What happened
On 13 July 2022, at approximately 11:03 local time, a loss of separation occurred between an Airbus A330-343X, registration C-GHLM, operated by Air Canada, and a Cessna Citation 550 military aircraft, registration U20.03, operated by the Spanish Navy.
The Air Canada flight, ACA824, was on final approach to runway 32 L at Adolfo Suárez Madrid-Barajas Airport. Simultaneously, the Spanish Navy aircraft, flight ORCA03D, had recently departed from runway 22 at Torrejón Air Base (LETO).
As the Cessna Citation 550 climbed, it deviated from its assigned flight path. At the point of closest approach, the two aircraft were separated by only 0.6 NM horizontally and 400 ft vertically. The crew of the Air Canada aircraft eventually reported having the military aircraft in sight and received a TCAS RA (Resolution Advisory) warning, which instructed the crew to "DON'T CLIMB" as the aircraft passed through the same level.
The investigation
The investigation examined the coordination between five different air traffic control units, including both civilian (Madrid-Barajas and Madrid ACC) and military (Torrejón Air Base) controllers.
Investigators analyzed radar data and the Quick Access Recorder (QAR) from the Airbus A330-343X. The investigation revealed that while controllers had coordinated a specific departure procedure (SID NANDO 3H) to ensure separation, the military aircraft did not follow this path. Furthermore, a breakdown in communication occurred when the Torrejón local controller transferred the aircraft to the Madrid departure sector without the crew being fully aware of the specific heading and altitude instructions previously agreed upon by the controllers.
Findings
- The primary cause of the loss of separation was the failure of the crew of the Cessna Citation 550 to adhere to the authorized departure procedures (SID NANDO 3H).
- The crew of the military aircraft continued on the runway heading beyond the intended turn point, crossing the localizer for runway 32 R and encroaching on the approach path for runway 32 L.
- Ineffective coordination between the Torrejón local controller and the GCA controller meant the aircraft was transferred to the next sector without the crew receiving the specific heading and altitude instructions established during controller coordination.
- The crew of the Cessna Citation 550 later stated that the aircraft had a wider turning radius than anticipated, which contributed to the deviation.
- The investigation also noted that the crew of the Airbus A330-343X received a TCAS RA warning at approximately 3,000 ft during the encounter.