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Attributes | |
ACN | 111764 |
Time | |
Date | 198905 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : lrp |
State Reference | PA |
Altitude | msl bound lower : 16000 msl bound upper : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Route In Use | enroute airway : zny |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : corporate |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : non radar |
Experience | controller non radar : 4 controller radar : 3 |
ASRS Report | 111764 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : investigated |
Miss Distance | horizontal : 18000 vertical : 100 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I was working the iad arrival push over robrt with 14 flts. Air carrier X was en route to iad via lrp V143 robrt aml iad. Cga Y departed abe en route to iad via same routing, climbing to FL180. Air carrier X was descending to FL200 and was traffic for a phl departure wbound on J110. I needed to continue his descent for the traffic and to contain him in my very small sector.I put 17000' in the data block and wrote 17000' on the strip, but for some unknown reason said 12000' and the pilot read back 12000'. I first noticed the problem when air carrier X descended through 17000' and the C/a went off. At that time I asked air carrier X to verify at 17000' and he said, 'no, we're descending to 12000'.' I then turned cga Y wbound, and since air carrier X was assigned 310 KTS and cga Y 280 KTS with val 143M was 4 mi in front, I had him continue his descent. However, for some reason the oedp said they got closer. I believe a contributing factor is that cga Y could have been left on the ground by tmc until the push was over that would have meant maybe a 5 min delay instead of departing him right underneath. A human factor involved is that it is standard operation to go to 12000' with the iad arrs, which may have led me subconsciously to say 12000' instead of what I thought I said. I believe another contributing factor is the snitch machine. I was at a stage where I could not have another error because of fear of administrative retribution because I was involved in a minor error less than 6 months prior to this one. The increase in errors since implementation of oedp has put added, unnecessary pressure on myself and many of my coworkers. The reason we use 5 mi instead of 3 is because of inadequacies in the data display, and yet that machine can pinpoint errors to a hundredth of a mile using the same display. I am sure because I was there and history proves that the system was just as safe or safer before 'big brother' was put in--I don't think new people will make it more than 10 yrs.
Original NASA ASRS Text
Title: CTLR INADVERTENTLY ISSUED THE WRONG ALT RESULTING IN AN ACR DESCENDING THROUGH THE ALT OF ANOTHER ACFT.
Narrative: I WAS WORKING THE IAD ARR PUSH OVER ROBRT WITH 14 FLTS. ACR X WAS ENRTE TO IAD VIA LRP V143 ROBRT AML IAD. CGA Y DEPARTED ABE ENRTE TO IAD VIA SAME ROUTING, CLBING TO FL180. ACR X WAS DSNDING TO FL200 AND WAS TFC FOR A PHL DEP WBOUND ON J110. I NEEDED TO CONTINUE HIS DSCNT FOR THE TFC AND TO CONTAIN HIM IN MY VERY SMALL SECTOR.I PUT 17000' IN THE DATA BLOCK AND WROTE 17000' ON THE STRIP, BUT FOR SOME UNKNOWN REASON SAID 12000' AND THE PLT READ BACK 12000'. I FIRST NOTICED THE PROB WHEN ACR X DSNDED THROUGH 17000' AND THE C/A WENT OFF. AT THAT TIME I ASKED ACR X TO VERIFY AT 17000' AND HE SAID, 'NO, WE'RE DSNDING TO 12000'.' I THEN TURNED CGA Y WBOUND, AND SINCE ACR X WAS ASSIGNED 310 KTS AND CGA Y 280 KTS WITH VAL 143M WAS 4 MI IN FRONT, I HAD HIM CONTINUE HIS DSCNT. HOWEVER, FOR SOME REASON THE OEDP SAID THEY GOT CLOSER. I BELIEVE A CONTRIBUTING FACTOR IS THAT CGA Y COULD HAVE BEEN LEFT ON THE GND BY TMC UNTIL THE PUSH WAS OVER THAT WOULD HAVE MEANT MAYBE A 5 MIN DELAY INSTEAD OF DEPARTING HIM RIGHT UNDERNEATH. A HUMAN FACTOR INVOLVED IS THAT IT IS STANDARD OPERATION TO GO TO 12000' WITH THE IAD ARRS, WHICH MAY HAVE LED ME SUBCONSCIOUSLY TO SAY 12000' INSTEAD OF WHAT I THOUGHT I SAID. I BELIEVE ANOTHER CONTRIBUTING FACTOR IS THE SNITCH MACHINE. I WAS AT A STAGE WHERE I COULD NOT HAVE ANOTHER ERROR BECAUSE OF FEAR OF ADMINISTRATIVE RETRIBUTION BECAUSE I WAS INVOLVED IN A MINOR ERROR LESS THAN 6 MONTHS PRIOR TO THIS ONE. THE INCREASE IN ERRORS SINCE IMPLEMENTATION OF OEDP HAS PUT ADDED, UNNECESSARY PRESSURE ON MYSELF AND MANY OF MY COWORKERS. THE REASON WE USE 5 MI INSTEAD OF 3 IS BECAUSE OF INADEQUACIES IN THE DATA DISPLAY, AND YET THAT MACHINE CAN PINPOINT ERRORS TO A HUNDREDTH OF A MILE USING THE SAME DISPLAY. I AM SURE BECAUSE I WAS THERE AND HISTORY PROVES THAT THE SYS WAS JUST AS SAFE OR SAFER BEFORE 'BIG BROTHER' WAS PUT IN--I DON'T THINK NEW PEOPLE WILL MAKE IT MORE THAN 10 YRS.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.