Casualties unknown

2020-01-01: (TF-KFG) — IS

IS

On January 1, 2020, an aircraft (registration TF-KFG) was involved in an aviation accident near IS. Investigators recorded the probable cause as: The pilots of TF-KFG did not report at the compulsory reporting point; the pilots of TF-KFG did not hear the communication between the tower and the crew of HA-LXG; one ATCO person operating multiple frequencies; lack of situation awareness of possible… This summary draws on records from the Icelandic Transportation Safety Board (RNSA).

Sourcesthe Icelandic Transportation Safety Board (RNSA)Primary reportUpdated 1785094830Data APIEditorial standards

A training flight (Diamond DA-20, TF-KFG) entered final for Runway 01 ahead of a scheduled passenger flight (Airbus A320, HA-LXG), resulting in a minimum vertical separation of 225 feet and horizontal separation of 0.59 NM. The passenger aircraft performed a go-around; both landed safely.

Incident Overview

On 22 August 2020 at approximately 16:15 local time, a near miss occurred on short final for Runway 01 at Keflavik Airport. A Diamond DA-20 training aircraft (registration TF-KFG) was conducting a training flight with an instructor and a student pilot. An Airbus A320 (registration HA-LXG) was operating a scheduled passenger flight. Both aircraft were inbound to land on the same runway in Class D airspace.

Sequence of Events

The training flight initially contacted Keflavik Tower (ATCO 2) from KUAGERDI, reporting altitude and requesting a full-stop landing. The ATCO provided the altimeter setting, confirmed Runway 01 in use, and instructed the pilot to report over PATTERSON, a compulsory reporting point. The student pilot read back the altimeter setting and confirmed full-stop landing. The ATCO acknowledged with "ROGER" and reiterated to report over PATTERSON. The student pilot replied "WILCO."

However, the training flight flew over PATTERSON without reporting. Meanwhile, the passenger aircraft had been cleared to land approximately 7 NM from the threshold, about 30 seconds after the last communication with the training flight. When HA-LXG was approximately 4 NM from the runway, its crew noticed traffic on the Navigation Display approaching final from the east. After visual confirmation, they heard a radio transmission from the other aircraft announcing it was on final. The passenger aircraft crew initiated a go-around; during the first phase, they received a TCAS Traffic Advisory.

When the training aircraft entered final, the student pilot reported his position. The ATCO immediately instructed them to fly toward Hafnir (through the final). The instructor then took over control and radio communications, directing the aircraft toward Hafnir.

Separation and Outcome

According to surveillance data, the minimum vertical separation was 225 feet with a horizontal distance of 0.59 NM at that moment. The minimum lateral distance was 0.27 NM with a vertical separation of 600 feet. Both aircraft landed safely shortly after the incident.

Contributing Factors

The investigation identified several factors contributing to the incident:

  • The pilots of TF-KFG did not report at the compulsory reporting point (PATTERSON).
  • The pilots of TF-KFG did not hear the communication between the tower and HA-LXG.
  • One ATCO was operating multiple frequencies (combined GND/TWR position).
  • Lack of situational awareness of potential conflict for both the training flight pilots and the ATCO.
  • Fast transmission due to multiple frequency transmissions likely caused a hear-back error by the training flight pilots.
  • The pilots did not request confirmation in an uncertain situation; they replied "WILCO" instead of a full readback, which did not contain previous communication and left the ATCO unaware of the misunderstanding.
  • The location of the training aircraft was not actively monitored by the ATCO.
  • Traffic was unusually low.
  • Traffic visible on the surveillance display was not used or monitored.

Post-Incident Actions

Following the incident, the use of surveillance displays was added to recurrent training for Keflavik Tower ATCOs. Additionally, a Short-Term Conflict Alert (STCA) system was implemented in the Keflavik approach area in June 2021, though it was not yet used for the control zone at the time of the incident.

Probable cause

The pilots of TF-KFG did not report at the compulsory reporting point; the pilots of TF-KFG did not hear the communication between the tower and the crew of HA-LXG; one ATCO person operating multiple frequencies; lack of situation awareness of possible conflict for both the pilot of the training flight as well as the ATCO; fast transmitting due to multiple frequency transmissions at the same time, probably caused a hear-back error by the pilots of the training flight; confirmation by the pilots of communication not requested in an uncertain situation; readback from the training aircraft was WILCO; WILCO does not contain information from previous communication, rendering the ATCO unaware of the mishearing; the traffic was unusually low; the location of the training aircraft was not actively monitored by the ATCO; traffic visual on surveillance display not used or monitored.

Investigation report by the Icelandic Transportation Safety Board (RNSA). Original record: https://rnsa.is/flug/slysa-og-atvikaskyrslur/2020/. This page is a structured re-presentation; facts and quotes are in the Rannsoknarnefnd samgonguslysa (RNSA), Iceland.