AEROPORTOS DE MOAMBIQUE DIRECO DE OPERAES SERVIOS DE GESTO DE TRFEGO AREO

Subject: Mozambique ATS Incident Analysis Follow-Up This is to acknowledge the receipt of the 22 ASRs sent to us in November 15, 2011 and we are sending the outcomes herein, after our investigation on each particular case (Procedural and lack of Communication). Please be informed that all these incident reports and other related incidents were one of the subjects that our Administration- Operational Directorate have discussed with the all concerned including ATS Units in order to minimize its recurrence. The preliminary findings indicate that the incidents are genuine. Therefore; we came to learn that all concerned Departments should be flexible towards safety improvement within Beira FIR Please reprieve assured that we are committed with air safety too and, all Air Safety Reports ( ASRS) which are received in time will get feedback as quick as possible. It was found important to remaind you that not all 22 ASRs were true off course unless it was not done deliberately, some of them were just a duplication, those are: Reference number 1927 and 1986 is the same flight ; Reference number 1913 and 1984 is the same flight ; Reference number 1912 and 1983 just for sample Earnestly yours. 1.MAU 845 /3BNBF A342 FIMP/FALE F360 May 08, 2011 INCREP 1510. 1.1 Factual Information a) MAU 845 was a regular over flight FIMP/FALE UA402 F360 coordinated traffic to Beira FIC from Antananarivo as ETGUN O7:18 later on this traffic was also coordinated to Maputo Area Sub-center as ETMOS 07:53 F360.

b) Information from the tape transcription shows that: -There were no estimates to Johannesburg ACC; -There are several calls from Beira HF to MAU845 with no response -There no single call from MAU845 to Beira ACC/FIC on HF in the all frequencies in use at that FIC; -The crew member of MAU845 did not call Maputo Area sub-center on the Maputo ACC VHF 127.3MHZ. -There were preceding reports about Beira HF inefficiency 1.2. Conclusion The Beira HF inefficiency was one of the causes of lack of communication The non reporting position of MAU845 at ETMOS would have called Maputo Area Controller traffic awareness into his area of responsibility. 1.3 Action taken - NOTAM (A0123) W.I.E 11071857 to 1112312359 was issued about Beira HF limited range and efforts to purchase a new and reliable HF equipment is in process; - Close supervision was assumed to ACC shifts 2. SAA286 A346 FAJS/VHHH F330 COMMMS 1664 MAY 16, 2011 2.1. Factual findings a) SAA286 was a regular over flight FAJS/ VHHH routing UG745/UB536 F330 coordinated traffic by Johannesburg to Maputo Area Sub-center, later, was also coordinated to Beira FIC and Antananarivo with the following estimates : BOTAM 16:12, EROPA 16:35; b) Information from the tape transcription shows that: -SAA286 was in two way communications on VHF with Maputo until USUMO were she was requested to report at the transfer point BOTAM by time 16:12;

-There is no report position at BOTAM to Maputo either to Beira on HF of SAA286; There are several calls from Beira FIC on SAA286 -There is a confirmation from Antananarivo that SAA286 is in contact with him -There were preceding reports about Beira HF inefficiency 2. Conclusion -The Beira HF was the cause of lack of communication, 2.3 Action taken NOTAM (A0123) W.I.E 11071857 to 1112312359 was issued about Beira HF limited range while an effort to purchase new and reliable HF equipment is in process; 3. SAA287 A346 VHHH/FAJS F340 COMMS1662 May 20, 2011 3.1. Factual findings a) SAA287 was a regular over flight VHHH/ FAJS routing UB536/UG745 F340 coordinated traffic by Antananarivo to Beira FIC and with the following estimates EROPA 03:35, later, was also coordinated to Maputo Area Sub-center BOTAM 04:11, b) Information from the tape transcription shows that: -There are no two way communication between Beira FIC and SAA287 at entering point EROPA -SAA287 was in two way communication on VHF with Maputo not later after USUMO -SAA287 fails to report position EROPA and BOTAM to Beira on HF until when she established VHF comms with Maputo prior after BOTAM -There were preceding reports about Beira HF inefficiency 3.2. Conclusion -The Beira HF was the cause of lack of communication,

