Final Report No. 2075 by the Aircraft Accident Investigation Bureau

Büro für Flugunfalluntersuchungen BFU Bureau d’enquête sur les accidents d’aviation BEAA Ufficio d’inchiesta sugli infortuni aeronautici UIIA Uffizi d'inquisiziun per accidents d'aviatica UIAA Aircraft Accident Investigation Bureau AAIB

concerning the serious incident (AIRPROX) involving the Cirrus SR20 aircraft, registration HB-KHF and the Piper PA-28-181 aircraft, registration HB-PPV

on 24 June 2008

approximately 3.5 NM east of Bern-Belp Airport

Aéropôle 1, Route de Morens, CH-1530 Payerne Final Report HB-KHF/HB-PPV

General information on this report

This report contains the AAIB’s conclusions on the circumstances and causes of the accident/serious incident which is the subject of the investigation.

In accordance with Art 3.1 of the 9th edition, applicable from 1 November 2001, of Annex 13 to the Convention on International Civil Aviation (ICAO) of 7 December 1944 and Article 24 of the Federal Air Navigation Act, the sole purpose of the investigation of an aircraft accident or serious incident is to prevent accidents or serious incidents. The legal assessment of accident/incident causes and circumstances is expressly no concern of the accident investigation. It is therefore not the purpose of this investigation to determine blame or clarify questions of liability.

If this report is used for purposes other than accident prevention, due consideration shall be given to this circumstance.

The definitive version of this report is the original in the German language.

All times in this report, unless otherwise indicated, follow the coordinated universal time (UTC) format. At the time of the incident, Central European Time (CET) applied as local time (LT) in Switzerland. The relation between LT, CET and UTC is: LT = CET = UTC + 2 hours

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Final Report

Aircraft HB-KHF, Cirrus SR20 Owner and operator: Private

Bern-Belp (LSZB) – Bern-Belp (LSZB)

Type of operation: Training flight, IFR

HB-PPV, Piper PA-28-181 Owner and operator: Segel- und Motorfluggruppe Grenchen [Grenchen gliding and flying club]

Grenchen (LSZG) - Bern-Belp (LSZB)

Type of operation: Private flight, VFR

Crew HB-KHF Trainee pilot: French citizen, born 1958 Flying instructor: Swiss citizen, born 1944

HB-PPV Pilot: Swiss citizen, born 1982

Location Approximately 3.5 NM east of Bern-Belp airport

Date and time 24 June 2008, 14:24 UTC

ATS unit Bern aerodrome control, control tower TWR

Air traffic controllers Aerodrome controller, aerodrome control ATCO ADC

Swiss citizen, born 1955

______

Airspace D

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1 Factual information

1.1 History of the flight

On the afternoon of 24 June 2008, the flying instructor made an IFR training flight on a Cirrus SR20 aircraft, registration HB-KHF, with the trainee pilot. Ac- cording to the flying instructor’s statement, the trainee pilot had approximately 15 IFR flying hours’ experience on this aircraft type. The flight took off and landed in Bern. The trainee pilot’s task was to fly to beacon VOR WIL after take- off and then to make two IFR approaches in Bern.

In the Bern control tower the approach (APP) and aerodrome control (ADC) workstations were each manned by one air traffic controller (ATCO). The traffic volume was average and of elevated complexity. A Beechcraft KingAir, callsign Navchecker 411, was making calibration flights for the new runway 14 instrument landing system, and this increased the workload. The two aircraft involved in the serious incident, as well as Navchecker 411, were on the 121.025 MHz Bern tower (TWR) aerodrome control frequency.

At 14:01:29 UTC, the crew of HB-KHF received clearance from the ADC with the standard departure route SID RAMOK2S (see Annex 1) and at 14:13:24 UTC they received taxiing clearance to runway 14, BRAVO intersection.

At the same time, the pilot of the Piper PA-28, callsign HB-PPV, was on a VFR flight from Grenchen to Bern. He reported to Bern TWR for the first time at 14:15:45 UTC. At this point in time he was flying over the town of Kirchberg at an altitude of 4500 ft AMSL. His intention was to fly via reporting point NOVEM- BER into the Bern control zone (CTR) (see Annexes 2 and 3). However, because of the traffic situation, the ADC ATCO instructed him to fly in via reporting points HASLE and ECHO for the left downwind for runway 14. This instruction was confirmed correctly by the pilot of HB-PPV after a brief query.

At 14:17:40 UTC the crew of the Cirrus HB-KHF reported their readiness for take- off to Bern TWR and requested a back track to the start of runway 14; this was approved by the tower. At 14:19:24 UTC, shortly before take-off, the crew of the Cirrus HB-KHF were given traffic information about the inbound Piper HB-PPV by the ADC ATCO: “Hotel Hotel Foxtrot, VFR traffic about ten miles north-east of the field inbound to… join left downwind runway one four, single engine, keep an eye”. The crew replied: “Will do, Hotel Hotel Foxtrot”. The ADC ATCO then cleared the Cirrus HB-KHF for take-off.

Shortly afterwards, at 14:19:51 UTC, the pilot of HB-PPV was also given traffic information in the form of essential local traffic information (see section 1.6.1) concerning the Cirrus SR20 which was taking off and which would pass through its flight level in a climb in a north-easterly direction: “Hotel Papa Victor look out for… a… single engine traffic departing runway one four, north-east bound, climbing through your level”.

The pilot answered that he would keep an eye out for a single-engined aircraft and at the same time reported his position over HASLE at an altitude of 4500 ft AMSL.

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At 14:22:08 UTC, the crew of Navchecker 411 received clearance from aerodrome control for a “low go-around” on runway 14. At the same time it was informed via traffic information about the position of the Cirrus and the Piper.

At 14:23:20 UTC the pilot of the Piper HB-PPV received traffic information from the ADC ATCO about the position of the Navchecker 411: “Hotel Papa Victor keep an eye for a ... twin engine, in a go around runway one four, in a left turn direction north. The pilot answered: “Looking out for the twin engine, Hotel Papa Vic- tor, thank you”.

At 14:23:32 UTC the Navchecker 411 was issued with a second traffic information about the Cirrus which had taken off from Bern and the approaching Piper as follows: “Navchecker four one one to confirm, we have a Cirrus on ah... two miles east of Bern beacon, three thousand feet, north-east bound, and ah... opposite traffic four miles north-east of the field, four thousand feet for left downwind for runway one four, Piper”. The crew replied to this information with: “Yeah roger, looking out”.

At 14:23:51 UTC the pilot of the Piper HB-PPV reported his position, ECHO, at an altitude of 3800 AMSL. The ADC ATCO then issued the pilot with further essential local traffic information: “Hotel Papa Victor report on downwind and the advised Cirrus is ah... at your twelve o’clock, range half a mile, three thousand three hundred feet in climb”. At this time HB-PPV and NB-KHF were roughly on an opposite course. The Cirrus HB-KHF was at an altitude of 3300 ft AMSL, climbing to FL 80.

At 14:24:07 UTC the pilot of the Pilot HB-PPV reported visual contact with the twin-engined Navchecker. According to his statement, he had seen the Navchecker above the line of the horizon at an early stage, but was initially unable to detect the lower-flying Cirrus.

The pilot of the HB-PPV stated that he had seen the opposing aircraft late and was only able to pull slightly on the controls. Shortly before the two aircraft crossed, the flying instructor in the Cirrus HB-KHF saw the opposing aircraft which in his estimation was somewhat higher. He gripped the controls in a reflex action and according to his statement carried out an avoiding manoeuvre to the left and descending slightly.

According to the radar recording, the minimum separation between the two aircraft was a lateral distance of 0.1 NM and an altitude difference of 200 ft, at an altitude of approximately 3500 ft AMSL.

The flying instructor in the Cirrus HB-KHF later stated that the convergence could have been very dangerous if he had not seen the other aircraft shortly before he crossed it. The pilot of the Piper HB-PPV assessed the situation as “tight”, since he saw the opposing aircraft so late.

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1.2 Meteorological information

The following information was provided by MeteoSwiss.

