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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Air carrier X non adherence to ATC clearance descent readback wrong altitude had less than standard separation from air carrier Y. Pilot deviation. System error.
| Attributes | |
| ACN | 209860 |
| Time | |
| Date | 199205 |
| Day | Sun |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | atc facility : bdf |
| State Reference | IL |
| Altitude | msl bound lower : 29000 msl bound upper : 31000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | artcc : zau |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | descent other |
| Route In Use | enroute : on vectors |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | descent other |
| Route In Use | enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government : faa |
| Function | controller : radar |
| Qualification | controller : radar |
| Experience | controller military : 4 controller radar : 10 |
| ASRS Report | 209860 |
| Person 2 | |
| Affiliation | government : faa |
| Function | controller : radar |
| Qualification | controller : developmental |
| Events | |
| Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : required legal separation non adherence : clearance non adherence : published procedure |
| Independent Detector | atc equipment other atc equipment : unspecified other controllera |
| Resolutory Action | other |
| Consequence | faa : investigated |
| Miss Distance | horizontal : 10800 vertical : 1300 |
| Supplementary | |
| Primary Problem | ATC Human Performance |
| Air Traffic Incident | Pilot Deviation Operational Error |
Narrative:
Air carrier X and air carrier Y were both on vectors for in trail spacing to ord during a very heavy inbound rush. Air carrier Y was at FL290 descending to FL240 and air carrier X was given descent to maintain FL310. I observed the mode C readout at 30.7 so I told him again to maintain FL310. I received no response until the third call when he told me he was climbing back up to FL310 and he had understood his altitude to be FL210. FL210 is what he said he read back and the tape verified that he indeed said FL210. Like usual the pilot made an error (wrong altitude readback) and nothing happens. I miss one readback out of probably 100 during that rush and I get decertified and placed into a performance improvement program. Not much of a shared responsibility.
Original NASA ASRS Text
Title: ACR X NON ADHERENCE TO ATC CLRNC DSCNT READBACK WRONG ALT HAD LTSS FROM ACR Y. PLTDEV. SYS ERROR.
Narrative: ACR X AND ACR Y WERE BOTH ON VECTORS FOR IN TRAIL SPACING TO ORD DURING A VERY HVY INBOUND RUSH. ACR Y WAS AT FL290 DSNDING TO FL240 AND ACR X WAS GIVEN DSCNT TO MAINTAIN FL310. I OBSERVED THE MODE C READOUT AT 30.7 SO I TOLD HIM AGAIN TO MAINTAIN FL310. I RECEIVED NO RESPONSE UNTIL THE THIRD CALL WHEN HE TOLD ME HE WAS CLBING BACK UP TO FL310 AND HE HAD UNDERSTOOD HIS ALT TO BE FL210. FL210 IS WHAT HE SAID HE READ BACK AND THE TAPE VERIFIED THAT HE INDEED SAID FL210. LIKE USUAL THE PLT MADE AN ERROR (WRONG ALT READBACK) AND NOTHING HAPPENS. I MISS ONE READBACK OUT OF PROBABLY 100 DURING THAT RUSH AND I GET DECERTIFIED AND PLACED INTO A PERFORMANCE IMPROVEMENT PROGRAM. NOT MUCH OF A SHARED RESPONSIBILITY.
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.