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|
Attributes | |
ACN | 236426 |
Time | |
Date | 199303 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : den |
State Reference | CO |
Altitude | msl bound lower : 7200 msl bound upper : 7200 |
Environment | |
Flight Conditions | IMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : den tower : den |
Operator | common carrier : air taxi |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : initial |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air taxi |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : initial |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : radar |
Experience | controller radar : 11 |
ASRS Report | 236426 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Events | |
Anomaly | conflict : nmac 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 | vertical : 200 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Inter Facility Coordination Failure |
Narrative:
It was very early on a foggy late winter day. The runway confign was landing west, departing north. I had just arrived in the tower and was working all of the tower position combined. Due to the WX some of the cargo haulers were still leaving. I departed small transport X off of runway 36. His route was to join V-81 (den 155 degree radial) south to pueblo. His initial assigned heading was 040 degrees (keeping within noise abatement constraints). He should have stayed on that heading until at least 7500 ft MSL. He was put on this heading to be separated from the next departure, small transport Y who was on a runway heading after departure to eventually join the den 335 degree radial. When small transport X was out of 6400 ft MSL the departure controller called up to request an early turn. I approved this assuming the departure controller would turn him right to join his requested route. Instead the departure controller thought small transport X was assigned runway heading (which is normal) and turned small transport X left to a heading of 190 degrees. The 040 degree heading was clearly written on the flight strip. When departure controller called to request the turn I reiterated the fact that the small transport X was on a 040 degree heading. Later he said he didn't hear that part of the coordination (which the tape recording clearly demonstrated) nor did he notice the 040 degree radial written on the flight progress strip. Small transport X passed the departure flight path at an altitude of 1100 ft above the departure aircraft. At this point normally altitude separation could be discontinued because the flight paths were diverging. (7110.65G paragraph 5-73.) however, small transport X continued his left turn back towards the airport on a seasterly heading. The departure controller noticing the problem issued traffic to the small transport Y then attempted to turn the small transport X to a 270 degree heading. At this point the small transport X was heading approximately 160 degrees. Small transport X made a complete 360 degree turn and ended up heading due north before finally getting a turn to a heading of 090 degrees to get separated from the small transport Y. He had completely circled the small transport Y flight path. An operational error was called on the local controller because I allowed the departure to turn the aircraft without specifying a right turn towards the filed route. No deviation was called on the small transport X for turning beyond the 190 degree heading that was issued. The aircraft passed within a couple hundred ft of each other while the small transport X was on the southeast heading.
Original NASA ASRS Text
Title: SMT X HAD NMAC LTSS FROM SMT Y. SYS ERROR.
Narrative: IT WAS VERY EARLY ON A FOGGY LATE WINTER DAY. THE RWY CONFIGN WAS LNDG W, DEPARTING N. I HAD JUST ARRIVED IN THE TWR AND WAS WORKING ALL OF THE TWR POS COMBINED. DUE TO THE WX SOME OF THE CARGO HAULERS WERE STILL LEAVING. I DEPARTED SMT X OFF OF RWY 36. HIS RTE WAS TO JOIN V-81 (DEN 155 DEG RADIAL) S TO PUEBLO. HIS INITIAL ASSIGNED HDG WAS 040 DEGS (KEEPING WITHIN NOISE ABATEMENT CONSTRAINTS). HE SHOULD HAVE STAYED ON THAT HDG UNTIL AT LEAST 7500 FT MSL. HE WAS PUT ON THIS HDG TO BE SEPARATED FROM THE NEXT DEP, SMT Y WHO WAS ON A RWY HDG AFTER DEP TO EVENTUALLY JOIN THE DEN 335 DEG RADIAL. WHEN SMT X WAS OUT OF 6400 FT MSL THE DEP CTLR CALLED UP TO REQUEST AN EARLY TURN. I APPROVED THIS ASSUMING THE DEP CTLR WOULD TURN HIM R TO JOIN HIS REQUESTED RTE. INSTEAD THE DEP CTLR THOUGHT SMT X WAS ASSIGNED RWY HDG (WHICH IS NORMAL) AND TURNED SMT X L TO A HDG OF 190 DEGS. THE 040 DEG HDG WAS CLRLY WRITTEN ON THE FLT STRIP. WHEN DEP CTLR CALLED TO REQUEST THE TURN I REITERATED THE FACT THAT THE SMT X WAS ON A 040 DEG HDG. LATER HE SAID HE DIDN'T HEAR THAT PART OF THE COORD (WHICH THE TAPE RECORDING CLRLY DEMONSTRATED) NOR DID HE NOTICE THE 040 DEG RADIAL WRITTEN ON THE FLT PROGRESS STRIP. SMT X PASSED THE DEP FLT PATH AT AN ALT OF 1100 FT ABOVE THE DEP ACFT. AT THIS POINT NORMALLY ALT SEPARATION COULD BE DISCONTINUED BECAUSE THE FLT PATHS WERE DIVERGING. (7110.65G PARAGRAPH 5-73.) HOWEVER, SMT X CONTINUED HIS L TURN BACK TOWARDS THE ARPT ON A SEASTERLY HDG. THE DEP CTLR NOTICING THE PROB ISSUED TFC TO THE SMT Y THEN ATTEMPTED TO TURN THE SMT X TO A 270 DEG HDG. AT THIS POINT THE SMT X WAS HDG APPROX 160 DEGS. SMT X MADE A COMPLETE 360 DEG TURN AND ENDED UP HDG DUE N BEFORE FINALLY GETTING A TURN TO A HDG OF 090 DEGS TO GET SEPARATED FROM THE SMT Y. HE HAD COMPLETELY CIRCLED THE SMT Y FLT PATH. AN OPERROR WAS CALLED ON THE LCL CTLR BECAUSE I ALLOWED THE DEP TO TURN THE ACFT WITHOUT SPECIFYING A R TURN TOWARDS THE FILED RTE. NO DEV WAS CALLED ON THE SMT X FOR TURNING BEYOND THE 190 DEG HDG THAT WAS ISSUED. THE ACFT PASSED WITHIN A COUPLE HUNDRED FT OF EACH OTHER WHILE THE SMT X WAS ON THE SE HDG.
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.