METAR Bern

LSZB 241420 VRB02KT 9999 FEW110 BKN150 29/15 Q1017 NOSIG=

TAF Bern

LSZB 241200Z 241322 33005KT CAVOK TEMPO 1320 9999 FEW050 SCT 120=

On the basis of the available information, it is possible to conclude that the weather conditions at the time of the incident in the airspace above Bern between 3000 and 4000 ft AGL were as follows:

Cloud: 1-2/8 at 11,000 ft AGL. 5-7/8 at 15,000 AGL

Weather: -

Visibility: over 10 km

Wind: 3000 ft AGL: south-west at 15 kt

4000 ft AGL: south-south-west at 15 kt

Temp./dew point: 3000 ft AGL: 19°C / 10°C

4000 ft AGL: 18°C / 02°C

Atmospheric pressure: QNH LSZH 1017 hPa, LSZH 1017 hPa, LSZA 1016 hPa

Position of the sun Azimuth 251°, elevation 48°

Hazards: None detectable

1.3 Aircraft: Cirrus HB-KHF

The Cirrus HB-KHF aircraft was equipped with a TAS (traffic advisory system), type Sky 497. The TAS is used mainly in smaller executive and sports aeroplanes. It shows the pilot, on a screen, aircraft that are flying in the surrounding airspace within a circumference of 6 NM and within an altitude band of plus/minus 9000 ft, if these are equipped with a transponder and have it switched on. In the event of a possible risk of collision, an audio alert “traffic, traffic” is generated in addition to the corresponding symbol on the screen. Unlike a TCAS (traffic collision avoidance system), no avoiding manoeuvres (reso- lution advisories – RA) are generated on the TAS. After the Cirrus HB-KHF took off and shortly after it turned onto the standard departure route SID RAMOK2S in the direction of intersection ZB520, the crew received a TAS indication on the multifunction display in the cockpit and at the

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same time the audio alert: “traffic, traffic”. According to the flying instructor’s statement, this made him aware that an aircraft was dangerously close. Both pilots then scanned the airspace. About 20 seconds after they had been made aware by the TAS, they saw the aircraft flying towards them.

The flying instructor saw the aircraft in approximately the “one o'clock” direction, somewhat higher. In a reflex action, he pushed on the controls and initiated a slightly downward left turn.

When the two aircraft crossed, the crew of the Cirrus HB-KHF felt the turbulence caused by the Piper HB-PPV passing above them. At this time, the right door on the Cirrus disengaged from the lock and remained slightly open. This caused the crew to abort the flight and return to Bern. A few minutes later the aircraft landed in Bern-Belp without further incident.

1.4 Aircraft: Piper PA-28 HB-PPV

The Piper HB-PPV aircraft was equipped with a Mode S transponder. The latter was switched on in A/C mode with Code 7000.

The pilot was following the approach route instructed by Bern Tower, which was via reporting points HASLE and ECHO. At 14:19:51 UTC, when over HASLE, approximately 4 minutes before the serious incident, he received the first traffic information about the Cirrus HB-KHF taking off from Bern. According to his state- ments, it was clear that an aircraft would be flying towards him. He then intensified his monitoring of the airspace.

After the traffic information from the ADC ATCO concerning the position of the Navchecker 411, the pilot located the Beechcraft KingAir relatively early above the line of the horizon. He was unable to detect the second aircraft, the Cirrus HB-KHF, which was lower. At reporting point ECHO, he received the second traffic information from the ADC ATCO concerning the Cirrus, which was half a mile in front of him on an opposite heading. Shortly afterwards, the pilot of the Piper HB-PPV saw the Cirrus. He realised that the aircraft would fly under his aircraft and pulled a little on the controls to increase the vertical separation.

1.5 Air traffic control

Bern aerodrome control is equipped with a Tower Air Situation Display (TASD). The radar data for the TASD is supplied by the Zurich Multi Radar Tracker (MRT). The ATCO possessed a rating for approach radar air traffic control. According to Bern Tower regulations it was within the ADC ATCO’s discretion to provide radar services.

According to the radar recording, the Cirrus HB-KHF was first displayed on the TASD at 14:23:27 UTC at an altitude of 3000 ft AMSL, while the Piper HB-PPV was already visible above Kirchberg at the time of the first call. When HB-KHF was first displayed, the Piper HB-PPV was still about 4.5 NM away from reporting point ECHO.

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Figure 1: Sketch of the flight paths of HB-KHF and HB-PPV. Reporting point HASLE is out- side the CTR north-east of ECHO.

According to his statement, the ADC ATCO had routed the Piper HB-PPV via reporting points HASLE and ECHO because of the Navchecker 411 calibration flight.

The time span between the take-off of the Cirrus HB-KHF from Bern at 14:20 UTC and the serious incident was approximately 5 minutes.

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1.6 Collision avoidance

1.6.1 Air traffic control

The serious incident occurred in the Bern CTR in class D airspace. In this airspace separation between IFR flights is guaranteed. Traffic information is issued to IFR/VFR and VFR/VFR flights. Air traffic control provides avoidance recommendations at the pilot’s request.

In the Air Traffic Management Manual Switzerland (ATMM), the following information relevant to the ATCO is listed, among other things:

1.2 CLEARANCES AND INFORMATION (Ref: Section 9) Issue information and clearances to aircraft under your control to achieve a safe, orderly and expeditious flow of air traffic on the aerodrome and in the vicinity of the aerodrome, with the objective of preventing collision(s) between:

a) aircraft flying in the aerodrome traffic circuits around an aerodrome; b) aircraft operating on the manoeuvring area; c) aircraft landing and taking off; d) aircraft and vehicles operating on the manoeuvring area; e) aircraft on the manoeuvring area and obstructions on that area. Maintain a continuous watch on all visible flight operations on the aerodrome and in the vicinity of the aerodrome, including aircraft, vehicles and personnel on the manoeuvring area, and control such traffic in accordance with the procedures described herein and in local instructions.

4.7 ESSENTIAL LOCAL TRAFFIC INFORMATION (Ref: Section 9) Due to the restrictive space on and around manoeuvring areas and restricted view from the flight deck it is essential that traffic information be issued to aircraft to assist with collision avoidance. Transmit, without delay, information on known essential local traffic to departing and arriving aircraft. Require APP to issue direct information to aircraft on essential local traffic under its responsibility when, in your judgement, such information is necessary in the interest of safety, or when requested by the flight crew. Describe essential local traffic in a clear, concise and complete manner so as to facilitate recognition.

Note: Essential local traffic consists of any aircraft, vehicle or personnel, on or near the manoeuvring area, or traffic operating in the vicinity of the aerodrome, which may constitute a hazard to the aircraft concerned.

1.6.2 The ‘see-and-avoid’ principle

Regardless of whether he is on a VFR or IFR flight, under visual meteorological conditions (VMC), the pilot is responsible for collision avoidance according to the see-and-avoid principle as per ICAO, Annex 2. Flights according to instrument

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flight rules must be separated by ATC or provided with information relating to collision avoidance.

Avoidance of collisions (Ref. ICAO Annex 2 Section 3.2) Note.— It is important that vigilance for the purpose of detecting potential collisions be not relaxed on board an aircraft in flight, regardless of the type of flight or the class of airspace in which the aircraft is operating, and while operating on the movement area of an aerodrome.

1.6.3 Pilot

Art. 16 1bis of the traffic rules states the following:

“If two aircraft are converging on opposite or approximately opposite headings and if there is a danger of collision, both pilots must avoid it by turning right.”

1.6.4 The fundamentals of visual airspace monitoring

Early visual detection by a pilot of an aircraft flying in the same airspace depends on the following factors:

 a properly functioning capability for accommodation and binocular vision. Accommodation is the ability to adjust the refractive power of the eye in order to be able to see objects at different distances sharply. Binocular vision enables a pilot to correctly estimate the heading of the aircraft concerned and the distance in relation to him- self. Both functions are subject to physiological limits.

 atmospherically determined transparency. For example, with clear visibility the maximum distance for detecting an aircraft with a 30 m wing span is 14 km. This distance may be considerably reduced with reduced transparency.

 the latency time between visual detection by the retina and realisation by the brain (approximately 3 s).

 the speed of both aircraft. For example if an aircraft were to emerge descending from cloud at a speed of 900 km/h at a distance of 100 m, the pilots, given the above-mentioned latency time of 3 s, would not have enough time to detect each other and react accordingly.

 contrast against the background (e.g. close to the ground).

 pilot distraction due to monitoring instruments or concentration on a specific flying manoeuvre (e.g. approach).

 field of vision, restricted, e.g. by the frame of spectacles or the cockpit window frame.

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1.7 Standard departure route SID RAMOK2S

Departure route RAMOK TWO SIERRA is defined as follows, according to the AIP Switzerland:

PROCEDURE DESIGN GRADIENT (PDG) 7% TO 3500FT.

Climb on track 124, but not before the departure end of runway 14 (DER14).

At 2600ft turn left (CAT A: MAX IAS 120KT, MNM BANK ANGLE 15° / CAT B & C: MAX IAS 180KT, MNM BANK ANGLE 25°) Establish TR358 to intercept R223 WIL (QDR 043 BER). Proceed to RAMOK.

Cross ZB520 at 5500ft or above, RAMOK at 6000ft or above.

INITIAL CLIMB CLEARANCE FL80.

1.8 Transponder procedures

In class D airspace the regulations for transponder procedures according to AIP RAC 4-0-5 read as follows: “The transponder may be switched on only in accordance with instructions from the air traffic control unit.”

1.9 Additional information

1.9.1 Crews

The flight instructor on the Cirrus HB-KHF and the pilot of the Piper HB-PPV had been trained as air traffic controllers.

1.9.2 Cirrus door lock

According to the pilot, after the serious incident the door again disengaged from the locking system on the same day. It was possible to remedy the problem after the door mechanism was adjusted by the maintenance company.

