park was issued by Liverpool. A Basic Service was agreed outside Controlled Airspace and the C182 was given a SSR code of 5050. The issuance of such a code does not constitute the provision of a surveillance related service1. The C182 reported at Oulton Park at 1728:48 but it was approximately 20 seconds before this was acknowledged by the controller. When the call was acknowledged generic traffic information was passed to advise the C182 of traffic in the vicinity that was not working Liverpool. CPA occurred at 1729:27, vertical 100ft and approximately 0.1NM horizontally (Figure 1). Oulton Park VRP is approximately 1 NM southeast of the Liverpool CTR (Figure 2). The unknown aircraft had been routing eastbound until approximately 2 minutes prior to the reported Airprox, when it had turned left onto a westerly track. Under a Basic Service a controller is not required to monitor a flight. Whether traffic information has been provided or not, the pilot remains responsible for collision avoidance without assistance from the controller.2

1 CAP493 Section 1 Chapter 12 para 2D. 2 CAP493 Section 1 Chapter 12 para 2E.5

Airprox 2015092

Figure 1 – CPA – Swanwick MRT at 1729:27

Figure 2

UKAB Secretariat

The C182 and Eurofox pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard3. If the incident geometry is considered as converging then the C182 pilot was required to give way to the Eurofox4.

Summary

An Airprox was reported when a C182 and a Eurofox flew into proximity at 1725 on Tuesday 23rd June 2015. The pilot of the C182 was operating under VFR in VMC, in receipt of a Basic Service from Liverpool; the Eurofox pilot was conducting circuits at Ashcroft airfield.

3 SERA.3205 Proximity. 4 SERA.3210 Right-of-way (c) (2) Converging.

Airprox 2015092

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

The Board first addressed the actions of the C182 pilot and commended him for actively building his situational awareness by keeping a listening watch. However, having contacted Liverpool and been warned that there was traffic in his vicinity; he had assumed (incorrectly) that an aircraft that he had acquired visually was the traffic in question. This assumption was backed up and reinforced by indications on his PCAS receiver, and by transmissions that he had heard relating to an aircraft routing across his track en-route to Hawarden. His incorrect mental model of what was going on had thus lulled him into focusing his attention solely on that aircraft, probably at the expense of maintaining a fulsome lookout elsewhere. That being said, it was noted that the relative positions of the two aircraft meant that the Eurofox would probably have been obscured by his instrument panel anyway, and this in itself was a reminder to all of the need to proactively search the surrounding area for other aircraft, and to regularly manoeuvre the aircraft to uncover any blind spots caused by such obscuration.

For his part, the Eurofox pilot was operating in the Ashcroft circuit, some 2 miles south-east of the Oulton Park VRP. Members commented that, although the aircraft had every right to be there, it appeared that the Eurofox pilot had somewhat extended his circuit and, if this appeared to be the case, although no doubt concentrating on his circuit procedures, extra vigilance was required in the proximity of the Oulton VRP given that this was a likely place for other aircraft to route to in what was fairly busy Class G airspace.

In considering the cause of the Airprox, the Board noted that neither pilot had seen each other and that this was the reason they had come into proximity. The Board were fortunate that the C182 pilot had provided video of the encounter and, in examining this video; members agreed that safety margins had been much reduced below the norm.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: A non-sighting by both pilots.

Degree of Risk: B.

AIRPROX REPORT No 2015093

Date: 25 Jun 2015 Time: 1307Z Position: 5109N 00146W Location: Boscombe Down

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Gazelle Tutor (A) Operator MoD ATEC HQ Air (Trg) Airspace Boscombe ATZ Boscombe ATZ Class G G Rules IFR VFR Service Aerodrome Aerodrome Provider Boscombe TWR Boscombe TWR Altitude/FL NK ~1100ft Transponder A, C1 A, C Reported Colours Grey/green White Lighting Strobes NK Conditions VMC VMC Visibility 15km NK Altitude/FL NK NK Altimeter NK (1007hPa) NK Heading 225° NK Speed 70kt NK ACAS/TAS TAS TAS Alert TA Unknown Separation Reported 100ft V/5m H Not seen Recorded NK

THE GAZELLE PILOT reports being cleared for an IF take off and procedural climb on runway track amongst an exceptionally busy visual circuit. During the climb, at approximately 500ft with the pilot flying simulated IMC using the IF hood and the safety pilot looking out, the TAS alerted for a TA showing at +800 (800ft above) and slightly ahead. As the safety pilot looked ahead and up for the contact, the Tower controller made an urgent call for the Gazelle to stop climb due to a Tutor immediately above. The safety pilot then looked directly up to see a Tutor, approximately 100ft above, very slightly to the right and drawing ahead, apparently having almost directly over-flown the Gazelle. The climb was stopped and the Tutor allowed to continue opening ahead before they resumed the IF climb. The pilot stated that other relevant factors were: TAS saturation due to high levels of alert due to circuit traffic; exceptionally busy circuit traffic and encroachment of visual circuit traffic onto departing IF traffic; an excellent response from the Tower controller which prevented collision; the fact that the Gazelle was climbing in a blind spot for the Tutor; and a very late spot of the Tutor from the Gazelle as it was overtaking directly above. The pilot also noted that if they had made an early switch to the approach frequency it was quite likely that warning would not have been passed in time, with a significantly higher risk of collision.

He assessed the risk of collision as ‘Medium’.

THE TUTOR (A) PILOT reports that, on a ‘standard Berwick recovery’, he requested an orbit with Boscombe Approach to give Tutor(B) ‘more space in front of him’, which was approved . He called ‘West point’ and then downwind to land on the main. ATC were very busy and did not respond to his two downwind calls. When he subsequently called finals he was told to ‘go around’. He overshot and turned early onto the downwind leg to get out of the way of those below. On the second circuit he was told to continue his approach before once again being told to ‘go around’ (prior to his finals turn). On

1 The Gazelle did not appear on area radar recordings until after CPA.

1 Airprox 2015093 the final circuit, his downwind call for a full stop was responded to and he then called for finals. ATC cleared him for a touch and go, which he corrected to a full-stop landing. He landed and departed the runway without hindrance.

THE TUTOR (B) PILOT reports he joined from Berwick with Tutor (A) behind him. He flew to ‘West Point’ at 120kt to increase spacing from Tutor (A). As he called ‘West Point’, Tutor(C) was landing on the main and Tutor (A) was spaced nicely behind. He completed a normal circuit to the main for a touch and go. When he was late downwind on the second circuit, he saw an Alpha Jet, which he was aware was in the circuit, in his 10 o'clock. Knowing it would turn final and was travelling faster than he was, he waited until it passed in front of him before he turned final, which would have allowed him to land on the main in turn. Early in the final turn, ATC asked him to position for the northern runway. He then completed a touch and go on the northern. He finally completed a normal circuit to land on the main and exited the runway behind Tutor(C) before taxiing back. He noted that ATC were very busy and didn't reply to his downwind call on two of the circuits.

THE TUTOR(C) PILOT reports flying the third in a series of dual-to-solo sorties after first solo, consisting of four circuits to be flown solo. He flew the first two circuits without hindrance and, upon beginning his third circuit, Tutor (A), Tutor (B) and an Alpha Jet had joined him in the circuit. Both the Alpha Jet and Tutor (B) were ahead of him, whilst Tutor (A) was behind, on their downwind legs. The Alpha Jet subsequently landed and was stationary by taxiway Echo in the centre of the main runway so Tutor(B) was then asked to position to the northerly runway. When Tutor(C) pilot was on finals, Tutor (A), behind him, was told to ‘go around at circuit height' by ATC. Tutor(C) pilot then carried on with his own final approach until he reached a point where the Alpha Jet hadn't vacated the runway and he wasn't content with its position relative to his own aircraft. He then climbed away calling ”[Tutor(C) C/S] going around, not above 600ft, please advise” with the knowledge that Tutor(A) would be close behind and at 800ft. ATC asked him if he was visual with Tutor(A), which he wasn’t. He then saw Tutor (A) high in his three o’clock, which was then confirmed by ATC. He proceeded to 800ft and went back into the normal circuit pattern. He then completed the rest of his sortie without hindrance, except for ATC missing a few of his calls that were subsequently repeated.

THE BOSCOMBE TOWER CONTROLLER reports a circuit state of 3 Tutors in the northern circuit, one A109 south side with an Alpha Jet holding on RW23 to allow approaches to the RW23 North. All three Tutors were student callsigns. One Gazelle was holding on taxiway Echo for an IF departure from the main RW23. He gave the Alpha Jet pilot clearance to vacate the main runway following a Tutor approach to the northern. A Tutor (believed to be Tutor (A)) called final to the main. With the Alpha Jet still vacating, he told Tutor (A) to ‘go around’. Once the Alpha Jet had vacated he gave the Gazelle a clearance to line up abeam taxiway echo on RW23. He instructed the Alpha Jet pilot to contact Boscombe Ground once he was vacated. He gave the Gazelle pilot clearance to take off. He then attempted to re-identify the Tutors in the visual circuit. It was not clear where Tutor (B) was as he had been cleared to touch-and-go on the northern runway some time previously but could not be seen as was expected on crosswind or early downwind. He broadcast a request for his position and he replied he had just taken off from RW23. This was confusing as it would not have been possible, even without a clearance, given that the Alpha Jet was still on the main when the clearance to Tutor (B) to touch-and-go on the north runway was broadcast. With both he and the other people in the Tower focusing on the downwind leg, attempting to identify the three tutors, it was only when he checked on the position of the Gazelle that he noticed Tutor (A) overhead it. He immediately broadcast that the Gazelle should stop its climb, thereby preventing a collision.

He perceived the severity of the incident as ‘Medium’.

THE BOSCOMBE SUPERVISOR reports that at the time of the incident he was downstairs in the Approach Control Room (ACR). At the time of the incident the unit was experiencing exceptionally high workload. In addition to the workload of each controller, the airspace management around Boscombe and Salisbury Plain Training Area (SPTA) was particular complex. The Watchkeeper RPAS was operating in D122, para-dropping was taking place at Old Sarum and Netheravon, and a Tornado had only just completed a trial in the Boscombe overhead and SPTA. The Zone controller in particular was experiencing a very high workload, and the SUP was involved in helping her out with

2 Airprox 2015093 pre-notes, handovers and MATZ crossing clearances. The Zone position was also busier than normal due to an increased number of rotaries transiting to and from Glastonbury for the upcoming festival. He did not witness the incident, and was told of its details when the Tower controller was relieved from position. The Supervisor noted that, due to the inexperience of the Tutor pilots in the visual circuit at the time of the incident, his presence in the Tower would have been useful. However, he was needed in the ACR due to the unit’s workload.

Factual Background

The weather at Boscombe was recorded as follows:

METAR EGDM 251250Z 34004KT 9999 SCT030 08/M00 Q1012 BLU NOSIG

The UK MIL AIP at AD 2 – EGDM – 1 – 10, EGDM AD 2.20 - LOCAL TRAFFIC REGULATIONS, dated 29 Sep 05, states:

‘Warnings a. No Dead Side. Left hand visual circuit flown at 1200ft QFE. All breaks are to be Level breaks at 1200ft QFE. b. Light aircraft operate to parallel section of the Northern Taxiway from non-standard 800ft QFE Northerly circuit. c. Rotary aircraft may also be operating to grass surface abeam Rwy 05/23.’

AD 2 - EGDM - 1 – 13, dated 17 Oct 13 states:

‘VISUAL CIRCUIT PROCEDURES 1. Parallel Surface. High-intensity, multi-type, acft and hel operations occur to multiple operating surfaces as depicted on the AD chart. All parallel rwy operations are under positive ATC control. By exception, however, hel operating to Rwy 05/23 Grass, as the only occupants of the combined circuit to the Grass and Northern, may operate to negative RT when approved by ATC. Visitors to Boscombe Down are to comply meticulously with ATC instructions and, when required, are to overshoot on rwy Tr. ... WARNINGS 4. Acft landing on Rwy 05/23 are not to vacate the rwy until cleared by ATC. When vacating Rwy 23 at the end, acft are not to proceed past '05 North Hold' without positive clearance from ATC.

5. Acft overshooting or executing M/App are to maintain rwy Tr to avoid impinging on the visual circuits to the north and hel operations 'Southside'. Exceptionally, if a confliction arises with acft in the Northern circuit, use of the area between the RCL and 'Southside' as depicted on the AD chart, is permitted. …’

A transcript of the Tower frequency is as follows:

From To Speech Transcription Time Tutor (A) Tower Boscombe Tower, [Tutor (A) C/S] join with Charlie 12:59:14 [Tutor (A) C/S] join runway 23 right hand, Q F E 1007, 2, er 1 in, 2 Tower Tutor (A) 12:59:17 northside, 1 southside Tutor (A) Tower 23, 1007, and [Tutor (A) C/S] 12:59:26 Tutor (B) Tower [Tutor (B) C/S] downwind touch and go main 12:59:47 Gazelle Tower Tower, [Gazelle C/S] request line up runway 23 12:59:53 [Gazelle C/S], Boscombe Tower, hold and, correction, taxi Echo and Tower Gazelle 12:59:57 hold short Runway 23 Gazelle Tower Echo and hold short [Gazelle C/S] 13:00:03 Tutor C/S Tower {stepped on} 13:00:10 Tower Tutor C/S Uniform...er, callsign say again. 13:00:14

3 Airprox 2015093

From To Speech Transcription Time Tutor (A) Tower [Tutor (A) C/S] at West Point 13:00:16 [Tutor (A) C/S], 1 Tutor just turning downwind, 1 Tutor Mid Downwind, Tower Tutor (A) 13:00:18 Alpha-Jet downwind on the Main Circuit Tutor (A) Tower Copied, [Tutor (A) C/S] 13:00:27 Tutor (C) Tower [Tutor (C) C/S] downwind touch and go main 13:00:29 Tower Tutor (C) [Tutor (C) C/S] 3 ahead, wind 230 6 13:00:36 Tutor (C) Tower 3 ahead, [Tutor (C) C/S] 13:00:42 Tutor (B) Tower [Tutor (B) C/S] is late downwind touch and go main 13:00:44 Tower Tutor (B) [Tutor (B) C/S], 1 ahead, main approved, wind 230 6 13:00:49 Tutor (B) Tower 1 ahead, [Tutor (B) C/S] 13:00:56 Alpha Jet Tower [Alpha Jet C/S] late downwind, full stop 13:00:58 Tower Alpha Jet [Alpha Jet C/S] wind 230 6 13:01:01 Alpha Jet Tower [Alpha Jet C/S] and confirm we're number 1 13:01:06 Tutor (A) Tower [Tutor (A) C/S] downwind full stop main 13:01:07 Alpha Jet Tower Tower, [Alpha Jet C/S] finals gear down 13:01:13 Tower Alpha Jet [Alpha Jet C/S] cleared touch and go barrier down 13:01:21 Alpha Jet Tower [Alpha Jet C/S] er... to land 13:01:26 Tower Alpha Jet [Alpha Jet C/S] cleared to land barrier down 13:01:28 Alpha Jet Tower Cleared to land [Alpha Jet C/S] 13:01:30 Tutor (A) Tower [Tutor (A) C/S] downwind full stop main 13:01:33 Tower Tutor (A) [Tutor (A) C/S] main approved, 1 ahead, wind 230 6 13:01:39 Tutor (A) Tower 1 ahead, [Tutor (A) C/S] 13:01:43 Tutor (B) Tower [Tutor (B) C/S] final main, visual with the traffic 13:01:44 Tower Tutor (B) [Tutor (B) C/S] continue approach 13:01:48 Tutor (B) Tower Continue approach [Tutor (B) C/S] 13:01:50 Tutor (C) Tower [Tutor (C) C/S] final main, visual with traffic 13:02:00 Tower Tutor (B) [Tutor (B) C/S] can you position to the north? 13:02:05 Tutor (B) Tower [Tutor (B) C/S] 13:02:08 Tutor (B) Tower [Tutor (B) C/S] final touch and go north 13:02:23 Tutor (A) Tower [Tutor (A) C/S] final main 13:02:31 Tower Tutor (B) [Tutor (B) C/S] cleared touch and go north 13:02:36 Tutor (B) Tower Cleared touch and go north [Tutor (B) C/S] 13:02:38 Tower Tutor (A) [Tutor (A) C/S] it'll be er go around circuit height 13:02:43 Tutor (A) Tower Go around circuit height [Tutor (A) C/S] 13:02:47 Tower Alpha Jet [Alpha Jet C/S] hold on the main abeam Foxtrot 13:02:50 Alpha Jet Tower [Alpha Jet C/S] abeam Foxtrot, Wilco 13:02:52 Tower Gazelle [Gazelle C/S], Boscombe Tower, Line-up runway 23 abeam Echo 13:03:02 Gazelle Tower Line-up abeam Echo, [Gazelle C/S] 13:03:06 [Gazelle C/S] on departure it'll be not above height 2000ft, Tower Gazelle 13:03:11 acknowledge Gazelle Tower [Gazelle C/S] we're going to hold, there’s a Tutor going for the main 13:03:13

4 Airprox 2015093

From To Speech Transcription Time Tower Tutor (A) [Tutor (A) C/S] confirm breaking off circuit height 13:03:15 Tower Gazelle [Gazelle C/S] hold in your current position 13:03:21 Gazelle Tower Holding, [Gazelle C/S] 13:03:24 Other Tower Tower, [Other C/S] requesting cross runway 23 for north point 13:03:30 Tutor (C) Tower [Tutor (C) C/S] going around 13:03:33 Tower Tutor (C) [Tutor (C) C/S] {stepped on} 13:03:38 Tower Tutor (C) [Tutor (C) C/S] one Tutor overhead circuit height 13:03:42 Tutor (C) Tower Be advised maintain 600ft [Tutor (C) C/S] 13:03:45 Tower Tutor (C) [Tutor (C) C/S] are you visual with the tutor overhead 13:03:50 Tutor (C) Tower No, [Tutor (C) C/S] 13:03:54 Tower Tutor (C) [Tutor (C) C/S] not above height 600ft on the go around 13:03:57 Tutor (C) Tower Not above 600ft going around [Tutor (C) C/S] 13:04:01 Tower Tutor (C) In your right 3 o'clock now, high 13:04:05 Tutor (C) Tower Visual [Tutor (C) C/S] 13:04:09 Tutor (C) Tower {stepped on} request normal circuit [Tutor (C) C/S] 13:04:11 [Tutor (C) C/S] affirm, turn downwind now normal circuit height with Tower Tutor (C) 13:04:12 the Tutor insight Tutor (C) Tower Affirm, [Tutor (C) C/S] 13:04:18 Tower Tutor (B) [Tutor (B) C/S] 13:04:20 Tutor (B) Tower Boscombe Tower, [Tutor (B) C/S], pass message 13:04:22 Tower Tutor (B) [Tutor (B) C/S], request your current position 13:04:25 Tutor (B) Tower [Tutor (B) C/S] just taking off runway 23, 600ft A G L 13:04:31 Tutor (A) Tower [Tutor (A) C/S] downwind full stop main 13:04:38 Tower Tutor (B) [Tutor (B) C/S] say again 13:04:42 Tutor (B) Tower [Tutor (B) C/S] just turning downwind 13:04:45 Tower Tutor (B) [Tutor (B) C/S] 13:04:47 Tower Alpha Jet [Alpha Jet C/S] vacate onto Foxtrot 13:04:51 Alpha Jet Tower Vacate onto Foxtrot [Alpha Jet C/S] 13:04:54 Tutor (A) Tower [Tutor (A) C/S] final main 13:04:58 Tower Tutor (A) [Tutor (A) C/S] go around 13:05:00 Tutor (C) Tower [Tutor (C) C/S] downwind touch and go main 13:05:03 Tutor (A) Tower Going around [Tutor (A) C/S] 13:05:07 Tower Tutor (C) [Tutor (C) C/S] main approved, wind 210 6 13:05:10 Tower Gazelle [Gazelle C/S] line up runway 23 abeam Echo 13:05:13 Gazelle Tower Line-up abeam Echo, [Gazelle C/S] 13:05:15 Alpha Jet Tower [Alpha Jet C/S] is clear of the active 13:05:18 Alpha Jet Tower Tower, [Alpha Jet C/S] is clear of the active 13:05:29 Tutor (B) Tower {Unclear transmission} 3 Tutors ahead [Tutor (B) C/S] 13:05:31 Tower Alpha Jet [Alpha Jet C/S] continue with Boscombe Ground stud 2 13:05:33 Alpha Jet Tower Stud 2, [Alpha Jet C/S] 13:05:36 Tower Gazelle [Gazelle C/S] clear for takeoff runway 23, wind 200 07, barrier down 13:05:41

5 Airprox 2015093

From To Speech Transcription Time Gazelle Tower Clear for takeoff [Gazelle C/S] 13:05:50 Other Tower Tower, [Other C/S] is going to be off freq for approximately 2 mikes 13:05:56 Tower Other [Other C/S] roger continue with Boscombe Ground stud 2 13:06:00 Other Tower [Other C/S] is going to be holding on runway 17 off freq for 2 mikes 13:06:05 Tower Other [Other C/S] roger 13:06:12 Tutor (C) Tower [Wrong C/S], correction [Tutor (C) C/S] final main 13:06:23 Tower Tutor (C) [Tutor (C) C/S] is this to touch and go? 13:06:29 Tutor (C) Tower Touch and go [Tutor (C) C/S] 13:06:32 Tower Gazelle [Gazelle C/S] er...[Gazelle C/S] Tutor overhead, stop climb now 13:06:38 Gazelle Tower Stop climb [Gazelle C/S] 13:06:44 Tower Gazelle [Gazelle C/S] now clear of that Tutor 13:06:48 Gazelle Tower er [Gazelle C/S], continuing to climb 13:06:51 Tower Tutor (C) [Tutor (C) C/S] cleared touch and go main, barrier down 13:06:58 Tutor (C) Tower Cleared touch and go main [Tutor (C) C/S] 13:07:01 Tower Gazelle [Gazelle C/S] continue with Boscombe Approach stud 4 13:07:07 Gazelle Tower Stud 4, [Gazelle C/S] 13:07:09

An extract from the Aerodrome chart at AD 2 - EGDM - 1 - 15, dated 12 Dec 13, is shown below:

6 Airprox 2015093

Analysis and Investigation

Military ATM

The incident occurred on 25 June 15 between a Gazelle and a Tutor, both under an Aerodrome Control Service with Boscombe Down Aerodrome Controller. The Radar Analysis Cell were not able to capture the incident on radar due to the heights involved.

