TABLE 1. ASSESSMENT SUMMARY SHEET FOR UKAB MEETING ON 24th APRIL 2013 Total Risk A Risk B Risk C Risk D Risk E 14 1 1 10 1 1 Remaining Ineffecti Barrier Not Barriers ve Applicable Barriers Controller Aircrew Barriers Barriers board board Risk - No Reporting Reported Airspace Cause Cat Controller Action Action Controller tech by prompt Rules Procedures& Sighting Visual SART from SA from on Rules Procedures& Action Controller systems SAfrom ACAS ACAS RA Score 2012154 DHC8 A319 D/A The Air Controller did not ensure C 1 (CAT) (CAT) (Gatwick separation before transferring the CTR/LTMA) aircraft. 2012164 AW139 C150 G In the absence of TI the AW139 C 10 (CAT) (CIV) (London FIR) crew was concerned by the proximity of the C150. Recommendation: The current RDP design for the Anglia Radar sector highlights the coastline in white, which is the same colour as radar tracks. NATS Ltd is recommended to amend the RDP to provide greater clarity between radar tracks and map features. 1 2012167 JS41 T ucano G In the absence of an agreement C 50 (CAT) T MK 1 (London FIR) with the Tucano pilot, the (MIL) controller did not take further action to achieve deconfliction minima. 2012171 ASK13 Hughes G The MD500 pilot flew close C 10 (CIV) MD500 (London FIR) enough to a promulgated and (CIV) active glider site to cause the launch party concern. 2012173 AS332L EC135 D The AS332 crew did not take C 50 (CAT) (CIV) (Aberdeen timely action to give way to the ATZ/CTR) EC135. 2012175 B777-200 2 U ntraced D A sighting report on final D X (CAT) Objects (NK) (Gatwick approach. CTR) 2013002 PA28 NANCHANG G The CJ6 pilot flew into conflict C 4 (CIV) CJ6 (White with the PA28 on final approach, (CIV) Waltham ATZ) which he did not see. 2013003 PA18 NANCHANG G The CJ6 pilot did not conform to B 20 (CIV) CJ6 (White the pattern of traffic formed and (CIV) Waltham ATZ) flew into conflict with the PA18 on final, which he had not seen. 2 2013004 2 X Hawk Hawk G Hawk B crew deviated from the C 2 T MK2(A) T MK2(B) (LFIR/Valley Mona-Valley transit procedure (MIL) (MIL) AIAA) without informing ATC and turned in front of Hawk (A) No2, which he did not see. 2013006 Wildcat Wildcat G A conflict resolved by Wildcat (A) C 21 AH1(A) AH1(B) (London FIR) pilot. (JHC) (CIV) Contributory Factor: Wildcat (B) pilot utilised an inappropriate ATS while conducting an air test. 2013007 Hawk Hawk G Effectively non-sightings by the A 100 T MK 2 T MK 1 (Valley AIAA) crews of both ac. (MIL) (MIL) 2013008 DA42 FA20 G FA20 crew flew close enough to C 1 TwinStar Falcon (SFIR/OTA E) cause the TAY controller and (CIV) (CIV) DA42 crew concern. Recommendation: The FA20 operator is recommended to comply with Leuchars ASA requirements when operating in OTA E. 2013012 Cessna F86A G Controller perceived conflict. E 1 C510 (CIV) (London FIR) (CIV) 3 2013013 Viking T1 PA28 G The PA28 pilot flew close enough C 4 (CIV) (CIV) (London FIR) to cause concern to the Viking pilot downwind in the Wethersfield circuit. NB. Event Risk Barriers: It is important to note that the assessment records only whether a barrier failed to achieve what it is designed to do in terms of safety mitigation or still remained as an actual or possible safety mitigation. The ineffectiveness of a barrier does not imply failure or blame on the part of the pilot or controller responsible for implementing it. 4 ANNEX A TO APRIL BOARD REPORT DATED 03 MAY 2013 EVENT RISK CLASSIFICATION TRIAL Question 1 Question 2 If this event had escalated into an What was the effectiveness of the remaining barriers accident outcome, what would between this event and the most credible accident have been the most credible scenario? outcome? No Effective Limited/ Minimal Not credible Partial effective accident scenario Catastrophic Multiple 1 50 102 502 2500 Accident passenger fatalities on ac with >19 seats or MTOW >5700kg or significant 3rd party risk. Major Multiple 10 21 101 500 Accident passenger fatalities on ac with 5-19 seats or >5 crew fatalities. Serious <6 fatalities or 2 4 20 100 Accident multiple injuries or ac damage No accident May be outcome operational implications (eg diversion) 5 AIRPROX REPORT No 2012154 Date/Time: 3 Oct 2012 1719Z Position: 5108N 00017W (3·5nm W Gatwick - elev 203ft) Airspace: CTR/LTMA (Class: D/A) GATWICK CTR SFC-2500ft LTMA 2500ft+ Reporter: LTC SW DEPS 19:30 A47 1st Ac 2nd Ac 1718:12 1718:00 Gatwick A28 A22 Type: DHC8 A319 19:12 Elev 203ft A42 18:48 A319 19:06 A35 A3919:00 Operator: CAT CAT A33 A37 A17 A34 DHC8 A21 Alt/FL: 2000ft NK 19:00 1718:12 