What happened
On July 2, 2020, an Embraer ERJ-170-200LR, registration SP-LIG, was prepared for a high-profile "HEAD 1" mission from Zielona Góra (EPZG) to Warsaw (EPWA). The flight, designated LOT7004, experienced delays due to the late arrival of passengers.
While the aircraft was preparing for departure, the Aerodrome Control Tower (TWR) at EPZG reached the end of its scheduled working hours. At 22:00, the tower officially closed, and the airspace transitioned from controlled to uncontrolled Class G. Although the controller remained on-site to assist with coordination, the airport was technically closed.
Due to a series of communication and preparation failures, the flight crew proceeded to taxi and take off under the impression that they were still operating within controlled airspace. The aircraft performed an IFR departure through uncontrolled airspace until reaching FL 95, at which point it entered controlled airspace and eventually landed safely in Warsaw.
The investigation
The PKBWL investigation examined the flight preparation, the actions of the air traffic controllers, and the coordination between the airline and airport services. The investigation focused on why the crew was not informed of the change in airspace status and why the flight documentation was incomplete. The inquiry also looked into the performance of a junior dispatcher who was undergoing an internal examination at the time of the flight preparation.
Findings
- The flight documentation for the VIP mission was improperly prepared.
- A junior dispatcher, who was in the middle of an internal examination, failed to pass on a critical warning from the flight planning system regarding the airport's closing time.
- The instructor dispatcher failed to supervise the junior dispatcher's briefing with the crew.
- The flight crew was not informed during the pre-flight briefing that the control tower's working hours were ending.
- The crew experienced situational tunnel vision caused by operational stress, leading them to incorrectly interpret instructions and proceed with the takeoff without the necessary radio correspondence or required clearances for uncontrolled airspace.
- The presence of a senior instructor in the right-hand seat created a "confusion over authority gradient," affecting the crew's decision-making process.
Safety action
- The Commission recommended that the Polish Air Navigation Services Agency (PAŻP) take steps to eliminate conflicting interpretations of the law regarding the maximum daily working hours for air traffic controllers by clearly defining the limit of operational duty.