At 1259:17, the Tutor (A) joined the visual circuit and was given a traffic update. At 1301:33, the Tutor (A) pilot called downwind for a full stop landing and the main runway was approved with one aircraft ahead. At 1302:43, the Tutor (A) was sent around at circuit height.

At 1303:11, the Gazelle pilot was informed of a climb-out restriction to 2000ft and the pilot responded that they were holding as a Tutor [(C)] was going for the main. Tutor (A) was asked to confirm that he was breaking off the approach and Tutor(C) informed the ADC that he was

At 1304:58, the Tutor (A) pilot called for finals and was sent around again at 1305:00. At 1305:13, the Gazelle was lined-up on the main runway at point Echo. The take-off clearance was passed at 1305:41 and the next transmission to the Gazelle was at 1306:38 when the Tower controller said, “[Gazelle C/S] Tutor overhead, stop climb now.”

At 1306:44, the Gazelle pilot replied with “stop climb.” At 1306:48, the Gazelle pilot confirmed that he was clear of the Tutor (A).

The visual circuit at the time was busy, resulting in a high workload for the Aerodrome Controller, including integrating a number of different aircraft types with circuits flown to the north and south. The Tutor (A) was sent around because the main runway was occupied and the Gazelle was then cleared for an IFR departure from RW23. The Aerodrome Controller saw the potential confliction and warned the Gazelle to stop climb; the call from ATC allowed the Gazelle to level-off and resulted in an estimated vertical separation of 100ft.

An in-depth local investigation found that the Aerodrome Controller had cleared the Gazelle pilot to depart and climb through circuit height whilst the Tutor (A) was flying directly over the main runway on a go-around. As the controller’s workload increased he had lost situational awareness and was unaware of the position of the Tutor (A). The controller had tried to move two of the Tutors onto RW23 North but had been informed that two of the students were not cleared to operate on the northern runway and had to use the main runway. The investigation centred on the non-standard airfield layout at Boscombe, and particularly its lack of a deadside for aircraft going-around. Controller workload was further increased because of the different aircraft types flying northerly and southerly circuits to two parallel runways, where it is difficult to ascertain the relative positions of each aircraft and which runway they are using. To add to the task difficulty, the Tutors were difficult to acquire visually from the Tower. With inexperienced Tutor pilots operating to two different runways, it could be difficult for the controller to correlate specific aircraft with callsigns; non-standard radio calls and circuit patterns could also exacerbate the situation. The ATC Supervisor was assisting another controller in the Approach Control Room at the time.

A number of recommendations were made to help prevent reoccurrence. A restriction would be placed on the number of Tutors allowed in the circuit that could not use RW23 North and ATC would be pre-noted with student pilot qualifications for runway usage. The unit would provide additional training to increase awareness of the potential issues of traffic going around at an airfield without a deadside. Measures to improve Tutor conspicuity were also recommended. In addition, a review of ATC manpower would be conducted to include the complexities at Boscombe, with a view to providing a Supervisor or suitably qualified controller in the Visual Control Room when the visual circuit was busy. An event was organised to review the FOB to re- assess traffic patterns, runway usage and circuit restrictions to provide the safest operating environment. The role of the Duty Instructor based in ATC for Tutor flying, was also under review.

7 Airprox 2015093

Furthermore, an investigation into TAS limitations would be conducted to understand potential blind spots or areas of poor performance.

The normal barriers to an Airprox in the visual circuit would be lookout, TAS and ATC Traffic Information and deconfliction procedures. As Boscombe lacks a deadside, any aircraft going- around would have to be deconflicted with a departing aircraft through means other than lateral separation. The deconfliction could be achieved by holding a departure or ensuring that crews were visual. Specific Traffic Information was not passed to either of the Airprox aircraft pilots and it would appear that the busy Aerodrome Controller temporarily lost situational awareness of traffic positions. The investigation added context to the controller error, explaining the complexities and difficulties involved. Ultimately, the visual information available to the Aerodrome Controller was not detected and, as a result, the clearance was given for departure. The crews were not visual with each other, and the busy RT may have weakened their awareness of other circuit users. Lookout for both crews would have been hampered because the Gazelle was underneath the Tutor, and the Tutor was overtaking, above and behind the Gazelle. The TAS does not appear to have alerted the Tutor pilot but did give an alert to the Gazelle crew, albeit with indications that reportedly did not correlate with the position of the Tutor.

UKAB Secretariat

The Gazelle and Tutor pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard2.

Occurrence Investigation

The Occurrence Investigation identified a number of factors including:

• Loss of SA of the Tower controller. • Number of Tutor aircraft in the visual circuit whose pilots could not use the ‘Northern’. • ATC lack of appreciation as to which Tutor pilots were cleared to use the ‘Northern’. • Previous training of the ADC. • Consequential effects of the lack of a deadside at Boscombe. • Lack of visual conspicuity of the white Tutor aircraft. • Potential consequences of flying a non-standard circuit pattern. • Complexity of procedures and airspace at Boscombe.

Comments

HQ Air Command

The narrative of this Airprox describes an extremely complex situation and shows how important it is for all concerned to use all means possible to gain full situational awareness before IF traffic integrates into the visual circuit. A thorough Occurrence Safety Investigation has taken place which resulted in 14 recommendations. Many of the recommendations include revising procedures and training such that the chances of a controller losing Situational Awareness in the future are much reduced. There will also be revisions to the way that Tutor aircraft (with quite often inexperienced pilots) operate at Boscombe Down. Ultimately the ‘stop climb’ call from the controller prevented the situation becoming more significant.

Summary

An Airprox was reported when a Gazelle and a Tutor flew into proximity at about 1307 on Wednesday 25th June 2015. Both pilots were operating in VMC in receipt of an Aerodrome Control Service, the Gazelle pilot under IFR with safety pilot lookout and the Tutor pilot under VFR. The Tutor pilot, on

2 SERA.3205 Proximity.

8 Airprox 2015093 final approach to RW23 main, had been cleared to go around and the Gazelle pilot had been cleared to take off. There is no deadside at Boscombe.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft, transcripts of the relevant RT frequency, radar photographs/video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities.

This complex Airprox was the subject of much debate. A military ATC member started by adding some detail to the already well documented events. In the 7min prior to the Airprox, the Tower controller was busy, with transmissions every 6-7sec, and the multi-runway, multi-aircraft visual circuit, with departing IFR traffic, was a challenging environment for all concerned. Crucially, the Tower controller was unaware as to which Tutor pilots were cleared, or not, to use RW23 North. He had asked the pilot of Tutor(B) whether he could position for RW23 North, he had responded with his callsign only, and he had subsequently called final for, and been cleared to, touch-and-go on RW23 North. It transpired that the Tutor (B) pilot was inexperienced, was not cleared to use RW23 North, and had in fact flown his approach to the main RW23. It also transpired that the runway caravan controller had fired a red verey flare but the Tutor (B) pilot did not see it.

The Board noted that the threshold of RW23 North is at about the mid-point of RW23 main, so Tutor (B) (making an approach to RW23 main) was then not in the position the Tower controller expected. When he requested Tutor (B) state his position the reply, ‘just taking off runway 23’, did not conform to his situational awareness and this was probably the point at which the seed of confusion was sown. Members acknowledged that the Tower controller had requested Tutor (B) to re-position to RW23 North in order to expedite the IFR departure of the Gazelle. The Gazelle pilot had then informed the Tower controller that ‘we're going to hold, there’s a Tutor going for the main’ (Tutor(C), ahead of Tutors (A) and (B)) which caused growing confusion for the controller.

Meanwhile, Tutor (A) had already been instructed to go-around and Tutor(C) was concerned because he perceived that Tutor (A) (who was behind him) would be in proximity as Tutor (A) potentially overtook him on his approach. In order to mitigate this, Tutor (A) pilot turned downwind early to increase separation and was then in front of Tutor(C). The Tower controller then became uncertain as to the relative position of Tutors. In the confusion as to which Tutors were going round, the Tower controller cleared the Gazelle to depart, having already instructed Tutor(A) pilot, now on his next approach, to go-around. Unfortunately, the lack of a deadside at Boscombe provided the final link in the chain with Tutor (A) then tracking overhead the departing and climbing Gazelle.

In some high-workload conditions situational awareness does not gradually diminish but collapses entirely after a trigger event. Additionally, the mental workload involved in re-establishing situational awareness is highly capacity sapping. In instances such as this, detecting the aircraft, processing the pilots’ current and future intentions, and influencing events may be carried out in an unstructured rather than prioritised manner because the situational awareness required to establish priorities has not yet been re-established. Civilian ATC members commented that in high workload situations such as this they would have limited circuit traffic, either by instructing pilots to land, or to orbit downwind. The military ATC member commented that this was not usual practice at military aerodromes.

Members went on to discuss the supervisory aspects of the incident. They first wondered what actions the Duty Pilot might have made in order to assist ATC be more directive in managing the complexities of the situation. It was felt that his role would be especially important at a station like Boscombe with its inherent circuit complexity, and scope to increase in complexity rapidly and with little notice, especially if there were student pilots in the circuit with limited experience and restrictions as to which runway surfaces they could use. Members also echoed the Occurrence Investigation recommendation that an additional supervisor, or suitably experienced controller, could gainfully be positioned in the Tower when visual circuit traffic reached a pre-determined level. After considerable discussion wherein it was recalled that other units routinely did so, members resolved to recommend that, ‘HQ Air Command considers the value of having a Supervisor in both the VCR and the ACR’.

9 Airprox 2015093

Comment was also made on the proximity of the RW23 main and North runways, and the fact that their thresholds were significantly displaced. This essentially resulted in there being two light aircraft circuit patterns, both right hand for RW23, but to the main and North runways respectively. Light aircraft using each circuit would commence their circuit turns at different positions, and any change to ‘standard’ turn positions could result in Tutors appearing to, or actually, overtaking other Tutors, either in the same circuit or operating to the other runway surface. Additionally, the stagger between thresholds meant that circuit radio calls could not be correlated easily to an aircraft’s position. For example, two aircraft in proximity, one pilot calling late downwind for RW23 North and the other calling downwind for RW23 main may not be easily differentiated. This situation would be exacerbated if the call was not made in the correct position; a common occurrence amongst inexperienced pilots. It seemed to the Board that there was considerable latent risk in operating both runways simultaneously in this manner, and they wondered whether a displaced threshold for light aircraft using the main runway, to bring it more adjacent to the RW23 North threshold, was an option. The MAA member was queried as to the proximity and layout of the two RW05/23 tarmac surfaces and commented that whilst this layout was not standard practice, the DDH had accepted the risk, as mitigated by Boscombe procedures and regulations, and had duly authorised their use. However, many members felt that this incident had raised questions concerning the complexity of operations at Boscombe in the presence of inexperienced pilots, and that the situation was worthy of further review; the Board resolved to recommend that, ‘HQ Air Command reviews the practice of using both runways simultaneously with inexperienced pilots’.

Members quickly agreed that the Airprox had occurred because the Tower controller had cleared the Gazelle pilot to depart into conflict with the overshooting Tutor (A). It was also agreed that the complex visual circuit, with multiple aircraft types and runways, had overloaded the controller and that this was contributory to the Airprox. Considering the risk, members noted that the Tower controller had happened to see the converging Tutor and Gazelle as he checked on the Gazelle’s position. Moreover, they noted that neither of the pilots had been aware of the conflict until they were warned at a very late stage. Some members were of the opinion that although the potential for collision had been very serious, in the event, effective action had been taken to prevent collision as a result of the oncoming controller’s warning, albeit with safety margins much reduced below normal. Others were of the opinion that the situation had only just stopped short of an actual collision and that separation had been reduced to the very minimum, with chance playing a major part. In a vote, these two views were shared equally amongst the Board members and so, after some further discussion, the Director cast his deciding vote that the situation had only just stopped short of collision; risk Category A.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The Tower controller cleared the Gazelle to depart into conflict with the overshooting Tutor (A).

Contributory Factor: The complex ATC circuit with multiple aircraft types and runways overloaded the controller.

Degree of Risk: A.

Recommendations: 1. HQ Air Command considers the value of having a Supervisor in both the VCR and the ACR.

2. HQ Air Command reviews the practice of using both runways simultaneously with inexperienced pilots.

10 AIRPROX REPORT No 2015098

Date: 25 Jun 2015 Time: 1842Z Position: 5234N 00001W Location: IVO March

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Tornado Paramotor Operator HQ Air (Ops) Civ Pte Airspace Lon FIR Lon FIR Class G G Rules VFR VFR Service Traffic Nil Provider Marham NA Altitude/FL 1500ft 1500ft Transponder A,C,S Not fitted Reported Colours Grey Burgundy/white/orange Lighting HISLs Nil Conditions VMC VMC Visibility 30km 25km Altitude/FL 1500ft 1550ft Altimeter QFE (1017hPa) QFE Heading 360° 350° Speed 400kt 26kt ACAS/TAS Not fitted Not fitted Separation Reported 0ft V/50-100ft H 350ftV/300ft H Recorded NK

THE TORNADO PILOT reports that he was holding over March prior to undertaking a flypast at Marham. Upon leaving the hold, a paraglider [UKAB note – later found to be a paramotor] was seen to pass down the right-hand side of the aircraft, at the same level, and displaced by an estimated 50- 100ft. Due to the late sighting, no evasive action was taken.

He assessed the risk of collision as ‘High’.

THE PARA-MOTOR PILOT had foot-launched from UKPPG March and climbed out at approximately 250ft/minute; he reported that he carries a Garmin GPS and so was able to assess accurately his flight details. At 1500ft the air was calmer, so he levelled out to head towards Holbeach. He had been in the cruise for about 3-4 minutes when he saw a Tornado pass him in his 10 o’clock, at the same height, and heading as he was. He noted that because it approached from behind him he hadn’t seen it earlier. He watched it initially remain on heading before making a 90° turn right, heading towards Kings Lynn. It is common paramotor practise to fly hands off the controls when the air is stable but, once the Tornado had passed, he took hold of the controls in case wake turbulence caused the wing to collapse. He also practised a front reserve chute deployment just in case. After about 20 seconds, he felt some minor wash and experienced some minor rocking, but the glider was unaffected. Having seen the Tornado disappear near to Kings Lynn, he decided to descend to 1000ft and continued his flight to Holbeach. He commented that he believed that sport aviation airfields are not marked on the RAF maps, and noted that the Tornado had descend down in a spiral to 1500ft in an area where skydiving and para-motoring sports are registered.

He assessed the risk of collision as ‘High’.

THE MARHAM CONTROLLER reports that the pilot of the Tornado did not report the Airprox on frequency, and so the controller did not find out about it until the following day. He had no

1 Airprox 2015098 recollection of the incident, and was unable to offer any further information, although he perceived the severity of the incident as ‘High’.

Factual Background

The weather at Marham was recorded as:

METAR EGYM 251750Z 24007KT CAVOK 22/11 Q1020 BLU NOSIG

Marham issued a NOTAM covering the flypast at Marham as follows:

H2594/15

Q) EGTT/QWALW/IV/M/AW/000/020/5239N00032E005FLYPAST BY 1 TORNADO ACFT AT PSN 5239N 00032E (RAF MARHAM) LOWER: SFC UPPER: 2000FT AMSL FROM: 25 JUN 2015 18:36 TO: 25 JUN 2015 18:56

Analysis and Investigation

Military ATM

The incident was investigated locally by RAF Marham. The paramotor did not appear on radar, and ATC were therefore unable to provide Traffic Information. The investigation found that the paramotor also provided a small visual cross-section, especially when viewed from astern, as per the view from the Tornado cockpit. Furthermore, the paramotor provided no initial relative movement to the Tornado crew, and these characteristics would have imposed limitations to ‘see- and-avoid’. The investigation also found that there was no way for Marham’s radar to detect a non-transponding paramotor, and that the Fenland Centre involved had not attended the East Anglia Airspace User Working Group (EAAUWG).

Following on from the investigation, it was agreed that the Fenland Centre would be invited to the next EAAUWG in order to promote a better understanding of operating practices and a potential means to deconflict movements. The Tornado simulator procedures would also be reviewed to scope the inclusion of ‘foot-launched’ air vehicles, such as paragliders and microlights, to highlight the difficulty in acquiring and avoiding these particular types.

UKAB Secretariat

Both pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. When two aircraft are converging at approximately the same level, the aircraft that has the other on its right shall give way, except as follows: (i) power-driven heavier-than-air aircraft shall give way to … sailplanes...2 The ANO states that the definition of a sailplane includes self-propelled hang-gliders.3

Comments

HQ Air Command

This incident once again highlights the importance of lookout, by all parties, as mitigation to MAC. It was a very late sighting by the Tornado crew that left them with no time to increase separation, and the para-motor pilot did not see the Tornado prior to CPA because it approached him from behind. It is once again disappointing that the Airprox was not filed on frequency as this would

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way. 3 ANO 2009 Article 255

2 Airprox 2015098

have prompted the controller to take certain actions, including preparing a statement, although it is acknowledged that since there was no radar contact with the paramotor, the controller’s input would be very limited.

The unit investigation identified recommendations which have now been implemented; notably, a representative from the BHPA will be invited to attend future East Anglian Airspace User Working Group meetings in order for all parties to better understand each other’s capabilities (with respect to detection of other aircraft) and the Tornado simulator will now include ‘foot-launched vehicles’ as part of the synthetic lookout training provided to Tornado crews. A more detailed NOTAM specifying the ingress route to the flypast location (in particular the Initial Point and final LOA) may have increased awareness of where the Tornado might reasonably have been expected to be seen.

BHPA

Although the BHPA was able to assist in the tracing action, this pilot and the operators of the location that they were flying from both choose to operate outwith the BHPA. Through the latest phase of the ANO consultation, the CAA has indicated that it is content for such operations to continue without any form of external validation or oversight. The BHPA believes that for the benefit of those under training, and fellow Class G users, all paramotor training operations should be subject to external validation and oversight. Had the operator been part of the BHPA they would have been part of the on-going liaison work with the military.

