What happened
On Sunday, 16 October 2005, at approximately 13:15 UTC, a Malév Hungarian Airlines Boeing 737-800, registration HA-LOM, was cruising at flight level 280 near Zaragoza, Spain. Simultaneously, an Iberia Airbus 320-214, registration EC-HAF, was descending toward Madrid.
At approximately 13:14, the air traffic controller at the Madrid Area Control Center (LECM) identified a potential conflict. The controller issued instructions in Spanish to the Iberia crew and in English to the Malév crew to alter their courses. During this process, the Iberia crew initially performed a right turn instead of the requested left turn. Shortly thereafter, the crew of the Boeing 737-800 received a TCAS descend resolution advisory (RA) due to the proximity of the Airbus 320-214. Radar data indicated the aircraft reached a minimum vertical separation of 400 feet and a horizontal separation of 6 NM. There were no injuries and no damage to either aircraft.
The investigation
The investigation examined the air traffic control communications, radar data, and flight progress strips. The investigation established that the Iberia crew had been cleared to flight level 250, though there was ambiguity regarding whether the controller intended to assign level 290. The investigation also looked into the language used during the conflict, noting that the controller communicated with the Iberia crew in Spanish, which left the Malév crew unaware of the specific traffic situation and the intentions of the other aircraft.
Furthermore, the investigation reviewed the controller's workload and the training environment. At the time of the incident, the controller had just begun a new shift and was managing a complex environment involving multiple similar flight call signs. It was also noted that it was unclear whether the services were being provided by a trainee or an instructor.
Findings
- The incorrect assignment of flight level 250 to the Airbus 320-214 was the primary cause of the loss of separation, likely due to the controller confusing the flight with a similar aircraft (IBE 3477) that had been cleared to the same level seconds earlier.
- The use of Spanish for communications with the Iberia crew prevented the Malév crew from understanding the conflict and the necessary maneuvers.
- The operating environment was highly complex due to high traffic volume and similar call signs.
- The controller's situational awareness was likely compromised by the recent shift change and the presence of a trainee in the sector.
Safety action
- It is recommended that AENA revise the criteria and methodology used for assigning trainees to different operating posts.