What aircraft was involved and where did it happen?

The accident on 2003-11-27 involved a BOEING B767-300, registration N194DN, at UAC West MILPA, CH.

Near miss in Geneva airspace caused by flight level error and crew distraction (N194DN)

On November 27, 2003, a BOEING B767-300 (registration N194DN) was involved in an aviation accident near UAC West MILPA, CH. Investigators recorded the probable cause as: The incident was caused by the Iberia crew incorrectly entering an unauthorized altitude into the flight control unit, a mistake that was compounded by crew distraction during cockpit maintenance tasks. This summary draws on records from the Swiss Transportation Safety Investigation Board (STSB / SUST).

Sourcesthe Swiss Transportation Safety Investigation Board (STSB / SUST)Primary reportUpdated 1785034239Data API Editorial standards

Aircraft registered N194DN. Photo: Juergen Lehle / CC BY-SA 3.0, via Wikimedia Commons

An Airbus 320 and a Boeing 767 narrowly avoided a collision in Swiss airspace after a crew error led to an unauthorized climb through assigned altitude.

What happened

On 27 November 2003, an air traffic incident occurred 3 NM northwest of MILPA within the Geneva control sector. The crew of an Iberia Airbus 320, registration EC-IEF, was operating a scheduled flight from Frankfurt to Madrid. After being cleared to climb to flight level 340, the crew mistakenly set flight level 350 in the flight control unit (FCU) altitude window.

Simultaneously, a Delta Airlines Boeing 763, registration N194DN, was cruising at flight level 350 on a flight from New York to Venice. Because the Iberia aircraft climbed through its assigned level, it intercepted the flight path of the Delta aircraft. The conflict triggered a Short Term Conflict Alert (STCA) and a TCAS Resolution Advisory (RA) for the Delta crew. At the closest point, the two aircraft were separated by only 4.6 NM horizontally and 6/00 FT vertically.

The investigation

The investigation established that the Iberia crew failed to monitor the aircraft's altitude correctly due to significant distractions. The commander reported that the crew was preoccupied with checking circuit breakers and addressing an ECAM consultative message. Additionally, the pilots had requested a flight attendant to check the cabin for unauthorized electronic devices.

Radar controllers noted that the controller in charge was a trainee under supervision. The investigation found that the controller had observed the aircraft's climb and had even issued reminders to the pilot to maintain flight level 340 before the STCA alert was triggered. The investigation also noted that the control frequencies for the sectors involved were coupled.

Findings

The primary cause was a crew member on EC-IEF erroneously setting flight level 350 instead of the cleared flight level 340.

The error went unnoticed by the second crew member due to distractions caused by the disorganized handling of an ECAM message and the checking of cockpit circuit breakers.

The radar controller's proactive monitoring and reminders helped alert the crew to the deviation before the loss of separation became critical.

Probable cause

The incident was caused by the Iberia crew incorrectly entering an unauthorized altitude into the flight control unit, a mistake that was compounded by crew distraction during cockpit maintenance tasks.

2003-11-27: BOEING B767-300 (N194DN) — UAC West MILPA, CH