UKPPG Operator

UKPPG (March Airfield) is a full time professional PPG (Powered Paragliding) training organisation, operating under the auspices of APPI PPG, a Worldwide recognised training syllabus, specifically for Paragliding and Powered Paragliding. UKPPG and its instructors proactively engage other airspace users to enable everyone to operate safely within our area via NOTAMS and radio / telephone communications, these include liaisons with the Parachute and Microlight Centre at Chatteris Airfield, Upwood and Crowland Gliding Clubs, Benwick Airfield and the Local Military Air-Bases including RAF Marham, Lakenheath and Mildenhall. March Airfield was also added to the CAA Air Charts as an unlicensed Airfield for additional safe guarding to other airmen and we have our own radio frequency of 118.675mHz (PPR). Following this incident, we have also taken the initiative to add High Powered Self Contained LED Strobe Lights to our Training Paramotors for added awareness to other aircraft. The pilot in question has also followed our initiative with his own Paramotor.

Summary

An Airprox was reported on 25th June 2015 at 1842 between a Tornado and a para-motor. The Tornado was flying VFR in VMC at 1500ft when the pilot saw the para-motor pass down the right- hand side of his aircraft. The para-motor pilot didn’t see the Tornado until it had passed him from behind and was in his 10 o’clock. The incident did not show on the NATS radars, and so the exact separation is not known.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft, transcripts of the relevant RT frequencies, radar photographs/video recordings, and reports from the appropriate ATC and operating authorities.

The Board first discussed the NOTAM, issued by RAF Marham, warning of the Tornado fly-past. They were split on the merits of issuing such a NOTAM, with some members noting that Tornados fly around that area at various levels all the time and so, in their opinion, there was little value in issuing a NOTAM at all; in contrast, others believed that a more detailed NOTAM, indicating the area the aircraft was in the hold, would have been useful to other airspace users given that the Tornado pilot

3 Airprox 2015098 specifically planned to fly that track and hold in that area, and that this information might have alerted others to sharpen their lookout as they flew nearby.

The Board then looked at the assertion made by the para-motor pilot that para-gliding sites are not marked on RAF charts; the military ATC member informed them that this is not the case; any such sites listed in the AIP are marked on military charts. However, neither March, nor the UKPPG, are listed in the AIP under para-gliding activities, nor do they appear in any other publications; this led the Board to wonder how they then came to be annotated on the CAA charts, for which the CAA Airspace advisor was unsure. Given that March is not a licensed airfield and therefore does not have a ATZ, military members opined that if every sport aviation site was marked on the maps they would soon become unreadable, and so the information displayed had to be carefully selected. Despite this discussion centred around the marking of sites on the charts, the Board noted that the Tornado pilot did not overfly the site anyway, so, even if it had been marked on his charts, the Airprox may well have still occurred.

Members noted that this incident had occurred in see-and-avoid airspace, where both pilots were entitled to fly, but which required good look-out from all pilots concerned. They also noted that the Tornado pilot was receiving a Traffic Service from Marham ATC, but it was thought that the paramotor would be moving too slowly, and present too weak a radar target, for the Marham radar to pick it up; therefore, for this incident they agreed that the controller would not have been able to assist.

When it came to determining the cause of the Airprox, the Board agreed that it was effectively a non- sighting by the Tornado pilot (because he didn’t see the para-motor in time to take any avoiding action), and a non-sighting by the para-motor pilot (who only saw the Tornado after it had passed by). This led the Board to assess the risk as Category A; in their opinion, chance had played a major part in the event, and separation had been reduced to a minimum.

The Board were heartened to hear that RAF Marham had taken steps to reach out to the UKPPG at March and include them in their EAAUWG activities; such opportunities for information exchange and education about each other’s activities provided a real opportunity to help prevent further incidents by enhancing the awareness of all aviation operators in the local area.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: Effectively a non-sighting by the Tornado crew and a non-sighting by the para-motor pilot.

Degree of Risk: A.

4 AIRPROX REPORT No 2015099

Date: 29 Jun 2015 Time: 14.08Z Position: 52 36N 00102W Location: Leicester Airport

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Cabri G2 DR400 Operator Civ Trg Civ Club Airspace ATZ ATZ Class G G Rules VFR VFR Service AGCS AGCS Provider Leicester Radio Leicester Radio Altitude/FL 700ft 1000ft Transponder On A,C Standby A,C Reported Colours Grey/white Blue/white Lighting HISL HISL Conditions VMC VMC Visibility 10K 10K Altitude/FL 650ft 1000ft Altimeter QFE (1004hPa) NK Heading 100° 280° Speed 70kt 90kt ACAS/TAS Not fitted Not fitted Separation Reported 30ft V/50m H NK Recorded NK

THE CABRI G2 PILOT reports being downwind left-hand for RWY28 at Leicester at 700ft QFE. He was made aware of fixed-wing traffic joining deadside for the right-hand fixed-wing circuit so kept a good lookout. He spotted opposite direction traffic at the same level at a range of 500m and took evasive action to avoid. He later spoke to the pilot, who did not seem concerned about the incident. This pilot informed him that the DR400 was positioning in to get a ‘dodgy’ altimeter fixed and was using Sat Nav for altitude guidance. The Cabri pilot also spoke to the A/G operator who was concerned that the correct pressure setting had not been passed.

He assessed the risk of collision as ‘High’.

THE DR400 PILOT reports being inbound to Leicester to join deadside right-hand RWY28. He experienced problems with the altimeter when he attempted to set the QFE, the needles moved but the scale didn’t. He compensated for this by reducing the setting by 500ft from that shown when on the QNH in order to compensate for the elevation of the aerodrome. On the deadside descent, just before the right turn towards the active runway, he noticed a helicopter pass below him. He stated that he did not descend below 1000ft on the deadside.

He assessed the risk of collision as ‘Low’.

Factual Background

The East Midlands weather at the time was:

METAR EGNX 291350Z 21008KT 160V270 9999 SCT038 SCT045 21/11 Q1021

1 Airprox 2015099

The DR400 pilot supplied the screenshot below of his Skydemon log showing the portion approaching Leicester, which appears to indicate that the DR400 maintained just above 1000ft inside the Leicester ATZ, until on final approach.

Analysis and Investigation

UKAB Secretariat

Both pilots shared an equal responsibility for not flying into such proximity as to create a collision hazard1. An aircraft operated on or in the vicinity of an aerodrome shall2:

1 SERA 3205, Proximity. 2 SERA.3225, Operation on and in the vicinity of an aerodrome.

2 Airprox 2015099

(a) observe other aerodrome traffic for the purpose of avoiding collision; (b) conform with or avoid the pattern of traffic formed by other aircraft in operation;

The UK AIP at AD 2.EGBG-63 states:

‘1 Circuits (a) Fixed wing circuits left hand on Runways 10, 33, 22, 34 and 24. Fixed wing circuits right hand on Runways 28, 15, 04, 16 and 06. (b) The standard overhead join is preferred for fixed wing. (c) Fixed wing circuits will be at 1000ft QFE (d) Helicopter circuits are to the left on runways 28, 15, 04, 16 and 06. Helicopter Circuits are to the right on runways 10, 33, 22, 34 and 24. (e) Helicopter circuits will be at 700ft QFE. (f) Helicopter joins for a right hand circuit will be downwind. Joins for left hand circuits are overhead.’

Summary

An Airprox was reported when a Cabri G2 and a DR400 flew into proximity at 1408 on Monday 29th June 2015. Both pilots were operating under VFR in VMC, and both were in receipt of an Air/Ground service from Leicester Radio.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft and area radar recordings together with a Skydemon log of the DR400 flight.

The Board first noted that the procedures at Leicester allowed for helicopters and fixed-wing aircraft to conduct opposite direction flights with the helicopter downwind being at 700ft and the fixed-wing deadside being at 1000ft. The Board discussed at length the fact that the joining on the ‘fixed-wing deadside’ was somewhat of a misnomer because that side of the airfield was actually active up to 700ft thus only giving some 300ft separation from the helicopter circuit. In setting the context for the discussion, members recalled that a recent Airprox investigation had discussed the same procedures at length, and had concluded that they were safe provided pilots complied with the appropriate height restriction, which was an important consideration (Airprox 2015048).

In discussing the actions of the DR400 pilot, the Board noted that he had elected to join on the ‘deadside’ whilst the helicopter circuit was active and they wondered whether he had assimilated fully that this put him into potential conflict with the Cabri G2 whereas, in contrast, a standard overhead join would have built in some separation from the left-hand circuit and allowed him to assess the circuit flow. They were especially concerned that he had done so despite knowing that he could not set his altimeter accurately, and that height separation was critical even with a fully serviceable altimeter – especially as there were no ATC services to assist either, only an A/G operator. Unfortunately, radar recordings for the event were incomplete, and it was thus impossible to ascertain the exact height of the DR400 as it flew deadside, although the Skydemon log appears to show the aircraft at approximately 1000ft agl as it entered the Leicecester ATZ.

Turning to the Cabri G2 pilot, the Board noted that he was aware of the potential joining traffic and was keeping a good lookout. Nevertheless, the sight of the DR400 had concerned him sufficiently enough to take evasive action. The Board could not determine whether this was because the DR400 pilot was lower than he should be, or whether the Cabri pilot had misjudged the visual picture of 300ft separation, which had been the case before at Leicester for helicopter pilots sighting fixed-wing aircraft in similar situations.

Notwithstanding the lack of positive data, the Board decided that in conducting a ‘deadside’ join with an uncertain altimeter setting in what was a critical separation environment, the cause of the Airprox

3 EGBG AD 2.22 FLIGHT PROCEDURES

3 Airprox 2015099 was that the DR400 pilot had flown into conflict with the Cabri G2. Because the helicopter pilot had had to take evasive action to avoid a collision, they agreed that safety margins had been much reduced below the norm.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The DR400 pilot flew into conflict with the Cabri G2.

Degree of Risk: B.

4 AIRPROX REPORT No 2015100

Date: 2 Jul 2015 Time: 1455Z Position: 5305N 00018W Location: 3nm NE Coningsby

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Tornado Sentinel Operator HQ Air (Ops) HQ Air (Ops) Airspace Coningsby Lincs AIAA MATZ Class G G Rules IFR VFR Service Traffic Traffic Provider Coningsby Cranwell Departures Approach Altitude/FL FL014 FL019 Transponder A,C,S A,C,S Reported Colours Grey Grey Lighting Strobes, Nav, Strobes, Nav formation lights lights. Conditions VMC VMC Visibility 10km 10km Altitude/FL 1500ft 1800ft Altimeter QFE (1016hPa) QFE Heading Turning to 030° 090° Speed 300kt 200kt ACAS/TAS TCAS II TCAS II Alert RA RA Separation Reported 500ft V/ 1nmH 300ft V/1nm H Recorded 1000ft V/1.1nm H

THE TORNADO PILOT reports that prior to departure he was cleared for a Coningsby SID 2, climbing to FL130. Immediately after take-off, the aerodrome controller advised that there was traffic 8nm west of the airfield at 1800ft, tracking east. The crew switched to the Departures frequency, were identified under a Traffic Service, and cleared to climb to FL130, with no mention of the traffic. At 2.5 DME, they turned right in accordance with the SID and, climbing through 1500ft, the controller transmitted that the previously called traffic was now east-north-east 4nm, inbound to Cranwell, and that the Tornado should stop climb at 1200ft. At the same time, a TCAS TA was displayed so, being VMC, the pilot decided to tighten the right turn whilst descending back to 1200ft. During this manoeuvre, a TCAS RA to descend was received, followed swiftly by ‘level off’ and ‘clear of conflict’ notifications. He rolled out on a heading of 030°, and the crew became visual with the conflicting traffic, judged to be 1nm away and 500ft above. The TCAS RA was reported to ATC.

He assessed the risk of collision as ‘Low’.

THE SENTINEL PILOT reports he was the PF in the left-hand seat, and that the Sentinel was downwind in the Cranwell radar pattern receiving vectors for the ILS. It was a northerly feed-in as they were returning from Doncaster. They descended under instruction from Cranwell to 1800ft on the QFE, and were expecting to receive a right turn towards the localiser. ATC made them aware of Coningsby traffic outbound, and assured them that it was co-ordinated. He monitored an approaching contact on TCAS, whilst the pilot non-flying (PNF) attempted to visually acquire the traffic. The PNF, then the PF, saw an on-coming Tornado in their 12 o’clock, climbing towards. Thinking the Tornado had ‘TCAS limitations’ he was about to take avoiding action when he saw the Tornado break to its right and pass down the left-hand side of the Sentinel. At this point they had a TCAS RA instructing

1 Airprox 2015100 them to climb. Although visually clear of the conflict, he followed the RA in case there was a second, unseen Tornado. Once clear of conflict they continued the recovery to Cranwell.

He assessed the risk of collision as ‘Low’.

THE CONINGSBY ADC reports that he had been in position for about an hour with a Ground controller in position. The Tornado taxied out on Ground frequency, and the controller obtained clearance for a SID2 departure. As it approached the holding position the ADC requested an IFR release from the Departure controller, which was granted without any caveat or restriction. The Tornado was cleared for take-off and, very shortly afterwards, the UT Approach controller called to advise that after the Tornado had departed there was to be a climb out restriction of 1200ft which was in place because of a Cranwell inbound for a northerly feed-in. This traffic was identified to the ADC on the Air Traffic Monitor (ATM); at this time the Tornado was turning onto the runway. The ADC was aware that the Tornado would spend some time on the runway prior to rolling, so he continued to monitor the Cranwell traffic on the ATM. When the Tornado became airborne and was at the departure end of the runway, the Cranwell traffic was 8nm away to the NW. The ADC decided to pass Traffic Information as a ‘heads-up’ to the pilot but, because the aircraft was for a SID2, which was RW track to 1200ft or 2.5DME, he was nonetheless confident that it would turn and climb clear of the Cranwell inbound so he did not impose the climb-out restriction. The pilot acknowledged the Traffic Information and immediately reported changing to the Departures frequency. He continued to monitor the traffic on the ATM and saw that the Tornado was later in the turn than would normally be expected.

He assessed the risk of collision as ‘Medium’.

THE CONINGSBY DEPARTURES CONTROLLER reports issuing a release on the Tornado departing on a SID 2 climbing to FL130. The Approach controller was notified about an inbound to Cranwell on a northerly feed, which he approved. It was agreed that a climb out restriction of 1200ft QFE would be put in place against this traffic, and that this would be applied to all departing traffic except the Tornado on release because they both thought it would be well ahead of the Cranwell traffic. The ADC frequency was on speaker, and the Departures controller heard Tower pass the Traffic Information to the Tornado, which at that stage was no factor. However, it took longer than anticipated for the aircraft to power-up and get airborne, which resulted in the Tornado climbing out beneath the Cranwell traffic. The controller gave Traffic Information but unfortunately gave an incorrect position report, and then instructed the Tornado to stop climb at 1200ft. The pilot acknowledged this and subsequently called level; he then reported a TCAS RA and, after a brief pause, called to say the confliction was resolved.

He assessed the risk of collision as ‘Medium’.

THE CONINGSBY SUPERVISOR reports overhearing the UT Approach Controller approve traffic for a northerly approach in the Cranwell radar pattern, and heard them ascertain details. The UT informed the Supervisor of the position of the Cranwell Traffic and, because it was SW of Waddington, he was satisfied that it would not be a factor for the Tornado shortly due to depart. The Instructor and the UT then discussed various courses of action, including issuing a climb-out restriction for all aircraft departing after the subject Tornado. The plan of action was relayed to the Departures controller. On climb-out the Tornado seemed to take longer than normal before the right turn onto north, which put it into confliction with the Cranwell traffic. The Supervisor advised the Departures controller to stop the Tornado climb at 1200ft, which the Departures controller implemented. The Supervisor then heard the Tornado pilot called a TCAS RA, and the controller then correctly allowed the pilot to complete his manoeuvre as required. The Approach controller received a call from Cranwell stating that their traffic had also received a TCAS RA. Shortly afterwards, the Cranwell Supervisor rang to discuss the incident and advise that a DASOR would be filed. Discussion within Coningsby ATC revealed that it was thought that the Sentinel had ‘sensitive TCAS’ that required 1000ft separation. Cranwell ATC had not informed Coningsby ATC that the aircraft was a Sentinel and that it required 1000ft separation; had that happened, then the Tornado would have been held on the ground, or the departure profile amended. 2

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THE CRANWELL APPROACH CONTROLLER reports instructing with a UT controller. The Sentinel was returning from the north and a northerly feed was agreed in advance with Coningsby. His understanding of the Letter of Agreement (LOA) was that once a northerly feed had been agreed, Coningsby outbound traffic and visual circuit would be restricted to 1200ft - once clear of the Cranwell traffic the Coningsby traffic can then climb; the intention being to allow the Cranwell traffic a normal pattern height radar approach without coming into conflict with the departing Coningsby traffic. When traffic departing Coningsby was spotted they were unconcerned at first, believing that it would be stopped off at 1200ft. Coningsby then communicated via landline that they intended to climb up ahead but through the level of the Sentinel. Looking at the tracks at that stage, and believing the departing traffic to be a Typhoon, the controller was still unconcerned, because the climb rate of a Typhoon would have taken it clear. However, it wasn’t communicated by Coningsby that this was in fact a Tornado and, as it became apparent that the climb rate of the Tornado was not enough to ensure separation, the closure rate was such that he decided that avoiding action, without the known intentions of the Coningsby traffic, might put the Sentinel in greater jeopardy. The Sentinel pilot then reported the TCAS RA.

He perceived the severity of the incident as ‘Medium’.

Factual Background

The weather at Coningsby was reported as:

METAR EGXC 021450Z 10004KT 9999 FEW030 BKN180 24/16 Q1017 BLU NOSIG

Analysis and Investigation

Military ATM

The Tornado was under a Traffic Service with Coningsby Departures and the Sentinel was under a Traffic Service with Cranwell Approach.

Portions of the tape transcript are below, between the Sentinel, Tornado, Cranwell Approach (CWL RA), Cranwell Departures (CWL Dep), Coningsby Approach (CBY RA), Coningsby Aerodrome Controller (CBY ADC) and Coningsby Departures (CBY Dep):

From To Speech Time CWL RA CBY RA Cranwell approach, request northerly feed for traffic Scampton 14:49:28 south west one zero miles tracking south east squawking two, six, zero, five. CWL RA Sentinel {Sentinel c/s}, Cranwell approach squawk two, six, zero, seven. 14:49:40 CBY RA CBY RA This one...a two, six, zero, five, so {Tornado c/s} will be ahead of 14:49:48 OJTI him…. CBY RA CWL RA Yeah…yea that is approved. 14:49:54 CWL RA CBY RA Down to one thousand, eight hundred feet our QFE one, zero, one, 14:49:57 zero. CBY RA CWL RA One, zero, one, zero, Roger, thanks Coningsby. 14:49:59 CBY RA CBY Dep Approach, traffic information. 14:51:49 CBY Dep CBY RA Go ahead 14:51:49 CBY RA CBY Dep Erm, Cranwell north west ten miles, tracking east squawking two, 14:51:50 six, zero, seven CBY Dep CBY RA Contact 14:51:54 CBY RA CBY Dep That is a northerly feed and then if we can get {Tornado c/s} away 14:51:54 before him, after that it will be a one thousand, two hundred feet climb out restriction. ADC CBY Dep Tower, request release {Tornado c/s}. 14:52:11 CBY Dep CBY ADC {Tornado c/s} released. 14:52:12 CBY RA CBY ADC Approach, err climb out restriction, not for the {Tornado c/s} but after 14:52:28

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him one thousand, two hundred feet QFE. ADC CBY RA One thousand, two hundred feet after the {Tornado c/s}. 14:52:33 CBY RA CBY ADC That’s against traffic CWL north six miles, tracking east squawking 14:52:35 two, six, zero, seven. CBY ADC CBY RA Contact 14:52:38 CBY RA CBY ADC That’s a northerly feed. 14:52:39 CBY ADC CBY Deps {Tornado c/s} rolling. 14:53:49 CWL Dep CBY RA Go ahead 14:54:13 CBY RA CWL Dep One track, he’s just getting airborne now from Coningsby squawking 14:54:14 one, seven five, three. CWL Dep CBY RA Contact. 14:54:18 CBY RA CWL Dep He’ll be turning to the north...erm. We’ll keep him laterally away 14:54:19 from the two six zero seven. CBY ADC Tornado … (Inaudible)… Traffic west, eight miles, tracking er east, Cranwell 14:54:20 inbound indicating one thousand eight hundred feet. CWL Dep CBY RA Ok that’s the Sentinel. The two six, zero, seven. 14:54:22 CBY RA CWL Dep Thanks. 14:54:25 CWL RA Sentinel {Sentinel c/s} traffic left eleven o’clock seven miles, crossing left 14:54:26 right, one thousand five hundred feet below climbing. CWL RA Sentinel {Sentinel c/s} previously reported traffic is turning to the north, 14:54:32 Coningsby will keep it clear. Tornado CBY Deps {Tornado c/s} airborne passing eight hundred feet traffic service 14:54:34 CBY Tornado {Tornado c/s} Coningsby departures, identified, traffic service. SID 14:54:37 Deps two approved, climb flight level one three zero Tornado CBY Deps Climb flight level one three zero {Tornado c/s}. 14:54:42 CBY Tornado {Tornado c/s} previously called traffic now east north east, four 14:54:44 Deps miles tracking east at one thousand eight hundred feet. CBY Dep Tornado {Tornado c/s} stop climb at height one thousand two hundred feet. 14:54:52 Tornado CBY Deps Stop climb height one thousand two hundred {Tornado c/s} ……and 14:54:56 you called the traffic to the east. CWL RA Sentinel {Sentinel c/s} previously reported traffic twelve o’clock two miles 14:55:02 heading north bound, five hundred feet below climbing. Sentinel CWL RA {Sentinel c/s} is visual and TCAS RA climbing. Tornado CBY Deps {Tornado c/s} TCAS RA... Standby! 14:55:08

At 1451:54, the CGY Approach controller called the Departures controller and identified the Sentinel (squawk 2607) on a northerly pattern at Cranwell, predicted that the Tornado could get away before him and stated that after that all departures would be restricted to 1200ft QFE. At 1452:12 (Figure 1), the Tornado was released by the CGY Departures controller.

