Final Report no. 2189, Loss of separation between SB20 and C510, Lugano Switzerland, 16 Dec 2011

Final Report no. 2189, Loss of separation between SB20 and C510, Lugano Switzerland, 16 Dec 2011

Publication info
Author
SAIB (Switzerland)
Category
Accident Reports Loss of Separation Human Factors

On 16 December 2011, a Saab 2000 in the hold and an opposite direction Cessna VLJ joining it lost procedural separation in IMC near Lugano due to conflicting ATC clearances issued by the same controller who had used the wrong Transition Level. Any risk of collision was removed by a TCAS RA activated on the Saab 2000 but the Investigation found that the DFTI radar display available to the controller to help resolve unexpected emergency situations was configured to systematically convert SSR standard pressure altitudes to QNH for altitude display using a distant and inappropriate value of QNH.

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