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|
Attributes | |
ACN | 191094 |
Time | |
Date | 199109 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : jfk |
State Reference | NY |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : n90 tower : jfk |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : radar |
Experience | controller radar : 3 |
ASRS Report | 191094 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance non adherence : published procedure non adherence : required legal separation other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 9000 vertical : 400 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Narrative:
I cleared air carrier X for takeoff runway 13L. Air carrier X had received his IFR clearance earlier through pre departure clearance (pre departure clearance) a new procedure at jfk. The clearance was fly heading 090, maintain 5000 for radar vectors. Air carrier X read back runway heading 5000, I did not hear runway heading and expected a left turn to 090. However, due to strong xwinds reported by an INS equipped aircraft (210 at 27 at 400 ft), I observed a low straight climb by air carrier X but deemed it normal due to the crosswind component. When air carrier X cleared/passed runway 22L, passing the final approach course I changed him to departure control, having no further traffic conflicts. I was very busy at this time working 3 runways at once. There were 2 departure controllers on to handle the amount of traffic that I was moving. My problem occurred when I cleared air carrier Y for takeoff on runway 13R, staggering him approximately 1.5 mi behind air carrier X. Air carrier Y clearance was to turn left heading 110, and he did. Believing I would have at least 15 degree divergence and at least 1 mi longitudinal separation (separation minima, 7110.65, ATC handbook), I never realized there was a problem. Air carrier X never turned, air carrier Y did and allegedly passed behind on these parallel (13L and 14R) runways all traffic making left turns should be worked by the same controller. As these aircraft checked in with new york departure they were told radar contact, climb and maintain, and nothing more. Each one was worked by a different controller, and neither departure controller knew of the conflict until air carrier Y complained approximately 8-10 mi out. I realize that pilots have workload problems too, but they should not rush the readback, make the readback intelligible. If I had heard any heading you can bet I would have taken appropriate action. I have noticed on other occasions that pre departure clearance aircraft don't refer to the SID when the runway changes and fly the wrong procedure. In this case air carrier X was issued 090, I don't know how he came up with runway heading. Heading 130 is not in the computer for issuance, but heading 220 (runway heading for 22R departure) is, but was not issued. We have a formal noise abatement policy here causing runway rotation policies, confign problems due to proximity of lga and ewr and a general complacency by our supervisors as to what is safe, when to change runways. This night we should have been on the 22's and I would not have had an operational error pinned on me.
Original NASA ASRS Text
Title: ACR X NON ADHERENCE TO ATC CLRNC READBACK WRONG HDG HAD LTSS FROM ACR Y. SYS ERROR. PLTDEV.
Narrative: I CLRED ACR X FOR TKOF RWY 13L. ACR X HAD RECEIVED HIS IFR CLRNC EARLIER THROUGH PDC (PRE DEP CLRNC) A NEW PROC AT JFK. THE CLRNC WAS FLY HDG 090, MAINTAIN 5000 FOR RADAR VECTORS. ACR X READ BACK RWY HDG 5000, I DID NOT HEAR RWY HDG AND EXPECTED A L TURN TO 090. HOWEVER, DUE TO STRONG XWINDS RPTED BY AN INS EQUIPPED ACFT (210 AT 27 AT 400 FT), I OBSERVED A LOW STRAIGHT CLB BY ACR X BUT DEEMED IT NORMAL DUE TO THE XWIND COMPONENT. WHEN ACR X CLRED/PASSED RWY 22L, PASSING THE FINAL APCH COURSE I CHANGED HIM TO DEP CTL, HAVING NO FURTHER TFC CONFLICTS. I WAS VERY BUSY AT THIS TIME WORKING 3 RWYS AT ONCE. THERE WERE 2 DEP CTLRS ON TO HANDLE THE AMOUNT OF TFC THAT I WAS MOVING. MY PROBLEM OCCURRED WHEN I CLRED ACR Y FOR TKOF ON RWY 13R, STAGGERING HIM APPROX 1.5 MI BEHIND ACR X. ACR Y CLRNC WAS TO TURN L HDG 110, AND HE DID. BELIEVING I WOULD HAVE AT LEAST 15 DEG DIVERGENCE AND AT LEAST 1 MI LONGITUDINAL SEPARATION (SEPARATION MINIMA, 7110.65, ATC HANDBOOK), I NEVER REALIZED THERE WAS A PROBLEM. ACR X NEVER TURNED, ACR Y DID AND ALLEGEDLY PASSED BEHIND ON THESE PARALLEL (13L AND 14R) RWYS ALL TFC MAKING L TURNS SHOULD BE WORKED BY THE SAME CTLR. AS THESE ACFT CHKED IN WITH NEW YORK DEP THEY WERE TOLD RADAR CONTACT, CLB AND MAINTAIN, AND NOTHING MORE. EACH ONE WAS WORKED BY A DIFFERENT CTLR, AND NEITHER DEP CTLR KNEW OF THE CONFLICT UNTIL ACR Y COMPLAINED APPROX 8-10 MI OUT. I REALIZE THAT PLTS HAVE WORKLOAD PROBLEMS TOO, BUT THEY SHOULD NOT RUSH THE READBACK, MAKE THE READBACK INTELLIGIBLE. IF I HAD HEARD ANY HDG YOU CAN BET I WOULD HAVE TAKEN APPROPRIATE ACTION. I HAVE NOTICED ON OTHER OCCASIONS THAT PDC ACFT DON'T REFER TO THE SID WHEN THE RWY CHANGES AND FLY THE WRONG PROC. IN THIS CASE ACR X WAS ISSUED 090, I DON'T KNOW HOW HE CAME UP WITH RWY HDG. HDG 130 IS NOT IN THE COMPUTER FOR ISSUANCE, BUT HDG 220 (RWY HDG FOR 22R DEP) IS, BUT WAS NOT ISSUED. WE HAVE A FORMAL NOISE ABATEMENT POLICY HERE CAUSING RWY ROTATION POLICIES, CONFIGN PROBLEMS DUE TO PROX OF LGA AND EWR AND A GENERAL COMPLACENCY BY OUR SUPVRS AS TO WHAT IS SAFE, WHEN TO CHANGE RWYS. THIS NIGHT WE SHOULD HAVE BEEN ON THE 22'S AND I WOULD NOT HAVE HAD AN OPERROR PINNED ON ME.
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.