What happened
On October 15, 2019, two aircraft operating under Instrument Flight Rules (IFR) experienced a loss of separation within the Kraków CTR and TMA. The first aircraft, a Piper PA-2 andR-201 Arrow III with registration SP-TUT, was performing a low approach over runway 07 at EPKK. Following the low approach, the Kraków Tower controller instructed the Piper to climb to 4,000 ft AMSL on a runway 07 heading.
Shortly after the Piper completed its low approach, the tower controller cleared an Airbus A319, registration G-EZIY, to line up on runway 07. At 15:14 local time, the controller issued takeoff clearance to the Airbus. During this period, the Piper was climbing and had reached 2,000 ft AMSL. The airport was experiencing high traffic density, which included a helicopter landing and another passenger aircraft on a 10 NM final approach.
After clearing the Airbus for takeoff, the tower controller contacted Kraków Approach (APP) to discuss a heading change for the Piper to clear the departure path. However, the tower controller failed to notify Approach regarding the departing Airbus or to interrupt its takeoff. As the Airbus climbed, it closed the distance to the Piper. The crew of the Airbus eventually notified Approach that they were observing the Piper ahead of them. In response, the Approach controller ordered the Piper to turn right to a heading of 160° and the Airbus to turn left to 360°.
At the closest point, the horizontal separation between the aircraft was 2.01 NM, with a vertical separation of only 400 ft, significantly below the required minimums of 5 NM and 1,000 ft.
The investigation
The investigation examined the sequence of communications between Kraków Tower and Kraków Approach, the traffic density at the time of the incident, and the coordination procedures between the two controlling units. The investigation established that the tower controller's perception of time may have been disrupted by the high volume of simultaneous traffic operations.
Findings
- The primary cause of the incident was the tower controller issuing takeoff clearance to the Airbus without maintaining required time separation and without coordinating with Kraków Approach.
- High traffic density in the airport vicinity contributed to the event.
- The tower controller experienced a loss of situational awareness.