Figure 1: Tornado released by CGY Departures with Sentinel 15.9nm away.

CGY Approach then re-iterated to the Aerodrome Controller at 1452:28 that the climbout restriction of 1200ft did not apply to the Tornado. Traffic Information was then passed to the Aerodrome Controller on the Sentinel (using the radar feed on display in the Visual Control 4

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Room). At 1453:49, the Aerodrome Controller provided a ‘rolling’ call on the Tornado as it was departing. At 1454:19 (Figure 2), CBY Approach had informed Cranwell Departures that the Tornado would be turning north and separation on the Sentinel would be lateral.

Figure 2: CGY inform CWL of lateral separation on Tornado outbound turning north.

At 1454:20, the Aerodrome Controller called Traffic Information as, “Traffic west, eight miles, tracking er east, Cranwell inbound indicating one thousand eight hundred feet.” At 1454:37 (Figure 3), CGY Departures identified the Tornado, applied a Traffic Service and approved the SID2 to FL130.

Figure 3: Tornado (squawk 1753) approved on SID2 climbing to FL130.

At 1454:44 (Figure 4), an update was provided by CBY Departures, “previously called traffic now east north east, four miles tracking east at one thousand eight hundred feet.” The Sentinel was in fact west by 5nm.

Figure 4: Traffic Information at 1454:44. 5

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At 1454:52 (Figure 5), the CBY Departures controller issued a stop climb at 1200ft. The Tornado pilot readback the stop climb and questioned the ‘traffic to the east’ call.

Figure 5: CGY Departures issued a stop climb instruction to the Tornado.

The Tornado was in the right turn at 1455:04 (Figure 6).

Figure 6: Tornado turning right at 3.9nm from CGY.

The Tornado reported a TCAS RA at 1455:08. The CPA was estimated between 1455:08 and 1455:16 (Figure 7) with a height separation of 1000ft and 1.1nm horizontally.

Figure 7: Geometry at 1455:16.

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The CGY SIDS are outlined in Figure 8. The SID2 approved on the tape transcript refers to the SID25 North.

Figure 8: Coningsby SIDs.

The Tornado pilot was on a SID in VMC and had initial Traffic Information from Tower, a TCAS TA once airborne, updated and incorrect Traffic Information from Departures and a descent instruction against the profile, coupled with a TCAS RA. The Tornado was on a SID2: Climb to FL150, maintain Rwy Tr to 1200 of 2.5 DME, whichever later, then right on Tr 009 degrees. At the time, the GR4 crew would have been following the SID, responding to TCAS and attempting to get visual sighting of the Sentinel. The pilot reported turning at 2.5 nm DME, as per the SID and the ATC Supervisor commented upon a delay in turning (Figure 6 demonstrated the Tornado in the turn). It is feasible that the Tornado may have required more than 2.5 nm DME to reach 1200 feet and Coningsby ATC were used to station-based Typhoons with a quicker rate of climb and tighter turns.

The Cranwell Approach controller had called two sets of accurate Traffic Information to the Sentinel, as per the provision of a Traffic Service. The LOA between Cranwell and Coningsby (IFR recoveries to Cranwell on a northerly feed) requires Cranwell to identify their aircraft to Coningsby and request the northerly feed. As per the LOA, Coningsby approved the northerly approach at 1800ft Cranwell QFE 1010hPa. The LOA also states that, “CGY will then coordinate IFR traffic as appropriate and warn VFR traffic as necessary.” Having approved a northerly feed, the onus was upon Coningsby to coordinate the IFR Tornado outbound. At 1454:18, Cranwell were informed of the Tornado getting airborne and Coningsby confirmed that they would take lateral separation on the Sentinel.

The Coningsby Approach controller (as discussed by the OJTI and trainee) had initially devised the plan to allow the Tornado to depart unrestricted prior to imposing a climbout restriction on all subsequent departures. At the time of the decision, the Sentinel was at range and the Supervisor 7

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had also thought it a sound plan. Coningsby may be used to Typhoons with potentially a shorter period spent on the runway and higher rate of climb; the Tornado rolled at 1453:49, which was 1 min 37 secs after the release from Departures. Following the rolling call from Tower, the Coningsby Approach controller called Cranwell to identify the Tornado squawk and advise of the intention to achieve lateral separation; at this point, Coningsby Approach still felt that the Tornado could turn north, as per the SID profile, to provide lateral separation.

The Coningsby Departures controller had been provided a plan by the Approach controller and was well aware of the Sentinel positioning. Departures released the Tornado with 15.9nm separation (Figure 1). Once the Tornado was airborne, Departures issued almost continuous transmissions to provide a climb to FL130, Traffic Information and then a stop climb at 1200ft. The Traffic Information was inaccurate (north-east versus west) and this was likely to have been a slip by the controller. Once it was apparent that the original plan of lateral separation would not work, Departures issued the ‘stop climb’ instruction to the Tornado to provide vertical separation. The Departures controller had not witnessed this scenario before and the Sentinel would have been quicker than most tracks experienced in the Cranwell pattern.

Coningsby were attempting to be pro-active and flexible by allowing a non-standard northerly pattern for Cranwell and allowing the Tornado to continue climb on departure; parts of the Radar Vector Chart are above 1200ft and the controllers were generally not keen on maintaining the fast-jet at that height for any length of time. At any point, Coningsby could have insisted on a southerly pattern for the Sentinel, capped the Tornado climb, or held the departure. As events changed, the plan needed to be re-assessed and by the time it was evident that lateral separation was not going to be achieved, the stop climb instruction was passed to rectify the situation, with Traffic Information to amplify.

TCAS had alerted both crews to each other and this barrier was always present. The procedure itself required coordination of a SID against a northerly pattern but the original assessment was that the Tornado would have departed before becoming a confliction for the Sentinel. The ATC team were aware of the aircraft and Traffic Information was passed; however, as the dynamic situation changed, it was apparent that that the original plan of timed deconfliction would not work and the substitute plan of lateral deconfliction was not going to be achieved. The controller had then resorted to height deconfliction but the aircraft were on such trajectories that crews received TCAS RAs. At the closest point the crews were 1.1nm apart with 1000ft height separation. The slow reaction from the whole team may have been a planning/decision making error, as the plan was insufficient to cater for a delayed departure and there was a failure to integrate the information available.

UKAB Secretariat

Both pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. If the incident geometry is considered to be converging then Tornado pilot was required to give-way2, if it If the incident geometry is considered as head-on, or nearly so, then both pilots were required to turn to the right3.

Comments

HQ Air Command

There are lessons for all parties involved in this incident as an Airprox resulted from fairly benign origins. Whilst the controllers at Coningsby and Cranwell wanted to provide each aircraft with the best possible service, safety margins were eroded as the deconfliction plan was always going to be ‘tight’. It relied on the Tornado turning at 2.5nm on the SID whereas a turn initiated at an

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-Way (c) (2) Converging. 3 SERA.3210 Right-of-way (c) (1) Approaching head-on. 8

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altitude of 1200ft and at a distance marginally greater than 2.5nm was more likely given the performance of a heavy Tornado (though on-board recording equipment shows the aircraft commencing a turn at 2.5nm); it may be that the controllers at Coningsby are more used to the performance of Typhoons. TI issued to the Tornado that traffic was to the east may also have led to the pilot believing that there was no ‘urgency’ to turn to the north. Pilots should be mindful that their clearances are issued on an assumption that certain parameters will be met and that the controllers may well be formulating a deconfliction plan based on those assumptions. Contingency plans should also consider alternative actions to maintain separation where the initial plan does not execute as expected (such as an unanticipated delay to aircraft departure resulting in erosion of lateral separation); perhaps a more prudent course of action might have been to apply the climb out restriction to all aircraft in the first instance, and clear the Tornado for further climb if it became apparent that lateral separation would be achieved. Ultimately, the TCAS II systems fitted to both aircraft interacted as expected and issued a coordinated RA once separation had sufficiently reduced. However, the Sentinel pilots were visual with the Tornado in time to take action should the RA not have been issued, and the Tornado pilot had started to tighten his turn based on SA gained from the TCAS, so it is unlikely that the aircraft would have come into close proximity.

Summary

An Airprox was reported when a Tornado and a Sentinel flew into proximity at 1455z on 2 July 2015. The Sentinel was in receipt of a Traffic Service from Cranwell Approach and the Tornado in receipt of a Traffic Service from Coningsby Departures. The Sentinel was operating VFR in VMC; inbound to Cranwell and positioning for a northerly radar pattern. The Tornado was departing Coningsby IFR on a northerly SID. Both pilots received TCAS RAs.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

The Board first looked at the actions of the Tornado pilot. Some of the civilian members wondered whether it was usual for an aircraft to remain on the runway for such a long period of time before take-off, but were assured by the military members that it was normal for some types if, for example, engine checks were required; it is standard procedure for Tornados to conduct a 30 second engine run-up check once lined up on the runway. That said the Tornado spent approximately 1min 30 on the runway and the Board weren’t able to ascertain what caused the delay. Nevertheless, although it didn’t preclude air traffic asking the pilot to expedite if necessary, once the controller had given the pilot the runway by clearing him for departure, the pilot could take as long as he needed to get airborne. Turning to the comments that the Tornado turned late, the Board noted that the Coningsby SID2 was clear in that it required the pilot to remain on runway track until reaching 1200ft or 2.5DME, whichever is later. Military members commented that a heavy-weight Tornado might easily extend beyond 2.5nm before reaching 1200ft. The Tornado pilot had confirmed that he initiated the turn at 2.5DME based on a reading on his HUD, however the radar display indicated that the track went beyond 2.5nm, leading to controller perception that he had turned late. Ultimately the Board noted that the Tornado pilot had descended promptly when instructed to by the controller, and that this, coupled with the TCAS information, had enabled him to see the other aircraft and avoid it in a timely manner.

From the Sentinel pilot’s perspective, the Board thought that there was very little that he could have done differently under the circumstances. Having been told by air traffic that the traffic departing from Coningsby was co-ordinated, the Board felt that he had no way of knowing that the Tornado was not going to keep clear of him. The Board commended him for correctly following the TCAS RA, even though he was visual with the Tornado because, as he rightly pointed out, there could easily have been another aircraft that he was not visual with in the vicinity.

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Turning to Coningsby Air Traffic, the Board acknowledged that they were trying to remain flexible and provide everyone with the service they wanted. However, although the original plan may have been appropriate when it was first made, it clearly required updating once the controllers became aware that the Tornado’s take-off had become protracted. The controllers also had a flawed expectation of what they thought would happen given their experience of station-based Typhoons, but when circumstances didn’t play out as intended, the plan should have been reassessed. Some controlling members felt that the fail-safe option would have been to put a climb-out restriction of 1200ft on the Tornado anyway, and then, if circumstances proved favourable once the exact geometry was known, it would be easier to remove the restriction rather than impose one at the last moment. Returning to the incident itself, controller members acknowledged that the ADC did what he could to help the situation by passing a rolling call to the Departures controller and giving the Tornado pilot Traffic Information as he got airborne; however, they opined that, ultimately, it had been for the radar controllers to decide on suitable action. Finally, they noted that the erroneous Traffic Information from the Departures controller had been unfortunate in compounding the situation; had he passed the correct bearing this may have alerted the Tornado pilot earlier to the proximity of the Sentinel.

In looking at the actions of the Cranwell controllers, the Board felt that the circumstances were largely beyond their control. That being said, it was noted that the Sentinel was quicker than the usual Cranwell traffic of Tutors and King Airs, and some members wondered whether had that been mentioned by the Cranwell controllers during the initial request for the northerly radar pattern the Coningsby controllers might have made a different plan. Members also noted that although the Cranwell controller had told the pilot that the Coningsby traffic was co-ordinated, in fact the telephone conversation between the two units did not include the term ‘co-ordination’; they wondered whether the LOA had lulled the controllers into believing they had protection, when in fact Coningsby VFR traffic would simply only be warned of the Cranwell radar traffic rather than being specifically coordinated against it.

The Board debated at length whether the procedures, and in particular the SID2, were partially to blame for this incident. Some members felt that the option of turning at 2.5DME or maintaining runway track until 1200ft whichever is the later could cause confusion; however, ultimately it was agreed that the Coningsby controllers should have known what the SID was, that there was nothing inherently unsafe about it, and, furthermore, controllers are always able to amend the profile tactically to fit with specific circumstances.

Finally, the Board discussed the merits of TCAS, which, in this instance, had provided both pilots with an instruction to take action, albeit at the same time that the Departure controller had instructed the Tornado to descend. The Board noted the controllers’ comments about the Sentinel’s ‘sensitive TCAS’, but were advised by military members that at the time of the Airprox TCAS was relatively new to the military and that there had been misconceptions about how it worked. Since then, controllers have been educated that the vertical and horizontal boundaries of TCAS alerting are not type- specific, but based on set algorithms.

In looking at the cause of the Airprox, the Board quickly agreed that it was that Coningsby ATC had allowed the Tornado to depart into conflict with the Sentinel. Nevertheless, the actions taken by the pilots had been timely and effective, and so the risk was assessed as Category C.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: Coningsby ATC allowed the Tornado to depart into conflict with the Sentinel.

Degree of Risk: C.

AIRPROX REPORT No 2015101

Date: 2 Jul 2015 Time: 1407Z Position: 5300N 00037W Location: 5nm SW Cranwell

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Tutor (A) Tutor (B) Operator HQ Air (Trg) HQ Air (Trg) Airspace London FIR London FIR Class G G Rules VFR VFR Service Traffic Traffic Provider Cranwell DEP Cranwell DEP Altitude/FL FL035 FL031 Transponder A, C, S A, C, S Reported Colours White White Lighting NK HISLs, nav Conditions VMC VMC Visibility 20km 20km Altitude/FL 2500ft NK Altimeter RPS (1012hPa) NK (NK hPa) Heading 240° 090° Speed 80kt NK ACAS/TAS TAS TAS Alert TA TA Separation Reported 200ft V/<0.1nm H 350ft V/0.5nm H Recorded 400ft V/0.2nm H

THE TUTOR (A) PILOT reports conducting a training flight. The student departed on a SID and was in the climb to 5000ft. Passing 2000ft, on a south-westerly heading, they heard another Tutor being passed Traffic Information on their location. At 2500ft they were told of its location and the instructor directed the student to level the aircraft at 3000ft, to allow 1000ft separation. Shortly after this they were told the other Tutor was at a range of 2nm, in the 12 o'clock, 1000ft above. The TAS showed the other Tutor still descending and closing inside 1nm, at which point the TAS gave a Traffic Alert. The instructor became visual with the other Tutor in a descending turn, pointing towards his aircraft, with the TAS showing 300ft separation. He took control and maintained heading until he was sure of the other pilot’s intentions so that he could take appropriate action to avoid any collision. As the TAS read 200ft, the other Tutor turned away and continued with Cranwell Tower.

He assessed the risk of collision as ‘Low’.

THE TUTOR (B) PILOT reports conducting an Air Experience Flight, returning to base from the west- southwest. He received information on a similar type departing from the airfield which was already showing on TAS and was discussed with the Air Cadet passenger. The aircraft was immediately visually identified in the climb at a range of about 3nm, to the right of the nose, separated horizontally, with more than 1000ft separation. Because he was visual, TAS had alerted and he had Traffic Information on the other aircraft, he continued the descent, maintaining lateral separation of not less than 0.5nm at all times. As they passed abeam, separated vertically by some 300-400ft, he turned through 90° in order to ‘show the other Tutor to the passenger’. The nose of his aircraft remained behind the other Tutor at all times and they continued to diverge. The pilot noted to the passenger that although there was a ‘big sky’, look-out and use of TAS were essential in maintaining SA and separation. He stated that no Airprox had occurred because he was visual with the other aircraft.

He assessed the risk of collision as ‘Low’.

1 Airprox 2015101

THE DEPARTURES CONTROLLER reports that he took over from the off-going controller with Tutor(B) conducting general handling to the west-southwest by about 8-10nm. He could not recall the altitude block. Tutor (A) was pre-noted and got airborne on a SID. Both Tutor pilots were operating under a Traffic Service, and both aircraft were called to each other on the same frequency.

He perceived the severity of the incident as ‘Low’.

THE SUPERVISOR reports he had no recollection of the incident. He subsequently spoke with the Controller who indicated that it was an innocuous event and did not feel it necessary to highlight. ATC were unaware an Airprox had been reported until later on.

Factual Background

The weather at Cranwell was recorded as follows:

METAR EGYD 021350Z 29004KT CAVOK 23/15 Q1017 BLU NOSIG METAR EGYD 021450Z 16002KT 9999 FEW030 SCT090 24/16 Q1017 BLU NOSIG

A transcript of the Cranwell Departures frequency is shown below:

From To Speech Transcription Time Tutor (A) DEP Cranwell departures, [Tutor (A) C/S] uh SID 1B, passing 1000 uh passing 14:03:23 600 feet. DEP Tutor (A) [Tutor (A) C/S], Cranwell departures, identified traffic service, depart SID 1B 14:03:31 Tutor (A) DEP Traffic service [Tutor (A) C/S] 14:03:34 DEP Tutor (B) [Tutor (B) C/S] previous reported traffic west 1 and half mile, south east 14:03:40 bound, 3 tutors slightly below, new Barnsley pressure 1012. Tutor (B) DEP [Tutor (B) C/S], just confirm the lateral displacement 14:03:50 DEP Tutor (B) West 1 and a half miles, south east bound 14:03:55 Tutor (B) DEP Uh, Roger I will take a southerly heading and continue {last part unreadable} 14:03:58 DEP Tutor (B) Roger Barnsley pressure 1012 14:04:01 Tutor (B) DEP 1012 copied 14:04:04 DEP Tutor (B) [Tutor (B) C/S], further traffic just departed Cranwell similar type, east 2 14:05:40 miles, south west bound, 2000 ft below climbing DEP Tutor (A) [Tutor (A) C/S] traffic west 2 miles maneuvering east bound similar type 2000 14:05:57 ft above Tutor (A) DEP [Tutor (A) C/S] 14:06:05 DEP Tutor (B) [Tutor (B) C/S] traffic east 1 mile south west bound, tutor 1000 ft below 14:06:17 climbing out Tutor (B) DEP [Tutor (B) C/S] is looking and uh, sortie complete requesting a mast(?) join 14:06:22 for downwind, visual with that aircraft DEP Tutor (B) [Tutor (B) C/S] roger downwind join approved Runway correction, code R 26, 14:06:34 colour blue, QFE 1010 Tutor (B) DEP Downwind join [Tutor (B) C/S] 14:06:42 DEP Tutor (B) [Tutor (B) C/S] no radar traffic, report visual with the aerodrome 14:06:45 Tutor (B) DEP Visual with the aerodrome [Tutor (B) C/S] 14:06:50 DEP Tutor (B) [Tutor (B) C/S] squawk circuit continue with Cranwell tower stud 2 14:06:52 Tutor (B) DEP Circuit, Stud 2 [Tutor (B) C/S] 14:06:56 Tutor (A) DEP [Tutor (A) C/S] visual with the traffic and uh, request own navigation south 14:07:04 west, uh south east DEP Tutor (A) [Tutor (A) C/S] roger own navigation south east 14:07:10

2 Airprox 2015101

Analysis and Investigation

Military ATM

The incident occurred on 2 Jul 15 at 1410 between two Tutor aircraft, both of who’s pilots were under a Traffic Service from RAF Cranwell ATC. The Radar Analysis Cell captured the incident on radar based upon the London QNH 1018 hPa.

