Investigation number
200200094
Occurrence date
Location
111 km NNE PUMIS, (IFR)
State
International
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence category
Loss of separation
Occurrence class
Incident
Highest injury level
None

A Boeing 747-48HE registered VH-OEB (OEB) was en-route from Los Angeles, USA to Auckland, New Zealand was maintaining flight level (FL) 330 as assigned by Tahiti air traffic control (ATC). A Boeing 747-4H6 registered VH-OED (OED) was en route from Auckland to Los Angeles and was also maintaining FL330. The crew of OEB reported that they observed, on their traffic alert and collision avoidance system (TCAS), another aircraft that was on a reciprocal track at the same level (OED). The crew of OEB turned their aircraft right 15 degrees and descended to FL325. The crew of OED later reported that they observed, on their TCAS, another aircraft that was on a reciprocal track at the same level (OEB), and climbed their aircraft to FL333. A third aircraft, a Boeing 747, was en-route from Los Angeles to Auckland at FL340. The crew of OED also observed an indication of that aircraft on their TCAS.

The vertical separation standard was 1,000 ft. The vertical distance between OED and OEB reduced to 800 ft, and to 700 ft between OED and the third aircraft. There was an infringement of separation standards.

The crews of OEB and OED were communicating with Tahiti ATC via both Controller-Pilot Data Link Communications (CPDLC) and high frequency (HF) radio. CPDLC was a 'means of communications between a controller and pilot using data link for [Air Traffic Control] communication' (ICAO Doc 4444 ATM/501 14.1.1). Messages were compiled and initiated either by the crew of the aircraft or by ATC and were, in this case, pre-formatted. The use of pre-formatted messages was 'intended to reduce the possibility of misinterpretation and ambiguity' (ICAO Doc 4444 ATM/501 14.3.4).

The crew of OEB had requested climb from FL320 to FL340 but that request was denied. About ten minutes later the crew of OED requested climb from FL330 to FL350. Tahiti ATC asked the crew of OED, via CPDLC, when they could reach FL350 and then denied the request for climb. The French Bureau d'Enquetes et d' Analyses pour la Securite de l'Aviation Civile (BEA) produced a report on the occurrence. The BEA reported that the crew of OED then contacted Tahiti ATC via HF radio and advised that they could reach FL350 by time 1140 universal coordinated time. The controller responded via HF radio and instructed the crew of OED to maintain FL330. The crew of OEB then requested, via CPDLC, climb to FL330. The CPDLC response provided to the crew of OEB was 'climb to and maintain FL330 due to traffic' even though FL330 was not available. The message was selected by the controller from the menu of pre-formatted messages available in the system.

The South Pacific Operations Manual (SPOM Part 5.5) stated that 'when a clearance request is denied, the controller shall use the element "UNABLE" in the uplink message'. The SPOM detailed the procedures and requirements applicable in the South Pacific flight information regions (FIRs) for CPDLC equipped aircraft and applied within the Tahiti FIR. The SPOM (Part 5.1) also stated that `generally, when a CPDLC aircraft is operating within a CPDLC FIR, CPDLC will be the primary means of communication'.

Subsequent to the occurrence OEB returned to FL320 and OED returned to FL330. The crews then reported to Tahiti ATC at those respective levels. The controller had not intended to assign FL330 to the crew of OEB and did not realise that they had been assigned FL330, or that they had climbed to FL330 and subsequently returned to FL320. When the crews reported at FL330 and FL320 respectively, after the occurrence, that information was consistent with the information the controller had recorded on the flight progress strips. The controller was not aware that there had been an infringement of separation standards.

The BEA reported that the controller believed there were possibly two reasons why a climb instruction had unintentionally been assigned to the crew of OEB:

1. In reply to the request by OEB for climb to FL330, the controller pre-selected the wrong pre-formatted CPDLC message and sent the message without checking it, or

2. The controller confused the two aircraft because of their similar callsigns.

The BEA reported that four controllers had been rostered for the period between 1900 hours and 0700 hours (Papeete local time) and were rostered to cover the aerodrome control position, the approach control position and the area control position. The event occurred at 0050 Papeete local time. The controller involved in the occurrence was alone in the tower at the time of the occurrence and was performing all three functions. That controller considered that the workload was high due to poor quality HF radio, increased coordination with other centres in relation to aircraft using 'flexible routes' and difficulty validating CPDLC messages with OED.

The controllers at Tahiti had been trained in France but that training had not included the use of CPDLC. Initial training on the use of CPDLC was incorporated into a one-week training program in Papeete that included CPDLC with other local training requirements. Ongoing CPDLC training was incorporated into on-the-job training which could take controllers around 57 weeks to complete. Controllers reported that the initial training was essential but they had not been exposed to the system sufficiently during training to master all aspects of the system.

The controller involved in the occurrence had been working Tahiti Oceanic Controlled Airspace for approximately three and a half years and was qualified on the three ATC positions being managed at the time of the occurrence.

Aircraft Details
Manufacturer
The Boeing Company
Model
747
Registration
VH-OED
Serial number
25126
Operation type
Air Transport High Capacity
Sector
Jet
Departure point
Auckland, NEW ZEALAND
Destination
Los Angeles, U.S.A.
Damage
Nil
Aircraft Details
Manufacturer
The Boeing Company
Model
747
Registration
VH-OEB
Serial number
25778
Operation type
Air Transport High Capacity
Sector
Jet
Departure point
Los Angeles, U.S.A.
Destination
Auckland, NEW ZEALAND
Damage
Nil
Aircraft Details
Manufacturer
The Boeing Company
Model
747
Registration
ZK-SUJ
Operation type
Air Transport High Capacity
Sector
Jet
Departure point
Los Angeles, U.S.A.
Destination
Auckland, NEW ZEALAND
Damage
Nil