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|
Attributes | |
ACN | 141261 |
Time | |
Date | 199004 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : san |
State Reference | CA |
Altitude | msl bound lower : 4000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : san |
Operator | general aviation : personal |
Make Model Name | Small Aircraft |
Flight Phase | descent other |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : handoff position |
Qualification | controller : radar |
Experience | controller radar : 21 |
ASRS Report | 141261 |
Person 2 | |
Affiliation | government : faa |
Function | controller : handoff position |
Qualification | controller : developmental |
Events | |
Anomaly | non adherence : required legal separation non adherence : published procedure other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Miss Distance | horizontal : 12000 vertical : 0 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Intra Facility Coordination Failure Operational Error Pilot Deviation |
Narrative:
WX was bad, causing very heavy traffic. Controller training in progress on both radar and handoff position adding to confusion and extra coordination, and coordination breakdown. Aircraft a on a localizer D approach to gillespie airport lost standard sep with aircraft B en route to montgomery airport. Aircraft a was over the OM at 4000' on gillespie towers frequency. He should have been descending towards the airport. This is in controllers east airspace. A target was spotted in controllers M airspace at 4000' heading southbound towards gillespie airport and into east airspace. No handoff had been completed on aircraft B. The radar instructor at east told his handoff trnee to slow aircraft B to 120 KTS and fly heading 120 and point out aircraft a to controller M, while taking handoff on aircraft B. The handoff trnee displayed aircraft a to controller M radar scope and completed coordination as requested except he did not verbally point out aircraft a to controller M. His reasoning was that aircraft a would be descending on approach and would not be a factor. Position east handoff instructor attempted to finish up point out for trnee but line was disconnected before completed. Instrument did not reseize line to complete coordination. Aircraft B entered controller east airspace with no frequency change. Aircraft a never descended below 4000', probably because he never received the OM. Handoff controller east instructed controller M to turn aircraft B our of east airspace. When aircraft a missed approach he was instructed to make left turn but made right turn instead and further reduced the sep. Controller M erased display of aircraft a thinking he was not a factor. Callback conversation with reporter revealed the following information. Reporter gave experience time and some details. Was working instrument at position M and was blamed for the error. Facility did not file system error report. Traffic was exceptionally busy during this period. Aircraft involved got within 2 mi at the same altitude. Not known why aircraft a turned right instead of left.
Original NASA ASRS Text
Title: INTRAFAC COORD BROKE DOWN CAUSING LESS THAN STANDARD SEPARATION BETWEEN TWO SMA'S.
Narrative: WX WAS BAD, CAUSING VERY HVY TFC. CTLR TRNING IN PROGRESS ON BOTH RADAR AND HDOF POS ADDING TO CONFUSION AND EXTRA COORD, AND COORD BREAKDOWN. ACFT A ON A LOC D APCH TO GILLESPIE ARPT LOST STANDARD SEP WITH ACFT B ENRTE TO MONTGOMERY ARPT. ACFT A WAS OVER THE OM AT 4000' ON GILLESPIE TWRS FREQ. HE SHOULD HAVE BEEN DSNDING TOWARDS THE ARPT. THIS IS IN CTLRS E AIRSPACE. A TARGET WAS SPOTTED IN CTLRS M AIRSPACE AT 4000' HDG SBND TOWARDS GILLESPIE ARPT AND INTO E AIRSPACE. NO HDOF HAD BEEN COMPLETED ON ACFT B. THE RADAR INSTRUCTOR AT E TOLD HIS HDOF TRNEE TO SLOW ACFT B TO 120 KTS AND FLY HDG 120 AND POINT OUT ACFT A TO CTLR M, WHILE TAKING HDOF ON ACFT B. THE HDOF TRNEE DISPLAYED ACFT A TO CTLR M RADAR SCOPE AND COMPLETED COORD AS REQUESTED EXCEPT HE DID NOT VERBALLY POINT OUT ACFT A TO CTLR M. HIS REASONING WAS THAT ACFT A WOULD BE DSNDING ON APCH AND WOULD NOT BE A FACTOR. POS E HDOF INSTRUCTOR ATTEMPTED TO FINISH UP POINT OUT FOR TRNEE BUT LINE WAS DISCONNECTED BEFORE COMPLETED. INSTR DID NOT RESEIZE LINE TO COMPLETE COORD. ACFT B ENTERED CTLR E AIRSPACE WITH NO FREQ CHANGE. ACFT A NEVER DSNDED BELOW 4000', PROBABLY BECAUSE HE NEVER RECEIVED THE OM. HDOF CTLR E INSTRUCTED CTLR M TO TURN ACFT B OUR OF E AIRSPACE. WHEN ACFT A MISSED APCH HE WAS INSTRUCTED TO MAKE L TURN BUT MADE R TURN INSTEAD AND FURTHER REDUCED THE SEP. CTLR M ERASED DISPLAY OF ACFT A THINKING HE WAS NOT A FACTOR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO. RPTR GAVE EXPERIENCE TIME AND SOME DETAILS. WAS WORKING INSTR AT POS M AND WAS BLAMED FOR THE ERROR. FAC DID NOT FILE SYS ERROR RPT. TFC WAS EXCEPTIONALLY BUSY DURING THIS PERIOD. ACFT INVOLVED GOT WITHIN 2 MI AT THE SAME ALT. NOT KNOWN WHY ACFT A TURNED R INSTEAD OF L.
Data retrieved from NASA's ASRS site as of July 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.