2 Analysis

2.1 History of the flight of the Cirrus SR20, HB-KHF

Before the Cirrus HB-KHF took off, the crew received traffic information from the ADC ATCO concerning a single-engined aircraft flying from the north-east under visual flight rules; at this point in time it was still approximately 10 NM from the aerodrome. This early information was appropriate, as the IFR departure crossed the VFR approach route and a possible conflict was looming, given the chrono- logical sequence.

The flying instructor, who had previously worked as an air traffic controller in Bern Tower, was able to get a good overview of the traffic situation from the traffic information and the ongoing radio conversations.

The TAS installed in the aircraft proved to be beneficial. About 20 seconds before the two aircraft crossed, it made the pilots aware of the conflict by means of an alert and enabled them to locate the converging aircraft shortly before they

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crossed and to initiate an avoiding manoeuvre. This alert was only triggered because the transponder on the opposing Piper HB-PPV aircraft was switched on.

When the two aircraft crossed, the crew of the Cirrus HB-KHF felt the turbulence caused by the Piper HB-PPV passing above them. It must remain an open ques- tion whether the release of the right entry door from the lock was due to the pressure of the turbulence from the aircraft crossing or to the avoiding manoeuvre initiated by the crew.

2.2 History of the flight: Piper PA-28 HB-PPV

The pilot of the Piper HB-PPV had been instructed by the ADC ATCO to enter the Bern CTR via HASLE and ECHO.

Initial early traffic information concerning the Cirrus HB-KHF which had taken off from runway 14, was received by the pilot of the Piper HB-PPV at reporting point HASLE. When the Navchecker 411 was going around on runway 14, the pilot of the Piper HB-PPV was also correctly informed about this. This traffic information enabled him to carry out selective monitoring of the airspace.

He was then able to locate the twin-engined Navchecker 411, as it was flying above the line of the horizon. The pilot was aware that another aircraft was en route in the opposite direction to his aircraft. He intensified monitoring of the airspace, but was initially unable to establish any visual contact. Only when the ADC ATCO issued essential local traffic information to him with heading and distance to the converging aircraft was he able to detect the Cirrus and initiate an avoiding manoeuvre, though only just before the two aircraft crossed.

2.3 Traffic information issued by ATC

Issuing traffic information to the two flight crews was in this case an important precondition for making the pilots aware of a possible conflict. The sequence of events, with the approach and flight route of the Piper HB-KHF and the time of the take-off of the Cirrus HB-PPV meant that the aircraft could be expected to cross in the vicinity of reporting point ECHO.

The ADC ATCO issued the first traffic information to the crew of the Cirrus HB-KHF, concerning the approaching Piper HB-PPV, when the aircraft was on the ground at the take-off position. His concern was to inform the crew at an early stage and without other additional instructions. He did not issue further traffic information to HB-KHF. According to the ATCO’s statement, in principle and according to procedures in the tower environment, traffic information is issued only once and no update is provided. In addition, he stated that aircraft on standard instrument departure route SID RAMOK2S were only visible on the TASD above approximately 3000 to 3500 ft AMSL.

The statement that traffic information is issued only once as a matter of principle is not comprehensible. In this case, further traffic information issued to the pilots of the Cirrus HB-KHF after take-off would have been appropriate, because none of the crews concerned had reported visual contact with the other aircraft. Even if the aircraft had not yet become visible on the TASD, information concerning the position and altitude of the Piper HB-PPV, which had been visible on the

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TASD since its approach, would have been useful to the crew of the Cirrus HB- KHF for location purposes and as a complement to the TAS alert.

Both crews would have had the option of requesting an avoidance recommendation from Bern Tower when it became clear that the traffic information provided by the ATCO were not sufficient to locate the converging aircraft.

According to the radar recording, the position of the Cirrus HB-KHF was first displayed at 14:23:27 UTC at an altitude of 3000 ft AMSL and then regularly up- dated on the TASD.

At 14:23:51 UTC the position report concerning the Piper HB-PPV diverted the ADC ATCO’s attention to reporting point ECHO. He then issued the pilot of the Piper HB-PPV with the current position, direction, distance and altitude of the closing Cirrus. However, the latter was only half a mile away and was passing 3300 ft AMSL in a climb. There was no longer sufficient time to issue traffic information to the Cirrus HB-KHF.

The flight programme of the Navchecker 411 caused additional complexity for the ADC ATCO. He had to keep the pilots of the two aircraft involved in the serious incident, plus the crew of the Navchecker 411, continuously informed about the position of the aircraft in potential conflict. Between 14:19:24 UTC and 14:23.57 UTC the ADC ATCO issued traffic information a total of six times.

2.4 The ‘see-and-avoid’ principle

The concept applied in the present serious incident was based on the ‘see-and- avoid’ principle which is usual in the environment of an aerodrome with air traffic control and with IFR and VFR traffic.

However, application of this principle is subject to certain limitations. In this case, these are primarily: The limits on the pilot’s vision, the airspace observation method – scanning –, the workload in the cockpit, the size of the converging aircraft, the position of the sun, the background of the area being scanned and visibility conditions.

The physical capabilities of the human eye are such that despite thorough scanning there is no guarantee of being able to locate an aircraft. The effectiveness of vision can be improved by specific training, to partially compensate for the limitations of human vision.

It should be noted that it is fundamentally difficult to detect converging aircraft, because of their attitude.

In the present case an attempt was made to resolve the conflict on the basis of the see-and-avoid principle. A dangerous convergence occurred despite the following favourable conditions:

 The flying instructor on the Cirrus HB-KHF was acquainted with the environment of the aerodrome.

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 The flying instructor on the Cirrus HB-KHF and the pilot of the Piper HB-PPV had a good overview of the traffic situation – situational awareness—based on their professional activity.

 On the basis of the traffic information received from the tower, both crews were aware that their flight paths would cross.

 The Cirrus HB-KHF was equipped with a TAS, which also generated a corresponding alert.

 The two flight crews scanned the airspace intensively for the converging aircraft, but were able to detect it only shortly before they crossed.

2.5 Standard departure route SID RAMOK2S

The flight path of standard departure route SID RAMOK2S takes a left turn to the north once 2600 ft AMSL has been reached. This geographically intersects with the VFR approach routes from the north and east, in the area of reporting point ECHO.

In the case of aircraft with a relatively slow rate of climb, there is the possibility, as in the present serious incident, that the IFR SID will transit the altitude band of aircraft approaching under VFR. The maximum altitude within Bern CTR for VRF aircraft is set at 4500 ft AMSL, and the circuit altitude is set at 3000 ft AMSL. The serious incident occurred at an altitude of approximately 3500 ft AMSL, whilst the Cirrus HB-KHF was climbing and the Piper HB-PPV was descending.

Segregating IFR and VFR routes could prevent such situations.

2.6 Transponder use in class D airspace (CTR)

Within class G and class E airspace below 7000 ft AMSL, provided that the aircraft is equipped with a functioning transponder, pilots are obliged to switch the the latter to Code 7000 Mode A/C or Mode S. The pilot of the Piper HB-PPV did this correctly on take-off from Grenchen.

Nonetheless, it would not have been mandatory under the regulations to switch on the transponder in the Bern CTR. However, because the transponder on the Piper HB-PPV was switched on, the ADC ATCO was able to use the information from the Tower Air Situation Display (TASD) to identify the aircraft and provide the pilot of the Piper with accurate position information concerning the converging Cirrus HB-KHF. This helped the pilot to locate the aircraft and initiate an avoiding manoeuvre.

Because the transponder on the Piper HB-PPV was switched on, the Piper was perceived by the onboard TAS on the Cirrus HB-KHF as an intruder and an alert was triggered. Approximately 20 seconds later, the crew were able to make visual contact with the Piper and also initiate an avoiding manoeuvre.

The fact that the transponder on the Piper HB-PPV was switched on made a considerable contribution to easing the impending conflict.

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The use of a transponder within a CTR has played a role in several serious incidents investigated by the AAIB. Current regulations do not prescribe general use of a transponder in the CTR.

AAIB Investigation Report No. 1 Aircraft involved Date of incident

A045 HB-PHW / CRX169 26 April 2002

1817 SWR345 / F-GLVL 27 April 2003

1975 DWT 501 / HB-CIG 29 April 2005

One example is a serious incident within the Bern CTR (AAIB No. 1975). Before take-off from Bern on a VFR flight, on his own initiative the pilot switched on the transponder set to code 7000 in A/C mode. If the aircraft had flown without the transponder set, the crew of flight DWT 501 would have had no possibility of detecting the impending conflict on their TCAS and taking appropriate avoiding action.

Consistent activation of the transponder in aircraft equipped with one could con- tribute to improving safety even within a CTR.

3 Conclusions

3.1 Findings

 The crews of the aircraft involved in the incident and the ADC ATCO were in possession of the necessary licences.

 The serious incident took place in the Bern CTR, in class D airspace.

 The Cirrus HB-KHF was making a Bern – Bern IFR training flight and was following departure route RAMOK2S.

