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Ciaiac@Fomento.Es C/ Fruela, 6 Fax: +34 91 463 55 35 28011 Madrid (España) Foreword CCIAIIAACIAC COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Report IN-038/2016 Incident involving a BOEING 737-400, registration SP-ENA, operated by ENTER AIR, and a CESSNA 172, registration EC-JOB, operated by BARCELONA FLIGHT SCHOOL, at the Barcelona TMA (Spain) on 28 September 2016 Report IN-038/2016 Incident involving a BOEING 737-400, registration SP-ENA, operated by ENTER AIR, and a CESSNA 172, registration EC-JOB, operated by BARCELONA FLIGHT SCHOOL, at the Barcelona TMA (Spain) on 28 September 2016 SUBSECRETARÍA GOBIERNO MINISTERIO DE ESPAÑA DE FOMENTO COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Edita: Centro de Publicaciones Secretaría General Técnica Ministerio de Fomento © NIPO: 161-16-318-8 Diseño, maquetación e impresión: Centro de Publicaciones COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Tel.: +34 91 597 89 63 E-mail: [email protected] C/ Fruela, 6 Fax: +34 91 463 55 35 http://www.ciaiac.es 28011 Madrid (España) Foreword This report is a technical document that reflects the point of view of the Civil Aviation Accident and Incident Investigation Commission (CIAIAC) regarding the circumstances of the accident object of the investigation, and its probable causes and consequences. In accordance with the provisions in Article 5.4.1 of Annex 13 of the International Civil Aviation Convention; and with articles 5.5 of Regulation (UE) nº 996/2010, of the European Parliament and the Council, of 20 October 2010; Article 15 of Law 21/2003 on Air Safety and articles 1.4 and 21.2 of Regulation 389/1998, this investigation is exclusively of a technical nature, and its objective is the prevention of future civil aviation accidents and incidents by issuing, if necessary, safety recommendations to prevent from their reoccurrence. The investigation is not pointed to establish blame or liability whatsoever, and it’s not prejudging the possible decision taken by the judicial authorities. Therefore, and according to above norms and regulations, the investigation was carried out using procedures not necessarily subject to the guarantees and rights usually used for the evidences in a judicial process. Consequently, any use of this report for purposes other than that of preventing future accidents may lead to erroneous conclusions or interpretations. This report was originally issued in Spanish. This English translation is provided for information purposes only. Report IN-038/2016 Table of contents Abbreviations ............................................................................................................................... vii Synopsis ........................................................................................................................................ ix 1. Factual information ............................................................................................................... 1 1.1. History of the flight........................................................................................................ 1 1.2. Injuries to persons .......................................................................................................... 2 1.2.1. Aircraft SP-ENA ................................................................................................ 2 1.2.2. Aircraft EC-JOB ................................................................................................ 2 1.3. Damage to aircraft ......................................................................................................... 2 1.4. Other damage ................................................................................................................ 2 1.5. Personnel information .................................................................................................... 2 1.5.1. Information on the personnel in aircraft SP-ENA ............................................. 2 1.5.2. Information on the personnel in aircraft EC-JOB ............................................. 3 1.5.3. Information on the control personnel .............................................................. 3 1.6. Aircraft information ........................................................................................................ 4 1.6.1. Information on aircraft SP-ENA ........................................................................ 4 1.6.2. Information on aircraft EC-JOB ........................................................................ 4 1.7. Meteorological information ............................................................................................ 4 1.8. Aids to navigation .......................................................................................................... 5 1.8.1. Arrival and approach charts for the Girona Airport ......................................... 5 1.8.2. TMA Barcelona sectors involved ...................................................................... 8 1.9. Communications ............................................................................................................ 9 1.10. Aerodrome information .................................................................................................. 18 1.11. Flight recorders .............................................................................................................. 18 1.12. Wreckage and impact information ................................................................................. 18 1.13. Medical and pathological information ............................................................................ 18 1.14. Fire ............................................................................................................................ 18 1.15. Survival aspects .............................................................................................................. 18 1.16. Tests and research .......................................................................................................... 18 1.16.1. Report from Enter Air ...................................................................................... 18 1.16.2. Report from the crew of EC-JOB ..................................................................... 19 1.16.3. Report from the executive controller in sector T1E .......................................... 20 1.16.4. Report from the executive controller in sector TGR ......................................... 21 1.16.5. Report from the executive controller at the Girona Airport tower ................... 21 1.16.6. Change in operating configuration .................................................................. 24 1.16.7. Loss of air navigation data network ................................................................ 25 1.17. Organizational and management information ................................................................ 25 1.18. Additional information ................................................................................................... 25 1.18.1. Usage time for sectors, runways at LEGE and route SLL1K ............................. 25 1.18.2. Actions taken by ENAIRE ................................................................................. 26 1.18.3. Actions taken by AESA .................................................................................... 27 1.19. Useful or effective investigation techniques ................................................................... 27 v Report IN-038/2016 2. Analysis ................................................................................................................................ 29 2.1. Loss of separation between aircraft EC-JOB and SP-ENA ............................................... 29 2.2. Configuration change and opening of sectors ............................................................... 30 2.3. Loss of the REDAN network ........................................................................................... 30 2.4. Use of sectors TGR and D1E, RWY 02 LEGE and route SLL1K ....................................... 31 3. Conclusions ............................................................................................................................ 33 3.1. Findings .......................................................................................................................... 33 3.2. Causes/contributing factors ............................................................................................ 33 4. Safety recomendations ........................................................................................................ 35 4.1. Safety recommendations issued during the investigation ............................................... 35 4.2. New safety recommendations issued with this report .................................................... 35 vi Report IN-038/2016 Abbreviations ACC Area control center AESA Spain National Aviation Safety Agency AMSL Above mean sea level ATCO Air Traffic Controller ATPL(A) Airline transport pilot license (airplane) CECOA Coordination Center at airport CPL(A) Commercial pilot license (airplane) CTOT Calculated take off time CTR Control zone DME Distance measuring equipment EHEH Eindhoven (The Netherlands) airport ICAO designation EPWA Warsaw Chopin (Poland) airport ICAO designation ELR TMA east configuration FI Flight instructor rating FL Flight level FP Flight Plan ft Feet h Hour(s) hPa Hectopascals IAF Initial approach fix IFR Instrument flight rules IMC Instrumental Meteorological Conditions IR(A)
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