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Planes just 180 metres apart in 2007 near miss

Controllers insist there was no trace of light aircraft

A mid-air collision close to Malta's airport in April last year between a passenger jet and an ultralight aircraft was averted when the planes were just 180 metres apart, a preliminary report is expected to say.

Only quick thinking by the pilot of an Air Malta Boeing 737, making its final approach at the end of a flight from Rome with some 80 passengers on board, managed to prevent a potential disaster over a populated area two nautical miles away from Malta International Airport.

A report commissioned by the government to probe the incident is expected to point fingers at the Italian ultralight which entered Maltese airspace without a transponder and authorisation, and, to a certain extent, six local air traffic controllers on duty on April 21, 2007.

The findings are expected to anger air traffic controllers who are insisting that the processed radar picture presented to them on the day showed no trace of the Italian aircraft.

The report by the Bureau of Air Accident Investigation was presented to Communications Minister Austin Gatt in recent days, but it is not yet clear if and when it will be released. The chain of events which led to the near-miss began after the ultralight Storm aircraft flying from Lampedusa to Gela, encountered strong headwinds. The Italian pilot told investigators that the aircraft was running low on fuel and decided to make a technical stop in Malta for refuelling.

Sources told The Sunday Times that the Italian pilot said he made various unsuccessful attempts to establish radio contact with air traffic control. Then, as he approached Malta, he noted that his fuel gauge was critical and he switched on the aircraft Emergency Locator Transmitter. He claimed that since he could not find a suitable place to land, an emergency landing at MIA was his only option.

The Italian aircraft was at no time observed by controllers on approach or area radars and as a consequence entered Maltese controlled airspace undetected.

In the meantime, during the final stages of the approach, when breaking through cloud at approximately 1,300ft, the Air Malta pilot was shocked to see his aircraft on collision course with the ultralight.

The crew saw the small aircraft on their left hand side, "very close and just slightly higher", the sources said.

The Boeing 737 pilot took evasive action and executed a right turn, descending to 800 feet, followed by a climb. The Air Malta aircraft descended further, in order to avoid hitting the Storm with its left wing even though the aircraft was at such low altitude, the report is expected to show.

At the time, a 38-year-old passenger on board the flight had told The Times: "I had just spotted the Mosta church from the window seat and suddenly, out of nowhere, I saw a small blue plane alarmingly close."

The ultralight continued its approach and landed safely without appropriate clearance. The Boeing 737 was subsequently instructed to restart its approach and also touched down without further incident.

No flight plan had been filed by the Italian pilot and no radio contact was established. Furthermore, the ultralight did not have the correct radio communication frequencies and was transmitting on frequencies that had been replaced a few years before.

The Italian pilot told investigators that he had sent a fax to the Department of Civil Aviation in Malta a few days earlier in order to obtain permission to land in Malta for refuelling, if necessary. Permission for technical landing was issued a few days before the incident.

Although the Storm entered the airport area undetected, recovered radar traces subsequently showed that the radar plot indicated that the lateral trajectory of the ultralight started approximately 35 nautical miles from the airport.

However, despite being on the receiving end of some of the blame, air traffic controllers maintained they did not have any information about any light aircraft at the time.

All controllers also claim that no unidentified aircraft was observed on radar at any time before the incident and there was nothing unusual that might have led them to believe there was any unknown traffic in the vicinity.

It is only after the incident occurred that the aerodrome controller mentioned the presence of an aircraft on final approach with whom no radio contact had been established. The intercom conversation between two controllers also suggests that both controllers were shocked at the sudden appearance of the small aircraft.

The radar recordings show that the small aircraft was visible at approximately 35 nautical miles, the report is expected to say. The sources said that tests carried out by two software engineers showed that the radar was functioning properly at the time, a claim dismissed by the controllers.

Controllers insist that the recordings are not what they actually saw on their screens, and that the raw radar picture is processed and filtered before being presented on all six screens.

The report is expected to say there is no explanation why the small aircraft's presence was recorded and yet not seen on the radar display at the time of the incident. However, a plausible explanation is that the recorded picture is an unfiltered image, whereas the radar picture presented to the controller is filtered to remove unwanted clutter.