At 1405:40 (Figure 1), the controller transmitted, “{Tutor B}, further traffic just departed Cranwell similar type, east 2 miles south west bound, 2000 ft below climbing.”

Figure 1: Traffic Information at 1405:40 (Tutor A squawk 2613; Tutor B squawk 2611)

At 1405:57 (Figure 2), the controller transmitted, “{Tutor A} traffic west 2 miles manoeuvring east bound similar type 2000 ft above.”

Figure 2: Traffic Information at 1405:57

At 1406:17 (Figure 3), an update was provided, “{Tutor B}, traffic east 1 mile south west bound, tutor 1000 ft below climbing out.”

3 Airprox 2015101

Figure 3: Traffic update at 1406:17

At 1406:22 (Figure 4), Tutor (B) transmitted, “{Tutor B}, is looking and uh, sortie complete requesting a mast (?) join for downwind, visual with that aircraft.”

Figure 4: Tutor B confirming visual at 1406:22

The CPA was estimated at 1406:45 (Figure 5) with 0.3nm and 500ft

Figure 5: Geometry at 1406:45

At 1407:04, Tutor (A) confirmed, “visual with the traffic and uh, request own navigation south west, uh south east.”

4 Airprox 2015101

The controller provided accurate and updated Traffic Information, as per the provision of a Traffic Service. TAS had also alerted both crews to the potential confliction. Tutor(B) reported becoming visual at 2-2.5nm and Tutor(A) was not visual as TAS showed the other aircraft closing inside 1nm; Tutor(A) eventually became visual with Tutor(B). The barriers of TAS information and visual acquisition combined to assist the pilots in maintaining separation in Class G airspace.

UKAB Secretariat

Both Tutor pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. If the incident geometry is considered as head-on or nearly so then both pilots were required to turn to the right2, notwithstanding their responsibility for collision avoidance. The CPA was assessed as 400ft vertically and 0.2nm horizontally from area radar recordings made available to UKAB.

Comments

HQ Air Command

In this incident both pilots were on the same frequency and ATC had provided a Traffic Service to both, informing them of each other’s position. Whilst Tutor (B) pilot was visual with Tutor (A) and was happy with his separation, Tutor (A) pilot was relying on a back-up of TAS to build his SA. A little more communication between pilots and perhaps a slightly wider berth by Tutor (B) would have helped to alleviate Tutor (A) pilot’s concern.

Summary

An Airprox was reported when two Tutor aircraft flew into proximity at 1407 on Thursday 2nd July 2015. Both pilots were operating under VFR in VMC in Class G and both were in receipt of a Traffic Service from Cranwell Departures.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Members quickly agreed that both Tutor pilots had been given relevant and timely Traffic Information and that that they were both visual with the other aircraft before CPA, albeit with Tutor (A) pilot visual at a late stage. Members also agreed that it was probably this late sighting which had increased the Tutor(A) pilot’s concern at the proximity of Tutor(B), which he could see closing on his TAS. Although the Tutor(B) pilot had informed ATC that he was visual about 20sec before CPA, members felt that this may not have materially affected Tutor(A) pilot’s by then increasing concern, and that it was this concern which, members decided, had been the cause of the Airprox.

In the event, Tutor (B) pilot became visual, and flew a descending right-hand turn towards Tutor (A) as they passed, no closer than 0.2nm. Members agreed that there was no risk of collision, but wondered whether Tutor (B) pilot might have been more considerate of the other aircraft and the fact that it’s pilot might not be visual with him, or as comfortable with their relative geometry; a simple turn away or levelling off by Tutor (B) pilot at an earlier juncture would have helped to resolve Tutor (A) pilot’s concerns whilst still enabling Tutor (B) pilot to show the other Tutor to his passenger. Regarding the risk, members debated at some length whether action had had to be taken to prevent collision, or whether this event could be considered as normal operations. After considerable discussion, it was agreed in the end that normal procedures and safety standards had in fact pertained, but they noted that the Tutor (B) pilot had not needed to fly in such proximity to Tutor (A),

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way (c) (1) Approaching head-on.

5 Airprox 2015101 and that it was helpful to avoid other aircraft not by one’s own comfort margin but with consideration for the comfort margin of the other pilot (who might not have the same level of situational awareness as oneself).

Members also commented that, notwithstanding the risk assessment, Tutor (A) pilot had been absolutely correct to file an Airprox; in his opinion, the distance between aircraft, as well as their relative positions and speed, had been such that the safety of the aircraft involved may have been compromised3. It was evident to the Board that an Airprox had occurred, contrary to Tutor (B) pilot’s assertion otherwise.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: Tutor (B) pilot flew close enough to cause Tutor (A) pilot concern.

Degree of Risk: E.

3 The definition of Airprox is established in ICAO Doc 4444: ‘An Airprox is a situation in which, in the opinion of a pilot or air traffic services personnel, the distance between aircraft as well as their relative positions and speed have been such that the safety of the aircraft involved may have been compromised.’

6 AIRPROX REPORT No 2015105

Date: 10 Jul 2015 Time: 0838Z Position: 5048N 00109W Location: Gosport

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft EC135 Cessna 172 Operator HEMS Civ Club Airspace FIR FIR Class G G Rules VFR VFR Service Basic Basic Provider Solent Solent Altitude/FL 1300ft 1500ft Transponder A, C, S A,C Reported Colours Red/Yellow White Lighting HISL, Landing HISL Conditions VMC VMC Visibility 30km 50km Altitude/FL 1300ft 1500ft Altimeter QNH (1022hPa) NK Heading 040° 270° Speed 120kt 110kt ACAS/TAS Not fitted TAS Alert N/A None Separation Reported 100ft V/200m H ~150ft V/~200m H Recorded 200ft V/0.1nm H

THE EC135 PILOT reports on a CAT A Helimed task from the Isle of Wight to Portsmouth. He was under a Basic Service from Solent Radar and had informed Lee Radio of his intentions. He was aware of fixed-wing traffic in the vicinity of the Spinnaker Tower and briefed the crew to look out. On coasting-in, he noticed a Cessna 172 at about 100ft above at 200m range. He took avoiding action by turning right and descending and the Cessna passed safely down the left-hand side, but did not appear to deviate from its original track. He immediately asked Solent whether they had details of the conflicting traffic, which they did and on landing he telephoned Solent Radar to discuss the Airprox with the Watch Manager.

He assessed the risk of collision as ‘High’.

THE CESSNA172 PILOT reports proceeding westbound north of the coastline. Cockpit workload was low and he glanced down at his chart, when he looked up he observed a helicopter in his ten o’clock position, below his altitude, possibly proceeding on a north-easterly track. The helicopter was already in a right-turn and passed down his port side so he perceived that no avoiding action was necessary. He then heard a discussion between the helicopter pilot and ATC and realised they were discussing his aircraft.

He assessed the risk of collision as ‘Medium’.

THE SOLENT CONTROLLER reports providing both aircraft with a Basic Service. The EC135 pilot reported a Cessna 172 passing him and requested the details. The pilot later phoned the Watch Manager and reported that the other aircraft got very close to him. He was informed that he was on a Basic Service and whilst they endeavour to provide relevant Traffic Information, it does depend on controller workload. In this instance, it was very busy with a controller under training, no assistant and the co-ordinator had only just been able to return to position because of manning requirements.

1 Airprox 2015105

Factual Background

The Southampton weather at the time was:

METAR EGHI 100820Z 15006KT 110V190 9999 FEW020 17/08 Q1022

Analysis and Investigation

CAA ATSI

ATSI had access to both pilot reports, the Swanwick radar recording and recordings of the Solent radar (Southampton) and Fleetlands radio.

At 0834:12, the EC135 pilot established communication with Solent Radar and a Basic Service was agreed. The aircraft had just left the Isle of Wight and was tracking northbound towards a Portsmouth hospital at 1300ft. At 0836:32, the C172 pilot established communication with Solent Radar, as he reported passing the Spinnaker Tower at Portsmouth. A Basic Service was agreed as the aircraft tracked westbound at 1500ft. CPA occurred at 0838:15 (see Figure 1). No Traffic Information was passed to either aircraft.

The Solent Radar controller was under training, there was no radar assistant available and the workload was considerable. Under a Basic Service a controller is not required to monitor a flight. Whether Traffic Information has been provided or not, the pilot remains responsible for collision avoidance without assistance from the controller.1

Figure 1 – CPA - Swanwick MRT at 0838:15

UKAB Secretariat

The EC135 and Cessna 172 pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard2. The incident geometry was converging and the EC135 pilot was required to give way to the Cessna 1723.

Summary

1 CAP493 Section 1 Chapter 12 para 2E.5 2 SERA.3205 Proximity. 3 SERA.3210 Right-of-way (c) (2) Converging.

2 Airprox 2015105

An Airprox was filed when an EC135 and a Cessna 172 flew into proximity on 10th July 2015. Both aircraft were in receipt of a Basic Service from Solent Radar. And neither received Traffic Information. The EC135 pilot took avoiding action, but the Cessna pilot did not see the helicopter until after it had taken action.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

The Board first considered the actions of the EC135 pilot. It appeared that he had good situational awareness and was monitoring various frequencies which had alerted him to traffic in the vicinity and he briefed the crew to keep a good look-out. However, it was noted that the helicopter did not have TCAS fitted, and the Board opined that this would have increased his situational awareness also. In the end, members noted that the EC135 pilot had seen the C172 fairly late, and had had to take avoiding action.

For his part, the Board noted that the C172 pilot had also seen the EC135 but had taken no avoiding action because he considered no action was necessary.

The Board commented on the TAS/TCAS elements of the incident wherein it was noted that the C172 had TAS fitted but it was not made clear if any alert was received or even if the unit was turned on. A helicopter member of the Board also stated that he was surprised that the EC135 was not fitted with a traffic awareness or alerting system, although he was aware that increasingly many HEMS aircraft were being fitted with TCAS as part of SMS risk mitigation against mid-air collision.

It was pointed out to the Board that both aircraft involved were on a Basic Service provided by Solent Radar. The NATS member reported that the frequency was very busy at the time, and that the controller involved was under training, which would have both limited any ability to give Traffic Information to aircraft that had only requested a Basic Service.

In determining the cause, the Board quickly agreed that it was simply a late sighting by both pilots. Regarding the assessment of risk, the Board concurred that effective and timely action had been taken to prevent a collision and that this was a Category C incident.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: A late sighting by both pilots.

Degree of Risk: C.

3 AIRPROX REPORT No 2015107

Date: 9 Jul 2015 Time: 1417Z Position: 5311N 00031W Location: Cranwell visual circuit.

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Tutor King Air Operator HQ Air (Trg) HQ Air (Trg) Airspace Cranwell ATZ Cranwell ATZ Class G G Rules VFR IFR Service Aerodrome Traffic Provider Cranwell Tower Cranwell DEPS Altitude/FL 800ft 900ft Transponder A, C, S A, C, S Reported Colours White White/blue Lighting HISLs, nav, HISLs, nav landing Conditions VMC VMC Visibility 30km 10km Altitude/FL 800ft NK Altimeter QFE (1015hPa) QFE (NK hPa) Heading 360° 255° Speed 80kt 130kt ACAS/TAS TAS TCAS II Alert None1 TA Separation Reported 0ft V/50m H 300ft V/500m H Recorded 100ft V/<0.1nm H

THE TUTOR PILOT reports recovering to Cranwell after a solo GH sortie for a join through initials to RW26. At the initial point,2 he made a radio call and was made aware of a King Air on an instrument approach, which he soon saw, in his 7 o'clock. It was apparent at this stage that the circuit ahead was very busy. At 100kts and 800ft, he carried on towards the airfield, on the deadside, constantly looking for the King Air, which was now out of his field of view. His view of the runway was obstructed due to being in the right-hand seat and it being a left-hand circuit, so he often dipped the wing to watch for any aircraft on or around the runway. As he approached the turning point to the downwind leg he extended slightly upwind as he carried out an in-depth look to ensure he was safe to turn and that the King Air was no longer in the area. No traffic was spotted so he commenced the crosswind turn. As he was halfway through the left turn, perpendicular to the runway, he saw the King Air departing in his direction. It seemed like the King Air pilot raised his nose and turned right as he lowered his nose to avoid. Nothing was said on the tower frequency by the King Air pilot so, slightly confused, he regained height and heading and positioned for the downwind leg ready to land. The Tutor pilot noted that, had neither pilot taken avoiding action, the chance of collision was significant. He also stated that he was told by ATC to go around at circuit height, so he turned back onto the deadside, above the RW26 threshold. At this stage he was feeling quite shaken by the events so, to ensure he was safe, this time he requested clearance to turn onto the downwind leg, which was given by ATC. He was then told to go around at circuit height again during the downwind leg, which he did. Noticing he was now close to minimum fuel required on the ground, he requested an early turn to the downwind leg, which was approved. During the turn he noticed a Tutor approaching the low key position on a PFL, and ATC then asked if he was visual with the aircraft out of high key. He had previously been unaware of this aircraft. Knowing the PFL aircraft had priority, and seeing the aircraft

1 The TAS was selected off in the circuit, in accordance with SOP. 2 Initial point is a military term that describes a point 2nm on the approach to the runway, offset to the deadside, through which military aircraft route during visual recoveries.

1 Airprox 2015107 start a turn to the left, he applied full power and extended to initial. After his radio call, and en-route to initial, he was made aware of a King Air on an instrument approach around the area of the initial point, which he never managed to see. After this, he completed a normal and uneventful circuit to land. The pilot noted that he was well over the authorised sortie time and had just enough fuel to make the landing minima. He felt that the visual circuit was overly busy with Tutors, King Airs and a Tucano all performing different types of circuit, as well as with busy mixed instrument pattern traffic often passing through the visual circuit.

He assessed the risk of collision as ‘Medium’.

THE KING AIR PILOT reports conducting an Instrument Rating Test, with the handling pilot ‘under the hood’ and the aircraft captain as the non-handling safety pilot. He had been cleared for a low overshoot on RW26 following an asymmetric approach on the Talkdown frequency. ATC passed the circuit traffic, and advised that there was one Tutor deadside with others in the circuit. On starting the asymmetric go-around, at 250ft, the aircraft captain was looking out for the Tutor on the deadside and switched to Departure frequency. The Tutor was seen late as it turned at 800ft just past the upwind end of the runway and into the climb-out path of the King Air. The aircraft captain took control and manoeuvred to avoid the Tutor.

He assessed the risk of collision as ‘Low’.

THE TOWER CONTROLLER reports he was screening another controller in the position during a busy session with multiple visual circuit and radar traffic. The Tutor pilot requested to join the visual circuit from the southeast, was given the correct instructions and told about radar traffic (the King Air) and how many aircraft were in the circuit. The Tutor pilot appeared to cross the nose of the radar traffic King Air whilst positioning for initial, with about half a mile between them at around the same height. Once the Tutor pilot called initial, the air picture was given, including the radar traffic, and also the surface wind, which is standard practice. As the King Air had conducted its touch and go and departed upwind, the trainee noticed the Tutor pilot crossing in front of it; this looked very close as the screen controller looked towards the Air Traffic Monitor. The screen controller had not been looking in the same direction as the trainee because other aircraft in the circuit required attention. The Tutor pilot was subsequently sent around, the screen controller believed twice more, for further radar traffic. An Airprox was not declared on frequency.

He perceived the severity of the incident as ‘High’.

THE SUPERVISOR reports he was positioned in the VCR as the incident unfolded. He was first aware of the Tutor in question when it joined the circuit from the southeast, cutting across the nose of the King Air on radar to route through initial. As it flew through deadside he could see the Tutor rocking its wings and assumed it was trying to get visual with the King Air (which was now commencing its overshoot) and was presumably trying to decide whether it would have the separation to then cut across in front of the King Air. When the Tutor eventually turned crosswind, the Supervisor commented to the ADC that it would be close with the King Air climbing out. He did not ask the ADC controller to pass Traffic Information to the Tutor as he did not think the Tutor would turn crosswind without being visual with the King Air. Unfortunately there was no way of passing the proximity of the Tutor traffic to the King Air pilot quickly because he would have been changing between the Talkdown frequency and the Departures frequency.

Factual Background

The weather at Cranwell was recorded as follows:

METAR EGYD 091350Z 30005KT CAVOK 19/06 Q1022 BLU NOSIG METAR EGYD 091450Z 27008KT CAVOK 20/05 Q1022 BLU NOSIG

2 Airprox 2015107

Analysis and Investigation

Military ATM

The incident occurred between a Tutor and a King Air in the RAF Cranwell visual circuit at 1417 on 09 Jul 15. The Tutor pilot was under an Aerodrome Service with the Cranwell Aerodrome Controller and the King Air pilot was under a Traffic Service with Cranwell Talkdown. The incident was captured by the Radar Analysis Cell, based upon the London QNH 1023 hPa.

At 1413:50 (Figure 1), the Tutor pilot was given join instructions, “{Tutor c/s} Cranwell Tower join information code Juliet correct, circuit clear with 2 Tutors joining, one via overhead, one via High Key.”

Figure 1: Join instructions at 1413:50 (King Air 2604; Tutor 7010, Mode C 014)

At 1414:14, the Aerodrome Controller transmitted, “All stations, radar traffic 4 miles, low approach for further.” At 1414:19, the Tutor pilot called Initials and at 1414:24, the controller transmitted to all stations, “radar traffic 3.5 miles.”

At 1414:30, the Tutor pilot reported visual with the radar traffic (the King Air). At 1414:50 (Figure 2), the King Air pilot was cleared to low approach with 3 in the visual circuit and this was broadcast to all in the circuit.

King Air

Tutor

Figure 2: King Air cleared to low approach at 1414:50 (Airprox Tutor Mode C 008)

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At 1416:04 (Figure 3), the King Air was on finals indicating 002 on Mode C and the Tutor was established deadside showing 007 on Mode C.

Tutor

King Air

Figure 3: King Air on finals and Tutor deadside at 1416:04

At 1416:55 (Figure 4), the Tutor can be viewed turning crosswind as the King Air is climbing out.

Tutor

King Air

Figure 4: Tutor turning crosswind at 1416:55

At 1417:03 (Figure 5), the aircraft are shown at CPA with 0.1nm lateral and 100ft vertical separation.

4 Airprox 2015107

Figure 5: CPA at 1417:03

The Aerodrome Controller passed the circuit state to the Tutor pilot upon join (circuit clear with 2 Tutors joining for overhead and High Key) and the liaison broadcasts were made to inform of the King Air at 4 miles finals, cleared for a low approach for further radar approaches. The Supervisor was aware that the Tutor pilot was dipping his wing to get visual with the King Air, but the absence of any request for Traffic Information and the crosswind turn had indicated that the Tutor pilot was visual. The circuit had become busy with multiple types of recovery, leading to a high task difficulty for the trainee Aerodrome Controller. The ATC Supervisor had noticed the Tutor pilot looking for the King Air but in a busy circuit, apart from mandated Traffic Information, it may be impractical for ATC to pass constant traffic updates; the crews can ask for specific updates at any time. Solo student sorties are annotated by callsign and should receive the appropriate attention from ATC.

