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Attributes | |
ACN | 114145 |
Time | |
Date | 198906 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zme |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | landing other |
Route In Use | arrival other |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | ground other : taxi |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Experience | controller military : 6 controller non radar : 3 flight time last 90 days : 0 flight time total : 120 |
ASRS Report | 114145 |
Person 2 | |
Affiliation | government : faa |
Function | controller : ground |
Qualification | controller : non radar |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : published procedure non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Intra Facility Coordination Failure |
Narrative:
In 6/89 I was working as an ATC specialist at sfo, local control position. At approximately xx:xx, ground control requested to cross the active runways 28L and right, with 2 aircraft in different places on the runway. Since ground control showed he was aware of my traffic rolling out, I assumed he was aware of my traffic on final, air carrier X, and would be clear of the runway. I approved the crossing, and continued working traffic. I noted that air carrier Y under ground control was approaching 28L, with my traffic short final to 28L. I yelled at ground control and asked if he was crossing--he said yes. By then the landing aircraft was committed and air carrier Y's momentum carried him onto the runway, and was in the middle of the runway as the air carrier X touched down. Possible factors: equipment - radar/ARTS display was blinking on and off, and was eventually deemed unusable, and removed from service (ground control says he didn't see the aircraft on final). Human - local controller fatigue--10 hour shift previous day, poor night's sleep previous night, worked extremely busy session on ground control prior to working local, ground control very busy at time of runway crossing. Assumption - I assumed ground control new about my traffic, but did not ensure it. Sfo training - the training program is checking people out at the minimal proficiency level, with the expectations they will improve on their own; many do not. Though required by DOT/FAA regulations, this incident (and at least 1 other runway incursion) was not reported to anyone outside of sfo ATC tower. My opinion is the that air traffic manager is covering these up to further his personal goals. I will gladly discuss this report with you.
Original NASA ASRS Text
Title: ACR LANDED WHILE ANOTHER ACR WAS CROSSING THE RWY.
Narrative: IN 6/89 I WAS WORKING AS AN ATC SPECIALIST AT SFO, LCL CTL POS. AT APPROX XX:XX, GND CTL REQUESTED TO CROSS THE ACTIVE RWYS 28L AND R, WITH 2 ACFT IN DIFFERENT PLACES ON THE RWY. SINCE GND CTL SHOWED HE WAS AWARE OF MY TFC ROLLING OUT, I ASSUMED HE WAS AWARE OF MY TFC ON FINAL, ACR X, AND WOULD BE CLR OF THE RWY. I APPROVED THE XING, AND CONTINUED WORKING TFC. I NOTED THAT ACR Y UNDER GND CTL WAS APCHING 28L, WITH MY TFC SHORT FINAL TO 28L. I YELLED AT GND CTL AND ASKED IF HE WAS XING--HE SAID YES. BY THEN THE LNDG ACFT WAS COMMITTED AND ACR Y'S MOMENTUM CARRIED HIM ONTO THE RWY, AND WAS IN THE MIDDLE OF THE RWY AS THE ACR X TOUCHED DOWN. POSSIBLE FACTORS: EQUIP - RADAR/ARTS DISPLAY WAS BLINKING ON AND OFF, AND WAS EVENTUALLY DEEMED UNUSABLE, AND REMOVED FROM SVC (GND CTL SAYS HE DIDN'T SEE THE ACFT ON FINAL). HUMAN - LCL CTLR FATIGUE--10 HR SHIFT PREVIOUS DAY, POOR NIGHT'S SLEEP PREVIOUS NIGHT, WORKED EXTREMELY BUSY SESSION ON GND CTL PRIOR TO WORKING LCL, GND CTL VERY BUSY AT TIME OF RWY XING. ASSUMPTION - I ASSUMED GND CTL NEW ABOUT MY TFC, BUT DID NOT ENSURE IT. SFO TRNING - THE TRNING PROGRAM IS CHKING PEOPLE OUT AT THE MINIMAL PROFICIENCY LEVEL, WITH THE EXPECTATIONS THEY WILL IMPROVE ON THEIR OWN; MANY DO NOT. THOUGH REQUIRED BY DOT/FAA REGS, THIS INCIDENT (AND AT LEAST 1 OTHER RWY INCURSION) WAS NOT RPTED TO ANYONE OUTSIDE OF SFO ATC TWR. MY OPINION IS THE THAT AIR TFC MGR IS COVERING THESE UP TO FURTHER HIS PERSONAL GOALS. I WILL GLADLY DISCUSS THIS RPT WITH YOU.
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.