The Italian aircraft was allowed by the Department of Civil Aviation to leave just two hours after the incident, a decision which drew criticism at the time.

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Comments

major anthony abela (on 20/6/08)
It appears that as usual with our Maltese mentality we are not going to learn anything by this incident, which thanks God, was avoided through sheer coincidence. This is without discrediting the Air Malta Pilot's presence of mind and immediate avoidance manoeuvre he professionally performed.

I am positively sure that since the incident, instead of corrective measures to ovoid similar cases, the Malta Air Traffic Services opted to officially disregard 'Primary Only Tracks' (not False Plots) completely.

Is this decision backed with a Safety Case? Was it a recommendation by the Air Safety Body? Is it approved by the DCA who is the Regulator?

With full responsibility, I draw the attention to whoever has the political responsibility for DCA and MATS to investigate the matter, and if necessary ask foreign advice very urgently, as under these circumstances, the fact that we did not have a serious air incident in our FIR is just sheer luck, considering the amount of illegal and unidentified air traffic which presently is just being pretended by MATS as that it is not there.

As a loyal citizen I am available to offer my expertise on this subject free of charge to anyone requesting it.
Major Anthony Abela (on 17/6/08)
At last somebody is talking sense. Thanks Mr Valenzia.

This is my point, it is not to find a scapegoat but to enhance safety. In my opinion, in Malta's case there is no comparison to what Eurocontrol or ICAO minimum requirements states, but in our special circumstances how can we improve our air safety within our FIR.

I remeber very clearly that originbally I wanted to but CCTV looking at the Radar Screen in front of the Controllers, but this was not accepteable by because it was interpretede as a survielance means on Controllers rather than safety measure. Yes what the Radar Processor output records is not necessary what the Air Traffic Controller observes on his screen, that is why I never pointed my fingers to the Controllers on duty.

My main concern is that the argument that international and national requirements are only Secondary Radar Survielence as the bare minimum, in our case (and in every bodies case) air safety is enhanced with Primary Radar data.

That is why I will keep asking who's decision it was to ignore and disregard valid Primary Radar Data from the Maltese Air Traffic Radar System, and WHY???
John Valenzia (on 17/6/08)
What would perhaps be relevant is whether the Incident Investigation Report recommened that a controller's radar display (including range and settings) is recorded in the future.

It would seem to me that what was recorded was the radar data that was processed and not the information that was displayed to the Air Traffic Controller at the time of the incident. In my opinion if the test conducted by the software engineers involved a system test it would not be conclussive in establishing what was shown on the display. Did the tests involve replicating the scenario?

Incidentally, is there an operational requirement for Primary Radar? What are EurocontroI's requirements with respect to Primary Radar Systems? Is the radar system designed for Area Control or Approach Control? What is the radar coverage as established in the factory and site acceptance tests documentation? Was the system maintainted in accordance with unit instructions? Are there any unit instructions? Is there a Safety Management System in place? Was it complied to?

"....pointing fingers...". What a bad choice of words. Aircraft investigation is all about identifying the contributory factors leading to an incident and for corrective action to be taken. Not for evolving a "blame culture".




Major Anthony Abela (on 17/6/08)
Dear Mr Adrian Cardona,

Yes I know that Dingli Primary Radar was ON at the time of the incident, thanks to the Italian Civil Aviation Authorities who forced the Maltese Authorities to switched back in service after it was switched off for some months, as they do use Primary radar information for enhanced safety in Air Traffic

I also know that their is a 'Fallback System' because it was me who insisted on it more than 12 years ago, that is a 'FALLBACK' for such cases as a fault with the Radar Processor. Is it manned or just left switched ON?

Dear Adrian and friends, it is true that the las time a stepped in the Luqa ATC is more than 10 years ago, but basically your are still using the same system I specified, commissioned and certified. That is why I do have an interest as my interest is safety for air travellers.


Major Anthony Abela (on 17/6/08)
Dear Mr Charles Sammut, it appears that you are not up to date with 3rd Generation radars used in ATC at present.

