37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 166518 |
Time | |
Date | 199012 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : lfd |
State Reference | MI |
Altitude | msl bound lower : 31000 msl bound upper : 33000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zob |
Operator | common carrier : air carrier |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : corporate |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller non radar : 4 controller radar : 2 |
ASRS Report | 166518 |
Person 2 | |
Affiliation | government : faa |
Function | controller : flight data |
Qualification | controller : radar |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Miss Distance | horizontal : 15600 vertical : 1100 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Air carrier X was eastbound at FL330, cpr Y was westbound at FL310 requesting FL350. Cpr Y was cleared direct to fsd and when reinstating the altitude to maintain, the controller inadvertently said FL350 instead of FL310. The controller was aware of the traffic at FL330 and did not mean to say FL350. Neither controller (radar or assistant) caught the error before sep was lost, and cpr Y was descended to FL310. The closest proximity was 2.6 mi and 1100'. This incident shows, I believe, that human errors will happen and that most of the time they get caught but sometimes they get by everyone.
Original NASA ASRS Text
Title: CPR Y HAD LESS THAN STANDARD SEPARATION FROM ACR X. SYSTEM ERROR.
Narrative: ACR X WAS EBND AT FL330, CPR Y WAS WBND AT FL310 REQUESTING FL350. CPR Y WAS CLRED DIRECT TO FSD AND WHEN REINSTATING THE ALT TO MAINTAIN, THE CTLR INADVERTENTLY SAID FL350 INSTEAD OF FL310. THE CTLR WAS AWARE OF THE TFC AT FL330 AND DID NOT MEAN TO SAY FL350. NEITHER CTLR (RADAR OR ASSISTANT) CAUGHT THE ERROR BEFORE SEP WAS LOST, AND CPR Y WAS DSNDED TO FL310. THE CLOSEST PROX WAS 2.6 MI AND 1100'. THIS INCIDENT SHOWS, I BELIEVE, THAT HUMAN ERRORS WILL HAPPEN AND THAT MOST OF THE TIME THEY GET CAUGHT BUT SOMETIMES THEY GET BY EVERYONE.
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.