3.3 Action taken -NOTAM (A0123) W.I.E 11071857 to 1112312359 was issued about Beira HF limited range and an effort to purchase new and reliable HF equipment is in process; 4.MAS 201 B747-400 9MMPP WMKK/FAJS F360 ARMA INCREP 1571 4.1. Factual findings a) MAS 201 was a regular over flight WMKK/FAJS UG536/UG653 F360 coordinated traffic by Antananarivo to Beira FIC and with the following estimates EROPA 02:02, later, Beira also coordinated to Maputo Area Sub-center BOTAM 02:30 F360. b) Information from the tape transcription shows that: MAS 201 was in two way communication on VHF with Beira not later after BOTAM -The Controller at Beira ACC/FIC did not handle the traffic properly. -MAS201 was not transfered to VHF 127.3 MHZ Maputo Area Subcenter -MAS201 did not call Maputo ACC on VHF 127.3 MHZ until she was instructed by Joanesburg upon Maputo request -There is no any attempt call from Maputo ACC to MAS201 prior after BOTAM or VMA From the Ocurrence Report 01931 11 dated 25/05/2011 it was found that crew member of MAS 201 was not familiar with Beira FIR frequencies in use since within Beira FIR VHF127.9 operates in Northnean side of Beira routes UR409,UB400 and A405, VHF130.9 MHZ The VHF 130.9MHZ thought it is removed was removed fifteen years back and no long in use within Beira FIR it still appears in Mozambique AIP by mistake reference is made to Moambique AIP ENR3.1.1 to 3.2.17. - There were preceding reports about Beira HF inefficiency 4.2 Conclusion The evasive answers from Controller at Beira might have contributed to the incident; The non monitoring traffic from the Controller at Maputo ACC contributed to the lack of communication traffic awarness;

The non familiarity with the en rout frequencies by the crew member flight MAS201 contributed to lack of communication; The discrepancies of en-rout frequencies in the Moamque AIP missleaden the crew member -The inefficiency operation of Beira HF contributed to the lack of communication between Beira FIC and MAS201; 4.3. Action taken -Notification to the relevant CAA about the wrong frequency on Moambique AIP; -Reinforcement of the number of Controllers working at night to prevent somnolence; -NOTAM (A0123) W.I.E 11071857 to 1112312359 was released about Beira HF inefficiency and an effort to purchase new and reliable HF equipment is in process; -Bring to mind of Controllers the importance of traffic awareness. 5. SAA191 FIMP/ FAJS F340 June 09,2011 COMMS 1700 5.1. Factual findings a) SAA191 was a regular over flight FIMP/FAJS UG653/UG745 coordinated by Antananarivo to Beira FIC as sunir 14:59 further, it was coordinated to Maputo ACC as APLAR15:27 by Beira ACC; b) Information from the tape transcription shows that: -SAA191 had no contact wit Beira on HF as there are no indication of SAA calls -There are several calls from Beira HF to SAA191 without response -SAA191 established two way radio communication with Maputo ACC on VHF 127.3 MHZ prior after position APLAR. 5.2.Conclusion -The inefficiency of Beira HF equipment is the cause of lack of communication

5.3. Action taken NOTAM (A0123) W.I.E 11071857 to 1112312359 was released about Beira HF inefficiency and an effort to purchase new and reliable HF equipment is in process; 6.SAA287 VHHH/FAJS F380 June 18, 2011 COMMS1701 6.1. Factual findings a) SAA287 was a regular over flight VHHH/ FAJS routing UB536/UG745 F340 coordinated traffic by Antananarivo to Beira FIC and with the following estimates EROPA 03:22, later, was also coordinated to Maputo Area Sub-center BOTAM 03:51, b) Information from the tape transcription shows that: -There are no two way communications between Beira FIC and SAA287 at entering point EROPA -There was a serious concern from Beira Controller to know the traffic positioning through a constant check with adajecent ATS Units affected by the flight -SAA287 was in two way communication on VHF with Maputo not later after USUMO -SAA287 fails to report position EROPA and BOTAM to Beira on HF until when she established VHF comms with Maputo prior after BOTAM -There were preceding reports about Beira HF inefficiency 6.2 Conclusion Beira HF inefficiency was the cvause of lack of communication 6.3 Action taken NOTAM (A0123) W.I.E 11071857 to 1112312359 was released about Beira HF inefficiency and an effort to purchase new and reliable HF equipment is in process;

