Oslo: October 31, 2013, Near Miss

Thursday, November 14, 2013
By George Hatcher

We wrote about two Norwegian Air Shuttle planes that suffered a near miss when two planes followed the same instruction from ATC. The Accident Investigation Board Norway (AIBN) report on the event is below.

Report (Translation)
Description
The 31 October 2012, two airliners from English too close together under a simultaneous missed approach (NAX741) and departure (NAX740) at Oslo Airport. There was strong tailwind on final. The AIBN believes that the flight crew on NAX741 had unrealistic expectations of the ability to be stabilized later in 1000 ft above the airport elevation. The decision to initiate the missed approach was taken at a late stage. Expectations of final-controller and tower controller that the speed of the landing would be reduced sufficiently during the approach, was not met. The missed approach for NAX741 came into conflict with the simultaneous departure of NAX740.

Visibility conditions were such that the tower controller could not maintain visual separation between aircraft. Planes were for each other and both were rising. Tower air traffic controller instructed NAX741 to swing west. A mixture of callsign originated and led to NAX740 initiated clearance given to NAX741. The minimum horizontal distance between the aircraft was about. 0.2 NM (370 m) while the vertical height difference was 500 ft (152 m). AIBN considers that there was real danger of collision in the incident. When the situation first arose, prevented the situation awareness and good reviews from the flight crew and tower controller further escalation of the conflict.

AIBN considers that established and practiced procedures will help to ensure that situations are recognized and averted before they become critical. Data from the cockpit voice recorder (Cockpit Voice Recorder CVR) was not secured. CVR data is important to understand the sequence of events, and AIBN therefore it is unfortunate that CVR data is not guaranteed. AIBN no new safety recommendation in this report, but refers to a previously issued safety recommendation (SL no 2012/06T) not closed.

Type of report: Full report
Location: Oslo Airport Gardermoen ENGM
Event Date: 31/10/2012
ICAO Location indicator: ENGM
Aircraft: Boeing 737-600/700/800 / Boeing 737-600/700/800
Operator: Norwegian Air Shuttle / Norwegian Air Shuttle
Reg notice: LN-DYC / LN-NOM
Flight conditions: IMC
County: Akershus
Type of event: Serious incident
Type of flight: Commercial, scheduled / Commercial, scheduled
Category Aviation: Tung, aircraft (> 10 000kg) / Tung, aircraft (> 10 000kg)
Flykategori: Land plane, multi-engine, turbofan / turbojet
FIR / AOR: ENOS (Oslo ATCC)

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