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ASN Wikibase Occurrence # 210648
Last updated: 1 December 2021
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Date:23-FEB-2018
Time:11:31 LT
Type:Silhouette image of generic E190 model; specific model in this crash may look slightly different
Embraer ERJ-195LR
Owner/operator:Air Europa
Registration: EC-LFZ
MSN: 19000357
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:near Brussel -   Belgium
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Brussel-Zaventem Airport (BRU/EBBR)
Destination airport:Madrid-Barajas Airport (MAD/LEMD)
Investigating agency: AAIU Belgium
Narrative:
Lufthansa flight LH1009, an Airbus A320 (D-AIUI), was involved in an airprox incident with Air Europa flight UX1172, an Embraer ERJ-195LR (EC-LFZ) shortly after departure from Brussel-Zaventem Airport.

UX1137 took off from runway 07R at 11:30 hours, followed about a minute later by LH1009. Both aircraft followed runway heading before commencing a right-hand turn. This brought the two flights in conflict. Both flight crew responded to the TCAS-RA warnings and took action.
Minimum separation was 1,3 NM horizontally and 684 feet vertically, which should have been at least 1000 feet.

Findings as to causes and contributing factors
• The trainee ATCO gave an instruction to the A320 (DLH4Y) to turn earlier than foreseen by the published route without taking the projected flight path of the ERJ195 AEA1172 into consideration. He assumed that there would be enough separation.
[direct causal factor]
[Action/decision – Action – Incorrect action selection - ATCO]
[Action/decision – Info processing - Expectation/assumption- ATCO]
• The trainee ATCO declared he was a bit under stress and that he considered every shift as an examination. He was eager to show that he could be proactive
[contributing factor]
[Psychological – Mental/emotional state – Stress - ATCO]
• The potential conflict was initially not noticed by the OJTi. The trainee was speaking with rather low voice and the OJTi doesn’t dispose of a separate radar screen.
[contributing factor] [safety issue 4.1]
[Task performance – Monitoring – OJTi]
[Task environment – Physical workspace – Positioning – Effect on ATC OJTi]
[Management – Resources – Availability of equipment – ATC]
• The design of the departures from EBAW to GILOM and EBBR to REMBA lead to converging courses.
[contributing factor]
[Operating environment – Air traffic – Departure procedure(s) – Effect on operation]
• When the STCA popped up there was still a lack of situational awareness of the ATCO. He thought that the A320 was much lower than the ERJ195 while in fact the aircraft was already above. He initially gave the wrong instruction to stop climbing to the A320
[contributing factor]
[Psychological – Perception/orientation/illusion – Situational awareness - ATCO]

Sources:

BFU
https://mobilit.belgium.be/nl/nieuws/nieuwsberichten/2018/luchtvaartincident_23_februari_onderzoek_aaiu_bezig

Accident investigation:
cover
  
Investigating agency: AAIU Belgium
Status: Investigation completed
Duration:
Download report: Final report


Images:

Photo of EC-LFZ courtesy AirHistory.net


Madrid - Adolfo Suarez / Barajas (LEMD / MAD)
25 September 2019; (c) TavoCruz


Revision history:

Date/timeContributorUpdates
08-May-2018 19:33 harro Added
19-May-2018 17:27 harro Updated [Source, Narrative]
12-Sep-2020 19:23 harro Updated [Narrative, Accident report, ]

Corrections or additions? ... Edit this accident description