37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 257238 |
Time | |
Date | 199311 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : bjc |
State Reference | CO |
Altitude | msl bound lower : 7500 msl bound upper : 7500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : den tower : bjc tower : tlh |
Operator | general aviation : corporate |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
ASRS Report | 257238 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | Other |
Miss Distance | horizontal : 12000 vertical : 0 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure Operational Error other |
Narrative:
IFR aircraft off jeffco airport are issued as standard, heading 020 degrees, climb and maintain 8000 ft, initially. Jeffco tower (ground control/flight data position) issue the clearance and obtain the IFR release from denver radar approach. Often, denver will amend the heading, and occasionally, but less often, denver will amend the initial climb altitude. On this occasion, denver amended both the heading to 360 degrees and the altitude to 7000 ft. The flight data/ground control person verbally told local controller of the changes (supposedly). The heading change only, was put on the IFR strip. I took the local control position from another controller. He told me what he had, including this IFR departure. He said nothing about an altitude change. (Again, nothing was on the IFR strip.) only after the IFR departure was changed to denver's frequency did I notice another IFR aircraft just coming onto our BRITE radar at 7500 ft sbound. Denver was immediately notified that our departure was still climbing to 8000 ft. They said no problem. This lack of completed coordination and subsequent actual loss of IFR separation was caused by: 1) laziness on the part of the ground control/flight data person, 2) not following up to see if what he said was heard, or acknowledged, and 3) incompetence (same person). It's not the first time this type of thing has happened, nor will it be the last. If he had gotten up, out of his chair, and physically written the amendments, then the next controller may have issued them. Further, if he would have been paying attention, he would have heard the other controller's instruction, he may have caught that the change to 7000 ft was not issued. Either that, or make sure the first controller at least acknowledges the 'release instructions.'
Original NASA ASRS Text
Title: CPR X HAD LTSS FROM Y. SYS ERROR.
Narrative: IFR ACFT OFF JEFFCO ARPT ARE ISSUED AS STANDARD, HDG 020 DEGS, CLB AND MAINTAIN 8000 FT, INITIALLY. JEFFCO TWR (GND CTL/FLT DATA POS) ISSUE THE CLRNC AND OBTAIN THE IFR RELEASE FROM DENVER RADAR APCH. OFTEN, DENVER WILL AMEND THE HDG, AND OCCASIONALLY, BUT LESS OFTEN, DENVER WILL AMEND THE INITIAL CLB ALT. ON THIS OCCASION, DENVER AMENDED BOTH THE HDG TO 360 DEGS AND THE ALT TO 7000 FT. THE FLT DATA/GND CTL PERSON VERBALLY TOLD LCL CTLR OF THE CHANGES (SUPPOSEDLY). THE HDG CHANGE ONLY, WAS PUT ON THE IFR STRIP. I TOOK THE LCL CTL POS FROM ANOTHER CTLR. HE TOLD ME WHAT HE HAD, INCLUDING THIS IFR DEP. HE SAID NOTHING ABOUT AN ALT CHANGE. (AGAIN, NOTHING WAS ON THE IFR STRIP.) ONLY AFTER THE IFR DEP WAS CHANGED TO DENVER'S FREQ DID I NOTICE ANOTHER IFR ACFT JUST COMING ONTO OUR BRITE RADAR AT 7500 FT SBOUND. DENVER WAS IMMEDIATELY NOTIFIED THAT OUR DEP WAS STILL CLBING TO 8000 FT. THEY SAID NO PROB. THIS LACK OF COMPLETED COORD AND SUBSEQUENT ACTUAL LOSS OF IFR SEPARATION WAS CAUSED BY: 1) LAZINESS ON THE PART OF THE GND CTL/FLT DATA PERSON, 2) NOT FOLLOWING UP TO SEE IF WHAT HE SAID WAS HEARD, OR ACKNOWLEDGED, AND 3) INCOMPETENCE (SAME PERSON). IT'S NOT THE FIRST TIME THIS TYPE OF THING HAS HAPPENED, NOR WILL IT BE THE LAST. IF HE HAD GOTTEN UP, OUT OF HIS CHAIR, AND PHYSICALLY WRITTEN THE AMENDMENTS, THEN THE NEXT CTLR MAY HAVE ISSUED THEM. FURTHER, IF HE WOULD HAVE BEEN PAYING ATTN, HE WOULD HAVE HEARD THE OTHER CTLR'S INSTRUCTION, HE MAY HAVE CAUGHT THAT THE CHANGE TO 7000 FT WAS NOT ISSUED. EITHER THAT, OR MAKE SURE THE FIRST CTLR AT LEAST ACKNOWLEDGES THE 'RELEASE INSTRUCTIONS.'
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.