TCAS Activation and Separation Violation Involving Two Boeing 757s in Canary Islands

Casualties unknown • Aproximación Tenerife-Sur (Santa Cruz de Tenerife), ES

A radar error and improper pilot response to TCAS advisories led to a loss of separation between two Boeing 757 aircraft near the Canary Islands.

What happened

On November 20, 2011, two Boeing 757 aircraft were operating in the Canary Islands TMA. The first, a Finnair BOEING 757-2Q8 with registration OH-LBR, was descending from flight level 390 toward Tenerife South/Reina Sofia Airport. Simultaneously, a Thomas Cook Airlines BOEING 757-28A, registration G-TCBA, was maintaining flight level 370 on a similar arrival route.

Following a shift change in the NWW sector, the air traffic controller received a descent request from the crew of G-TCBA. Due to a radar garbling issue, the radar label for G-TCBA incorrectly displayed an altitude of flight level 405. Believing the aircraft was above the Finnair flight, the controller cleared OH-LBR to descend directly to flight level 250. This instruction caused the two aircraft to violate the minimum required radar separation of 5 NM and 1,000 ft.

As the aircraft approached, the Traffic Collision Avoidance System (TCAS) activated. The crew of OH-LBR reported receiving a resolution advisory (RA) and requested confirmation of their descent clearance. The crew of G-TCBA also experienced TCAS alerts, including a traffic alert and a resolution advisory to descend.

The investigation

The CIAIAC investigation focused on the radar malfunction and the subsequent crew responses. Technical analysis of the radar data revealed a garbling phenomenon, likely caused by similar oblique distances between the aircraft and the radar, which caused the transponder signal for G-TCBA to split into two incorrect labels.

Simulations using the Eurocontrol InCAS tool determined that while the crew of G-TCBA responded appropriately to their TCAS advisories, the crew of OH-LBR likely failed to follow the "climb" resolution advisory, continuing their descent instead. This improper response contributed to a secondary conflict where both aircraft received reversed advisories (climb for one, descend for the other) before the conflict eventually cleared.

Findings

  • A radar garbling error caused the controller to see an incorrect altitude for G-TC0BA.
  • The controller failed to detect the discrepancy between the radar display and the flight progress strips.
  • The clearance given to aircraft OH-LBR to descend through the altitude of G-TCBA caused the separation violation.
  • The crew of OH-LBR did not adequately respond to the TCAS climb advisory, continuing their descent despite the instruction.

Probable cause

The primary cause was the air traffic controller's instruction for the Finnair aircraft to descend through the flight level occupied by the Thomas Cook aircraft. This was facilitated by a radar error that incorrectly displayed the altitude of the second aircraft, and was compounded by the Finnair crew's failure to adhere to TCAS resolution advisories.

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Frequently asked questions

What happened in the 2011-11-20 Boeing 757-200 accident near Aproximación Tenerife-Sur (Santa Cruz de Tenerife), ES?

A radar error and improper pilot response to TCAS advisories led to a loss of separation between two Boeing 757 aircraft near the Canary Islands.

What aircraft was involved and where did it happen?

The accident on 2011-11-20 involved a Boeing 757-200, registration OH-LBR, at Aproximación Tenerife-Sur (Santa Cruz de Tenerife), ES.

What was the probable cause of the accident?

The primary cause was the air traffic controller's instruction for the Finnair aircraft to descend through the flight level occupied by the Thomas Cook aircraft. This was facilitated by a radar error that incorrectly displayed the altitude of the second aircraft, and was compounded by the Finnair crew's failure to…

Investigation report by the Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC). Original record: https://www.transportes.gob.es/recursos_mfom/2011_050_in_eng.pdf. This page is a structured re-presentation; facts and quotes are in the Comision de Investigacion de Accidentes e Incidentes de Aviacion Civil (CIAIAC), Spain - Ministerio de Transportes y Movilidad Sostenible.

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