 The Piper HB-PPV was on a VFR flight from Grenchen to Bern and was cleared by the ADC ATCO to enter the Bern CTR via HASLE – ECHO.

 Before take-off, HB-KHF received traffic information from the ADC ATCO; HB- PPV was informed via essential traffic information concerning the aircraft flying towards it.

 Both crews detected the opposing aircraft shortly before they crossed and were able to initiate an avoiding manoeuvre as a reflex action.

 According to the radar recording, the two aircraft crossed at an altitude of approximately 3500 ft AMSL with a lateral distance of 0.1 NM and an altitude difference of 200 ft.

1 The AAIB AIRPROX reports are filed at http://www.bfu.admin.ch/en/dokumentation_berichte.htm .

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 The Cirrus HB-KHF was equipped with a TAS, which triggered an alert.

 The volume of traffic was average and of elevated complexity.

 The IFR departure route RAMOK2S crossed the VFR approach route via ECHO.

 Visual flight conditions prevailed, with in excess of 10 km visibility.

3.2 Cause

The serious incident is attributable to the fact that both flight crews were late in detecting the opposing aircraft.

The following factors contributed to this:

 the limitations of the ‘see-and-avoid’ principle.

 the intersecting IFR standard departure route RAMOK2S and the VFR approach route via ECHO.

4 Safety recommendations and measures taken since the incident

4.1 Safety recommendations 4.1.1 Safety deficit On the afternoon of 24 June 2008, a flying instructor was making an IFR training flight with a trainee pilot on a Cirrus SR20. The trainee pilot’s task was to fly to beacon VOR WIL after take-off from Bern and then to make two approaches in Bern. Bern Tower assigned standard departure route SID RAMOK2S to the flight; this is routed to VOR WIL via reporting point ZB520.

At the same time, a pilot in a Piper PA-28, registration HB-PPV, was on a visual flight from Grenchen to Bern. Clearance to enter the Bern CTR via reporting points HASLE and ECHO was issued by Bern Tower. When the pilot entered the CTR, he left the transponder switched on and set to code A7000. The fact that the transponder on HB-PPV was switched on made a considerable contribution to easing the impending conflict.

Since it was foreseeable that the flight paths of the two aircraft would cross, traffic information was issued to the crews by Bern Tower. The traffic concept applied was based on the ‘see-and-avoid’ principle which is usual in the environment of an aerodrome with air traffic control and with IFR and VFR traffic.

Despite this information and despite intensive scanning by the crew for the converging aircraft, a dangerous convergence occurred: according to the radar recordings the minimum separation was a lateral distance of 0.1 NM and an altitude difference of 200 ft. The serious incident occurred at an altitude of approximately 3500 ft AMSL, whilst the Cirrus SR20 was climbing and the Piper PA- 28 was descending.

Aircraft Accident Investigation Bureau Page 16 of 17 Final Report HB-KHF/HB-PPV

4.1.2 Safety recommendation no. 418 The FOCA should arrange for the inclusion in the pilot training curriculum of a module with the objective of highlighting the limitations of the ‘see-and-avoid’ principle.

4.1.3 Safety recommendation no. 419 The FOCA should ensure that the IFR routes are separated from the VFR routes in the Bern CTR. The AAIB has already issued safety recommendation no. 399 to this effect, in February 2008.

4.1.4 Safety recommendation no. 420 The FOCA should ensure that the existing obligation for the use of the transponder in class G and class E airspace is extended to class D airspace within the control zones.

Payerne, 26 May 2010 Aircraft Accident Investigation Bureau

This report contains the AAIB’s conclusions on the circumstances and causes of the accident/serious incident which is the subject of the investigation.

If this report is used for purposes other than accident prevention, due consideration shall be given to this circumstance.

Aircraft Accident Investigation Bureau Page 17 of 17 05 JUN 2008 Beilage 1 AIP SWITZERLAND LSZB AD 2.24.7 - 5 05 JUN 2008

BERN-BELP LSZB STANDARD INSTRUMENT DEPARTURE CHART TRANSITION LEVEL by ATC (SID) - ICAO TRANSITION ALTITUDE 6000 SID RWY 14 - NON RNAV

47° 00'

250 250

15800

9000

005 005 7200 MSA BER

MONIN

10700

065 065 R099/D32 FRI Inner Circle: 10 NM IBE Outer Circle: 25 NM IBE QDR122 BER/D24.1 IBE NOT TO TO NOT SCALE 16000 D17 IBE 13 WIL NOT TO TO NOT SCALE DVOR 116.90 For routing after RAMOK / AMRID refer to LSZB AD 2.24.6-1.

QDR122 BER BER

ZB527 QDR122 BER/D11 IBE 11000

R223 WIL WIL R223 R223 6000 RAMOK R223/D13 WIL

RAMOK 2S AMRID 2S MONIN 2S

MONIN 2S D7.6 IBE

QDR122 BER BER TMA BERN ZB520 QDR043 BER/D5.1 IBE BER/D5.1 IBE R223/D18 WIL WIL 5500 TR358 Scale 1:250 000 D4 IBE IBE 7000

R238 WIL WIL R238 R238 12 3456789

0 10 KM

0 1 2 3 4 5 NM 2600 2600

BER QDM187 BER QDM187 QDM187

TR124 MONIN 2S MONIN 2710 INBD 320°, 6000 - FL110 1772 BER HLDG MAX IAS 180kt; 007° 30' 30' 007° 30' 30' 1min, MAX D5 IBE, LSZB 6000 BER NDB 335

BERN-BELP AMRID 2S AMRID IBE DME 110.10 SID RWY 14 - NON RNAV SID RWY

TMA BERN 8000 AMRID R023/D10 FRI FRI R238/D28 WIL WIL ALTITUDES IN FT ALTITUDES DISTANCES IN NM DISTANCES

RADIALS ARE MAGNETIC BEARINGS, TRACKS AND FRI

VAR 1° E 2008 E 1° VAR VOR 110.85 COR: COM FAILURE PROC: BER DEL BER PROC: FAILURE COM COR: PROCEDURE: FAILURE COMMUNICATION - Set transponder on code 7600. - Cross RAMOK / MONIN AMRID climbing to/at last assigned and acknowledged FL but not below MCA*. - Continue climb to FPL FL. earliest *) Leave last received and acknowledged FL or ALT three minutes after airborne. 47° 00'

SKYGUIDE, CH-8602 WANGEN BEI DÜBENDORF AMDT 006 2008

2008 Swisstopo. CH-3084 Wabern CH-3084 Swisstopo. 2008 c Beilage 2 Thun Kerzers FRI R037 / D11.7 FRI R067 / D12.3 WIL R225 / D20.5 / D23.6 WIL R218 WIL R242 / D19.8 COR: Completely revised Konolfingen Neuenegg AC auf der Rückseite AC VAC on reverse VAC V LSZB AD INFO 11 § 1.6 AD INFO 11 LSZB 4500 (confirm ATIS designator) (confirm ATIS (ATIS Kennung bestätigen) Kennung (ATIS 119.700 121.500 Entering prohibited when ACT when prohibited Entering Signau Einflug verboten wenn aktiv wenn Einflug verboten Höhen über Grund in ft avoid TMA BERN 1 + 2 avoid Schwarzenburg 127.325 121.025 125.125 Heights in ft Hasle GND 5500 LIMA BRAVO Compulsory for ARR only Compulsory for 46° 56’ 11’’ N / 007° 33’ 12’’ E 46° 52’ 05’’ N / 007° 33’ 11’’ E 46° 55’ 59’’ N / 007° 23’ 41’’ E Obligatorisch nur für Anflug nur für Obligatorisch 47° 01’ 22” N / 007° 28’ 48’’ E 46° 51’ 15’’ N / 007° 30’ 02’’ E HEL ARR / DEP HEL E S Z N W Transition Level: by ATC by Level: Transition APP / VDF APP / Riggisberg ATIS Kirchberg TWR / VDF TWR / MAX ALT within CTR: ALT MAX Funkausfallverfahren: procedure: RDO failure Höhen über Meer in ft; The intended routing (e.g. Neuenegg - WHISKEY) Neuenegg - (e.g. routing The intended CTR: Innerhalb ALT MAX Altitudes in ft; ATIS BERN abhöhren ATIS ATIS MNT BERN ARR / DEP LSZB: TMA BERN 1 + 2 meiden ARR / DEP LSZB: First RDO contact 5 min prior CTR or First RDO contact 5 min prior WHISKEY). Neuenegg - zu melden (z.B. Anflugweg with the first RDO contact. shall be submitted Mit dem ersten Funkkontakt ist der vorgesehene Funkkontakt Mit dem ersten Erster Funkkontakt 5 min vor Einflug in CTR oder 5 min vor Funkkontakt Erster

