Incident Overview
On February 10, 2023, at 14:26 local time, a serious incident occurred approximately 2.5 NM west of St. Gallen-Altenrhein Regional Airport (LSZR). The two aircraft involved were an Embraer EMB-505 Phenom 300, registration CS-PHM, operated by NetJets Europe on an instrument flight rules (IFR) flight from Giebelstadt (EDQB) to St. Gallen-Altenrhein, and a Diamond Aircraft DA 40 NG, registration HB-SHB, operated by Fliegerschule St. Gallen, Altenrhein AG, on a private visual flight rules (VFR) sightseeing flight departing from St. Gallen-Altenrhein.
Sequence of Events
The Phenom 300, call sign "Fraction 426N", was on an ILS approach to runway 10. At 14:23, the aerodrome controller informed the crew that they were number one for the approach and that a single-engine aircraft would depart to the northwest. The DA 40 NG departed from runway 28 at 14:24. According to the published visual approach chart (VAC), after takeoff from runway 28, aircraft are required to make a right turn to the north for crosswind departure. However, the DA 40 pilot initially flew slightly south of the extended runway centerline, then momentarily initiated a slight right turn but subsequently continued straight along the extended centerline. The controller repeatedly instructed the DA 40 pilot to turn right, but the pilot responded only with the aircraft's call sign without executing the turn. At 14:26, the Phenom 300 crew sighted the approaching DA 40 and increased their descent rate. Simultaneously, the Traffic Alert and Collision Avoidance System (TCAS) issued a resolution advisory to descend. The aircraft crossed at 14:26:50 with a horizontal separation of approximately 150 m and a vertical separation of about 400 ft, the DA 40 being above the Phenom 300. The location was at about 2500 ft AMSL. The DA 40 continued to the Victor waypoint, and the Phenom 300 landed uneventfully on runway 10.
Operational Context
St. Gallen-Altenrhein operates under a bilateral agreement between Switzerland and Austria. For noise abatement, IFR landings are normally conducted on runway 10, while departures are on runway 28, provided wind and safety conditions permit. This procedure inherently creates potential conflicts between arriving and departing traffic. The VAC for St. Gallen mandates a right turn after departure from runway 28 to avoid opposite-direction traffic.
Causal Factors
According to the Swiss Transportation Safety Investigation Board (STSB), the serious incident was caused by the light aircraft pilot maintaining the course after takeoff and not initiating the right turn into the crosswind leg as prescribed by the published departure route. Additionally, the STSB noted that the pilot's repeated failure to properly respond to the controller's instructions indicated significantly reduced situational awareness during that phase. The operating procedures at St. Gallen-Altenrhein, which regularly result in takeoffs and landings in opposite directions, contributed to the occurrence of the serious incident and represent a safety deficiency. This deficiency was previously addressed in the final report No. 2109 (2011) which issued safety recommendation No. 437, calling for technical or operational measures to reduce risks during simultaneous IFR approaches to runway 10 and VFR departures from runway 28.