Event Details
On 24 June 2015 at 14:43 UTC, a Cessna 182 operating a VFR flight from EPBC to EPKM via Opoczno and Ogrodzieniec entered the Military Aerodrome Traffic Zone (MATZ) EPTM without authorization. The zone was active from ground to 5500 ft ALT for instrument approach training of military helicopters under simulated IMC conditions. The pilot, aged 20 with a PPL(A) and 530h 40min total flight time (446h 30min on type), had received flight information services from FIS Warszawa.
Sequence of Events
At 14:14:46, the pilot checked in with FIS Warszawa, reporting position before WAR at 1900 ft ALT, squawk 7000. The FIS operator instructed to initially not exceed 1500 ft ALT and provided QNH. At 14:25:13, the pilot requested climb to 2000 ft ALT; the operator authorized up to 3500 ft ALT. The operator subsequently warned two other aircraft about MATZ EPTM activity but did not inform the Cessna pilot. At 14:37:14, a yellow ZONE alarm appeared on the radar display as the Cessna approached the MATZ; a red ZONE alarm followed at 14:39:13 as it entered segment BRAVO at 1900 ft ALT. At 14:42:21, the Cessna disappeared from radar inside segment CHARLIE. At that moment, a military W-3 Sokół helicopter was at 2100 ft ALT, approximately 4 NM away, descending on a converging course. The helicopter turned left toward the Cessna's last radar position at 14:43:00. Based on extrapolation, the minimum separation was estimated at 0.32 NM (600 m) horizontally and 200 ft vertically, but this figure is speculative due to radar loss.
Causes
The investigation identified two causes: 1) Entry into MATZ EPTM without obtaining clearance; 2) Workload at the operational position of the FIS Warszawa operator.
Contributing Factors
Six factors were noted: poor radio transmission quality on low altitudes; mismatch between the P_21 monitor aspect ratio and the sector shape, reducing effective radar display usage; large sector size requiring wide display range, obscuring airspace infringements; limited radar coverage at low altitudes (aircraft at 2000 ft ALT become invisible beyond about 45 NM); yellow ZONE alarm being inconspicuous in the track data block; and absence of STCA alerts in Class G airspace.
The FIS operator had not provided a warning about MATZ activity because he assumed the pilot's planned route would avoid the zone. During a shift handover lasting four minutes, the incoming operator was told that the Cessna pilot was "coordinating a transit with Tomaszow" (EPTM), leading to a lack of intervention. The operator's workload was high due to intense radio traffic; he had been on his second 12-hour day shift, preceded by three days off, and had worked earlier shifts that day (4:17–6:56, 9:58–10:56, and 13:02–14:43 UTC).