What happened
On September 5, 2023, a student pilot performing a solo flight for CPL(A) training was operating a Socata TB-9, registration SP-TUG. The flight was a long-distance navigation exercise covering 300 NM between various Polish aerodromes. During the approach to EPPT, the pilot relied on a VFR map that had been incorrectly marked with reversed runway headings (marking runway 03 as 21 and vice versa).
Upon entering the EPPT control zone, the pilot established contact with PIOTRKÓW RADIO. The air traffic controller instructed the pilot to join the left-hand pattern for runway 21R. However, due to the incorrect map markings and a loss of situational awareness, the pilot entered the right-hand pattern and was flying in the opposite direction of the active runway operations.
While the student pilot was on final approach for runway 03L, a Tecnam P2008-JC, registration SP-LFI, was climbing out after departing runway 21R. The crew of the Tecnam P2008-JC noticed the oncoming aircraft at approximately 230 ft AGL and performed an aggressive right turn to avoid a collision. The student pilot observed the departing aircraft but did not execute a go-around or a low-altitude turn, instead continuing the approach. The minimum vertical separation between the two aircraft was estimated at approximately 100-150 ft.
The investigation
The PKBWL investigation examined the pilot's navigation, the air traffic controller's responses, and the pre-flight preparation. The investigation established that the student pilot failed to verify the aircraft's heading using onboard instruments during the approach and failed to notice the discrepancy after reporting the straight-in position. The investigation also reviewed the controller's inability to visually confirm the aircraft's position due to workspace limitations and the failure to correct the pilot's incorrect position report.
Findings
- The primary cause was a partial loss of geographical orientation and situational awareness by the crew of the Socata TB-9 during the approach to EPPT.
- The use of a VFR map containing incorrect runway heading markings during pre-flight preparation.
- Inadequate supervision of the student pilot's preparation for the specific navigation task.
- A lack of corrective action by the air traffic controller following the pilot's incorrect position report.
Safety action
- Flight personnel at the aerodrome have been briefed on the incident.
- The Flight Safety Board has decided to re-administer the examination required before solo 300 NM flights. This exam will be conducted by an independent instructor, focusing specifically on the ability to determine headings during flight and approach to unfamiliar aerodromes.