Loss of Separation Between De Havilland DH8D-400 and Boeing 737-800 Near Warsaw

Casualties unknown • Warszawa (EPWA), PL

A loss of separation occurred between two aircraft near the boundary of Warsaw Approach and Area Control due to an untimely clearance for climb.

What happened

On August 12, 2019, a De Havilland DH8D-400, registration YL-BAH, was cruising at FL 240 within the Warsaw TMA2. Simultaneously, a Boeing 737-800, registration SP-LWA, was departing from Warsaw Chopin Airport (EPWA) and climbing through the airspace.

The crew of the Boeing 737-800 was initially cleared to climb to FL 230, which provided vertical separation from the De Havilland DH8D-400 while the aircraft worked toward achieving lateral separation. After crossing the flight path of the YL-BAH, the controller cleared the Boeing 737-800 to climb further to FL 340. However, at the time this clearance was issued, the lateral distance between the two aircraft was less than the required 5 NM.

As the Boeing 737-800 passed the DIBLO waypoint and began a left turn toward INDIG, the flight paths remained in a conflict state. At approximately 18:25 local time, as the Boeing 737-800 crossed FL 230, the distance between the aircraft had decreased to 2.62 NM, triggering a Short Term Collision Alert (STCA) via the PEGASUS_21 system.

Upon detecting the conflict, the controller immediately intervened by instructing the Boeing 737-800 to turn right to a heading of 295°. This maneuver increased the separation between the aircraft. The distance eventually grew to 3.93 NM with a vertical separation of 700 ft as they passed each other at FL 240. Once the required 5 NM lateral and 1000 ft vertical separation was established, the Boeing 737-800 was cleared back to the INDIG waypoint and transferred to ACC control.

The investigation

The investigation focused on the sequence of clearances issued by Warsaw Approach (APP) and the coordination between the Approach and Area Control Centre (ACC) sectors. The inquiry examined the timing of the climb clearance and the controller's assessment of the aircraft's planned trajectory.

Findings

  • The primary cause of the incident was the premature issuance of the clearance to climb for the Boeing 737-800.
  • The controller failed to account for the planned flight path of the Boeing 737-800 when issuing the climb clearance.
  • The transfer of the De Havilland DH8D-400 to ACC control occurred too early, contributing to the loss of separation risk.

Probable cause

The loss of separation was caused by the controller issuing a climb clearance to the Boeing 737-800 before sufficient lateral separation from the De Havilland DH8D-400 had been established, compounded by a failure to consider the aircraft's intended route and the premature transfer of the other aircraft to area control.

Frequently asked questions

What happened in the 2019-08-12 De Havilland DHC8-400 / Boeing 738-800 accident near Warszawa (EPWA), PL?

A loss of separation occurred between two aircraft near the boundary of Warsaw Approach and Area Control due to an untimely clearance for climb.

What aircraft was involved and where did it happen?

The accident on 2019-08-12 involved a De Havilland DHC8-400 / Boeing 738-800, registration YL-BAH / SP-LWA, operated by Air Baltic / PLL LOT, at Warszawa (EPWA), PL.

What was the probable cause of the accident?

The loss of separation was caused by the controller issuing a climb clearance to the Boeing 737-800 before sufficient lateral separation from the De Havilland DH8D-400 had been established, compounded by a failure to consider the aircraft's intended route and the premature transfer of the other aircraft to area…

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2019-3499/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.

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