On 22 December 2018, a Boeing 747-400 crew began to climb from FL310 without clearance and prescribed separation was lost against both an opposite direction Boeing 777-300 at FL 320 and another same direction Boeing 777-300 cleared to fly at FL330. The Investigation found that the 747 crew had requested FL 390 and then misunderstood the controller’s response of “level available 350” as a clearance to climb and gave a non-standard response and began to climb when the controller responded instructing the flight to standby for higher. Controller attempts to resolve the resultant ‘current conflict warnings’ were only partially successful.
Description
On 22 December 2018, a Boeing 747-400 BCF (919CA) being operated by National Air Cargo on an international cargo flight from Bagram to Hong Kong as NCR840 deviated from its clearance to fly level at FL310 at night in unrecorded flying conditions and separation was lost against an opposite direction Boeing 777-300 being operated by EVA Air on a scheduled international passenger flight from Bangkok to Vienna as EVA061 and a same direction Boeing 777-300 being operated by KLM on a scheduled international passenger flight from Amsterdam to Bangkok as KLM875. The minimum separation occurred between the manoeuvring 747 and KLM 777 which reached the same altitude when only 1.84 nm apart.
Investigation
A Serious Incident Investigation was carried out by the Indian Aircraft Accident Investigation Bureau (AAIB) in accordance with the Aircraft (Investigation of Accidents and Incidents) Rules 2017. Only ATC recorded radar and communications data were available and details of the experience of the pilots involved was only obtained for the National Air Cargo 747 flight crew. This flight’s augmented crew consisted of a Captain and two First Officers. The Captain had a total of 16,056 hours flying experience of which 2,746 hours were on type. He had previously been P1 rated on the Boeing 777 and several narrow body and business aircraft types. The two First Officers had total flying experience of 3,681 hours and 3,176 hours with a respective 102 hours and 617 hours of these totals being on type.
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