What happened
On June 29, 2000, at approximately 18:19 local time, a Cessna 441 operating an IFR charter flight from Cologne/Bonn to Augsburg and a Beech C90A operating under VFR encountered a serious loss of separation over the WALDA VOR. The Cessna 441 was established on an ILS approach for runway 25 at Augsburg, flying at 5,000 ft MSL.
The Beech C90A, which had previously aborted a simulated approach to Augsburg, was transitioning into a holding pattern over WALDA at 4,900 ft. As the two aircraft passed each other on a head-on course, the distance between them dropped below the minimum radar resolution. The crew of the Cessna 441 observed the Beech C90A at an 11:30 position and performed an immediate downward and rightward evasive maneuver to avoid a collision. No injuries or aircraft damage were reported.
The investigation
The BFU investigation examined the actions of the flight crews, the Augsburg Tower controller, and the Munich Radar controller. The investigation focused on the instructions issued by the Augsburg Tower regarding the Beech C90A's flight path and the coordination between the different air traffic control sectors. The investigation also analyzed the visual detection capabilities of the crews given the high closure speed of the two aircraft.
Findings
- The Augsburg Tower controller issued an instruction to the Beech C90A to enter a holding pattern over WALDA, despite the aircraft being outside the tower's jurisdictional area and the instruction involving airspace for which the tower was not responsible.
- The instruction was issued without prior coordination with the Munich Radar controller.
- The Augsburg controller provided traffic information to the Beech C90A in an incomplete and non-standard manner, using the term "birds" to refer to IFR aircraft.
- The Munich Radar controller observed the Beech C90A on radar but limited his actions to providing traffic advisories and an avoidance recommendation rather than intervening to regulate the traffic.
- The pilot of the Beech C90A followed the Augsburg controller's instructions critically, even though the aircraft was outside the tower's jurisdiction.
- The high closure speed of the two aircraft made it impossible for either crew to visually detect the other in time to take preventive action, as the window for detection and reaction was only approximately 5 to 6 seconds.