Serious incident Boeing 737-8LD (WL) ZS-ZWF,
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ASN Wikibase Occurrence # 276858
 
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Date:Tuesday 8 February 2022
Time:08:30 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8LD (WL)
Owner/operator:Comair
Registration: ZS-ZWF
MSN: 40856/5606
Year of manufacture:2015
Fatalities:Fatalities: 0 / Occupants: 114
Aircraft damage: None
Category:Serious incident
Location:near Lanseria -   South Africa
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Durban-King Shaka International Airport (DUR/FALE)
Destination airport:Lanseria International Airport (HLA/FALA)
Investigating agency: CAA S.A.
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A Basler BT-67 Turbo 67 (ZS-ASN) and Comair flight MN500, a Boeing 737-800 (ZS-ZWF) were involved in a serious airprox incident near Lanseria International Airport, South Africa.
The BT-67, a DC-3 turbine conversion, operated on a local flight from Lanseria International Airport. Upon their return, the pilot flying requested if he could do a simulated RNAV/GNSS approach for runway 07. Air traffic control (ATC) approved this request and instructed the pilot to report 6 nautical miles (nm) final approach.
Meanwhile, Comair flight 500 was inbound to Lanseria. The crew had requested a visual approach to runway 07. ATC approved this request and cleared the aircraft for right visual approach runway 07. Thereafter, the controller instructed them to report 5nm final approach and to reduce speed to the minimum safe approach.
There was loss of separation as ZS-ZWF was 500 feet above ZS-ASN and both aircraft were on final approach for runway 07.
ATC told ZS-ASN to turn left and report left downwind runway 07. Both aircraft received a Traffic Collision Avoidance System (TCAS) warning followed by a Resolution Advisory (RA). The BT-67 complied with the RA and ATC’s instruction. The Boeing 737 continued with the approach and landed on at 08:37 UTC.

Probable Cause
The ATCO permitted visual for two aircraft on the same runway, but did not warn them of each other’s status (proximity). The faster aircraft (B738) caught up with the slower aircraft (DC3), which resulted in reduced aerodrome separation.
Contributing Factors
• Poor situational awareness: late conflict detection.
• Instruction given to ZS-ASN (DC3) was late and provided without a reason and/or traffic information.
• The ATCO cleared ZS-ZWF (B738) for visual approach as requested and provided instructions of what to do next. The ATCO did not pick up that the pilot did not read back the speed instructions.
• The frequency was busy, there were 12 aircraft under the ATC’s jurisdiction at the time of the incident.

Accident investigation:
cover
  
Investigating agency: CAA S.A.
Report number: 
Status: Investigation completed
Duration: 1 year and 2 months
Download report: Final report

Sources:

SACAA

Revision history:

Date/timeContributorUpdates
26-Mar-2022 13:29 harro Added
26-Mar-2022 14:36 harro Updated [Date, Departure airport]
26-Mar-2022 14:36 harro Updated [Departure airport]

Corrections or additions? ... Edit this accident description

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