What happened
On 14 February 2021, a student pilot was conducting a solo VFR training flight in a Tecnam P200 and8-JC, registration SP-LFD, originating from the EPPT aerodrome. The flight objectives included performing non-precision instrument approaches to the EPMO aerodrome. During the flight, the student encountered Instrument Meteorological Conditions (IMC) for which they were not prepared, as the actual weather featured a cloud ceiling of 2500 ft AGL.
Following a touch-and-go maneuver at EPMO, the student was instructed by an air traffic control trainee to climb to 4000 ft AMSL. However, the trainee failed to specify a maximum altitude in the departure instructions. As the student climbed, the aircraft exceeded 2000 ft AMSL and entered the Warsaw TMA without proper clearance or established communications.
Simultaneously, a Boeing 737-800, registration SP-RKG, was departing the area following a standard instrument departure. Due to the higher speed of the Boeing aircraft, the distance between the two planes decreased. The aircraft reached a minimum horizontal separation of only 1.29 NM at an altitude of approximately 2300 ft AMSL, significantly violating the required 5 NM horizontal separation for Class C airspace. The conflict was resolved after the controller instructed the student to maintain an altitude of 1500 ft AMSL or below.
The investigation
The PKBWL investigation examined the student pilot's flight performance, the air traffic control instructions provided by the EPMO tower trainee, and the oversight provided by the On-the-Job Training Instructor (OJTI). The commission reviewed the meteorological conditions, which had transitioned from VFR to IMC, and analyzed the radar data from the PEGASUS_21 system, which had flagged the dangerous proximity between the two aircraft.
Findings
- The primary cause of the incident was the probable loss of situational awareness by the student pilot during the instrument approaches.
- The OJTI failed to intervene when the ATC trainee issued departure instructions that lacked a specified altitude limit.
- The student pilot'1s attention was inappropriately allocated during the climb following the touch-and-go maneuver.
- The student pilot performed solo instrument approaches in IMC conditions without adequate preparation.
- The ATC trainee failed to correct an incorrect readback by the student pilot regarding flight instructions.
- The student pilot's limited flying experience and the complexity of the radar-vectored approaches contributed to the loss of separation.