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| Date: | Friday 23 February 2018 |
| Time: | 11:31 |
| Type: |  Airbus A320-214 (WL) |
| Owner/operator: | Lufthansa |
| Registration: | D-AIUI |
| MSN: | 6265 |
| Year of manufacture: | 2014 |
| Engine model: | CFMI CFM56-5B4/P |
| Fatalities: | Fatalities: 0 / Occupants: |
| Other fatalities: | 0 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Brussels -
 Belgium
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Brussel-Zaventem Airport (BRU/EBBR) |
| Frankfurt International Airport (FRA/EDDF) | |
| Investigating agency: | AAIU Belgium |
| Confidence Rating: |  Accident investigation report completed and information captured |
Lufthansa flight LH1009, an Airbus A320 (D-AIUI), was involved in an airprox incident with Air Europa flight UX1172, an Embraer ERJ-195LR (EC-LFZ) shortly after departure from Brussel-Zaventem Airport.
UX1137 took off from runway 07R at 11:30 hours, followed about a minute later by LH1009. Both aircraft followed runway heading before commencing a right-hand turn. This brought the two flights in conflict. Both flight crew responded to the TCAS-RA warnings and took action.
Minimum separation was 1,3 NM horizontally and 684 feet vertically, which should have been at least 1000 feet.
Findings as to causes and contributing factors
• The trainee ATCO gave an instruction to the A320 (DLH4Y) to turn earlier than foreseen by the published route without taking the projected flight path of the ERJ195 AEA1172 into consideration. He assumed that there would be enough separation.
[direct causal factor]
[Action/decision – Action – Incorrect action selection - ATCO]
[Action/decision – Info processing - Expectation/assumption- ATCO]
• The trainee ATCO declared he was a bit under stress and that he considered every shift as an examination. He was eager to show that he could be proactive
[contributing factor]
[Psychological – Mental/emotional state – Stress - ATCO]
• The potential conflict was initially not noticed by the OJTi. The trainee was speaking with rather low voice and the OJTi doesn’t dispose of a separate radar screen.
[contributing factor] [safety issue 4.1]
[Task performance – Monitoring – OJTi]
[Task environment – Physical workspace – Positioning – Effect on ATC OJTi]
[Management – Resources – Availability of equipment – ATC]
• The design of the departures from EBAW to GILOM and EBBR to REMBA lead to converging courses.
[contributing factor]
[Operating environment – Air traffic – Departure procedure(s) – Effect on operation]
• When the STCA popped up there was still a lack of situational awareness of the ATCO. He thought that the A320 was much lower than the ERJ195 while in fact the aircraft was already above. He initially gave the wrong instruction to stop climbing to the A320
[contributing factor]
[Psychological – Perception/orientation/illusion – Situational awareness - ATCO]
Accident investigation:
 |
|
Sources:
BFU
https://mobilit.belgium.be/nl/nieuws/nieuwsberichten/2018/luchtvaartincident_23_februari_onderzoek_aaiu_bezig
Images:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 08-May-2018 19:32 | harro | Added |
| 19-May-2018 17:27 | harro | Updated [Source, Narrative, ] |
| 12-Sep-2020 19:23 | harro | Updated [Narrative, Accident report, ] |
| 15-Nov-2022 08:58 | Ron Averes | Updated [Location, ] |
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