What happened
On January 22, 2003, at 18:56 UTC, a loss of separation occurred approximately seven nautical miles west of Helsinki-Vantaa airport involving two commercial aircraft. The first aircraft, a Finnair ATR-72-201 (registration OH-KRC), departed Helsinki-Vantaa for Turku. Approximately two minutes later, a Pulkovo Airlines Tu-154M (registration RA-85185) departed the same runway for St. Petersburg.
Both aircraft were following standard instrument departure routes that initially shared the same path. While the Finnair flight followed instructions and contacted radar control, the Pulkovo Airlines crew failed to contact the departure radar controller as required by the departure charts. During the climb, the Tu-154M exceeded its assigned initial climb altitude of 4,000 feet, reaching approximately 5,100 feet.
Upon noticing the deviation and the approaching faster aircraft, the radar controller instructed the ATR-72-201 to turn away to maintain separation. By the time the Pulkovo Airlines crew established radio contact with the departure controller, the vertical separation had been compromised, with the aircraft passing each other at a horizontal distance of 2.2 NM and a vertical separation of only 500 feet. No injuries or aircraft damage occurred.
The investigation
The investigation examined the cockpit procedures, aircraft equipment, and air traffic control communications. Investigators found that the Pulkovo Airlines crew had experienced difficulties establishing radio contact, which increased their workload. The investigation also reviewed the cockpit ergonomics of the Tu-154M, specifically noting the lack of an altitude alert system and the difficulty of reading departure charts in the cockpit environment. While the pilot reported difficult weather conditions involving icing and turbulence, investigators found no evidence of significant turbulence or icing that would have prevented altitude maintenance.
Findings
- The primary cause of the incident was that the Tu-154M pilot forgot to perform post-takeoff procedures regarding the assigned climb altitude, and the remaining crew members failed to monitor and correct the deviation.
- Increased crew workload due to unsuccessful initial radio contact attempts.
- The aircraft lacked an altitude alert/capture system and altimeter markers to remind the crew of assigned altitudes.
- The use of departure charts in the cockpit was non-ergonomic, as the small text was difficult to read under cockpit lighting, requiring the crew to look away from flight instruments.
Safety action
- Pulkovo Airlines was recommended to improve crew resource management (CRM) to ensure all crew members actively monitor flight constraints.
- Pulkovo Airlines was recommended to install altitude alert/capture systems in its aircraft to provide visual and aural warnings when approaching or reaching assigned altitudes.