The filtering of 'false plots' is worked out by the Radar Processing Software and not manually by Controllers. A controller will only see a 'false plot' once in a while if any. This is becasue ONLY 'Radar Tracks' are presented on the Controllers Displays. Tracks can be either Secondary only, Primary only or as in most cases if transponders are switched on - Combined Tracks.

It is very clear that most of the contributors are passing a layman comment and not a technical one.

Another point is that even Seconadry Radar have its short comings, and 'Fruits' and 'Code Corruption' are some of them.

The subject of Radar and its science is a specialised one and unless you are specialised in it, it is difficult to pass a fair judgment.
Major Anthony Abela (on 16/6/08)
Mr Nicholl, I am sorry to say that it appears that your are missing the boat.

Can you point one instance that I blamed the Duty Controllers for the incident.

I blamed the Authority or body who decided to ignore 'Primary Tracks'.

I did raise the question and mentioned directly the DCA as the Regulator. Yes, I have no problem to say that the DCA should have never approved the switching off or disregardness of Primary Tracks. This is because while ti is true that the least that Air Traffic Services are obliged to give is Radar Control and Separation on SSR information, in Malta's case, Primary Tracks are of utmost importance if we have to give the highest possible level of safety in our FIR.

One question, does the DCA have any Radar Engineers on its payroll?
Major Anthony Abela (on 16/6/08)
First of all I never said that Air Traffic Controllers are at blame.

Secondly I still insist that the body who approved to ignore Primary Radar, (for some months the Primary Radar at Dingli was switched off or its data ignored completely) has to be accountable

Thirdly, the fact that some of your contributors turned the issue to the lowest level by person attacks and insulting remarks against me on personal basis shows the poor mentality of the persons involved.

Finally, the issue of Primary Radar false plots is a specialised subject for radar developers and engineers. With the software configuration of the Malta Radar Processing system (if left as originally configured) a 'Primary False plot' will never present a 'Primary Track' on the Controllers' Display.

I will not be surprised to find out that the light aircraft was detected and processed by the Malta Radar System. I just wait for the full report.

My interest is Air Safety and I will follow this issue as it is my duty as a responsible citizen to give my contribution, even during my retirement. If this does not please some people, it is their problem, not mine
Charles Sammut (on 16/6/08)
Raw primary radar presents many false returns, sometimes called "ghosts' or "angels". The causes can be many, such as flocks of birds, hot/cold air pockets, rain showers and so on. Primary radar can also display targets that are normally out of its range because of atmospheric phenomena such as inversions. A controller cannot possible be expected not to filter them out as this would make his job impossible. That is why all aircraft flying to Malta are required to carry a transponder.

A microlight aircraft flying into a headwind as it was in this case, would have a very low ground speed and even if it did show up above the background noise, it would appear as almost stationary and probably get filtered out.

The pilot, by his own admission, had faxed for landing permission. So he was well aware that he might possible have to divert to Malta. In that case, why did he not file a flight plan? Why did he not get up to date information about Malta Airport? Why did he not call up on 121.5MHz, the emergency frequency? Why? Why? Why?
James Nicholl (on 16/6/08)
Major Anthony Abela, you're still missing the boat, or avoiding to ask Director General of the DCA more Direct Questions;

1. Why did the Director General of the DCA ALLOW the Italian Aircraft to leave Malta after a mere 2 hours?

2. Why does it take the DCA so long, that is A YEAR from the Incident, for the Investigation to be finalised?

3. Why the DCA has not yet appointed any Incident Investigator from any of the Maltese Air Traffic Controllers (not only for this Incident).... Perhaps 2 WEIGHTS 2 MEASURES?

4. Why is it that as has happened in the past when a Pilot was more DIRECTLY involved in an Incident, everything was brushed under the carpet, & when an Air Traffic Controller was Involved, an Intensive Investigation was conducted....

cont'd.......