7. SAA287 VHHH/FAJS F360 AUGUST 02, 2011 COMMS1901 does not exist in our records but in its place we have SAA9287 VHHH/FAJS F360 at the same day. 7.1. Factual findings a) SAA9287 was a non regular over flight VHHH/ FAJS routing UB536/UG745 F340 coordinated traffic by Antananarivo to Beira FIC and with the following estimates EROPA 19:46, later, was also coordinated to Maputo Area Sub-center by Beira as BOTAM 20:15, b) Information from the tape transcription shows that: -There are no two way communications between Beira FIC and SAA9287 at entering point EROPA -There was a serious concern from Beira Controller to know the traffic positioning through a constant check with adajecent ATS Units affected by the flight -SAA9287 was in two way communication on VHF with Maputo not later after USUMO -SAA9287 fails to report position EROPA and BOTAM to Beira on HF until when she established VHF comms with Maputo prior after BOTAM -There were preceding reports about Beira HF inefficiency 7.2 Conclusion Beira HF inefficiency was the cvause of lack of communication 7.3 Action taken NOTAM (A0123) W.I.E 11071857 to 1112312359 was released about Beira HF inefficiency and an effort to purchase new and reliable HF equipment is in process;

8. SAA287 VHHH/FAJS F380 September 23, 2011 COMMS1968 8.1. Factual findings a) SAA287 was a regular over flight VHHH/ FAJS routing UB536/UG745 F340 coordinated traffic by Antananarivo to Beira FIC and with the following estimates EROPA 03:08, later, was also coordinated to Maputo Area Sub-center by Beira as BOTAM 03:40, b) Information from the tape transcription shows that: -There are no two way communications between Beira FIC and SAA287 at entering point EROPA -There was a serious concern from Beira Controller to know the traffic positioning through a constant check with adajecent ATS Units affected by the flight -SAA287 was in two way communication on VHF with Maputo not later after USUMO -SAA287 fails to report position EROPA and BOTAM to Beira on HF until when she established VHF comms with Maputo prior after BOTAM -There were preceding reports about Beira HF inefficiency 8.2 Conclusion Beira HF inefficiency was the cvause of lack of communication 8.3 Action taken NOTAM (A0123) W.I.E 11071857 to 1112312359 was released Beira HF inefficiency and an effort to purchase new and reliable HF equipment is in process; 9.SAA187 A319 HTDA/FAJS F380 September 01, 2011 COMMS1967 9.1. Factual findings a) SAA187 was a regular over flight HTDA/FAJS UG657/UG467 coordinated traffic by Dar-Es-Salam Bonap 14:02. b) Information from the tape transcription shows that:

-SAA187 established two way commmunication with Beira ACC at 14:03; prior after passing Bonap via relay -SAA187 was instructed via relay, to maintain the assigned level and to report position EPNOM; -SAA187 established two way communication at position EPNON time 14:38 - c) There is an information from maintenance office of unserviceability of the VHF127.7 MHZ Relay station of Songo and Nampula 9.2 Conclusion There was no serious worsening of communication. 9.3 Action taken The VHF 127.7MHZ was restored upon information of its unreliability 10.SAA189 A319 HTDA/FAJS F380 Sptember 19, 2011 COMMS 1970 10.1 Factual findings a) SAA189 was a regular over flight HTDA/FAJS UG657/UG467 coordinated traffic by Dar-Es-Salam BONAP 4:41. b) Information from the tape transcription shows that: -SAA189 established two way commmunication with Beira ACC at 04:49 F380 eight minutes after Estimated time to pass by BONAP 10.2 Conclusion Thought there is a report about an unsteadyness of the VHF127.7 signal from time to time it did not affect the flight SAA189 at all. 10.3 Action to take No action was required

