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|
Attributes | |
ACN | 114611 |
Time | |
Date | 198906 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | msl bound lower : 2500 msl bound upper : 2500 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other descent : approach |
Route In Use | arrival other enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | cruise other descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 28000 flight time type : 1000 |
ASRS Report | 114611 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : took evasive action other |
Consequence | Other |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Our approach to lax was normal from over santa monica. Another air carrier was in front of us several miles with only the last 2 digits the same as ours. We were given a base leg turn. The copilot commented that the controller transmission was chopped. He then repeated the clearance with our airline name. At the same time the other carrier for whom the clearance was issued acknowledged the clearance in such perfect timing that it covered most of our careful reply the tapes indicated. The flight crew was very heavy with both our aircraft on base leg 5 mi apart but a space for only one. The controller caught the problem and in a calm voice, but one that left no doubt about the urgency, told us to pull up immediately and turn left 030. I then saw lights to my left front and slightly higher. I placed the thrust levers to the stops, made an immediate bank 30-40 degree, called for flaps 22, gear up. Another set of conflicting lights came into view. The altitude we were told to go to was blocked so I kept the maximum rate of climb going and the turn going until the lights went below me, then my copilot worked on getting an altitude. I think the clear positive directions given by the controller was the first and most important step in defusing a bad situation. I feel that our rapid no nonsense response was essential as well. The odd sequence of events shows that there was no one at fault. Human performance: 1) the fact that I had so many conflicting lights approaching me from various angles was very confusing. If I had been in clouds the problem would have been easier. 2) with the rapid roll and pull up to a very high nose angle the pitch and course bar gave very confusing pitch attitude information and dividing my time looking outside avoiding lights and inside to see what the airplane was doing was difficult. I asked for calls from my first officer who was invaluable in helping sort out heading speeds, flap settings and the like. From our side it was a crew effort that helped keep things together, unravel the mess, then return to a normal instrument approach. It was essential that the crew function as a team and set our attention to the things that counted. It all happened very quickly. In retrospect, the controller could have taken steps to prevent the mix-up by using the airline name, call numbers, then the airline name from the very beginning. We could have helped bring this to the attention of the controller by responding in that fashion earlier. A minor point in this instance, but a potential major point, is that the controller should have turned us away from traffic not into the lights of oncoming descended traffic. It is easy to see how a pilot might set himself up for a loss of control situation trying to avoid lights that he perceives as too close. A turn away from oncoming traffic would always solve this problem.
Original NASA ASRS Text
Title: AS A RESULT OF CALL SIGN MIXUP AND FREQ CONGESTION CLRNC RECEIVED AND FOLLOWED BY WRONG ACFT. ATC RECOGNIZED THE ERROR AND INTERVENED AND ISSUED NEW CLRNC. VERY DANGEROUS.
Narrative: OUR APCH TO LAX WAS NORMAL FROM OVER SANTA MONICA. ANOTHER AIR CARRIER WAS IN FRONT OF US SEVERAL MILES WITH ONLY THE LAST 2 DIGITS THE SAME AS OURS. WE WERE GIVEN A BASE LEG TURN. THE COPLT COMMENTED THAT THE CTLR XMISSION WAS CHOPPED. HE THEN REPEATED THE CLRNC WITH OUR AIRLINE NAME. AT THE SAME TIME THE OTHER CARRIER FOR WHOM THE CLRNC WAS ISSUED ACKNOWLEDGED THE CLRNC IN SUCH PERFECT TIMING THAT IT COVERED MOST OF OUR CAREFUL REPLY THE TAPES INDICATED. THE FLT CREW WAS VERY HEAVY WITH BOTH OUR ACFT ON BASE LEG 5 MI APART BUT A SPACE FOR ONLY ONE. THE CTLR CAUGHT THE PROBLEM AND IN A CALM VOICE, BUT ONE THAT LEFT NO DOUBT ABOUT THE URGENCY, TOLD US TO PULL UP IMMEDIATELY AND TURN LEFT 030. I THEN SAW LIGHTS TO MY LEFT FRONT AND SLIGHTLY HIGHER. I PLACED THE THRUST LEVERS TO THE STOPS, MADE AN IMMEDIATE BANK 30-40 DEG, CALLED FOR FLAPS 22, GEAR UP. ANOTHER SET OF CONFLICTING LIGHTS CAME INTO VIEW. THE ALT WE WERE TOLD TO GO TO WAS BLOCKED SO I KEPT THE MAX RATE OF CLIMB GOING AND THE TURN GOING UNTIL THE LIGHTS WENT BELOW ME, THEN MY COPLT WORKED ON GETTING AN ALT. I THINK THE CLEAR POSITIVE DIRECTIONS GIVEN BY THE CTLR WAS THE FIRST AND MOST IMPORTANT STEP IN DEFUSING A BAD SITUATION. I FEEL THAT OUR RAPID NO NONSENSE RESPONSE WAS ESSENTIAL AS WELL. THE ODD SEQUENCE OF EVENTS SHOWS THAT THERE WAS NO ONE AT FAULT. HUMAN PERFORMANCE: 1) THE FACT THAT I HAD SO MANY CONFLICTING LIGHTS APCHING ME FROM VARIOUS ANGLES WAS VERY CONFUSING. IF I HAD BEEN IN CLOUDS THE PROBLEM WOULD HAVE BEEN EASIER. 2) WITH THE RAPID ROLL AND PULL UP TO A VERY HIGH NOSE ANGLE THE PITCH AND COURSE BAR GAVE VERY CONFUSING PITCH ATTITUDE INFO AND DIVIDING MY TIME LOOKING OUTSIDE AVOIDING LIGHTS AND INSIDE TO SEE WHAT THE AIRPLANE WAS DOING WAS DIFFICULT. I ASKED FOR CALLS FROM MY F/O WHO WAS INVALUABLE IN HELPING SORT OUT HDG SPEEDS, FLAP SETTINGS AND THE LIKE. FROM OUR SIDE IT WAS A CREW EFFORT THAT HELPED KEEP THINGS TOGETHER, UNRAVEL THE MESS, THEN RETURN TO A NORMAL INSTRUMENT APCH. IT WAS ESSENTIAL THAT THE CREW FUNCTION AS A TEAM AND SET OUR ATTN TO THE THINGS THAT COUNTED. IT ALL HAPPENED VERY QUICKLY. IN RETROSPECT, THE CTLR COULD HAVE TAKEN STEPS TO PREVENT THE MIX-UP BY USING THE AIRLINE NAME, CALL NUMBERS, THEN THE AIRLINE NAME FROM THE VERY BEGINNING. WE COULD HAVE HELPED BRING THIS TO THE ATTN OF THE CTLR BY RESPONDING IN THAT FASHION EARLIER. A MINOR POINT IN THIS INSTANCE, BUT A POTENTIAL MAJOR POINT, IS THAT THE CTLR SHOULD HAVE TURNED US AWAY FROM TFC NOT INTO THE LIGHTS OF ONCOMING DESCENDED TFC. IT IS EASY TO SEE HOW A PLT MIGHT SET HIMSELF UP FOR A LOSS OF CTL SITUATION TRYING TO AVOID LIGHTS THAT HE PERCEIVES AS TOO CLOSE. A TURN AWAY FROM ONCOMING TFC WOULD ALWAYS SOLVE THIS PROBLEM.
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.