00’ 47° MM (08) E 1° VAR

5 km

116.90

VOR/DME 23 3983 Rötenbach

2.5

Sumiswald

ELEVATIONS in ft ELEVATIONS R226 WIL

1:250 000 0 ALPEN 2913 3668

4567

Schwarzenegg Signau Lü Lützelflüh

MITTELLAND / JURA / MITTELLAND G5 344 BEARINGS ARE MAGNETIC PEILUNGEN SIND MISSWEISEND HÖHEN in ft

2.5 Wynigen 3812 338 348 315 367 348 348 331 367 Grosshöchstetten 5500 FL 100 371 Thun 3537 127.325 BERN APP D Konolfingen Hasle 08 Koppigen 1847 LSZW 3022 3143 Kirchberg Oberdiessbach

Kisen WORB

113.20 BURGDORF 184

THUN

LSZB 34

VOR/DME R191 L 14 GND

A 6 5000

MÜNSINGEN HOC LS-D 18 Aare 210 Utzenstorf U LSZB 1673

2152 LSZB AREA 6 A 1 A BERN-BELP Z 3684 2556 nsee E Hindelbank BERN-BELP 2382 Uetendorf 2037 Gürbe Mühlethurnen 2926 BER 335 Gerzensee 2710 S 1772 2500 ITTIGEN Belp Jegenstorf 007° 30’ 007° 30’ 1883 2156 Fraubrunnen 1873

N TMA BERN 2 BERN TMA Wattenwil Toffen 2063 2000 GND 2871 2001 5079 3465 Messen E TMA BERN 1 2093

GRE CTR BERN CTR 3369 Riggisberg

MUR 312 CTR 1 CTR VOR/DME ZURICH AREA R168 Zollikofen 17 BERN 115.45 2149 GENEVA AREA GND 5000 TWR d 120.100 230 KÖNIZ 2139 GRENCHEN D Niederscherli Nieder Münchenbuchsee 2139 3500 FL 100 127.325 BERN APP W

D 14 Maikirch

a.A. Wohlen R054 Bü Büren 262 Rüschegg SHU 356.5

Aare Schüpfen 2208 4252 ELEV 1673 ft (510 m)

LYSS G5 Schwarzenburg GND 5500

2690

SKYGUIDE, CH-8602 WANGEN BEI DÜBENDORF WANGEN CH-8602 SKYGUIDE, A 6 A 2106 Neuenegg LIMA BRAVO 1936 2267 05 5000 5000 GND FL 100 127.325 121.025 BERN APP 2001

BERN TWR

1696 1437 A 12 A 9 D 1939 LSZP Plaffeien BIEL-KAPPELEN 110.85 FRI FRIBOURG Aarberg

Laupen A 1 A PAYERNE 7 0 Aare n T Täuffelen Giffers e Tafers

Kerzers

ele

Saane TMA Saane

s Düdingen

581 000 581 581 000 581 177 000

Siselen W 104 BIEL/BIENNE VFR AREA KARTE-ICAO VFR AREA CHART-ICAO 04/08 APR 10 00’ 47° 8 5 3 0 7 2 1 9 6 4 NM 4000 FL 100 E

2008 Swisstopo. CH-3084 Wabern CH-3084 Swisstopo. 2008 Beilage 3 c LSZB 1.7 LSZB VAC LSZB VAC 17 BERN-BELP COR: Completely revised FRI R037 / D11.7 WIL R225 / D20.5 / D23.6 WIL R218 FRI R067 / D12.3 WIL R223 / D22.2 WIL R222 / D23 FRI R055 / D1 WIL R242 / D19.8 LSZB AD INFO 11 § 1.6 AD INFO 11 LSZB 4500 ering prohibited when ACT when prohibited ering (confirm ATIS designator) (confirm ATIS (ATIS Kennung bestätigen) Kennung (ATIS 119.700 121.500 Ent Einflug verboten wenn aktiv wenn Einflug verboten Höhen über Grund in ft avoid TMA BERN 1 + 2 avoid compulsory for ARR only compulsory for 127.325 121.025 125.125 Heights in ft GND 5500 LIMA BRAVO Compulsory for ARR only Compulsory for 46° 55’ 59’’ N / 007° 23’ 41’’ E 46° 54’ 26’’ N / 007° 32’ 16’’ E 46° 53’ 22’’ N / 007° 32’ 15’’ E 46° 56’ 11’’ N / 007° 33’ 12’’ E 46° 52’ 05’’ N / 007° 33’ 11’’ E Lärmempfindliche Gebiete Lärmempfindliche Obligatorisch nur für Anflug nur für Obligatorisch 47° 01’ 22” N / 007° 28’ 48’’ E 46° 53’ 21’’ N / 007° 27’ 23’’ E 46° 51’ 15’’ N / 007° 30’ 02’’ E Noise sensitive areas HEL REP; obligatorisch nur für Anflug nur für HEL REP; obligatorisch HEL Routen HEL routes E S H Z N W HE HW Transition Level: by ATC by Level: Transition APP / VDF APP / ATIS TWR / VDF TWR / Funkausfallverfahren: procedure: RDO failure MAX ALT within CTR: ALT MAX Höhen über Meer in ft; When ready for departure transmit outbound route transmit departure for When ready HASLE) CTR direction leaving (e.g. Altitudes in ft; vorgesehene Flugweg (z.B. ready for departure for ready (z.B. Flugweg vorgesehene MAX ALT innerhalb CTR: innerhalb ALT MAX ATIS BERN abhöhren ATIS ATIS MNT BERN TMA BERN 1 + 2 meiden ARR / DEP LSZB: ECHO-HASLE) angegeben werden. angegeben ECHO-HASLE) ECHO-HASLE). departure for ready (e.g. Das Verlassen der CTR muss gemeldet werden der CTR muss gemeldet Verlassen Das HASLE). CTR direction leaving (z.B. Report when leaving CTR when leaving Report Beim Anfordern einer Startfreigabe muss der einer Startfreigabe Anfordern Beim 1 2 0 4 3 7 5 6 8 9 NM 51’ 56’ 50’ 46° 57’ 55’ 59’ 46° 53’ 46° 52’ 46° 46° 46° 46° 58’ 54’ 46° 46° 46° MM

2000 m 2346 Ursellen 2717 5500 FL 100 127.325

1000 BERN APP D ELEVATIONS in ft ELEVATIONS 3035 Richigen gerts TMA BERN 2 Tägertschi 2421 N N 1:100 000 Enggistein

0 Trimstain 007° 35’ 5000 5000 GND 2720 007° 35’ FL 100 127.325 121.025 BERN APP BERN TWR D Wichtrach 2940 2067 1896 HÖHEN in ft CTR / TMA 1 BERN 1742

1000 MÜNSINGEN Vechigen 007° 34’ 007° 36’ 007° 34’ 007° 36’ A 6 Z

WORB Utzigen ELEV 1673 ft (510 m)

SKYGUIDE, CH-8602 WANGEN BEI DÜBENDORF WANGEN CH-8602 SKYGUIDE, E

L i n d e n t a l a t n e d n i L L i n d e n t a l a t n e d n i L Aare 1801 2119 Rubigen Boll 007° 33’ Gerzensee 007° 33’

262 152° 2408 HE H 2369 2021 Stettlen 2555 Bantiger Rüfenacht 2011 2926 1981 Allmendingen Kunstflug/ Belpberg

3684 6 Aerobatic W o r b l e t a l 2244

Gümligen 3000 B e l p b r g B e l p b r g Gelterfingen 1758 2037 2139 Dentenberg Gürbe 1961 2709 007° 31’ 007° 31’ Touchdown

1709

BER 335

32 1771 32 S Bolligen 332° 2175 1742 t a l H N G ü r b e Kaufdorf VDF 1761 H 2500 007° 30’ 2690 007° -mundigen 1703 14 1712 2017 2600

2063 Belp

Oster-

ITTIGEN

b e r g r e b 2800 g r e b Toffen L ä n g e n n e e g g n n ä ä L L

007° 29’ 007° 32’ 007° 29’ 007° 32’

2155 A 1 A 2870 Muri 2572 2034 O Oberbütschel MUR 312 007° 28’ 007° 28’ 2720 3465 2062 1811 Zimmerwald 2093 Englisberg Kehrsatz Wabern HW Bütschelegg Bütschelegg

3189

2815 Aare Aare GND 5500 Niedermuhlern 2937 Zollikofen LIMA BRAVO 3369 3100 Ulmizberg Ulmizberg

K ö n i z t a l 3238 G u r t e n G u r t e n

2148 ZURICH AREA 007° 26’ 007° 26’ 1955 2139 Bremgarten 2139 1699 GENEVA AREA 007° 25’ 007° 25’ BERN 2566 2037 Schlieren

2211 A 12 A Oberbalm 213 Herrenschwanden A 1 KÖNIZ

Niederscherli Hinterfultigen 007° 24’ 007° 27’

007° 24’ 007° 27’

BEARINGS ARE MAGNETIC (08) E 1° VAR PEILUNGEN SIND MISSWEISEND 2795

596 000 596 596 000 596 186 500 Uettligen 2159 Schwarzwasser W

SICHTANFLUGKARTE-ICAO CTR / TMA 1 BERN VISUAL APPROACH CHART-ICAO VISUAL APPROACH 04/08 APR 10 55’ 51’ 56’ 50’ 46° 46° 54’ 59’ 57’ 46° 53’ 46° 52’ 46° 46° 46° 46° 58’ 46° 46°

TRANSCRIPT OF TELEPHONY

OR RADIOTELEPHONY COMMUNICATION TAPE-RECORDINGS

Investigation into the incident that occurred on 24.06.2008

- Subject of transcript: HBKHF / HBPPV

- Centre concerned: Swiss Radar Area East

- Designation of unit: Bern Tower

- Frequency / Channel: 121.025 MHz

- Date and period (UTC) covered by attached extract: 24.06.2008 14:01:22 - 14:40:36 UTC - Date of transcript: 21 July 2008

- Name of official in charge of transcription: skyguide Safety Reporting & Investigation Management

- Certificate by official in charge of transcription:

We hereby certify:

- That the accompanying transcript of the telephony or radiotelephony communication tape-recordings, retained at the present time in the premises of the Safety Reporting & Investigation Management Department, has been made, examined and checked by one of its experts. - That no changes have been made to the entries in columns 2, 3 and 4, which contain only clearly understood indications in their original form.

