What happened
On March 10, 2021, two training aircraft were operating in the traffic pattern for runway 10R at Warsaw-Babice (EPBC). The first aircraft, a PS-28 Cruiser with registration SP-GBC, was returning from a previous flight segment and performing its second circuit. Simultaneously, a Tecnam P2008 JC, registration SP-LFE, was approaching the airport from Piotrków Trybunalski for a training flight.
The crew of SP-LFE entered the traffic pattern at the downwind position. To maintain separation from the preceding aircraft, the crew of SP-LFE increased their speed from 90 to 105 knots. However, the crew of SP-GBC had cut the second and third turns of the pattern, significantly reducing the distance between the two aircraft. As both aircraft proceeded toward the fourth turn, the lateral separation decreased to approximately 20 meters. To avoid a collision, the crew of SP-wide reduced speed and deployed full flaps, effectively dropping behind the SP-GBC. The AFIS controller subsequently instructed SP-LFE to perform a go-around.
The investigation
The PKBWL investigation utilized flight tracking data from FlightAware (MLAT and ADS-B) alongside pilot statements and radio transcripts from the AFIS controller. The investigation examined the flight paths, the adherence to published traffic pattern procedures, and the effectiveness of the air traffic services provided at EPBC. The investigators also reviewed the impact of local noise abatement restrictions and the specific constraints of the airport's traffic pattern design on pilot training and separation management.
Findings
- The primary cause of the incident was the cutting of the second and third turns by the crew of SP-GBC, which led to a loss of safe separation.
- The crew of SP-GBC failed to maintain situational awareness and incorrectly assumed the preceding aircraft was flying outside the published pattern.
- The AFIS controller failed to identify the potential for a dangerous close approach after receiving position reports from both aircraft within seven seconds of each other.
- The air traffic service provider's reactive comment—noting that "someone will always be in front"—was inadequate for the level of risk present.
- The traffic pattern at EPBC is constrained by strict noise abatement and flight path requirements, which limit the ability of pilots to extend their downwind leg to establish proper separation.
- The published information regarding the use of surveillance systems at the airport was inaccurate, as the AFIS does not possess the technical capability to monitor traffic in that specific area.