11. SAA188 A319 FAJS/HTDA F350 September 18, 2011 COMMS1971 11.1 Factual findings a) SAA188 was a regular over flight FAJS/HTDA UG467/UG657 coordinated traffic by Joanesburg EPSEK13:06. b) Information from the tape transcription shows that: -SAA188 did no established two way commmunications with Maputo ACC at EPSEK until time 13:20 when she came to be in contact with Beira ACC on VHF 127.7 MHZ; -Maputo ACC did not notice failure of Communication untill when the Controllerin position realised that SAA188 was no reporting position EPSEK five minutes after estimated time 13:11 11.2 Conclusion The lack of communication between SAA188 and Maputo ACC was due to unserviceability of Maputo 127.3MHZ 11.3 Action taken The VHF 127.3MHZ was restored after notification of its unserviceability. 12. SAA144 FAJS/FQMA on her approach to land at Maputo October10, 2011 REFERENCE: COMMS1899 12.1 Factual findings a) SAA144 was a regular flight to Maputo coordinated traffic by Joanesburg b) SAA144 was handled by Maputo priory to enter FIR Boundary on frequency 118.1 MHZ as previously coordinated between the the two ATS Units ( Maputo and Joanesburg) according to ATS LOPS signed. c) It was in conformity with ATS procedures Doc4444-ATM/501 Chapter4 Para 4.1.2a) 12.2 Conclusion

The report shouldnt have been filed if the SAA144 crew member was familiar with ATC procedures. 12.3 Actions to be taken No action was required 13. LAM130 filed as ATS MXE2322 DH8 FQMA/FQTT Versus ZS-NKE E120 FAJS/FQVL June 27, 2011 Reference:1844 ATSMXE2322 13.1 Factual findings a) LAM130 was a regular flight FQMA/FQTT coordinated traffic between Maputo ACC and Beira ACC planned flight level F270, routing UG656 b) ZS-NKE non regular flight FAJS/FQVL maintaining flight level 250 route UG466 c) LAM130 estimating EKEOT 05.50 assigned flight level F230 request level change enroute traffic given ZS-NKE. d) ZS-NKE estimating ESRAV 05:56 maintaining flight level F250 e) UG656 and UG466 are same track as DOC4444-ATM/501 para. 5.4.2.1.5 f) Both traffic were in two way communication with the ATS Unit Maputo ACC g) At 05:38 LAM130 insisted to climb to her intended flight level f270 and that she was aware of the conflicting traffic ZS-NKE at flight level F250. h)LAM130 was estimating ESRAV 05:55, i) LAM130 was cleared to climb to Flight level 270. j) There was no climb through between LAM and ZS-NKE. k) LAM130 did not fill the Incident report at her destination as required on DOC4444ATM/501 Apendix4. l) ZS-NKE did not fill the Incident report at her destination as required on DOC4444ATM/501 Apendix4.

13.2 Conclusion There was an AIRPROX The controller was aware there was no separation but pilot in command LAM130 insisted that he will provide separation with the conflicting traffic. 13.3 Action to be taken As this incident was no reported in time the opportunity of self-learning was overdue, however the supervisores are attentive to avoid its recurrence. 14. CAW 6298 AT45 FQMA/FANSon climb F120 Versus LAM306FAJS/FQMA descending F130 September 13, 2011 REFERENCE 1927 14.1 Factual findings a)CAW6298 was a regular flight FQMA/FANS flight level F120 b)LAM306 was a regular flight FAJS/FQMA on her descending phase initial flight level F130 c) No tape records were found the system was unserviceable reference to Maintenance report d) The Controller had no idea what happened that day e) The Unit did not receive the incident report on time until November 15, 2011 14.2 Conclusion No genuine conclusions are be made, the same as for CAW6297 of September 07, 2011 14.3 Action to be taken Urgent restorage of the recording equipment

15.SAA142 A319 on RNAV APP RWY23 October 20, 2011 Reference 1892 15.1 Factual findings a) SAA142 was a regular flight FAJS/FQMA and was on its Instrument Approach following RNAV Approach runway RWY 23 on request with APP UNIT. b) the runway in use was RWY05 at time of request RNAV APP c) SAA 142 reported field in sight and was changed to TWR for landing d) In contact with TWR S142 at 0837 was instructed to join left base runway RWY 05 upon this instruction the crew member argued that they were given RWY 23 for landing by Approach, TWR controller cleared SAA142 to proceed to final RWY 23 f) SAA142 landed safely at 0839 RWY 23 15.2 Conclusion There was no lack of procedures from ATC, pilot have right to choose the desirable runway different from the selected from TWR unless the safe orderly traffic is affected. Thought we responded all your concerns we remain truthful to collaborate in any other matter related to air safety. 15.3 Action taken No action was required Please do no hesitate to contact us on time whenever circumstance call for

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