Zürich, 21 July 2008

skyguide Safety Reporting & Investigation Management

M1FO0047E/8.0/2008-05-28 TRANSCRIPT OF TELEPHONY_HBKHF-HBPPV.doc 1 - 15

Abbreviations

Sector Designation of sector

ADC - Bern Tower

Aircraft - Call sign Type of aircraft Flight rules ADEP - ADES

HHF - HBKHF SR20 IFR LSZB - LSZB HDL - HB?DL - VFR xxxx - LSZB NAV4 - Navchecker 411 - - xxxx - xxxx HHV - HB?HV - VFR xxxx - LSZB HEZ - HBHEZ AS202 VFR LSZB - LSZB SUI - SUI003 - - xxxx - LSZB RUAG - RUAG Maintenance - - - - - HPT - HBPPT PA28 VFR LSZB - xxxx NAV3 - Navchecker 311 - - - - - HPV - HBPPV PA28 VFR LSZG - LSZB HPQ - HBXPQ B06 VFR xxxx - LSZB

SRO / 21.07.2008

… /TRANSCRIPT OF TELEPHONY_HBKHF-HBPPV.doc 2 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

Frequency: Bern Tower 121.025 MHz

HHF ADC 14:01:22 Hotel Bravo Kilo Hotel Foxtrot, ready to copy clearance?

ADC HHF :26 Affirm, Hotel Bravo Kilo Hotel Foxtrot.

HHF ADC :29 Hotel Hotel Foxtrot cleared to Bern via RAMOK two Sierra departure, transition Juliet seven one, climb to flight level eight zero and squawk six two three zero.

ADC HHF :43 Cleared to Bern via… RAMOK two Sierra departure and ah… Juliet seven one, flight level eight zero, squawk six two three zero, Hotel Hotel Foxtrot.

HHF ADC :54 Read back correct.

ADC HDL 14:02:06 Hotel Delta Lima… ah… downwind runway one four.

HDL ADC :17 Hotel… Delta Lima stand by short.

HDL ADC :44 Delta Lima report position in the pattern.

ADC HDL :47 Hotel Delta Lima end of runway ah… one four.

ADC HDL 14:03:03 Hotel Delta Lima confirm we're cleared for approach?

HDL ADC :10 Delta Lima is now in sight on a rather narrow downwind, continue towards ah… Bern city to stay clear of inbound axis one four, traffic is five miles out.

ADC HDL :21 Hotel Delta Lima stay... taking straight ahead and stay clear of the inbound traffic, Hotel Delta Lima.

NAV4 ADC :30 Navchecker four one one look out for traffic close to the runway axis on a left hand downwind extending to join behind you.

ADC NAV4 :39 Roger copied, looking out.

ADC HHV :52 …three thousand feet for landing via rate… right hand 2 stations downwind ah… one eight Hotel… one four, Hotel Hotel overlapping Victor.

HDL ADC 14:04:02 Two stations Hotel ah... Delta Lima roger.

HHV ADC :12 Hotel Hotel Victor roger, report on downwind abeam Tower, on right hand downwind abeam Tower.

3 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC HHV 14:04:20 Repeat Hotel Hotel Viktor?

HHV ADC :22 Hotel Hotel Victor, report abeam Tower on right hand downwind.

ADC HHV :28 Will report abeam Tower, Hotel Hotel Victor.

NAV4 ADC :32 Navchecker four one one, wind one five zero degrees, two knots, cleared for low go around.

ADC NAV4 :38 Cleared low go around, Navcheck four one one.

ADC HDL :44 Hotel Delta Lima may we turn in?

HDL ADC :47 Hotel Delta Lima affirm, number two, number one xxxxx unintelligible

ADC H-DL :53 Number two, Hotel Delta Lima.

HHV ADC 14:06:02 Hotel Hotel Victor number two, number one single engine on ah… long final for runway one four, turn base behind.

ADC HHV :10 I'm number two, Hotel Hotel Victor, will ca… watch for the traffic in long final.

HHV ADC :25 Hotel Hotel Victor, advised traffic is about two miles final.

ADC HHV :31 Will watch for the traffic in final Hotel Hotel Victor, actual position abeam Tower, in middle down wind, two thousand eight hundred feet.

HHV/HDL ADC :39 Roger, break break, Hotel Delta Lima, wind one zero zero degrees, two knots, runway one four cleared to land.

ADC HDL :46 Runway one four, cleared to land, Hotel Delta Lima.

NAV4 ADC 14:07:05 Navchecker four one one report your program?

ADC NAV4 :08 Yeah, another procedure ah Bravo, after that procedure X- Ray, followed by Echo and than Foxtrot.

NAV4 ADC :20 Roger, extend the downwind to join behind the Falcon fifty which is about ah… one two miles out on a left hand base at ah… five thousand feet, I call you back for the inbound turn.

ADC NAV4 :34 Roger copied.

ADC HHV :35 Hotel Hotel Victor turning base, one eight… one four.

4 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

HHV ADC 14:07:39 Hotel Hotel Victor roger.

ADC HEZ :43 Tower Hotel Bravo Echo Zulu, information November, ready for taxi, outbound ah… Zulu, for a short local flight.

HDL ADC :51 Hotel Delta Lima vacate next to the left.

ADC HDL :55 Vacate next to the left, Hotel Delta Lima.

HEZ ADC :57 Hotel Bravo Hotel Echo Zulu Bern Tower, hold position, call you back.

ADC HEZ 14:08:01 Roger.

ADC HHV :10 Hotel Hotel Victor turning final one four.

HHV ADC :13 Hotel Hotel Victor, Wind one one zero degrees, two knots, runway one four cleared to land.

ADC HHV :18 Cleared to land, Hotel Hotel Victor.

ADC HDL :22 Runway one four vacated, Hotel Delta Lima.

HDL ADC :26 Hotel Delta Lima, stand by for the marshaler track.

ADC HDL :30 Standing by, Hotel Delta Lima.

NAV4 ADC 14:09:02 Navchecker four one one, you're now coming abeam the unintelligible traffic ah.. which is xxxxx.

ADC NAV4 :08 Yeah traffic is in sight.

HHV ADC :18 Hotel Hotel Victor, taxi ahead and vacate via Delta.

ADC HHV :23 Vacated via Delta, Hotel Hotel Victor.

ADC NAV4 :30 Tower Navchecker four one one, may we turn inbound?

NAV4 ADC :37 Navcheck four one one report speed?

ADC NAV4 :41 Ah… one fifty indicated.

NAV4 ADC :46 Navcheck four one one stand by for inbound turn.

ADC NAV4 :49 Standing by.

5 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC SUI 14:09:52 Tower hello, Swiss Airforce zero zero three, ah… established at four thousand.

SUI ADC :58 Swiss Airforce zero zero three Bern Tower, wind two zero degrees, two knots, runway one four cleared to land.

ADC SUI 14:10:05 Cleared to land one four, Swiss Airforce zero zero three.

NAV4 ADC :09 Navcheck four one one inbound turn approved.

ADC NAV4 :11 Turning inbound, Navcheck four one one.

ADC HHV :17 Hotel Hotel Victor runway vacated.

HHV ADC :19 Hotel Hotel Victor stand by for the marshaler.

ADC HHV :22 Stand by, Hotel Hotel Victor.

ADC RUAG :40 Bern Tower from RUAG Maintenance?

RUAG ADC :44 RUAG Maintenance Bern Tower.

ADC RUAG :47 Request towing an aircraft ah.. via taxi way Kilo from RUAG Maintenance hangar to the outer "Bundesbasisplatz".

RUAG ADC :59 Ah… RUAG Maintenance Bern Tower, hold position call you back in approximately two minutes.

ADC RUAG 14:11:05 RUAG Maintenance hold position.

HEZ ADC :11 Hotel Bravo Hotel Echo Zulu taxi to holding point runway one four intersection Alpha, QNH one zero one seven.