A Duty Pilot was positioned in the Visual Control Room, responsible for the overall supervision of student flights. The Tutor pilot struggled to become visual with the King Air, partly due to the obscuration factors of being in the right-hand seat in a left-hand circuit. The King Air was on a low approach for further radar circuits which meant that the pilot did not switch to the Tower frequency; clearance to use the runway was relayed to the Talkdown Controller. As the King Air was not seen or heard, the Tutor pilot may have assumed that it had accelerated away. The circuit was a complex one, requiring a lot of a student pilot in terms of sequencing and separating against mixed types conducting different types of approaches and patterns. The solo students normally used Barkston Heath as a dedicated airfield; however, the student Tutor pilots were temporarily mixed with the main Cranwell circuit for periods in July 2015.

The normal barriers to an Airprox in the visual circuit would be lookout and ATC-derived circuit Traffic Information. TAS was turned off in the visual circuit, as per local SOP. General information on the three other aircraft entering the circuit was passed, although the other aircraft were joining from different positions: radar, high key and the overhead. An inexperienced pilot was responsible for visually acquiring the King Air prior to turning crosswind. A busy and complex circuit would have increased the workload for all involved and the stressors mentioned on the Tutor pilot, help provide context for the decision to turn crosswind.

5 Airprox 2015107

UKAB Secretariat

The Tutor and King Air pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard3. An aircraft operated on or in the vicinity of an aerodrome shall conform with or avoid the pattern of traffic formed by other aircraft in operation4. Although the King Air TCAS was selected on, its altitude was such that TCAS RA alerts would have been inhibited.

Comments

HQ Air Command

This incident took place in a complex circuit and was exacerbated by the Tutor Pilot’s limited experience. Once informed of the traffic at 4nm, the Tutor Pilot made unsuccessful attempts to visually re-acquire the King Air by dipping his wing; a request for a position update from the Tower controller may have been appropriate. Additionally, an opportunity may have existed for both the Duty Pilot and the Tower controller to proactively assist the solo student by prompting an early turn onto the downwind leg to avoid the potential for confliction. This event also highlights the issue of integrating traffic conducting an IFR procedure in a VFR environment versus traffic in the visual circuit. Thankfully, both the safety pilot in the King Air and the Tutor Pilot became visual, albeit at a late stage, and both pilots made adjustments to their flight path to ensure separation at the CPA.

At the time of this incident, the RAF Safety Centre were conducting a study into Airprox in the Aerodrome environment which concluded that passage of information when joining, mixed speed traffic and integrating radar traffic into the visual circuit were all areas for further analysis. Cranwell are also using this incident as an example of when the Duty Pilot needs to be pro-active.

Occurrence Investigation

This is an honest report from a junior aviator that highlights a number of useful points. The Sqn concerned had only recently relocated to Cranwell from Barkston Heath where they were used to operating in a single type environment. The traffic loading in the circuit at the time of this incident, although at the top end of the expected spectrum, was not over planning assumptions or operating limitations. We have a type specific Duty Pilot in the VCR at all times during Tutor solo student flying and that individual is charged (specifically) with the overall supervision and integration of circuit activity. All sqns will be tasked to use this incident as an example of when the DP needs to be pro-active.

Summary

An Airprox was reported when a Tutor and a King Air flew into proximity at 1417 on Thursday 9th July 2015. Both pilots were operating in VMC, the Tutor pilot, under VFR, in receipt of an Aerodrome Control Service from Cranwell Tower and the King Air pilot, under IFR, in receipt of a Traffic Service from Cranwell Departures.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft, radar photographs/video recordings, reports from the air traffic controllers involved and reports from the appropriate ATC and operating authorities.

Board members first discussed the overall sequence of events. The Tutor pilot had recovered to Cranwell from the southeast and, although he had not been given specific Traffic Information on the

3 SERA.3205 Proximity. 4 SERA.3225 Operation on and in the Vicinity of an Aerodrome.

6 Airprox 2015107

King Air, an all-stations broadcast was made 24sec after his clearance to join had been issued, “…radar traffic 4 miles, low approach for further”. A further all-stations broadcast was made 5sec later, “…radar traffic 3.5 miles”. The Tutor pilot reported he was visual with the King Air 10sec later, at 1440:30, when he was 2nm east-southeast of Cranwell, heading north with the King Air in his right 1.30 at 2nm and at about 3.5nm on the RW26 extended centreline. The Tutor pilot crossed the RW26 centreline 1nm ahead of and co-altitude with the King Air (descending on the glideslope) and turned left for initials. Having then lost visual with the King Air, it was clear to the Board that the Tutor pilot became uncertain as to its position and his repeated lowering of the left wing was an attempt to regain visual contact. He stated he had carried out an ‘in-depth look’ at the end of the downwind leg and, having not seen the King Air, turned left to crosswind and into proximity with the King Air.

Members noted the ATC Supervisor’s comments that he could see the incident unfolding as the Tutor pilot turned crosswind, and they wondered whether the Air Traffic team, including the Duty Pilot, could have helped more by providing more information, or even directing the obviously struggling student Tutor pilot as to when to turn. Members agreed that this would have been appropriate, but also noted that it was for the Tutor pilot to state his predicament if he was unsure; otherwise, ATC would be left in a permanent state of trying to second-guess pilots’ intentions in the circuit and when to intervene. That being said, they also noted that this was an inexperienced student pilot who may have been reticent to communicate his dilemma. It was in this respect that they thought that the Duty Pilot had a key role to play in thinking ahead for the student, and they wholeheartedly agreed with the Occurrence Investigation’s comments regarding the need for Duty Pilots to be pro-active. The military pilot member confirmed that the RAF had recently undertaken a thorough review of visual circuit activities, one of the results of which was that the Duty Pilot role had been clarified and emphasised.

Ultimately, the Board agreed that, notwithstanding his inexperience, it was for the student Tutor pilot to either request Traffic Information on the King Air before he turned or simply extend upwind if he was in doubt, informing ATC of his intentions. Notwithstanding, although members agreed that this would have resolved the situation, they emphasised that a student pilot would likely be more prone to stress factors, in this case that he had exceeded the authorised sortie duration and that he was approaching his minimum landing fuel, which in turn could reduce capacity and the ability to maintain an appropriate level of situational awareness. Mention was also made of the common theme of IFR radar traffic integration into and through the visual circuit; members agreed this was also a factor but that it was also well understood and that current procedures, taken in their entirety, provided effective mitigation against conflict. Finally, members noted that the Tutor pilot had had his TAS turned off, and that this might have been a useful tool in aiding his situational awareness. It was also pointed out that the Tutor pilots were at a very early stage of their flying training and that the addition of TAS information to their situational awareness may be more demanding than was realistically possible.

The Board considered the likely cause and, after further discussion, agreed that although more help would have been appropriate, it was that the student Tutor pilot had turned into conflict with the King Air. The collision risk was assessed by the pilots as ‘Medium’ and ‘Low’, Board members considered, however, that the separation at CPA was such that safety margins had been much reduced below normal, and that both pilots had had to take late avoiding action.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The student Tutor pilot turned into conflict with the King Air.

Degree of Risk: B.

7 AIRPROX REPORT No 2015109

Date: 9 Jul 2015 Time: 1321Z Position: 5349N 00135W Location: Leeds Bradford (LBA) CTR

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft B737 Drone Operator CAT Unknown Airspace LBA CTR LBA CTR Class D D Rules IFR Service Aerodrome Provider LBA Tower Altitude/FL 1800ft Transponder A, C, S Reported Colours Red/white Lighting NK Conditions VMC Visibility >10km Altitude/FL 1800ft Altimeter QNH (1021hPa) Heading 320° Speed 180kt ACAS/TAS TCAS II Alert None Separation Reported 300ft V/300m H Recorded NK

THE B737 PILOT reports fully established on final approach to RW32, passing 1800ft on the ILS. Both crew saw a black and white, 4-rotor helicopter type drone to the left of them. The drone was seen too late to take avoiding action and passed abeam them.

He assessed the risk of collision as ‘Medium’.

THE DRONE OPERATOR could not be traced.

THE LBA TOWER CONTROLLER did not file a report.

Factual Background

The weather at LBA was recorded as follows:

METAR EGNM 091320Z 27011KT 240V320 9999 SCT040 15/13 Q1022=

Analysis and Investigation

CAA ATSI

Radar replay confirmed that no other contacts were visible in the area.

1 Airprox 2015109

UKAB Secretariat

The Air Navigation Order 2009 (as amended), Article 1381 states:

‘A person must not recklessly or negligently cause or permit an aircraft to endanger any person or property.’

Article 166, paragraphs 2, 3 and 4 state:

‘(2) The person in charge of a small unmanned aircraft may only fly the aircraft if reasonably satisfied that the flight can safely be made. (3) The person in charge of a small unmanned aircraft must maintain direct, unaided visual contact with the aircraft sufficient to monitor its flight path in relation to other aircraft, persons, vehicles, vessels and structures for the purpose of avoiding collisions.’ (4) The person in charge of a small unmanned aircraft which has a mass of more than 7kg excluding its fuel but including any articles or equipment installed in or attached to the aircraft at the commencement of its flight must not fly the aircraft (a) in Class A, C, D or E airspace unless the permission of the appropriate air traffic control unit has been obtained; (b) within an aerodrome traffic zone …; or (c) at a height of more than 400 feet above the surface unless it is flying in airspace described in sub-paragraph (a) or (b) and in accordance with the requirements for that airspace.’

A CAA web site2 provides information and guidance associated with the operation of Unmanned Aircraft Systems (UASs) and Unmanned Aerial Vehicles (UAVs).

Additionally, the CAA has published a UAV Safety Notice3 which states the responsibilities for flying unmanned aircraft. This includes:

‘You are responsible for avoiding collisions with other people or objects - including aircraft.

Do not fly your unmanned aircraft in any way that could endanger people or property.

It is illegal to fly your unmanned aircraft over a congested area (streets, towns and cities).

Also, stay well clear of airports and airfields’.

Summary

An Airprox was reported when a B737 and a drone flew into proximity at about 1321 on Thursday 9th July 2015. The B737 pilot was operating under IFR in VMC in receipt of an Aerodrome Control Service from LBA Tower. The drone was being operated within the Class D airspace of the LBA CTR without the permission of the ATSU.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of a report from the B737 pilot, radar photographs/video recordings and a report from the appropriate ATC authority.

Members noted the requirements of Article 166 of the ANO and the additional CAA material regarding drone operations and quickly agreed that, even had they been operating using first-person view (FPV), the drone operator should neither have allowed the drone to fly above 1000ft nor operate over a built-up area. Therefore, because the drone was being flown inappropriately, they determined the cause of the Airprox to be that the drone had been flown into conflict with the B737. Members then

1 Article 253 of the ANO details which Articles apply to small unmanned aircraft. Article 255 defines ‘small unmanned aircraft’. The ANO is available to view at http://www.legislation.gov.uk. 2 www.caa.co.uk/uas 3 CAP 1202

2 Airprox 2015109 discussed the risk and, although there was no measurable data available, after some debate, they decided that for the drone to have been identified specifically as a black and white 4-rotor drone this indicated that it was probably closer than the pilots’ estimate of 300m. As a result, they considered that, in this case, it was therefore likely that safety margins had been much reduced below the normal and that this was a Category B incident.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The drone was flown into conflict with the B737.

Degree of Risk: B.

3 AIRPROX REPORT No 2015110

Date: 14 Jul 2015 Time: 0937Z Position: 5256N 00002E Location: 10nm NW Holbeach

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Tornado A Tornado B Operator HQ Air (Ops) HQ Air (Ops) Airspace Lon FIR Lon FIR Class G G Rules IFR IFR Service Traffic Traffic Provider Marham App Marham App Altitude/FL FL158 FL161 Transponder A,C,S A,C,S Reported Colours Grey Grey Lighting HISLs Conditions IMC IMC Visibility In cloud 20m (in cloud) Altitude/FL FL150 FL170 Altimeter 1013hPa 1013hPa Heading 330° 330° Speed 350kt 250kt ACAS/TAS Not fitted Not fitted Separation Reported 0ft V/0.2nm H 0ft V/~75m H Recorded 300ft V/0.1nm H

THE TORNADO (A) PILOT reports he was No2 in a formation of two Tornados. They had departed from Marham and were conducting a snake climb through IMC layers.1 As the aircraft broke cloud at FL060, the he called ‘visual’ to the leader but briefed that he would maintain the snake climb. Shortly afterwards, Marham ATC informed them that they would have to be a single speaking unit within the next 10nm for their radar handover to Swanwick if they wished to remain as a formation. The lead pilot (in Tornado (B) ahead) briefed that he would slow to 250kts and the No2 pilot then selected reheat to close up on the leader. The No2 aircraft Weapons System Officer (WSO) was “heads-in” to try to establish radar lock on the leader; however, when he looked up he noticed they were IMC again, and asked the pilot to confirm he was still visual with the lead. The pilot replied negative, and the WSO called for a bunt to increase separation. As they bunted, the crew fleetingly gained visual with the lead aircraft on their right, co-altitude and close aboard (subsequent on-board tape analysis indicated 0.2nm separation). They then continued to descend, received a separate squawk from ATC and continued as a separate unit until the formation was able to rejoin visually.

He assessed the risk of collision as ‘High’.

THE TORNADO (B) PILOT reports he was the lead pilot of a pair of Tornados conducting a 30- second snake climb out of Marham. On passing FL120, climbing to FL180, ATC advised that the formation would need to be in standard formation to cross controlled airspace. As the lead pilot, he called slowing to 250kts from the SOP climb speed of 300kts to expedite the join, and noticed the Air- to-Air TACAN range reduce as the No2 closed up. On passing FL170, with the Air-to-Air TACAN reading 0.1nm, the aircraft entered patchy cloud. On exiting the cloud some 4-5 seconds later, the No2 aircraft was seen in the 9 o’clock position, slightly high, at approx 50-100m range moving away

1 A snake climb is a military procedure whereby formations of aircraft follow each other during IMC climbs after take-off, normally separated at 30 second intervals. The leader calls each turn on the radio, and subsequent aircraft wait their specified separation time before they then turn to follow the same track. If still IMC at the top of climb, each aircraft levels at their own Flight Level, stepped down from the leader.

1 Airprox 2015110 from the lead aircraft, at which point the aircraft entered cloud again. With the formation now split again, and in IMC, a separate transit altitude through the airway was requested from ATC.

He assessed the risk of collision as ‘Medium’.

Factual Background

The weather at Marham was reported as:

METAR EGYM 140850Z 29003KT 7000 HZ FEW010 SCT014 BKN015 18/15 Q1016 GRN NOSIG

Analysis and Investigation

Military ATM

The Airprox occurred between two Tornados (Fang formation) under a Traffic Service from RAF Marham. The Marham controller was in the process of handing over Fang to RAF (U) Swanwick at the time of the Airprox.

Portions of the tape transcript between Fang and Marham Approach (RA) are below:

From To Speech Transcription Time Fang RA Approach Fang one passing fifteen hundred feet requesting Deconfliction 09:31:49 Service. RA Fang Fang one Marham Approach identified Deconfliction Service reduced climb 09:31:53 flight level one eight zero own navigation. Fang RA Deconfliction service reduced climb flight level one eight zero own 09:31:59 navigation Fang one flight. RA Fang Fang one are you urgh happy MARSA2 with Fang two? 09:32:07 RA Fang Fang one flight what heading are you rolling out on? 09:32:55 Fang RA Three three zero fang one flight. 09:33:00 RA Fang Fang one flight roger. 09:33:01 RA Fang Fang one are you happy with MARSA Fang two? 09:33:51 Fang RA Affirm Fang one. 09:33:55 RA Fang Fang one roger, report holding hands.3 09:33:57 Fang RA Wilco Fang one. 09:33:59 RA Fang Fang one flight I will need you holding hands within the next one zero miles 09:35:08 to hand you over to Swanwick. Fang RA Copied Fang one. 09:35:14 RA Fang Fang one flight there is traffic to the west one zero miles believed to be a 09:36:42 threeship or fourship of Typhoons coordinated to the west. Fang RA Copied and Fang one is holding hands. 09:36:50 RA Fang Fang one roger. 09:36:53 RA Fang Fang one flight traffic twelve o clock one five miles opposite direction 09:37:05 indicating flight level one three zero. Fang RA Looking Fang one. 09:37:12 RA Fang Fang two squawk standby. 09:37:20 ??? ??? Passing one seven zero now. 09:37:40 RA Fang Fang one flight continue with Swanwick mil two five nine decimal six zero. 09:37:44 Fang RA Two five nine six zero fang one flight. 09:37:48

2 MARSA - Military Accepts Responsibility for Separation of Air Systems. 3 ‘Holding hands’ is a military term for flying in formation.

2 Airprox 2015110

At 0936:44 (Figure 1), Fang can be viewed in trail.

Figure 1: Geometry at 0936:44 (Fang 1 squawk 6074; Fang 2 squawk 3542).

Figure 2 at 0937:01 shows Fang 2 closing at 450 knots.

Figure 2: Fang 2 closing at 0937:01.

At CPA, the aircraft were showing 0.1nm horizontal separation and 300ft vertical separation, at 0937:18 (Figure 3).

Figure 3: CPA at 0937:18.

3 Airprox 2015110

Marham Approach applied a reduced Deconflcition Service in the climb to FL180. The controller checked that the flight were content with Military Accepts Responsibility for Separation of Air Systems (MARSA). MARSA is defined as, “Within a formation of military Air Systems the formation leader is responsible for separation between units comprising the formation.”4 Following agreement of MARSA, the controller would not be expected to deconflict the two elements within Fang formation. The regulations also state that, “Prior to a formation entering CAS, controllers will obtain confirmation on RT that all formation elements are contained within 1 nm laterally and longitudinally for military Air Systems and are at the same level.”5 By confirming that the formation were ‘holding hands’, the controller was confirming that the crew were complying with formation procedures for controlled airspace.

The controller’s responsibility was for deconflicting Fang with other aircraft and not within the formation. The request for the formation to close was based on the requirements to cross controlled airspace.

UKAB Secretariat

Both pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard6. SERA rules for formation flights are as follows:

Aircraft shall not be flown in formation except by pre-arrangement among the pilots-in-command of the aircraft taking part in the flight and, for formation flight in controlled airspace, in accordance with the conditions prescribed by the competent authority. These conditions shall include the following:

(a) one of the pilots-in-command shall be designated as the flight leader; (b) the formation operates as a single aircraft with regard to navigation and position reporting; (c) separation between aircraft in the flight shall be the responsibility of the flight leader and the pilots-in- command of the other aircraft in the flight and shall include periods of transition when aircraft are manoeuvring to attain their own separation within the formation and during join-up and breakaway; and

(d) for State aircraft a maximum lateral, longitudinal and vertical distance between each aircraft and the flight leader in accordance with the Chicago Convention. For other than State aircraft a distance not exceeding 1 km (0, 5 nm) laterally and longitudinally and 30 m (100 ft) vertically from the flight leader shall be maintained by each aircraft.7

Comments

HQ Air Command

This incident led to a detailed investigation on the Unit concerned and a number of recommendations have been made. The snake climb procedure, when correctly flown, is a valid IMC formation procedure. However, deviation from pre-briefed parameters will invariably increase the likelihood of misunderstanding unless clear direction is forthcoming from the formation leader. Furthermore, as the joining aircraft there should always be an ‘escape plan’ (lateral or vertical separation) and this should be vocalised within the crew. Following the investigation, a review of the Tornado Force handbook covering snake climb and radar trail procedures has been undertaken and snake climbs are being considered for inclusion within the Tornado simulator syllabus. This incident is also used as an example when delivering Human Factors and Crew Resource Management training to the Tornado Force.

4 MAA RA 3234(1) para2. 5 MAA RA 3234(1) para 8. 6 SERA.3205 Proximity. 7 SERA.3135 Formation Flights

4 Airprox 2015110

Summary

An Airprox was reported on 14 July 2015 at 0937 between two Tornados. The Tornados were trying to effect a formation join between cloud layers but did not achieve this before entering IMC. Both aircraft were receiving a Traffic Service from Marham ATC but were operating as a single entity responsible for their own intra-formation separation. Tornado (A) was the No2 in the formation and was rapidly closing on his leader from behind as they entered cloud. As the aircraft broke through the cloud, the No2 pilot saw the lead aircraft in close proximity.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

The Board heard from the military members that the snake climb had been used successfully for many years in the Tornado force, there were specific procedures involved to ensure it’s safe use, but that it did need a fair amount of time and track miles to effect a join up after achieving VMC; they emphasised that the join up was not intended to be in IMC.