19:12 A29 18:48 A12 (QNH) (NK) 19:30 A32 A25 A37 19:06 A31 Weather: IMC KLWD NK NR 0 1 ATZ Visibility: NR NM Radar derived Levels show Reported Separation: altitudes as Axx LON QNH 1005hPa NR NR SW DEPS 400ft V/1nm H Recorded Separation: 800ft V/1·5nm H CONTROLLER REPORTED PART A: SUMMARY OF INFORMATION REPORTED TO UKAB THE LTC SW DEPS reports that the DHC8 flight called on departure from Gatwick following a SAM SID. Without identifying the flight formally she observed the ac to be 400ft, she thought, and approximately 1nm from the previous departing A319 on a DVR SID which was in a R turn. She gave the DHC8 flight an avoiding action L turn onto heading 240° and the ac were seen to pull apart. She asked the DHC8 crew whether they had been visual with the ac ahead and they replied negative. THE GATWICK AIR CONTROLLER reports the A319 departed on a R turn DVR SID and the DHC8 was departed behind on a SAM SID. The A319 flight was transferred early passing 2300ft with the DHC8 just getting airborne. He noted the A319 GS was slow so he ensured that it was established in the R turn before looking to transfer the DHC8 flight noting that there was 1000ft separation. Shortly afterwards he noted the DHC8 had been turned L off the SID but the next departure was a R turn so would not be affected. THE DHC8 PILOT reports on departure from Gatwick, IFR and in communication with Gatwick Tower and then London on 134·12MHz, squawking an assigned code with Modes S and C. Gatwick cleared them for departure from the full length of RW26L after having just cleared an A319 for take- off and its wheels had just left the RW. Heading 259° climbing through 2000ft they lost sight of the A319 in cloud but thought nothing of it as it was normal at Gatwick for departures to be close. They started to accelerate to 210kt in the climb to 4000ft on the SAM2M departure as Gatwick handed them over to London. As soon as they selected the London frequency they were given avoiding action onto heading 230° by the controller. They had not received a TCAS warning but the ac ahead was displayed on their TCAS screen. The avoiding action was carried out and then the controller said they would be filing a report owing to Gatwick ATC departing their ac so soon after another ac. He assessed the risk as low. 1 THE A319 PILOT reports being unaware of an Airprox during their departure from Gatwick so they were unable to provide any detailed information about the incident. ATSI reports that the Airprox was reported by the LTC SW (Deps) controller in Class A airspace, when avoiding action was given to the DHC8 after departure from London Gatwick Airport, due to the DHC8 having less than the required radar separation (3nm/1000ft) against a previous departing A319. The A319 was operating IFR on a flight from Gatwick to Frankfurt and was in receipt of a RCS from LTC BIG on frequency 120·525MHz. The DHC8 was operating IFR on a flight from Gatwick to Nantes and was in receipt of a RCS from LTC SW (Deps) on frequency 134·125MHz. CAA ATSI had access to written reports from both pilots, the Gatwick AIR controller, the LTC SW (Deps) controller, area radar recordings, RT recordings and transcripts of the Gatwick Tower frequency and the SW (Deps) frequency together with the unit investigation report from London Terminal Control. The Gatwick METARs are provided for 1650 and 1720 UTC: EGKK 231650Z 21008KT 180V240 9999 FEW024 13/09 Q1006= and EGKK 231720Z 22007KT 9999 FEW022 BKN046 13/09 Q1006= At 1717:15 UTC the A319 became airborne on a DVR8M SID, which requires a climb to altitude 4000ft with a R turn at 2·3DME from I-WW at Gatwick. At 1717:42 (27sec after the A319 was airborne) the DHC8 became airborne on a SAM2M SID climbing to altitude 4000ft, initially straight ahead before a slight L turn at 8DME from MID. The AIR controller was using reduced separation in the vicinity of the aerodrome. CAP493 Section 1, Chapter 3, Page 1, Paragraph 3.2 states: ‘In the vicinity of aerodromes, the standard separation minima may be reduced if: a) adequate separation can be provided by the aerodrome controller when each aircraft is continuously visible to this controller;’ or b) each aircraft is continuously visible to the pilots of other aircraft concerned and the pilots report that they can maintain their own separation; or c) when one aircraft is following another, the pilot of the succeeding aircraft reports that he has the other aircraft in sight and can maintain own separation.’ At 1718:00 the A319 was transferred to LTC BIG.