ADC HEZ :16 Alpha, Hotel Echo Zulu.

ADC HHF :29 Hotel Bravo Kilo Hotel Foxtrot, ready to taxi.

HHF ADC :38 Hotel Bravo Kilo Hotel Foxtrot… stand by short.

HHF ADC 14:12:02 Hotel Hotel Foxtrot hold position, call you back shortly.

ADC HHF :06 Holding position, Hotel Hotel Foxtrot .

ADC SUI :23 Swiss Airforce zero zero three at short final, confirm cleared to land?

SUI ADC :26 Affirm, cleared to land, wind variable, two knots.

6 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC SUI 14:12:28 Thanks.

SUI ADC 14:13:11 Swiss Airforce zero zero three vacated vie Foxtrot.

ADC SUI :14 Vacating via Fox, Swiss Airforce zero zero three.

ADC HHF :20 Hotel Fox ready.

HHF ADC :24 Hotel Fox taxi to runway one four, intersection Bravo.

ADC HHF :28 Taxi runway one four intersection Bravo, Hotel Hotel Foxtrot.

ADC HEZ :32 Tower Echo Zulu, we're ready with departure outbound Zulu.

HEZ ADC :40 Hotel Echo Zulu hold position.

ADC HEZ :42 Holding Echo Zulu.

ADC HPT :46 Bern Tower Hotel Bravo Papa Papa Tango, green three, request taxi for outbound Echo – Hasle with information November.

HPT ADC :59 Hotel Papa Tango, hold position call you back.

ADC HPT 14:14:02 Hold position, Hotel Papa Tango.

ADC NAV3 :29 Tower Navchecker three one one?

NAV3 ADC :32 Navcheck three one one Bern Tower, go ahead.

ADC NAV3 :34 Ja, may we break off here, ah… left break off… for another approach?

NAV3 ADC :41 Navcheck four one one affirm, break off is approved, and confirm then again Bravo?

ADC NAV3 :46 That's affirmative.

NAV3 ADC :47 Roger.

HEZ ADC :54 Hotel Echo Zulu wind variable, two knots, runway one four cleared for take off outbound Zulu.

ADC HEZ 14:15:02 Echo Zulu is cleared to go xxxxx. unintelligible

7 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

HPT ADC 14:15:09 Hotel Papa Tango, taxi to holding point runway one four intersection Alfa.

ADC HPT :14 Taxi to holding point one four intersection Alfa, Hotel Papa Tango.

ADC HPV :45 Bern Tower Hotel Bravo Papa Papa Viktor "grüezi", VFR from Grenchen, Kirchberg four thousand five hundred feet, for landing via route November, information is November, QNH one zero one seven.

HPV ADC 14:16:00 Hotel Bravo Papa Papa Viktor Bern Tower, proceed via Hasle and enter via Echo due traffic, for left hand downwind runway one four, QNH one zero one seven.

ADC HPV :12 Inbound via Echo to Bern and ah… Hotel Papa Viktor?

HPV ADC :17 Affirm Hotel Papa Viktor, due traffic proceed to Hasle and enter via Echo for left hand downwind runway one four.

ADC HPV :24 Roger, say again the point before Echo please?

HPV ADC :28 To Hasle!

ADC HPV :30 Roger, proceeding to Hasle and then Echo, Hotel Papa Viktor.

HPV ADC :34 Call in for left hand downwind runway one four, QNH one zero one seven.

ADC HPV :38 Enter downwind one four, QNH one zero one seven, Hotel Papa Viktor.

ADC RUAG 14:17:09 Bern Tower from RUAG Maintenance?

RUAG ADC :14 RUAG Maintenance Bern Tower, taxi via Kilo is now approved to outer "Bundestarmac".

ADC RUAG :19 Taxi is approved via Kilo, xxxxx. unintelligible

ADC HHF :40 Hotel Hotel Foxtrot, ready for departure, request back track.

HHF ADC :51 Hotel Hotel Foxtrot back track runway one four.

ADC HHF :54 Back track runway one four, Hotel Hotel Foxtrot.

ADC NAV4 14:18:17 Navchecker four on is turning inbound.

8 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

NAV4 ADC 14:18:23 Navchecker four one one inbound turn approved.

ADC NAV4 :26 Roger copied.

HHF ADC 14:19:24 Hotel Hotel Foxtrot, VFR traffic about ten miles north-east of the field inbound to… join left downwind runway one four, single engine, keep an eye.

ADC H-HF :34 Will do, Hotel Hotel Foxtrot.

HHF ADC :36 Hotel Hotel Foxtrot, wind variable two knots, runway one four cleared for take off.

ADC HHF :42 Cleared for take off runway one four, Hotel Hotel Foxtrot.

HPV ADC :51 Hotel Papa Victor look out for… a… single engine traffic departing runway one four, north-east bound, climbing through your level.

ADC HPV 14:20:02 Looking out for a single engine and ah.. now Hasle four thousand five hundred feet, next Echo, Hotel Papa Viktor.

HPV ADC :10 Roger.

ADC HPT :54 Hotel Papa Tango intersection Alfa, ready for departure.

HPT ADC :59 Hotel Tango stand by.

ADC HEZ 14:21:13 Hotel Echo Zulu xxxxx four thousand xxxxx Fribourg unintelligible xxxxx.

HEZ ADC :31 Hotel Echo Zulu may leave, good bye.

ADC HEZ :33 Good bye.

NAV4 ADC 14:22:08 Navchecker four one one cleared for the low go around runway one four … wind calm, traffic is a Cirrus on your left cross wind departure, north-east bound, about ah… two miles north-east of the field, additionally one Piper, six miles north-east of the field, four thousand feet inbound.

ADC NAV4 :37 Roger, confirmed cleared low approach, for Navcheck four one one?

NAV4 ADC :40 Four one one I confirm, cleared for low approach.

ADC NAV4 :43 Roger, and then afterwards ah… procedure X-Ray.

9 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

NAV4 ADC 14:22:50 X-Ray approved, four thousand three hundred feet.

ADC NAV4 :55 Yeah confirmed.

H-PV ADC 14:23:20 Hotel Papa Viktor keep an eye for a… twin engine, in a go around runway one four, in a left turn direction north.

ADC H-PV :27 Looking out for the twin engine, Hotel Papa Viktor, thank you.

NAV4 ADC :32 Navchecker four one one to confirm, we have a Cirrus on ah… two miles east of Bern beacon, three thousand feet, north-east bound, and ah… opposite traffic four miles north-east of the field, four thousand feet for left down wind for runway one four, Piper.

ADC NAV4 :48 Yeah roger copied, looking out.

ADC HPV :51 Hotel Papa Viktor, Echo, three thousand eight hundred feet, descending for the left hand downwind one four.

HPV ADC :57 Hotel Papa Victor report on downwind and the advised Cirrus is ah.. at your twelve o'clock, range half a mile, three thousand three hundred feet in climb.

ADC HPV 14:24:07 Yeah, twin is now in sight and number one for runway one four, Hotel Papa Victor.

ADC HHF :33 Hotel Fox?

HHF ADC :38 Go ahead.

ADC HHF :39 Ah… we have to return to the field for landing, we… have an open door.

HHF ADC :44 Hotel Hotel Foxtrot roger, join left hand downwind runway one four and ah… report visually.

ADC HHF :50 Left hand downwind one four, call you.

ADC HHF :51 "xxxxx bi uns düre welä und zwar gseh dürre Druck isch grad d'Tür uf".

ADC HPV :59 "Ja Hotel Papa Victor, Ich has au gseh, ja".

ADC HEZ 14:25:20 Tower Hotel Bravo Echo Zulu, information Oscar, xxxxx unintelligible landing via Sierra.

10 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

HEZ ADC 14:25:28 Hotel Echo Zulu via Sierra, join right hand down wind one four, QNH one zero one seven.

ADC HEZ :32 Roger via Sierra, xxxxx right hand down wind one four, unintelligible Echo Zulu.

ADC NAV4 :37 Tower Navchecker four one one?

NAV4 ADC :39 Go ahead.

ADC NAV4 :40 May we turn left to join the arc?

NAV4 ADC :43 Affirm, join the arc.

ADC NAV4 :45 Wilco.

ADC HPV :46 Hotel Papa Victor, now left hand downwind runway one four for full stop.

HPV ADC :53 Hotel… Papa… Victor… roger… number one, make short approach, wind calm, cleared to land.

ADC HPV 14:26:01 Number one, short approach one four, Hotel Papa Victor.

HHF ADC :07 Hotel Hotel Foxtrot make altitude behind the Piper on a ah… end of left downwind one four.

ADC HHF :13 Have the aircraft in side, number two behind, Hotel Hotel Foxtrot.

ADC HEZ 14:27:23 Hotel Echo Zulu is Sierra, next xxxxx. unintelligible

HEZ ADC :29 Hotel Echo Zulu roger.

HPV ADC 14:28:14 Hotel Papa Victor, vacate next to the left via taxiway Delta, expedite when clear of runway, hold position, stand by for marshaler.

