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AIR ACCIDENTS INVESTIGATION INSTITUTE

Covering form of preliminary or final report


Date of event : 2022-06-30
Incident number : CZ-22-0627
Report : Final report
Place of event : MCTR Kbely
Registration mark : Serious incident
Weight category MTOM: : <2250 kg
Type of operation : Recreational and sport aviation
Plane / SFM : Airplanes
Type of plane / SFM : Cessna 208B
Health effects of event : Without injury
PDF document : pdf

Description:

The pilot of Cessna 208B, callsign SPWAW (hereinafter the “SPWAW”) was performing a flight from LKKB to EPBC. After take-off, he was identified by MTWR Kbely TEC (hereinafter the “TEC”), instructed to continue to the LIMA exit point, then informed about the traffic at the long final segment of RWY 24 and instructed to continue to the LIMA exit point. Due to SPWAW’s approach to the extended RWY 24 centre line, TEC provided SPWAW with further information about traffic located at the distance of 4 NM and instructed him to turn to the right to LIMA. The SPWAW pilot replied that he was scanning the traffic. Insufficient separation was caused by mutual position and trajectories of the SPWAW flight and the flight of L-410 UVP-E-20M, callsign GRZL45 (hereinafter the “GRZL45”). As the SPWAW pilot kept turning to the collision course with RWY 24 extended centre line, TEC issued strong instruction to SPWAW to immediately turn to the right at the recommended heading of 090 degrees. Immediately after that, TEC instructed GRZL45 to promptly climb due to traffic crossing the descent line of RWY 24 and specified the SPWAW position. The GRZL45 pilot replied that he was climbing. TEC then informed GRZL45 about traffic crossing. The GRZL45 pilot confirmed visual contact.

The cause of the serious incident was an erroneous navigation procedure of the SPWAW pilot during visual departure from LKKB and his late response to ATC commands. As a result, a dangerous situation occurred given the mutual position and trajectories of SPWAW and GRZL45.

Attached final report in PDF file is in original Czech language.