Aviation safety investigations & reports

Boeing Co 767-338ER, VH-OGP

Investigation number:
200402411
Status: Completed
Investigation completed

Summary

Sequence of events

On 19 June 2004, at about 1908 Coordinated Universal Time (UTC), two Australian registered Boeing Company 767-338ER aircraft were involved in a serious incident in the Ujung Pandang Flight Information Region (FIR) on air route B473, approximately 60 NM northwest of waypoint SAMGE (latitude 02o21/10//N, longitude 129 o39/00//E).

Flight number QF 83, registered VH-OGP was northbound and flight number QF 98, registered VH-OGQ was southbound on the same air route. The crew of QF 83 reported at SAMGE at 1901 UTC. The crew stated that Ujung Control cleared the crew to `Descend flight level (FL) 350, cross SADAN at FL350 and report leaving FL360'. At about 1906, while continuing to maintain FL360, the crew observed an aircraft (QF 98) on the reciprocal track. The crew of QF 98 were cruising at their cleared level of FL350. This aircraft passed 1,000 ft below QF 83 at about 1908. The crew of QF 98 asked Ujung Control to confirm their clearance. The controller then replied `Maintain FL360, report at time 1917'. If the crew of QF 83 had descended their aircraft from FL360 to FL350 there would have been an infringement of separation standards and an increased risk of collision, with QF 98.

The Australian Transport Safety Bureau (ATSB) was advised of the incident and commenced an investigation. The crews of both aircraft were interviewed and data from each aircraft's quick access recorder was analysed. A review of that data subsequently revealed that the incident occurred inside Indonesian territory. Accordingly, the Indonesian National Transportation Safety Committee (NTSC) had the responsibility to conduct an investigation in accordance with Annex 13 to the Convention on International Civil Aviation.

On 8 July 2004, the NTSC informed the ATSB that they had commenced an investigation into the incident and the ATSB appointed an accredited representative to that investigation. The NTSC, being the investigation agency of the country in which the incident occurred, will be preparing the report and has control over the public release of any investigation findings.

The ATSB will publish the NTSC report on its website www.atsb.gov.au when released by the NTSC.

Safety Action

The operator has implemented the following procedures to be followed when its aircraft are operating in the Ujung Pandang FIR:

  • Depart with an operative Traffic Alert and Collision Avoidance System (TCAS)
  • Cruise at standard levels
  • Logo lights ON at night (excluding A330 aircraft)
  • TCAS on for en route climb or descent, or for the entire climb and descent into Indonesian airports
  • If TCAS becomes unserviceable en route, flight crew must not request or accept en route climb or descent.
General details
Date: 19 June 2004   Investigation status: Completed  
Time: 1908 hours UTC    
Location   (show map): Samge, (IFR)    
State: International   Occurrence type: Loss of separation  
Release date: 15 February 2005   Occurrence class: Airspace  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration VH-OGP  
Serial number 28153  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, VIC  
Destination Hong Kong  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration VH-OGQ  
Serial number 28154  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Hong Kong  
Destination Brisbane, QLD  
Last update 13 May 2014