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|
Attributes | |
ACN | 147828 |
Time | |
Date | 199006 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : hcm |
State Reference | VA |
Altitude | msl bound lower : 37000 msl bound upper : 37000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : corporate |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute airway : j193 enroute airway : j191 |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar pilot : private |
Experience | controller non radar : 2 controller radar : 5 flight time last 90 days : 0 flight time total : 160 |
ASRS Report | 147828 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 45 flight time total : 8500 flight time type : 1850 |
ASRS Report | 147533 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance non adherence : required legal separation other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Miss Distance | horizontal : 12000 vertical : 0 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation Operational Error |
Narrative:
Light transport was handed off to me climbing to FL390, leaving FL330. Handoff point is approximately when J191 and J193 and J61 come together at the hubbs intersection. Light transport should have been flying down J193. I noticed one radar return towards J191 and believed it to be a bad 'hit' because we see so many bad hits so frequently. Light transport continued to track down J191. Seeing traffic (in another sector) I turned light transport to heading 170 degree and tried to call the sector that was controling air carrier X. After two tries, I told the controller talking to air carrier X that light transport was off course and that I had turned him left. This controller was not yet aware of imminent situation because conflict alert had not yet gone off. (It had not gone off because of the lag in the vector lines that the ca uses to warn controllers of problems. The computer still 'thought' light transport was tracking down J193 even though 3 or 4 radar returns showed him tracking down J191). Light transport thought he had been cleared on J191. Apparently there was communications problem somewhere earlier in the flight, either a 'readback' or 'hearback' problem. Also it seems dangerous to have two arwy with 'like callsigns' come together at the same point. Also, if I could trust the radar to give accurate information almost 100% of the time, I would have turned light transport away from conflicting traffic after the first radar return showing him off course. But instead I thought it was just giving me bad information as it so often does. Supplemental information from acn 147533. During climb out, the aircraft was given new routing. I copied 'turn to new heading to intercept J61, then J61/J191/J121 to chs. Center's routing was intended to be 'J61/J193/J121'. While I may have read back 'J193', I copied 'J191'. Long sequences of arwy numbers, all using the same few digits (ie, 6-1-1-9-3-1-2-1) west/O using any intermediate fixes allows the 'short term' memory to readback the sounds, phonetically, while the finger may write down one digit out of sequence.
Original NASA ASRS Text
Title: CPR LTT TRACK HEADING DEVIATION RESULTS IN LESS THAN STANDARD SEPARATION.
Narrative: LTT WAS HANDED OFF TO ME CLBING TO FL390, LEAVING FL330. HDOF POINT IS APPROX WHEN J191 AND J193 AND J61 COME TOGETHER AT THE HUBBS INTXN. LTT SHOULD HAVE BEEN FLYING DOWN J193. I NOTICED ONE RADAR RETURN TOWARDS J191 AND BELIEVED IT TO BE A BAD 'HIT' BECAUSE WE SEE SO MANY BAD HITS SO FREQUENTLY. LTT CONTINUED TO TRACK DOWN J191. SEEING TFC (IN ANOTHER SECTOR) I TURNED LTT TO HDG 170 DEG AND TRIED TO CALL THE SECTOR THAT WAS CTLING ACR X. AFTER TWO TRIES, I TOLD THE CTLR TALKING TO ACR X THAT LTT WAS OFF COURSE AND THAT I HAD TURNED HIM L. THIS CTLR WAS NOT YET AWARE OF IMMINENT SITUATION BECAUSE CONFLICT ALERT HAD NOT YET GONE OFF. (IT HAD NOT GONE OFF BECAUSE OF THE LAG IN THE VECTOR LINES THAT THE CA USES TO WARN CTLRS OF PROBS. THE COMPUTER STILL 'THOUGHT' LTT WAS TRACKING DOWN J193 EVEN THOUGH 3 OR 4 RADAR RETURNS SHOWED HIM TRACKING DOWN J191). LTT THOUGHT HE HAD BEEN CLRED ON J191. APPARENTLY THERE WAS COMS PROB SOMEWHERE EARLIER IN THE FLT, EITHER A 'READBACK' OR 'HEARBACK' PROB. ALSO IT SEEMS DANGEROUS TO HAVE TWO ARWY WITH 'LIKE CALLSIGNS' COME TOGETHER AT THE SAME POINT. ALSO, IF I COULD TRUST THE RADAR TO GIVE ACCURATE INFO ALMOST 100% OF THE TIME, I WOULD HAVE TURNED LTT AWAY FROM CONFLICTING TFC AFTER THE FIRST RADAR RETURN SHOWING HIM OFF COURSE. BUT INSTEAD I THOUGHT IT WAS JUST GIVING ME BAD INFO AS IT SO OFTEN DOES. SUPPLEMENTAL INFO FROM ACN 147533. DURING CLBOUT, THE ACFT WAS GIVEN NEW RTING. I COPIED 'TURN TO NEW HDG TO INTERCEPT J61, THEN J61/J191/J121 TO CHS. CTR'S RTING WAS INTENDED TO BE 'J61/J193/J121'. WHILE I MAY HAVE READ BACK 'J193', I COPIED 'J191'. LONG SEQUENCES OF ARWY NUMBERS, ALL USING THE SAME FEW DIGITS (IE, 6-1-1-9-3-1-2-1) W/O USING ANY INTERMEDIATE FIXES ALLOWS THE 'SHORT TERM' MEMORY TO READBACK THE SOUNDS, PHONETICALLY, WHILE THE FINGER MAY WRITE DOWN ONE DIGIT OUT OF SEQUENCE.
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.