What happened
On August 29, 2024, a Tecnam P2008-JC, registration SP-MGT, was conducting a VFR training flight from EPPT through the Łódź (EPLL) controlled airspace, intending to land at EPLL. During the flight, the air traffic controller (ATC) issued an instruction for the crew to hold in the left pattern for runway 07. However, the crew did not confirm this instruction, and the controller did not repeat it. Instead, a lengthy exchange occurred between the aircraft and the controller regarding the crew's intentions after landing.
While the SP-MGT continued its pattern, a Tecnam P2006T, registration SP-OCA, was established on the final approach to runway 07 under IFR procedures. The controller failed to provide information regarding the IFR traffic on approach or the expected landing sequence. Crucially, the controller also did not inform the SP-OCA crew about the presence of the SP-MGT aircraft in the pattern.
As the SP-MGT reached the third turn of the left pattern, the controller issued a new holding instruction. By this time, the SP-MGT had already transitioned to the final approach, placing it directly in front of the approaching SP-OCA. Following an intense period of radio communication involving multiple aircraft, the controller instructed the SP-MGT to immediately climb out and return to the holding position. The SP-MGT crew did not comply with the instruction, forcing the SP and-OCA crew to perform maneuvers to avoid the preceding aircraft and subsequently abort their approach. Both aircraft eventually landed at EPLL without further incident.
The investigation
The PKBWL examined the radio communications, the controller's position within the tower, and the operational environment. The investigation established that the frequency was heavily congested with six aircraft communicating in two different languages. The investigation also looked into the physical limitations of the tower workstation, including visibility issues caused by light reflections on the windows and the controller's focus on electronic flight progress strip (EFES) technology.
Findings
- The controller failed to ensure that the SP-MGT crew had understood and acknowledged the holding instructions.
- The SP-MGT crew continued the approach despite the instruction to hold.
- The controller failed to provide necessary separation information regarding the relative movement between the SP-MGT and SP-OCA.
- Non-operational communications occupied the controller's attention and frequency time.
- There was a lack of radar coverage for the approach to runway 07, preventing the controller from visually confirming the IFR traffic position.
- Situational awareness was degraded by the use of two different languages for radio telephony and high frequency congestion.
- Physical visibility from the controller's desk was obstructed by light reflections on the tower windows.
- The controller's attention was diverted by managing the electronic flight progress strip (EFES) system.
- Potential fatigue was noted, as the controller had been on duty for over one hour.
Safety action
- The air traffic organization conducted an internal report to discuss proper readback procedures and traffic information exchange with the involved crews.
- The Tower Manager implemented measures to reduce or eliminate light reflections on the tower's operational room windows.
- The safety management system (SMS) identified the need to address "missing and ineffective barriers" to improve situational awareness.
- The aircraft operator implemented measures to prevent callsign confusion to reduce the risk of the controller misidentifying aircraft.