Air Traffic Controller Loss of Situational Awareness at Szczecin-Goleniów

Casualties unknown • Szczecin Goleniów (EPSC), PL

An air traffic controller issued conflicting instructions to two aircraft at Szczecin-Goleniów Airport, leading to a potential runway conflict during a low pass maneuver.

What happened

On March 10, 2016, a Cirrus CR22T was conducting IFR training approaches within the Szczecılık-Goleniów (EPSC) Control Zone. At approximately 14:00 UTC, while performing its second ILS approach to runway 31, the crew reported being stabilized and received authorization from the tower controller to perform a low pass over runway 31. The crew correctly acknowledged this instruction.

Roughly one minute later, the tower controller cleared a general aviation aircraft to taxi and enter the opposite threshold of runway 13. Upon noticing this, the instructor pilot of the Cirrus CR22T alerted the controller to the potential conflict, noting that the aircraft was still in the final approach phase for runway 31 under low pass authorization. Despite this warning, the controller reiterated the authorization for the low pass, stating that the other aircraft had only just begun taxiing.

The investigation

The investigation examined the instructions issued by the tower controller and the operational environment during the maneuver. It was noted that while there are no specific regulations governing the execution of a low pass maneuver, pilots are responsible for maintaining obstacle clearance based on visible terrain. The investigation established that the controller believed the runway would be clear of obstructions by the time the Cirrus CR22T completed its pass. However, the controller failed to provide the Cirrus CR22T crew with complete information regarding the movement of the second aircraft, leading the pilot to perceive the instructions as unsafe.

Findings

  • The primary cause of the incident was the loss of situational awareness by the air traffic controller.
  • The controller issued conflicting clearances that created a potential collision risk between the aircraft performing the low pass and the aircraft taxiing to runway 13.
  • The controller failed to communicate the full traffic situation to the crew of the Cirrus CR22T, resulting in a lack of confidence in the safety of the provided instructions.

Probable cause

The air traffic controller experienced a loss of situational awareness, leading to the issuance of conflicting clearances for a low pass and runway entry.

Frequently asked questions

What happened in the 2016-03-10 Cirrus CR22T accident near Szczecin Goleniów (EPSC), PL?

An air traffic controller issued conflicting instructions to two aircraft at Szczecin-Goleniów Airport, leading to a potential runway conflict during a low pass maneuver.

What aircraft was involved and where did it happen?

The accident on 2016-03-10 involved a Cirrus CR22T, at Szczecin Goleniów (EPSC), PL.

What was the probable cause of the accident?

The air traffic controller experienced a loss of situational awareness, leading to the issuance of conflicting clearances for a low pass and runway entry.

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2016-0383/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.

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