Some Board members wondered whether ATC had enticed the formation to rush their join by asking them to be in close formation to cross controlled airspace; however, other pilots with military experience opined that they would have been well aware of the need to join up before they crossed through controlled airspace, and that this would undoubtedly have been briefed during their mission planning, as would a contingency plan should they be unable to do so.

Ultimately, members agreed that the weather conditions had not been suitable for the join up, and the Board opined that it was fundamentally the lead pilot’s responsibility to make that decision, and for the No2 pilot not to try to attempt to do so if he could not be sure that he would remain VMC throughout. The Board heard that it was a relatively junior pilot in Tornado (A), and wondered whether he felt pressured by the more experienced crews around him into continuing a course of action which was clearly not ideal, when in fact he should have broken out of formation using an escape manoeuvre before he went IMC during the closure. They also wondered about the wisdom of the WSO focusing on achieving a radar lock on the leader, helpful though that might have been in providing a relative position for the pilot to use as a reference, when his inexperienced pilot was trying to effect a visual join in what were clearly marginal conditions. The Board heard that since the Airprox the Standard operating Procedures for snake climbs have been rewritten to specifically state that formations should go into trail positions should they go IMC whilst trying to join up. Furthermore, in the future the RAF intended to include snake climbs as part of simulator training.

When determining the cause, the Board agreed that the root cause was that the Tornado (A) pilot flew into conflict with Tornado (B) during the formation join. However, they assessed that it was a contributory factor that Tornado (B) pilot had instructed Tornado (A) pilot to close up in conditions that were not suitable. The Board discussed whether to make any recommendations with regard to snake climbs but, in the end, agreed that the Unit OSI had made sufficient recommendations which would only be repeated by the Board. When discussing the risk, the Board agreed that neither pilot had taken avoiding action and, although Tornado (A) had bunted, this was thought to have been after CPA and so the risk was assessed as Category A, chance had played a major part in events.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: Tornado (A) pilot flew into conflict with Tornado (B) during the formation join.

Contributory Factor(s): Tornado (B) pilot instructed Tornado (A) pilot to close up in conditions that were not suitable.

Degree of Risk: A.

5 AIRPROX REPORT No 2015112

Date: 15 Jul 2015 Time: 1145Z Position: 5254N 00333W Location: IVO Lake Vyrnwy

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft Hawk Hawk Operator HQ Air (Trg) HQ Air (Trg) Airspace LFA7 LFA7 Class G G Rules VFR VFR Service None None Altitude/FL 700ft agl 600ft Transponder A,C,S A,C,S Reported Colours Black Black Lighting Strobes, Nose Strobes, Nav and nav lights lights. Conditions VMC VMC Visibility >10km >10km Altitude/FL 250ft 615ft agl Altimeter RPS (1015hPa) RPS(1015hPa) Heading 180° 355° Speed 420kt NK ACAS/TAS Not fitted TCAS II Alert N/A TA Separation Reported 0ft V/1500ft H 100ftV 0.2nm H Recorded NK

THE HAWK (A) PILOT reports he was the wingman in Mustang, a formation of 2 Hawks conducting low-level simulated attack profiles in LFA 7. Prior to the flight, CADS had indicated a confliction with Jester, and the QFI of Jester 2 made contact in order to establish a de-confliction plan. However, it was established that, due to a difference in routing, there would be time-separation of 8 minutes in the operating area and so no confliction existed. Once airborne, prior to entering the area, Mustang gave a position report on the low-level common frequency, Jester responded indicating that they were conducting low-level operational manoeuvres in the same area. Due to the previous CADS confliction and subsequent telephone conversation, Mustang believed that Jester were completing their exercise and egressing the area to the NW. During a southbound turn, Mustang 2 became visual with a Hawk T2 aircraft in the left 9 o’clock also heading south. Whilst the QFI of Mustang 2 was briefing the student on the forthcoming target run, the student became visual with yet another aircraft directly on the nose, heading north, also at low-level. The student called ‘break right’, and the QFI, who was flying at the time, broke up and right to break the confliction. During the manoeuvre, he also became visual with the other aircraft and so reversed the turn to pass down its left-hand side. Further calls were made on the low-level frequency to establish whether it was part of Jester formation; however, this could not be confirmed. A subsequent radio call by Jester indicated that the formation was climbing to above 5000ft to allow Mustang to complete their exercise. After landing it was confirmed that the conflicting aircraft was Jester 1.

He assessed the risk of collision as ‘Medium’.

THE HAWK (B) PILOT reports that he was the QFI in Jester 1, the lead aircraft in a pair of Hawk T2s tasked with conducting a student low-level operational-training-manoeuvre sortie in LFA 7. Prior to the sortie, Jester 2 QFI telephoned Mustang 2 QFI, who it was known were also planning to conduct a sortie in LFA 7. It was established that there was a 30-min difference in planned take-off times and,

1 Airprox 2015112 provided Jester’s take-off time didn’t slip, there would be no confliction. At the out-brief, CADS was played through and checked by the crew and the Duty Authoriser. No conflictions were shown. Importantly, the play through happened before the Mustang formation had placed a ‘tac-box’ (an area specified by Mustang in which they would be manoeuvring tactically) on the northern plain and so this tac-box was not known about by Jester. Jester 2 subsequently needed to take a spare aircraft and this caused a delay to their planned take-off time. When signing out the spare aircraft, Jester 2 QFI asked the Duty Authoriser to slip their CADS and low-level booking times, and to telephone Mustang’s Duty Authoriser as there could now be a confliction between the pairs. Although not time- pressured, the QFI did not physically re-check CADS, this was done by the Duty Authoriser who noted that a confliction now appeared at 1155, (see Figure 1), as Jester entered Mustang’s ‘tac-box’ at the time that Jester were planning to exit low-level and climb to medium level.

Figure 1 screenshot of CADS forecasting the routing of the two formations.

As Jester 2 crewed-in to the replacement aircraft he reported the details to the lead crew on the radio. Mustang were also starting up at the time, and so Jester lead asked Mustang to contact him on the formation ‘chat’ frequency, which they did, and a deconfliction plan was discussed. From this it was established that Mustang would approach the northern plain at 1150z, flow north to Lake Brenig for a target which they would attack twice, spending 5 minutes in total on the plain.

Once airborne, at 1140:40 Mustang made a call to Jester on the low-level deconfliction frequency stating that they were 3 minutes away from the northern plain. This was acknowledged, and Jester lead decided to action an operational tactical manoeuvre that would take the formation away from the northern plain, where they would hold clear while Mustang flowed north to their target. At 1142:37, as the formation recovered from their manoeuvre, 2 TCAS contacts appeared and a traffic audio warning sounded. Jester lead turned away from the TCAS confliction; Jester 2 also received a traffic warning at 1142:47 and Jester 2 QFI directed the student to climb, shortly afterwards spotting one aircraft low and slightly behind. Mustang made another transmission on the low-level frequency that they had seen Jester at Lake Bala and were heading north to their target. This was acknowledged by Jester.

Immediately after this, at 1143:22, Mustang transmitted that they were now resetting south. This call was not acknowledged by either of the Jesters, who were now split by 9nm and had implemented their blind sanctuary plan (a height stack). Between 1143:22 and 1145 a series of calls were made between Jester 1 and 2 as they organised a rejoin. As it transpired, not realising that Mustang had split into separate units, both of the Jester crew had spotted Mustang 2 and believed it to be their

2 Airprox 2015112 lead/wingman. At 1144:52 Jester 1 attempted to join Mustang 2. In the next 40 seconds further radio calls were made both on the Low-Level frequency and on Jester’s formation frequency, and it became clear that a break down in situational awareness had occurred. Only at this point did Jester become aware that Mustang had also split. Jester lead then elected to climb the formation to 5000ft and hold until Mustang had completed their training. He noted that despite that fact that he had mis- identified Mustang as his wingman, he assessed the risk of collision as low because he was visual with the aircraft at range.

He assessed the risk of collision as ‘Low’.

Factual Background

The weather at Valley was reported as:

METAR EGOV 151150Z 34010KT 9999 FEW035 15/07 Q1021 BLU NOSIG

Analysis and Investigation

UKAB Secretariat

Both pilots shared an equal responsibility for collision avoidance and for not flying into such proximity as to create a danger of collision1. If the incident geometry is considered as head-on, or nearly so, then both pilots were required to turn to the right2.

Comments

HQ Air Command

A number of barriers to MAC were only partially effective in the lead-up to this incident: both formations had entered their routes onto CADS but some information was incomplete; the supervisors of the formations consulted each other and agreed a plan that relied on time deconfliction that was eroded by a delay to the take-off of one of the formations; the back-up plan of deconfliction by radio was subject to radio performance at low level in undulating terrain. In an ostensibly see-and-avoid environment the final barrier of lookout – cued by the TCAS II fitted to the Hawk T2s – led to sufficient separation between aircraft being achieved. The lessons here are clear – a number of tools exist to minimise the likelihood of MAC but lookout remains the final – and vital – barrier.

Summary

An Airprox was reported on 15 July 2015 at 1145 between two Hawks in LFA 7. Both Hawks were VFR and VMC and were conducting low-level sorties in the LFA. Neither pilot was receiving an ATS. Prior to take-off CADS had highlighted a confliction and the pilots were aware that the other would be operating in the area. The incident takes place beneath the radar cover of the NATS radars, so the exact separation is not known.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft and radar photographs/video recordings, and reports from the Operating Authorities.

The Board first considered the actions of the pilots and noted with some disappointment that despite both of these formations being from the same unit, CADS being used, one-to-one discussions on deconfliction taking place before take-off, and RT calls being made during an encounter prior to the

1 Rules of the Air 2007 (as amended), Rule 8 (Avoiding aerial collisions). 2 SERA.3210 Right-of-way (c) (1) Approaching head-on.

3 Airprox 2015112

Airprox in question, the 2 formations had still managed to come into unintended close proximity. The Board noted that during initial planning it had become obvious to the formations that there was a potential confliction if Jester delayed, which became a reality when Jester’s take-off time slipped. Although commendable that the pilots had made themselves aware of the conflict, and had formed a contingency plan to overcome it, it was evident that this plan had not been robust enough in that it relied on 2 highly dynamic formations establishing contact at low-level in mountainous terrain in order to pass information to each other. Superficially, this plan looked sound, but it rested on an assumption that the other formation would hear the transmissions. Although it was not for the Board to detail specifically how the formations should have operated, members with military fast-jet experience felt that there should have been a ‘hard’ deconflicition line imposed such that unless positive clearance had been obtained that one of the formations had excited the area, the other should not proceeded beyond.

The Board discussed at some length whether there were any supervisory issues at play. They noted that the Duty Authoriser was aware of the initial potential confliction problem if Jester delayed, but perhaps didn’t intervene enough to ensure that any contingency deconfliction plan was robust. It was also unclear to the Board whether Jester 2 was ever made aware of Mustang’s ‘tac-box’ when CADS was checked on the re-brief after the first aircraft went unserviceable. In the end, the Board agreed that, whilst the Duty Authorisers had the chance to add some input which might have helped cue the pilots to the issues, ultimately the responsibility for robust deconfliction lay with the individual pilots.

The Board noted that there had been a number of barriers in place to prevent a confliction from occurring, CADS, radios and timing, but these were all eroded to the point where only TCAS and pilot look-out were present. In the end, members felt that it was probably the TCAS alerts to Jester formation that gave the pilots the information they needed to avoid Mustang on the first encounter, and that the second encounter and subsequent Airprox had resulted from a loss of situational awareness from Hawk (B) pilot when he mis-identified Hawk (A) as his wingman and tried to join up in formation with him, from a head-on position, thereby startling the Hawk (A) pilot. Turning to the cause of the Airprox, the Board initially debated this as a late sighting. However, although they acknowledged that Hawk (A) pilot didn’t see Hawk (B) until the last moment, it was evident that Hawk (B) pilot was visual with Hawk (A) the whole time, and was actually intentionally manoeuvring in his proximity to effect a join up with what he thought was his wingman. In the end, members agreed that the most apt description of the incident was that the Hawk (B) pilot had flown close enough to Hawk (A) to cause its pilot concern. That being said, they thought that there were also two contributory factors: firstly, that there had been a loss a situational awareness by Hawk (B) pilot; and, secondly, that the deconfliction plan between Jester and Mustang was not robust enough. Notwithstanding, in discussing the risk, the Board agreed that although the separation may have been less than ideal, because Hawk(B) pilot was always visual with Hawk(A), there was no risk of collision and so the incident was assessed as Category C, timely avoiding action had been taken.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: Hawk (B) pilot flew close enough to Hawk (A) to cause its pilot concern.

Contributory Factor(s): 1. Loss of situational awareness by Hawk (B) pilot. 2. The back-up deconfliction plan between Jester and Mustang was not robust enough.

Degree of Risk: C.

4 AIRPROX REPORT No 2015116

Date: 23 Jul 2015 Time: 1100Z Position: 5757N 00113E Location: North Sea

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft EC225 BA146 Operator Civ Comm Civ Comm Airspace FIR FIR Class G G Rules VFR VFR Service None Basic Provider N/A Aberdeen Altitude/FL 500ft 800ft Transponder A,C A,C,S Reported Colours Blue/white White/blue Lighting Anti collision HISL, landing, nav Conditions VMC VMC Visibility 10K 10K Altitude/FL 500ft 750ft Altimeter QNH (1008hPa) Rad Alt Heading 090° NK Speed 145kt 210kt ACAS/TAS Not fitted TCAS II Alert N/A None Separation Reported 200ft V/0.5nm H 500ft V/1nm H Recorded 300ft V/NK H

THE EC225 PILOT reports being inbound to the Britannia oil platform in the North Sea. He was in receipt of an Offshore Traffic Service from Aberdeen. After descending through 1500ft he requested a frequency change and was told there was no known traffic to affect his descent. Five minutes from the rig he spotted an unknown aircraft at 1.5nm in a descending steep turn towards him at about 500ft. He turned right and descended to 300ft before then climbing back to 500ft and continuing the flight to his destination.

He assessed the risk of collision as ‘High’.

THE BA146 PILOT reports performing a NOTAM’d low-level survey activity in the North Sea on north-west/south-east tracks at 750ft. At the end of a run, and in a left turn onto a south-easterly track, he noticed a helicopter. By turning right and climbing, he positioned his aircraft behind and above the helicopter.

He assessed the risk of collision as ‘None’.

THE ABERDEEN CONTROLLER reports providing a Basic Service to the BA146 and an Offshore Traffic Service to the EC225. When the helicopter called for descent and a change of frequency, he informed the pilot he had no traffic to effect his descent and to continue offshore. At the time he was aware of the BA146 south-east of the helicopter some 10miles away, but it was heading south-east.

1 Airprox 2015116

Factual Background

The Aberdeen weather at the time was:

METAR EGPD 231050Z 24010KT 9999 FEW042 16/08 Q1008 NOSIG

The BA146 NOTAM was as follows:

A) EGTT EGPX B) 1507230830 C) 1507231530 E) MET RESEARCH FLT. BAE146 ACFT CALLSIGN METMAN OPR WI AREAS CHARLIE AND DELTA (SEE UK AIP). ACFT MAY NOT BE ABLE TO FLY SEMI-CIRCULAR FL. ACTIVITY MAINLY UNDER SWANWICK (MIL) CTL. SONDES WILL NOT BE DROPPED. ALL OPS SUBJ PRIOR ATC CLR. RTE AVBL FM 0600HR ON DAY OF FLT AT WWW.FAAM.AC.UK. 15-07-0820/AS2 F) SFC G) FL350

Analysis and Investigation

CAA ATSI

The EC225 was en-route to the Britannia Platform, in receipt of an Offshore Traffic Service. The BA146 was flying a north-westerly track, at low-level, in receipt of a Basic Service. Prior to the Airprox, the BA146 turned in the vicinity of the Alba and Britannia platforms onto a reciprocal track (Figure 1, Area A). Another helicopter flying inbound to this area approximately 30nm ahead of the EC225 had been passed traffic information on the BA146, as had the BA146 on the helicopter. On initial contact with the Aberdeen controller, the pilot of the EC225 was advised that there was no- known traffic to affect his descent, he was instructed to report passing 1500ft and given a barometric pressure setting.

Figure 1 – 1049:45

At 1053:40, the controller terminated the service being given to the EC225 and cleared the pilot to leave the frequency, which the pilot of the EC225 acknowledged. At this time the BA146 was manoeuvring approximately 35nm ESE of the EC225 at an indicated altitude of 800ft, the EC225 was descending, passing an indicated altitude of 1800ft (Figure 2).

2 Airprox 2015116

Figure 2 – 1053:30

At 1058:09, the BA146 had re-established on a north-westerly track back towards the area of the platforms flying at an indicated altitude of 800ft. The controller made a call to the EC225, which was now maintaining an indicated altitude of 500ft, but received no response (Figure 3).

Figure 3 – 1058:09

At 1059:50 a cursor was placed over the EC225 contact on the controller’s radar display (Figure 4).

Figure 4 – 1059:50

At 1100:36, the controller measured the distance between the EC225 and BA146 contacts on their radar display. The EC225 was maintaining an indicated altitude of 500ft and the BA146 800ft with an indicated horizontal separation of 2.5nm (Figure 5).

3 Airprox 2015116

Figure 5 – 1100:36

At 1100:44 the BA146 disappeared from radar, directly ahead of the EC225. The EC225 contact was observed making a right turn, now at an indicated altitude of 400ft (Fig 6).

Figure 6 – 1100:44

At 1101:37 the BA146 reappeared on radar now on a south-easterly track at an indicated altitude of 1000ft. The EC225 was observed making a turn to the left, with a climb to an indicated altitude of 600ft (Figure 7&8).

Figure 7 – 1101:37

4 Airprox 2015116

Fig 8 – 1102.01

The BA146 continued on its south-easterly track and descended to an indicated altitude of 500ft. The EC225 disappeared from radar at 1104:07 having completed a 180° turn to the right within the red- dashed area on the controllers radar display.

At no time did the controller pass Traffic Information to the BA146 on the EC225. However, when this point was raised by the unit investigator, the controller stated that because he had given the BA146 pilot the offshore frequency for the Britannia Platform, he had assumed that the Britannia radio operator would pass traffic information to the BA146 pilot on the EC225 and vice-versa. The controller was relatively new to the sector and as a result of this incident was debriefed on the level of service available from the offshore radio stations, and how this scenario could have been better handled.

UKAB Secretariat

Both pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. If the incident is considered as converging then the EC225 was required to give way to the BA1462.

Summary

An Airprox was reported when an EC225 and a BA146 flew into proximity at 1100 on Thursday 23rd July 2015. Both pilots were operating under VFR in VMC, the EC225 pilot not in receipt of an ATC Service and the BA146 pilot in receipt of a Basic Service from Aberdeen.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

The Board first considered the actions of the EC225 pilot. They noted that Aberdeen had told him that there was no traffic to affect, and they opined that the EC225 pilot would justifiably have felt some surprise when he had then sighted the BA146. Some members wondered whether this would have been reinforced by the oil platform’s radio operator also telling him he had ‘no known traffic’ although presumably this was only based on what was scheduled to land at the rig rather than any other information of aircraft in the area. The Board wondered whether the unexpected encounter with the

1 SERA.3205 Proximity 2 SERA.3205 Right-of-way (c) (2) Converging

5 Airprox 2015116

BA146 had therefore increased the EC225 pilot’s perception of the risk given that he had seen the BA146 at 1.5nm, which ordinarily would be sufficient distance to effect a timely and effective response. They noted, however, that the EC225 pilot had felt it necessary to descend to 300ft, and that he had described the risk of collision as high.

