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|
Attributes | |
ACN | 184055 |
Time | |
Date | 199107 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : nkx |
State Reference | CA |
Altitude | msl bound lower : 3000 msl bound upper : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : san tower : lax |
Operator | other |
Make Model Name | Experimental |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
ASRS Report | 184055 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : developmental |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure |
Independent Detector | other other : unspecified atc |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Deviation |
Narrative:
Military X was departing NAS miramar for a practice approach in the radar box pattern. He was on a standard instrument departure expecting radar vectors for approachs. During this operation I was providing OJT to a developmental (trainee controller). Military X first 2 calls airborne were blocked out by the tower calling the sector or an aircraft calling on a VHF frequency at the same time. Military X called airborne the third time and the trainee assigned 3000 ft due to traffic in the departure corridor north of the airport, not knowing that military X was incorrectly radar idented. I, as the instructor, did not hear this transmission since I was distracted by another sector violating our airspace with an aircraft east of the airport. I had to verbally coordinate this away from the scope. The fourth call military X made to us. The trainee realized that she had misidented military X, asked him to reset his transponder and identify. Military X never replied. During this transmission the instructor was distracted by the supervisor requesting that the trainee be relieved to assume duties at another sector. I took the sector from the trainee not knowing that military X was airborne. Subsequently I was relieved approximately 1 min later at the end of my shift, and briefed my relief that military X was not yet airborne. Exact altitudes that military X flew the departure are unknown since his transponder never came on allowing our computers to track and record his route of flight and altitudes. Several contributing factors led up to this operational error: 1) no transponder return from the aircraft. 2) poor communications. 3) misident of military X. 4) instructor being distracted several times. 5) trainee being relieved just prior to relief briefing. 6) adjacent sector violating our airspace. 7) both trainee and instructor fatigued at end of busy shift. 8) poor landline override capability for instructor at the miramar position.
Original NASA ASRS Text
Title: IMPROPER POS RELIEF BRIEFING. DEP CTLR FORGOT MIL X. FAILED TO TELL RELIEF.
Narrative: MIL X WAS DEPARTING NAS MIRAMAR FOR A PRACTICE APCH IN THE RADAR BOX PATTERN. HE WAS ON A STANDARD INST DEP EXPECTING RADAR VECTORS FOR APCHS. DURING THIS OP I WAS PROVIDING OJT TO A DEVELOPMENTAL (TRAINEE CTLR). MIL X FIRST 2 CALLS AIRBORNE WERE BLOCKED OUT BY THE TWR CALLING THE SECTOR OR AN ACFT CALLING ON A VHF FREQ AT THE SAME TIME. MIL X CALLED AIRBORNE THE THIRD TIME AND THE TRAINEE ASSIGNED 3000 FT DUE TO TFC IN THE DEP CORRIDOR N OF THE ARPT, NOT KNOWING THAT MIL X WAS INCORRECTLY RADAR IDENTED. I, AS THE INSTRUCTOR, DID NOT HEAR THIS XMISSION SINCE I WAS DISTRACTED BY ANOTHER SECTOR VIOLATING OUR AIRSPACE WITH AN ACFT E OF THE ARPT. I HAD TO VERBALLY COORDINATE THIS AWAY FROM THE SCOPE. THE FOURTH CALL MIL X MADE TO US. THE TRAINEE REALIZED THAT SHE HAD MISIDENTED MIL X, ASKED HIM TO RESET HIS TRANSPONDER AND IDENT. MIL X NEVER REPLIED. DURING THIS XMISSION THE INSTRUCTOR WAS DISTRACTED BY THE SUPVR REQUESTING THAT THE TRAINEE BE RELIEVED TO ASSUME DUTIES AT ANOTHER SECTOR. I TOOK THE SECTOR FROM THE TRAINEE NOT KNOWING THAT MIL X WAS AIRBORNE. SUBSEQUENTLY I WAS RELIEVED APPROX 1 MIN LATER AT THE END OF MY SHIFT, AND BRIEFED MY RELIEF THAT MIL X WAS NOT YET AIRBORNE. EXACT ALTITUDES THAT MIL X FLEW THE DEP ARE UNKNOWN SINCE HIS TRANSPONDER NEVER CAME ON ALLOWING OUR COMPUTERS TO TRACK AND RECORD HIS RTE OF FLT AND ALTS. SEVERAL CONTRIBUTING FACTORS LED UP TO THIS OPERROR: 1) NO TRANSPONDER RETURN FROM THE ACFT. 2) POOR COMS. 3) MISIDENT OF MIL X. 4) INSTRUCTOR BEING DISTRACTED SEVERAL TIMES. 5) TRAINEE BEING RELIEVED JUST PRIOR TO RELIEF BRIEFING. 6) ADJACENT SECTOR VIOLATING OUR AIRSPACE. 7) BOTH TRAINEE AND INSTRUCTOR FATIGUED AT END OF BUSY SHIFT. 8) POOR LANDLINE OVERRIDE CAPABILITY FOR INSTRUCTOR AT THE MIRAMAR POS.
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.