D Stellini (on 15/6/08)
The investigation does not mention the scope of the light aircraft's flight. Why did it not declare an emergency? Could it be the plane was up to something clandestine , like tuna spotting? If I recall correctly the reason given at the time was that the plane did "mercy flights" spotting illegal immigrants. Was this verified by the investigators? If the investigators overlooked this , as did the authorities by releasing the plane within 2 hours of the incident, then one can only conclude that this investigation is a bad joke. Would the investigation have come up with such a sterile conclusion had there been a tragedy with loss of more than 80 lives? Or the investigators of this one year old investigation were just not bothered because it was only a near miss?
It is indeed a disgrace if there was something more sinister about the flight itself, and trying to shift the blame onto the ATC's !
A Daley (on 15/6/08)
Even an idiotic pilot of a small aircraft takes us for a ride!
Pajjiz tal-Mickey Mouse, we are and will still remain so!
Adrian Cardona (on 15/6/08)
Must it be explained YET again to the internationally acclaimed radar installer, commissioner and certifier that the Primary radar was ON at the time of the incident??! And must it be repeated ad nauseum that primary radar data is still available on the fallback system right next to the main one?!
Thanks for the clear explanation Mr Allain...it seems you have a clearer grasp of the issues involved than an ex-army major with 40 years experience.
Anthony Mangion (on 15/6/08)
If it takes the DCA more than one year to investigate a near collision, how long will it take to investigate a more serious (God forbid) incident or accident? Will the pilot be informed of the mayhem he caused and retrained or just blame the Maltese Controllers who are not foreigners and have to stay and take it ? I wonder.....
Major Anthony Abela (on 15/6/08)
As the specialized person who prepared the Technical and Operational Specifications, Installation, Commission and Certification of the present Malta Air Traffic Radar System I demand the following questions to be answered by the competent Authorities:

1.Who, Why and When decided that the Primary Radar Data from this system shall be ignored as it is claimed that it is unrealible?
2.Why this data is valid for Italian Air TRaffic Controllers in Campino and Brindisi but is not acceptable by the Maltese Authorities?

3. Has the Regulator approved such important Air Safety issue?
4. Who is deciding about Maltese Air Traffic Services, DCA the Regulator, MATS the Managment or somebody else whose main interest is the well being of its members?

As a person with more than 40years experience in Air Traffic Systems with the RAF, the DCA, MIA and finally as a Consultant on a Trans-European Radar Safety matters I now understand why hell rose with personal attacks against me when I drew the attention that somebody in authority who decided to ignore Primary Radar Data is bound to be loosing some sleep on this incident.

As a responsible citizen I demand an International Inquiry.
Alfred Mercieca (on 15/6/08)
Ok. Its interesting to ask: If there is some kind of anomaly between the recordings and the actual picture (according to your report), how come the people responsable of the technical side of the radar equipment are not "on the receiving end" of the blame. Shouldn't they have dedected if there was this kind of problem? I cannot understand how the recordings are different from the information presented to the controller. Has something been done to rectify this?

I am no air traffic controller or pilot, just an enthusiast with some knowladge of aviation and aviation technology. In my humble opinion from what I have read, I find no blame in ATC.
Well done for the investigator giving the merit to the pilot avoiding the collision. The pilot did a magnificent job. Well done!!!! Is it true however that the investigator is a pilot himself with the same company?
Adrian Allain (on 15/6/08)
I cannot understand why the Storm pilot did not declare an emergency on the international distress frequency 121.5. This would have alerted Air Traffic Control and would also have been heard on the Air Malta B737 flight deck. No matter what frequencies are fitted on an aircraft's radio, 121.5 will always be one of them.

A light aircraft flying towards a radar scanner will produce a small return on the raw radar picture and when entering the area of PEs (permanent echos) overland and close to the radar head will be almost invisible even if the radar has MTI (moving target indicator) as the aircraft could be at 'blind speed'. If the aircraft had a transponder, all these problems would be overcome; but it didn't. The processed radar picture cleans up clutter and small returns so there was really little chance of the Storm showing once it was overland. I cannot see how the air traffic controllers can be blamed for the actions of a pilot who failed to make contact with them and of whose presence they were unaware.
Thank goodness the B737 crew were keeping a good lookout and acted swiftly to avert a collision. Well done

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