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|
Attributes | |
ACN | 202239 |
Time | |
Date | 199202 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : gve |
State Reference | VA |
Altitude | msl bound lower : 29600 msl bound upper : 31000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc tower : mia |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller non radar : 3 controller radar : 22 |
ASRS Report | 202239 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment other atc equipment : unspecified |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Miss Distance | horizontal : 15420 vertical : 1400 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I issued a clearance to air carrier X to FL330, air carrier Y acknowledged for the clearance and I missed the readback. Contributing factors: I had to ask air carrier X what his planned mach speed would be at FL350 before I could climb him. When I called air carrier X I transposed last 2 digits of his flight number to air carrier Y. It was at this time that air carrier Y (without giving his flight number gave me his planned mach speed at FL350, he was also requesting FL350). Air carrier Y climbed, when conflict alert triggered I descended air carrier Y to FL290, he was at FL296, which resolved the confliction between air carrier Y and another aircraft Z at FL310. Corrective action: I should never have missed the readback when air carrier Y acknowledged the clearance for air carrier X. Air carrier X should have been paying attention when I cleared him to FL330 not air carrier Y. Air carrier Y should have been paying attention to the flight numbers when the clearance was issued.
Original NASA ASRS Text
Title: ACR Y HAD LTSS FROM ACFT Z. SYS ERROR.
Narrative: I ISSUED A CLRNC TO ACR X TO FL330, ACR Y ACKNOWLEDGED FOR THE CLRNC AND I MISSED THE READBACK. CONTRIBUTING FACTORS: I HAD TO ASK ACR X WHAT HIS PLANNED MACH SPD WOULD BE AT FL350 BEFORE I COULD CLB HIM. WHEN I CALLED ACR X I TRANSPOSED LAST 2 DIGITS OF HIS FLT NUMBER TO ACR Y. IT WAS AT THIS TIME THAT ACR Y (WITHOUT GIVING HIS FLT NUMBER GAVE ME HIS PLANNED MACH SPD AT FL350, HE WAS ALSO REQUESTING FL350). ACR Y CLBED, WHEN CONFLICT ALERT TRIGGERED I DSNDED ACR Y TO FL290, HE WAS AT FL296, WHICH RESOLVED THE CONFLICTION BTWN ACR Y AND ANOTHER ACFT Z AT FL310. CORRECTIVE ACTION: I SHOULD NEVER HAVE MISSED THE READBACK WHEN ACR Y ACKNOWLEDGED THE CLRNC FOR ACR X. ACR X SHOULD HAVE BEEN PAYING ATTN WHEN I CLRED HIM TO FL330 NOT ACR Y. ACR Y SHOULD HAVE BEEN PAYING ATTN TO THE FLT NUMBERS WHEN THE CLRNC WAS ISSUED.
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.