What happened
On October 29, 1993, at approximately 12:04 local time, a serious loss of separation occurred at Helsinki-Vantaa Airport. An ATR 72, registration OH-KRA, operating flight FAV544 for Finnaviation (operated by Karair for Finnair), and a Piper PA-22-250 Aztec, registration OH-PNJ, conducting a training flight, passed each other over the airport's runway intersection area. Eyewitness reports indicated that the distance between the two aircraft at the moment of passing was between 10 and 100 meters. There were no fatalities or injuries among the 29 people on board the aircraft.
The investigation
The investigation was initiated following reports from the flight crew of FAV544 and the pilot of OH-PNJ. The investigation committee examined the sequence of events, radio and telephone communications, and the air traffic control (ATC) systems in place. The inquiry also reviewed two additional near-collision incidents that occurred in Finnish airspace in 1994 to determine if there were systemic patterns in air traffic control operations.
Findings
- The investigation identified significant deficiencies in the air traffic control system, specifically regarding instructions, equipment, and training.
- There were noted weaknesses in the process of issuing controller ratings and a lack of effective internal oversight and inspection within the ATC organization.
- The investigation highlighted risks in the coordination and communication between different ATC units (Tower, Approach, and Ground) during critical phases of flight.