Turning to the BA146 pilot, the Board noted that he was operating under a Basic Service, and some members questioned whether this was appropriate. The NATS member pointed out that although the radar tracks were visible in the screenshots provided, the limitations in radar cover in that area meant that tracks were intermittent and that a Traffic Service would therefore not be reliably achievable. Members then went on to examine the NOTAM that had been issued for the BA146’s activities, and commented that although it was in itself very non-specific, with little of value other than to provide generic information on airspace and heights which covered most of the North Sea, important routing details were available at the website given in the NOTAM, which could have been accessed by the EC225 pilot and ATC. There was a practical issue regarding whether the EC225 pilot and ATC would have been sufficiently cued to do this, or would have simply taken the NOTAM at face-value. It was acknowledged that the nature of meteorological research work meant that mission parameters often changed at the last minute, and members wondered how pro-active the EC225 pilot would have been in searching out the additional information, whether North Sea helicopter pilots had become desensitised to the NOTAM, and how pro-active the BA146 pilot had been in providing specific routing details to the Aberdeen controller (other than the website link) either before getting airborne or in-flight, so that ATC could then inform other aircraft. Board members felt that the fact that NOTAMs could not be easily submitted in a timely manner for dynamic operations was a contributory factor to the incident because it meant that the EC225 pilot was not as well informed as he might have been had the BA146’s activities been more explicitly linked to the operating area and heights of the rigs in the NOTAM itself. However, ultimately, they noted that the BA146 pilot had also spotted the EC225 in good time during his turn left, and that he had assessed there was no risk of collision as he then turned his aircraft right and climbed to position behind and above the helicopter.

The NATS representative then gave an account of the NATS internal investigation to explain what had influenced the controller’s actions. The Aberdeen controller had given Traffic Information on the BA146 to another helicopter that was some 20 miles ahead of the EC225, but when the EC225 pilot requested to leave his frequency, he had not given similar Traffic Information because the BA146 was heading in a south-easterly direction away from the helicopter. When the BA146 turned back towards the EC225 some two minutes before the incident, the controller unsuccessfully attempted to call the helicopter but by then it was on a different frequency. Members acknowledged this but enquired why the controller had not given generic Traffic Information that the BA146 was operating in the area, even if it was not specifically a threat at the time the EC225 had left the frequency. They also asked why the BA146 was not told of the proximity of the helicopter; although the BA146 was in receipt of only a Basic Service, the controller was obviously aware of the potential confliction because he had interrogated the radar return and had tried to contact the EC225. The NATS member replied that the controller was relatively new to the sector and was unsure as to what service if any, was being provided by the oil platform which he assumed they were both talking to. Members felt that the lack of Traffic Information to either of the pilots were contributory factors in the incident, and also pointed out that there seemed to have been misconceptions both by the controllers and the pilots as to the level of service, if any, provided by platforms within the North Sea.

In debating the circumstances of the Airprox, the Board assessed that it had more to do with the fact that the EC225 pilot had reportedly been surprised by the sight of a large aircraft at low-level conducting a steep turn towards him, in an area that was usually the domain of oil-rig helicopters, rather than any real risk of collision per se. After much debate, they decided that the cause of the incident was that the EC225 pilot had been concerned by the proximity of the BA146. The discussion on risk ebbed and flowed as members noted the vastly different perceptions by the pilots; ‘high’ from the EC225 pilot and ‘none’ from the BA146 pilot. In the end, the Board concluded that both pilots had seen each other early enough that no risk of collision had existed; timely and effective actions had been taken to prevent the aircraft from colliding.

6 Airprox 2015116

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The EC225 pilot was concerned by the proximity of the BA146.

Contributory Factor(s): 1. Aberdeen did not give traffic information to the EC225 pilot regarding the BA146. 2. Aberdeen did not give Traffic Information to the BA146 pilot despite being aware of the proximity of the EC225. 3. The NOTAM regarding the BA146 did not provide useful information.

Degree of Risk: C.

7 AIRPROX REPORT No 2015120

Date: 30 Jul 2015 Time: 1510Z Position: 5249N 00153W Location: ~ 5nm WNW Tatenhill

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft EC135 Light Aircraft Operator HEMS Unknown Airspace London FIR London FIR Class G G Rules VFR Service Basic Provider Birmingham Altitude/FL NK Transponder A, C, S A, C Reported Colours Red/yellow Lighting Strobe, nav, landing/search lights Conditions VMC Visibility >10km Altitude/FL 1200ft Altimeter QNH (1019hPa) Heading 290° Speed 125kt ACAS/TAS TCAS I Alert Choose an item. Separation Reported 50ft V/100m H Recorded NK

THE EC135 PILOT reports departing Tatenhill on a HEMS tasking. Shortly after departure another aircraft was seen at a range of 3nm, passing left to right and higher than their level altitude. He called the traffic to the helicopter crew for observation; it appeared to be tracking slightly behind. Having just left Tatenhill frequency, he called Birmingham Radar for a Basic Service and reported the other traffic in case its pilot was also working the Birmingham frequency. The other ‘Robin like’ aircraft was then observed to roll abruptly right and descend towards their current track, towards Tatenhill. Avoiding action was taken by rolling left away from the conflict, with the other aircraft passing close down the starboard side on a reciprocal course. The Airprox was initially reported on Birmingham Radar frequency with a follow up call by telephone later.

He assessed the risk of collision as ‘High’.

THE LIGHT AIRCRAFT PILOT could not be traced.

THE BIRMINGHAM CONTROLLER did not file a report.

Factual Background

The weather at East Midlands was recorded as follows:

METAR EGNX 301520Z 27014KT 9999 SCT042 18/06 Q1019

1 Airprox 2015120

Analysis and Investigation

CAA ATSI

CAA ATSI had access to a transcript of the Birmingham RTF. The EC135 pilot made an initial call to Birmingham Radar, requested and was given a Basic Service. He also reported visual with traffic in his 11 o’clock position which the Birmingham controller acknowledged. 90 seconds later, the EC135 pilot reported that the traffic he had previously been visual with had subsequently turned towards him, requiring him to take avoiding action. The Birmingham controller stated that coverage was poor in that area, that she thought she had seen a primary contact in that area, but that there was no secondary radar information.

Under a Basic Service there is no requirement to continually monitor the flight. A report by Birmingham ATC, confirmed that the helicopter had not been identified and was only painting intermittently on their radar. A review of area radar recordings also failed to show either the helicopter or any conflicting traffic in his vicinity. If a primary contact had been visible to the Birmingham controller, they would not necessarily be able to correlate that with the aircraft reported by the helicopter pilot. As the pilot of the helicopter had already reported visual with the traffic against which he subsequently took avoiding action, it could be assumed that he would maintain his own separation against that traffic.

UKAB Secretariat

The EC135 and light aircraft pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. If the incident geometry was converging, as reported, the light aircraft pilot was required to give way to the EC1352. The EC135 first appeared on area radar when 2nm west-northwest of the reported position, and some 1½min after the reported time of CPA. A radar return with VFR squawk was observed approaching the reported position of the Airprox at the corresponding time. The aircraft return indicated a descent but faded when 1.6nm west-southwest of, and 40sec before, reported CPA. Although each aircraft appeared separately on area radar recordings, they did not do so together in the reported vicinity of the CPA.

Summary

An Airprox was reported when an EC135 and a light aircraft flew into proximity at about 1510 on Thursday 30th July 2015. Both pilots were operating in VMC, the EC135 pilot under VFR and in receipt of a Basic Service. The light aircraft pilot could not be traced.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of a report from the EC135 pilot, radar photographs/video recordings and a report from the appropriate ATC authority.

Members first discussed the pilots’ actions and wondered whether the light aircraft pilot had seen the EC135. Given the reported sudden manoeuvre and reduced separation at CPA, it was considered unlikely that this was the case. On the other hand, the EC135 pilot had seen the light aircraft at range and was able to monitor it and subsequently take effective avoiding action when he saw it turning towards him. In the absence any further information on which to base an assessment of the geometry and separation, members commended the EC135 pilot for actively monitoring the light aircraft, which they felt he had probably seen as early as prevailing circumstances permitted, and agreed that he had taken the action necessary to significantly reduce the risk of collision. It had simply been unfortunate that the light aircraft had rapidly turned towards him as they closed, although members commented that there may have been value in the EC135 pilot considering an early turn

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way (c) (2) Converging.

2 Airprox 2015120 away on the first sighting just to account for such eventualities. The premise being that one should never assume that the other pilot is aware of one’s presence and may therefore manoeuvre unexpectedly, as happened in this case, given that they cannot be expected to give way to an aircraft they are not aware of.

Based on the information available, and noting that the circumstances of the light aircraft pilot were unknown, members agreed that the cause of the Airprox was a conflict of flight paths in Class G airspace, and that the EC135 pilot had resolved the conflict. Some members felt that the reported separation was such that safety margins had been much reduced and they wanted to classify the risk as Category B. However, in the discussion that followed, the counter view was that the EC135 pilot was visual with the light aircraft throughout the encounter and was always ready to manoeuvre if required; in the end, the majority opinion was therefore that effective and, given the circumstances, timely action had been taken to prevent the aircraft colliding.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: A conflict in Class G resolved by the EC135 pilot.

Degree of Risk: C.

3 AIRPROX REPORT No 2015123

Date: 30 Jul 2015 Time: 1045Z Position: 5200N 00306W Location: IVO Talgarth

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft SHK-1 Glider F15 Operator Civ Pte Foreign Mil Airspace Lon FIR LFA 7 Class G G Rules VFR VFR Service None None Altitude/FL NK NK Transponder Not fitted A,C,S Reported Colours White Grey Lighting Nil Anti-colls, 3 x position lights Conditions VMC VMC Visibility NK 12km Altitude/FL 1600ft 500ft agl Altimeter QFE QNH Heading 090° 330° Speed 60kt 450kt ACAS/TAS Not fitted Not fitted Separation Reported 200ft V/0ft H Not Seen Recorded NK

THE GLIDER PILOT reports ridge soaring in the Black Mountains at ridge-top height. He was flying from one ridge to another, passing over Gospel Pass Valley, when an F15 flew underneath the glider, crossing right to left, in a south to north direction.

He assessed the risk of collision as ‘High’.

THE F15 PILOT reports that he descended low-level at Pandy into the UKLF structure and transmitted on the low-level common frequency his intentions to remain within LFA 7 for 15-20 minutes. He flew down the Llantony Valley at 500agl and followed the planned route up the eastern- most valleys of the Black Mountains, marked on the UKLFD chart with a fast jet flow arrow. He then executed a ridge crossing at Gospel Pass, which is between 1600-2200ft MSL: in accordance with training regulations to remain 500ft agl, he was 2100-2700ft AMSL. He was aware of the glider site on the NW side of the black Mountains, and addressed the site in his mission planning and brief. Consequently he executed a clearing manoeuvre to the left and was looking west in the direction of the site during the ridge crossing. The crew did not see the glider.

He assessed the risk of collision as ‘None’.

Factual Background

The weather at Cardiff was reported as:

METAR EGFF 301020Z 31011KT 280V350 9999 FEW032 SCT048 16/08 Q1020

1 Airprox 2015123

Analysis and Investigation

UKAB Secretariat

Comments

Black Mountains Gliding Club Safety Officer

The Llantony valley has long been used as a low-level route and was (and probably still is) designated as such on the RAF low-level maps. During the 1990s that route was much used by the Harrier force, and we then had an understanding with the RAF that we would try to avoid crossing the Gospel Pass below 3,000 ft (QNH) on weekdays. That normally put any low-level fast-jet traffic well below the gliders. However military low-level activity is much reduced in recent years so this guidance may have been forgotten by our members, but I see no reason why previous understandings cannot be revived. The glider was 1600 ft on QFE Talgarth which would have been 2600 ft QNH.

USAFE

The F-15 crew were aware of the glider site and had planned accordingly. However, they - and indeed the wing - were unaware of any informal agreement made in the 1990s between the former Harrier Force and Talgarth.

Summary

An Airprox was reported on 30 July at 1045 between a glider and an F15. Both aircraft were flying VFR and VMC and neither were receiving an ATS. The glider was ridge soaring in the Black Mountains and saw the F15 pass beneath him. The F15 was in LFA 7 and did not see the glider.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft.

The Board first looked at the actions of the glider pilot. He was ridge soaring, which the Board were told can involve a high cockpit workload. The Board wondered whether the recent decline in military fast-jet low-flying meant that he was unused to seeing aircraft low-flying in that area. They noted, as they had on previous Airprox, that military flow arrows do not appear on civilian charts, and wondered whether, had it been, this may have enhanced the glider pilot’s awareness that fast-jet traffic may use the area, and also the direction in which they would be travelling (see diagram for the military version of the map which shows the flow arrow just to the East of the glider site). The Board noted that the Safety Officer at Talgarth referred to previous informal agreements between the military and the glider site, which he offered to resurrect. Whilst members welcomed such endeavours, they cautioned against setting up informal agreements,

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way.

2 Airprox 2015123 which invariably get forgotten about over time, and instead advocated making any such procedures more formal and therefore published in the AIP for all to see. Military members indicated that it would be possible to set up such agreements again, should personnel at the glider site wish to instigate them.

The Board were informed by the USAFE representative that the F15 pilot was based in the UK and was very familiar with the UKLFS. He had noted during his planning the glider site to the north-west of his exit point of the valley, and the Board commended him for proactively looking for gliders as he went past; it was simply unfortunate that, in this case, the glider was further north-east and above him and so he didn’t see it.

Ultimately, the Board agreed that this was see-and-avoid airspace where both pilots were entitled to operate. An ATS was not available to either pilot due to height and the terrain, and neither pilot had TAS or FLARM at their disposal to help in the detection of the other aircraft. Both pilots were therefore relying on look-out to mitigate the risk of collision.

In looking at the cause of this Airprox, the Board agreed it was a non-sighting by the F15 pilot and, because he hadn’t seen it until it passed underneath him, effectively a non-sighting by the glider pilot. When assessing the risk, the Board agreed that, although neither pilot had had time to take avoiding action, the separation had been sufficiently large that this could be assessed as Category B, recognising that safety margins had been much reduced below the norm.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: Non-sighting by the F15 pilot and effectively a non-sighting by the glider pilot.

Degree of Risk: B.

3 AIRPROX REPORT No 2015125

Date: 23 Jul 2015 Time: 1451Z Position: 5323N 00044W Location: 2nm WSW Sturgate airfield

PART A: SUMMARY OF INFORMATION REPORTED TO UKAB

Recorded Aircraft 1 Aircraft 2 Aircraft PA28 DA40 Operator Civ Pte Civ Trg Airspace London FIR London FIR Class G G Rules VFR VFR Service None None Provider Sturgate Radio Sturgate Radio Altitude/FL 1300ft 1400ft Transponder A, C, S A, C, S Reported Colours White/blue White/red Lighting Red tail beacon, Wing tip strobes white wingtip strobes Conditions VMC VMC Visibility 30km 8km Altitude/FL 1500ft 1800ft Altimeter QNH (1010hPa) QNH (NK hPa) Heading 010° 265° Speed 110kt 90kt ACAS/TAS Not fitted Not fitted Separation Reported 150ft V/60m H 200ft V/NK H Recorded 100ft V/<0.1nm H

THE PA28 PILOT reports that he called Waddington about 10 miles south of Sturgate to advise that he was going to land at Sturgate and wanted to go to their frequency. The squawk was changed to 7000 and he called Sturgate. He received no reply, but because he was a regular visitor, he was fully aware of the normal joining procedures. He made a traffic call advising that he was joining from the south, and that his intentions were to join downwind right for RW27. This involved routing through the centre line for RW27 which he did at 1500ft, 2 miles west of the field. He judged that he was unable to route around to the south of the field due to the Scampton restricted area, which Waddington had advised was hot, and that he could not do an overhead join for the same reason. He heard a call on the Sturgate frequency from a departing aircraft calling ‘rolling’ and so he and the other two experienced pilots in the aircraft looked out to try and become visual with the departing aircraft. At a point to the south east of Gainsborough the passenger pilot in the right-hand seat shouted urgently ‘descend now’, which he did immediately and rapidly and in so doing saw an aircraft to the right climbing above his aircraft. He continued the rapid descent to 1000ft, levelled off, and continued the approach to Sturgate as intended without further incident. Subsequent to the incident, and after discussion with the other experienced pilots in the aircraft, the pilot noted that the difficulty in seeing the other aircraft was compounded by its constant bearing prior to CPA and its colour making it difficult to see against the ground area background. It was believed that the other aircraft pilot did not see the PA28 until the last moment, when avoiding action was taken.

He assessed the risk of collision as ‘High’.

THE DA40 PILOT reports he climbed out of Sturgate on RW27 runway heading, intending to break off climb at about 2000ft, cross the Trent, and head south for Gamston staying out of the Doncaster CTA. Near top of climb, he lowered the nose for another forward vision check, and the other aircraft was seen left, forward and lower on a converging course. His reaction was to climb while the other

1 Airprox 2015125 aircraft passed under him. He estimated 200ft vertical separation although, in the nose up attitude, it was difficult to estimate separation.

He assessed the risk of collision as ‘Medium’.

Factual Background

The weather at Scampton was recorded as follows:

METAR EGXP 231450Z 28010KT CAVOK 18/06 Q1015 BLU

Analysis and Investigation

UKAB Secretariat

The PA28 and DA40 pilots shared an equal responsibility for collision avoidance and not to operate in such proximity to other aircraft as to create a collision hazard1. The incident geometry was converging and the PA28 pilot was required to give way to the DA402. The entry for Sturgate in a well known Flight Guide does not stipulate a preferred join but states:

‘Flights above the aerodrome are limited to 1500 ft aal.

Variable circuits on Rwy 09/27.’

Summary

An Airprox was reported when a PA28 and a DA40 flew into proximity at 1451 on Thursday 23rd July 2015. Both pilots were operating under VFR in VMC, neither in receipt of an Air Traffic Service.

PART B: SUMMARY OF THE BOARD'S DISCUSSIONS

Information available consisted of reports from the pilots of both aircraft and radar photographs/video recordings.

The Board first discussed the pilots’ actions. The PA28 pilot had made his intentions known on the Sturgate A/G frequency (there was no A/G Service at the time) but it was not clear whether the DA40 pilot had heard or assimilated those transmissions. However, the PA28 pilot did hear the DA40 pilot’s call of ‘rolling’, which prompted the occupants to lookout towards the airfield. The Board noted that it had been the right seat occupant who saw the DA40 at a late stage and had directed the pilot to ‘descend now’. Members agreed that the PA28 pilot probably saw the DA40 at about CPA. For his part, the DA40 pilot had departed from Sturgate, heading west in the climb, and had regularly lowered the nose of his aircraft to check for traffic ahead. This resulted in him seeing the PA28, albeit at close range, and re-establish the climb to increase separation. Members commented that both pilots had, by their actions, enabled the detection of the other aircraft, and had then taken appropriate action to ensure that collision was avoided.

However, members also felt that the PA28 pilot’s flight might have been conducted differently. The PA28 pilot stated that the proximity of the Scampton restricted area precluded his routeing south or joining overhead Sturgate. The Board disagreed, and felt that whilst a left-hand circuit to RW27 was constrained, it was possible. Similarly, they felt that a right-hand overhead join to RW27 was also entirely feasible, albeit conforming to the airfield 1500ft height limitation would require a modified version of the overhead join. Members recalled circuit joining issues being causal factors in previous Airprox and reiterated that, in their view, an overhead join provided the best opportunity to remain clear of other traffic operating in the vicinity of an airfield whilst establishing the circuit direction and

1 SERA.3205 Proximity. 2 SERA.3210 Right-of-way (c) (2) Converging.

2 Airprox 2015125 other participants in order to integrate effectively. It was also felt that, in this case, the downwind right-hand join to RW27 was always going to involve crossing the active runway centreline and that this was best done through the crosswind position, where other circuit traffic could better be seen and which afforded a degree of deconfliction from departing traffic, whichever runway was being used. They noted that the PA28 pilot was aware of the DA40 departing, and opined that crossing the extended centreline 2nm out at 1500ft without having it visual increased the risk of confliction, especially since the PA28 pilot was required to give way.

Lastly, members noted that both the PA28 and the DA40 pilots had had the opportunity to increase their situational awareness by restating their respective positions and intentions explicitly if they were uncertain of each other’s locations (allowing for the fact that the DA40 pilot may not have heard or assimilated the PA28 pilot’s radio call in order to prompt further action in his respect).

Turning to the cause, members agreed that the PA28 pilot was responsible for giving way to the DA40, and that he had flown into conflict with it. Although both pilots took avoiding action to prevent collision, and the pilot reports indicated the PA28 may have been slightly lower than the DA40 anyway, it was felt that in this instance safety margins had been much reduced below the norm.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The PA28 pilot flew into conflict with the DA40.

Degree of Risk: B.