ADC HPV :22 Next to the left, expediting to vacate, stand by for the marshaler, Hotel Papa Victor.

HHF ADC :28 Hotel Hotel Foxtrot, wind one niner zero degrees, two knots, runway one four clear to land.

ADC HHF :33 Clear to land ah… Hotel Hotel Foxtrot.

HPT ADC :47 Hotel Papa Tango behind traffic at threshold one four line up and wait behind.

11 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC HPT 14:28:52 Line up and wait behind, Hotel papa Tango.

ADC HHF 14:29:06 And Hotel Hotel Fox, request taxi to holding point one four again.

HHF ADC :09 Hotel Hotel Fox affirm, via Bravo Charlie to Alpha again.

ADC HHF :14 Ah… via Charlie to Alpha again, Hotel Foxtrot.

HHF ADC :17 Okay, the clearance is still valid.

ADC HHF :19 Okay.

ADC HHF :20 "Also mir hei ihn ufem TCAS gseh, es isch sehr nach gsi, der isch genau uf üs los, mir hei müese "avoiding action" mache, und irgendwie düre Druck isch den Türe uf, es isch unerklärlich"!

ADC HEZ :42 Hotel Echo Zulu right hand down wind one four.

HEZ ADC :47 Hotel Echo Zulu roger, number one, report final.

ADC HEZ :51 Report final, concrete or grass?

HEZ ADC :53 Concrete.

ADC HEZ :54 Concrete!

HPT ADC :56 Hotel Papa Tango leave CTR via Echo, wind… calm, runway one four cleared for take off.

ADC HPT 14:30:01 Cleared for take off, leave via Echo – Hasle, Hotel Papa Tango.

ADC NAV4 :06 And Navcheck four one one has this arc complete, request right turn to join procedure Echo.

NAV4 ADC :18 Navchecker four one one proceed to Echo approved, four thousand eight hundred feet.

ADC NAV4 :22 Thank you, Navcheck four one one.

ADC HEZ 14:31:22 Hotel Echo Zulu is turning final one four, request exit Delta for Airmatec.

HEZ ADC :29 Hotel Echo Zulu wind calm, runway one four cleared to land to vacate via Delta to Airmatec.

12 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC HEZ 14:31:35 Roger, cleared to land and cleared to go.

ADC HHF 14:32:20 Hotel Hotel Foxtrot, ready for backtrack runway one four.

HHF ADC :25 Hotel Hotel Foxtrot, backtrack runway one four.

ADC HHF :28 Backtrack runway one four, Hotel Hotel Foxtrot.

ADC HPT 14:33:10 Hotel Papa Tango, Echo three thousand five hundred feet, climbing direction Hasle.

HPT ADC :16 Hotel Papa Tango roger, report leaving CTR.

ADC HPT :19 Will report le… will report leaving CTR, Hotel Papa Tango.

ADC NAV4 :50 And Tower Navchecker four one one now on a right turn onto the arc.

NAV4 ADC :54 Navchecker four one one roger, are you in contact with Payerne?

ADC NAV4 :59 Negative.

NAV4 ADC 14:34:01 Roger, so if you approaching TMA Payerne, just to contact Payerne Tower in case you penetrate this airspace.

ADC NAV4 :11 "Ja", think we are free of ah… their control zone.

ADC HHF :24 Hotel Hotel Foxtrot ready.

HHF ADC :26 Hotel Hotel Foxtrot, wind variable three knots, runway one four, cleared for take off.

ADC HHF :30 Cleared for take off runway one four, Hotel Hotel Foxtrot.

ADC HPT 14:35:22 Hotel Papa Tango, I've leaved your CTR. xxx xxx :27 ….. some noise

ADC HPT :34 Bern Tower Hotel Bravo Papa Papa Tango, I have leaved you CTR.

HPT ADC :39 Papa Tango I say again, you may leave. strong background noise

HPT ADC :45 Papa Tango do you read? strong background noise

13 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC HPT 14:35:48 I can hear you, Hotel Papa Tango.

HPT ADC :51 You're cleared to leave, good bye. strong background noise

ADC HPT :56 Cleared to leave, good bye, Hotel Papa Tango.

ADC HPQ 14:36:42 Bern Tower Hotel Bravo X-Ray Papa Quebec, Schwarzenburg four thousand feet, inbound via Hotel- Whiskey, for landing Heliswiss with information Oscar.

HPQ ADC :52 Bravo X-Ray Papa Quebec Bern Tower, enter CTR via Hotel-Whiskey, QNH one zero one seven.

ADC HPQ :58 QNH one zero one seven, enter CTR via Hotel-Whiskey, Heli Papa Quebec.

ADC 918 14:37:32 Bern "guete Namittag" niner one eight, approaching xxxxx unintelligible four thousand five hundred, crossing direction Worb.

918 ADC :40 Niner one eight Bern "grüezi", … squawk ident, passing approved, QNH one zero one seven.

ADC 918 :47 Squawk ident, passing approved, one zero one seven, niner one eight.

918 ADC 14:38:14 Niner one eight, identified.

ADC 918 :16 "Merci villmal".

HPQ ADC :43 Heli Papa Quebec report position and altitude?

ADC HPQ :49 We're on emergency training, Heli Papa Quebec and ah… we're approaching soon Hotel-Whiskey.

H-PQ ADC :54 Okay… confirm ah… below three thousand four hundred feet?

ADC HPQ :59 Affirm Heli Papa Quebec.

HPQ ADC 14:39:01 Okay.

NAV4 ADC :19 Navchecker four one one, VFR traffic, twelve o'clock position, range two miles, three thousand six hundred feet in climb, west bound.

ADC NAV4 :26 "Ja" roger, looking out.

14 - 15 TRANSCRIPT SHEET Occurrence: HBKHF / HBPPV of 24.06.2008

To From Time Communications Observations Col.1 Col.2 Col.3 Col.4 Col.5

ADC NAV4 14:39:46 Navchecker have the traffic in sight.

NAV4 ADC :48 Roger.

HHF ADC 14:40:31 Hotel Hotel Foxtrot, contact Bern Departure one two seven decimal three two five, good bye.

ADC HHF 14:40:36 One two seven decimal three two five, Hotel Hotel Foxtrot.

- End of Transcript -

15 - 15 G104 Src Analysis: HBKHF / HBPPV Time:G096 24.06.2008 14:24:19 a36 MV_NT 7000 14:14:03 G103 M a28 a39 14:14:39 G103 a41 14:15:11 G 91 a44 14:15:39 G 93 G111 a44 a44 14:17:23 14:16:11 G104 BIEL KAPPELEN a44 14:18:07 G105 G 94 a45 14:18:39 a43 G108 14:17:03 a45 14:19:07 EENOTNOT G115 a45 14:19:31 G114 a45 14:19:55 G114 BADEP a45 14:20:23 G114 a46 G113 14:20:51 a44 14:21:31 KONOL G102 G117 a46 a40 14:21:11 14:22:15 G117 a42 G111 14:21:51 G166 a38 FCK411 14:22:59 ULMES a40 +1816 G120 ULMES G122 a39 G097 a38 14:22:35 HBKHF 14:23:39 a33 +0035 G115 G 95 0.1 NM G101 a34 200 fta38 14:23:19 7000 14:24:15 59 M a42 +0363 G134 G093 BERNa31 7000 14:23:39 G111 a36 HBPPV BER a36 -0463 G104 a30 14:23:27

N KOREDKORED 1 : 199172 km 0 2.5 5 NM 0 1.5 3 Name: Elke SCHAFFER SROec Eval Date: 27.06.2008 a3 G113 14 Src Analysis: HBKHF / HBPPV Time: 24.06.2008 14:24:19 MV_NT a38 14:22:51 G111 a38 G111 14:2 a38 14:22:59 G112 a38 G112 14:23: a38 14:23:07 G114 a38 G115 14:23:11 G120 a38 a38 14:23:19 14:23:27 G115 G120 a38 14:23:15 G166 a38 G120 FCK411 14:23:35 a38 a40 +1816 14:23:23 G119 G120 a38 a38 14:23:43 G118 14:23:31 a38 G122 14:23:51 a38 G116 14:23:39 a37 14:23:59 G118 G097 G114 a38 HBKHF a37 14:23:47 a33 +0035 14:24:07 G117 G111 a38 a36 14:23:55 14:24:15 G115 G 95 0.1 NM a37 a34 200G112 ft 14:24:03 14:24:15 a3659 14:24:11 G 93 a34 G111 14:24:07 HBPPV a36 -0463 G 94 G 97 a33 a33 14:23:59 14:23:55 G 96 G103 a33 14:23:51 BERN a33 14:23:47 G106 G134 a32 a31 14:23:43 14:23:39

G104 G118 a31 a30 14:23:35 14:23:31 G104 a30 14:23:27

BER

1 : 39834 km 0 0.5 1 NM 0 0.25 0.5 Name: Elke SCHAFFER SROec Eval Date: 27.06.2008