The IC did not reveal problems or conditions concerning the the crew or the operators of the aircraft involved that would call for a safety recommendation because similar occurrences can be prevented if the relevant rules and regulations are observed.
Upon finishing the investigation the IC proposes to issue the following safety recommendations:
BA2012-159-4P-1: It was found that the STCA alert was displayed near or beyond the edge of the EL EC operator’s field of vision resulting in a long reaction time.
Transportation Safety Bureau proposes HungaroControl to make use of another supplemental indication in addition to STCA alert that immediately draws the attention of the operator regardless of what part of the screen the operator is focusing on.
The approval and implementation of the recommendation would ensure that the ATC operators get timely notification on STCA warnings and alerts displayed on their screen outside their field of vision.
BA2012-159-4P-2: It was found that the S mode set altitude difference warning was not clearly noticeable for the operator resulting in a long reaction time.
Transportation Safety Bureau proposes HungaroControl to introduce a change in the displaying mode of S mode set altitude difference warning. In the proposed mode the named warning would switch to a higher level of alert if the altitude difference stays active for at least two consecutive signal refresh period.
The approval and implementation of the recommendation would ensure that ATC operators are notified faster and with higher reliability on the fact that a flight crew set an altitude different from the value cleared by ATC.
BA2012-159-4P-3: It was found that the serious incident happened near the end of 3-hour shift of EL EC. The long shift without break and the resulting tiredness of the operator could contribute to the occurrence, in fact, the operator did not notice the STCA alert.
Transportation Safety Bureau proposes HungaroControl to make it obligatory to its operators to have at least 15 minutes of rest after a 90-minute work in front of the screen.
The approval and implementation of the recommendation would reduce the possibility of work quality degradation due to fatigue and tiredness.