C1/2003L Loss of Separation West of Helsinki-Vantaa Airport on 22 January 2003

On Wednesday 22.1.2003 at 18.56 UTC (co-ordinated universal time, Finnish time -2 h) there was an aircraft incident approximately seven nautical miles west of Helsinki-Vantaa airport. A Pulkovo Airlines Tupolev Tu-154M airliner (PLK230) on a scheduled passenger flight from Helsinki to St.Petersburg climbed above the initial climb altitude of 4000 ft of the standard instrument departure and the required separation was lost to a Finnair ATR-72 airliner (FIN225) on a scheduled passenger flight from Helsinki to Turku. The Accident Investigation Board Finland appointed 28.1.2003 an investigation commission to investigate the incident and appointed airline transport pilot Jussi Haila investigator-in-charge and air traffic controller Erkki Lepola and MSc Ville Hämäläinen members of the commission.

FIN225 took off from Helsinki-Vantaa to Turku and PLK230 approximately two minutes later to St.Petersburg. The beginning of the flight paths after take off of both aircraft were identical. PLK230 did not contact the departure radar after take off as instructed by the standard instrument departure chart and climbed above the initial climb altitude of 4000 feet. The radar controller noticed this and that PLK230 was approaching the slower FIN225 flying ahead. He ordered FIN225 to turn away from the flight path of PLK230. After this the radar controller asked the tower controller to instruct PLK230 to contact radar, but PLK230 had already climbed to 5100 feet. FIN225 was at 5400 feet at the same time. The horizontal distance between the aircraft was 2.2 NM. After this the radio traffic between the controller and PLK230 was normal.

PLK230 probably climbed above the initial climb altitude because the commander had lost remembrance of the initial climb altitude as he was busy with the actions required after take off. It is probable that the rest of the crew did not call his attention to maintaining the initial climb altitude. Probable contributing factors were the increased crew work load caused by the unsuccessful radio contract attempts, the absence of altitude alerter and altimeter movable markers, and the non-ergonomic way of using the SID chart in the cockpit.

The investigation commission presented two safety recommendations for Pulkovo Airlines, in which the company was recommended to improve crew resource management and to install altitude alert/capture systems in its aircraft. The received comments to the final draft of the report have been taken into account in the investigation report.

C1/2003L Report (pdf, 0.12 Mt)