Event Details

Title:Near-miss involving an Air France Boeing 747-400 and an Airtours A330 in Shanwick Oceanic Airspace, North Atlantic Track Echo, November 10, 2001
Micro summary:Numerous events lead to a near-miss between this Boeing 747 and Airbus A330.
Event Time:2001-11-10 at 1059 UTC
File Name:2001-11-10-IE.pdf
Publishing Agency:Air Accident Investigation Unit (AAIU)
Publishing Country:Ireland
Report number:2002/009
Site of event:Shanwick Oceanic Airspace, North Atlantic Track Echo
First AirplaneSecond Airplane
Departure:Jose Marti Intenrational Airport, Havana, CubaGatwick Airport, London, England
Destination:Charles De Gaulle International Airport (Roissy Airport), Paris, FranceCancun International Airport, Cancun, Mexico
Airplane Type(s):Boeing 747-400Airbus A330-200
Flight Phase:CruiseCruise
Operator(s):Air FranceAirtours International
Type of flight:RevenueCharter
Serious Injuries:UnknownUnknown
Other Injuries:UnknownUnknown
Executive Summary:The circumstances leading to this serious incident were numerous. The first link in the chain of events was initiated by the Commander of AIH 065 (A330) requesting a westbound clearance for the oceanic entry point SOMAX for a time which was one hour later than actuality, his 1145 hrs request should have been 1045 hrs. This one hour error was not picked up by the Scottish Oceanic Control Area (OCA) based at Prestwick, whose callsign is Shanwick. OCA processed and approved the pilot’s requested clearance for 1145 hrs at Flight Level (FL) 370 at SOMAX, on North Atlantic Track (NAT) ECHO. AFR 3671 (B747), which was on an eastbound track at FL 370 also, estimated SOMAX at 1109 hrs. Thus, there were two aircraft on reciprocal tracks approaching the same Reporting Point, SOMAX, and at the same Flight Level, 370. AIH 065 entered Shannon Oceanic Transition Area (SOTA) and came under Shannon Radar control on handover from UK ATC (Appendix A). The Sector Controllers in Shannon, in turn, did not pick up on the one hour error and gave Shanwick a revised estimate of 1148 hrs, which was plus three minutes on the original estimate for AIH 065 at SOMAX. Shanwick queried this new estimate and it was only then that the one hour error in the AIH 065 estimate and its significance was fully realised by both the Shannon and Shanwick Controllers respectively. Flight level separation instructions were then initiated by Shanwick.

Contemporaneous to these unfolding events the pilots of AFR 3671 and AIH 065 later reported observing, on their onboard anti-collision device, the Traffic Alert and Collision Avoidance System (TCAS), Traffic Advisories (TA’s), as AIH 065 was descended by Shanwick to FL 350. The general area of the incident is West of 15º West, at approximately 50°N 1630° W, and is therefore outside the area of responsibility of Shannon ATC. It is also outside the area of coverage of Shannon Radar. In this non-radar environment over the North Atlantic the surveillance element of ATC relies on pilot’s “position reporting”.

3.2 Causal Factors

3.2.1 The incident was caused by the Commander (PNF) of AIH 065 requesting a westbound clearance at SOMAX which was incorrect by one hour.

3.2.2 This initial error was compounded by Shanwick Controllers confirming the requested clearance, through human factors and systemic failures to carry out an estimate credibility check. This error was further compounded by a human factors failure by the Controllers at Shannon to act on this incorrect estimate, which was being clearly indicated on their EDD. The final error was the passing of a revised estimate for SOMAX by the Planning Controller which continued with the original one hour incorrect clearance.
Learning Keywords:Operations - Airspace - Air Proximity
Operations - Airspace - Air Traffic Control
Operations - Airspace - TCAS


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