37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 174339 |
Time | |
Date | 199102 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : mtu |
State Reference | UT |
Altitude | msl bound lower : 23500 msl bound upper : 35000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zlc |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | other |
Make Model Name | Experimental |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller non radar : 2 controller radar : 3 |
ASRS Report | 174339 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Miss Distance | horizontal : 18000 vertical : 1500 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Air carrier X was issued a clearance to stop at FL330 for military Y traffic at FL350. Air carrier X continued climb through FL330 to FL380 resulting in loss of sep with utah 51. Closest proximity was 1500' and 3 mi. Review of tape revealed no readback from air carrier X. Air carrier X was noticed immediately climbing through FL330 and was issued clearance to maintain FL330. The crew acknowledged. I feel human error contributed greatly to this situation. I, as the controller, did not verify the readback. Possibly if the crew were paying more attention, the clearance would have been acknowledged the first time it was issued. Callback conversation with reporter revealed the following: reporter stated he was an fpl with 3 yrs radar and 2 yrs non radar experience. The incident happened 2 mins after position relief. C/a did not activate because FL330 was entered into the data block. The reporter had failed to receive an acknowledgement of the stop at FL330. Relieving controller heard FL330 issued during the position relief briefing and assumed the air carrier X flight crew had acknowledged.
Original NASA ASRS Text
Title: ACR X HAD LESS THAN STANDARD SEPARATION FROM MIL Y. SYSTEM ERROR.
Narrative: ACR X WAS ISSUED A CLRNC TO STOP AT FL330 FOR MIL Y TFC AT FL350. ACR X CONTINUED CLB THROUGH FL330 TO FL380 RESULTING IN LOSS OF SEP WITH UTAH 51. CLOSEST PROX WAS 1500' AND 3 MI. REVIEW OF TAPE REVEALED NO READBACK FROM ACR X. ACR X WAS NOTICED IMMEDIATELY CLBING THROUGH FL330 AND WAS ISSUED CLRNC TO MAINTAIN FL330. THE CREW ACKNOWLEDGED. I FEEL HUMAN ERROR CONTRIBUTED GREATLY TO THIS SITUATION. I, AS THE CTLR, DID NOT VERIFY THE READBACK. POSSIBLY IF THE CREW WERE PAYING MORE ATTN, THE CLRNC WOULD HAVE BEEN ACKNOWLEDGED THE FIRST TIME IT WAS ISSUED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR STATED HE WAS AN FPL WITH 3 YRS RADAR AND 2 YRS NON RADAR EXPERIENCE. THE INCIDENT HAPPENED 2 MINS AFTER POS RELIEF. C/A DID NOT ACTIVATE BECAUSE FL330 WAS ENTERED INTO THE DATA BLOCK. THE RPTR HAD FAILED TO RECEIVE AN ACKNOWLEDGEMENT OF THE STOP AT FL330. RELIEVING CTLR HEARD FL330 ISSUED DURING THE POS RELIEF BRIEFING AND ASSUMED THE ACR X FLT CREW HAD ACKNOWLEDGED.
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.