Serious incident Saab 340B G-LGNK,
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ASN Wikibase Occurrence # 230737
 
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Date:Tuesday 12 February 2019
Time:19:00 UTC
Type:Silhouette image of generic SF34 model; specific model in this crash may look slightly different    
Saab 340B
Owner/operator:Loganair
Registration: G-LGNK
MSN: 340B-185
Year of manufacture:1990
Fatalities:Fatalities: 0 / Occupants: 21
Aircraft damage: None
Category:Serious incident
Location:London-Stansted Airport (STN/EGSS) -   United Kingdom
Phase: Initial climb
Nature:Passenger - Scheduled
Departure airport:London-Stansted Airport (STN/EGSS)
Destination airport:Dundee Airport (DND/EGPN)
Investigating agency: AAIB
Confidence Rating: Information verified through data from accident investigation authorities
Narrative:
A Loganair Saab 340 (G-LGNK), flight LOG626 and a Laudamontion Airbus A320 (OE-IHD, flight LDM326) were involved in a serious airprox incident at London-Standsted Airport, U.K.

G-LGNK
The aircraft was routing from Stansted to Dundee, U.K. as flight LOG626 and cleared for an UTAVA 1R Standard Instrument Departure (SID) with a cleared altitude of 4,000 ft. As the aircraft approached holding point R1 for Runway 22, the crew reported to ATC that they were “ready for departure”. They were cleared for an immediate takeoff, and the departure was expeditious but routine. As the aircraft passed approximately 1,000 ft, the crew were advised by ATC that an aircraft on approach had initiated a go-around. ATC advised the crew to continue with the planned UTAVA 1R SID. Shortly after this, ATC instructed the crew to turn right onto a heading of 290⁰. By this point the autopilot (AP) was engaged so the commander initiated the turn using the AP. A further ATC instruction was then issued to “STOP CLIMB AT ALTITUDE 3,000 FT”. This instruction was acknowledged by the co-pilot and the commander set the aircraft altitude select/alert system to 3,000 ft.
On passing approximately 2,500 ft, the aircraft TCAS issued an audio Traffic Advisory (TA) message and the associated amber indication on the pilots’ displays. A few seconds later as the aircraft passed approximately 2,700 ft the TCAS issued a momentary “level off” RA instruction with the associated red indications on the pilots’ displays.
The commander disconnected the AP and began to level the aircraft. Almost immediately the TCAS issued a “clear of conflict” message. The commander subsequently climbed the aircraft to the cleared altitude of 3,000 ft and the AP was re-engaged. The co-pilot did not transmit a “tcas ra” message to ATC due to his high workload at the time of the event. The crew continued the flight to Dundee and reported the event to Stansted ATC upon arrival.

OE-IHD
During the arrival into Stansted, while at approximately 14,000 ft, ATC gave OE-IHD a short-cut and a speed reduction to 250 kt. The reduction in track-miles available to the crew meant the aircraft was now above the descent profile for the runway in use. The situation was noted by both pilots, but the co-pilot, who was PF, felt the approach was still acceptable. At approximately 7,000 ft, ATC cleared OE-IHD to descend to 2,000 ft and the crew decided they could reach the final approach fix at 2,000 ft by using the speed brakes to increase the descent rate.
ATC restrictions led to further reductions in speed to 220 kt and then 200 kt with the consequent effect of a reduced descent rate. ATC offered to increase the distance to landing but this was declined by the co-pilot. At this point the commander pointed out that the aircraft was above profile and that he wanted to extend the landing gear to increase drag and hence increase the descent rate. This was done and the aircraft began returning to the profile.
As the aircraft approached the planned ILS glidepath intercept point, the glideslope indication was near the lower end of the scale (fly down indication). Before the AP captured the glideslope, the AP entered an altitude capture mode and began to level at 2,000 ft so, again, the descent rate was reduced. The commander directed the co-pilot to use a vertical speed mode to increase the rate of descent. However, the co-pilot inadvertently triggered a climb mode in the AP. The co-pilot wanted to re-attempt the vertical speed selection, but recognising there was no prospect of a stable approach the commander ordered a go-around.
The co-pilot set Take Off Go- Around (TOGA) for the flight director and autothrottle, while also disconnecting the AP. The commander set the go-around altitude in the Flight Control Unit (FCU) and, very shortly afterwards, the aircraft was in altitude capture mode at 3,000 ft, the published go-around altitude. At 3,000 ft there was some confusion between the pilots over speed and flap selections, and the co-pilot reduced thrust to idle. The commander directed the co-pilot to “set thrust and Flap 1” but then, still not content, he took control of the aircraft.
As the commander took control, ATC instructed OE-IHD to climb to 4,000 ft and fly a heading of 135°M. This was shortly followed by a further turn to 090°M. The flight director was still giving directions to fly the aircraft along the planned navigation path for the published go-around so the commander did not engage the AP. He made a slight turn to the right and then immediately corrected to the left and ordered the co-pilot to set heading 090°M.
At this point there was an audio callout of “priority right” which indicated the co-pilot had pressed the priority take over button on his sidestick. The commander re-iterated his control of the aircraft, brought the control priority to the left, turned left to 090° and climbed to 4,000 ft. The departing Saab 340 indicated on the TCAS as a TA with the associated amber visual indications. The crew believed the aircraft were approximately 900 ft apart vertically, and the TA disappeared during the climb to 4,000 ft. The commander retained control and subsequently flew an uneventful approach to land at Stansted.

The aircraft passed 87 m apart laterally and 600 ft vertically.

AAIB Conclusion
The go-around and the very high resultant workload, followed by a change of PF, led to a situation where the ability of one of the A320 crew to react to ATC instructions was reduced. Due to the delay in the response by the A320 crew there was a short term loss of separation between the aircraft. The Saab 340 crew received a TCAS RA which prevented a further degradation of separation.

Accident investigation:
cover
  
Investigating agency: AAIB
Report number: EW/G2019/02/09
Status: Investigation completed
Duration: 9 months
Download report: Final report

Sources:

AAIB

Images:


Figure: AAIB

Revision history:

Date/timeContributorUpdates
17-Nov-2019 20:32 harro Added

Corrections or additions? ... Edit this accident description

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