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|
Attributes | |
ACN | 257996 |
Time | |
Date | 199312 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : hqm |
State Reference | WA |
Altitude | msl bound lower : 37000 msl bound upper : 37000 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zse |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : pacific enroute airway : zse enroute airway : zoa |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : non radar |
Qualification | controller : radar |
Experience | controller non radar : 8 controller radar : 6 |
ASRS Report | 257996 |
Person 2 | |
Affiliation | government : faa |
Function | controller : flight data |
Qualification | controller : developmental |
Experience | controller non radar : 3 |
ASRS Report | 258193 |
Events | |
Anomaly | non adherence : published procedure other anomaly other other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure other |
Situations | |
Navigational Aid | Unspecified |
Narrative:
I came back from a break at XX55 local. I was advised to relieve sector OC7. As I approached, I noticed the sector to be very busy. The backboard was being used and a second controller was being utilized on the overhead jack. I stood and watched for approximately 5 mins. I then proceeded to sequence strips per the OC7 controller's request. After approximately 20 mins, I sat down and began to take the progress reports. The controller working the overhead jack was no longer there. I noticed, shortly thereafter, that air carrier X should have progressed the boundary fix between ZSE and ZOA at sedar. I called and coordinated this transfer. ZSE was working this aircraft but had no traffic on him. I believe the cause of this error to be the fact the sector was unmanageable due to sector saturation. The odaps computer had gone down and just come up approximately 40 mins prior to the deviation. When I came up to the sector, I was in awe. There were strips everywhere! Most flight plans had 2 sets of strips. One from prior to odaps going down, and the flight plans that were being activated after odaps came back up. This outage occurred during a busy time of the day for OC7. I can honestly say that this was the busiest period I can remember working in my yrs of ATC. Callback conversation with reporter revealed the following: reporter stated that there was no loss of separation in this incident. The air carrier entered adjacent facility airspace without a handoff. A review board meeting was set up by the facility to discuss all the facts and to see how a similar incident in the future can be avoided. The board determined that the reporter was not at fault since the mistake occurred prior to him taking the sector. In addition, the air carrier aircraft had been in radar contact by the adjacent facility and they were expecting the aircraft. Reporter said that the facility is in the process of reclassifying this as a non occurrence instead of a system deviation. Reporter also said that the odaps has been causing them problems ever since it was installed. Supplemental information from acn 258193: included is a copy of my statement for the operational error review board. Traffic at the sector was determined to be moderate to heavy and complex. Odaps was taken down due to a failure of a new test version of odaps (1.2). I was working OC7 during the peak eastbound flow. Soon after sitting down I had to go to a backboard. OC1 was having trouble running flight plans beyond 160W and was passing me handwritten 160W strips. Odaps was taken down. I was extremely busy. The supervisor said he would get me some help. I interpreted this as another pair of eyes. I had to wait until odaps was restarted to get help. I did not press for help because the supervisor had told me that we were down 3 people due to sick leave. I expected I was going to get another pair of eyes as soon as they were available. Tower began inputting flight plans (starting with the south tracks). I was working the sector and inputting flight plans as time permitted. While inputting an air carrier my CRT malfunctioned. I informed the supervisor of the problem. I was able to clear my CRT. But I stopped inputting flight plans because I did not have time to waste on malfunctioning equipment. I gave the air carrier to tower to input. Meanwhile, mr. Z plugged in to relieve me. Since the sector was in no condition to be passed to a single person I asked mr. Z to start sequencing the re-input flight plans. At some point, mr. Z and I switched places and he began processing messages while I sequenced strips. Soon after this mr. Z noticed air carrier X inside ZSE's airspace without a manual transfer. Mr. Z then coordinated with seattle.
Original NASA ASRS Text
Title: ACR ENTERS ADJACENT FACILITY AIRSPACE WITHOUT COORD.
Narrative: I CAME BACK FROM A BREAK AT XX55 LCL. I WAS ADVISED TO RELIEVE SECTOR OC7. AS I APCHED, I NOTICED THE SECTOR TO BE VERY BUSY. THE BACKBOARD WAS BEING USED AND A SECOND CTLR WAS BEING UTILIZED ON THE OVERHEAD JACK. I STOOD AND WATCHED FOR APPROX 5 MINS. I THEN PROCEEDED TO SEQUENCE STRIPS PER THE OC7 CTLR'S REQUEST. AFTER APPROX 20 MINS, I SAT DOWN AND BEGAN TO TAKE THE PROGRESS RPTS. THE CTLR WORKING THE OVERHEAD JACK WAS NO LONGER THERE. I NOTICED, SHORTLY THEREAFTER, THAT ACR X SHOULD HAVE PROGRESSED THE BOUNDARY FIX BTWN ZSE AND ZOA AT SEDAR. I CALLED AND COORDINATED THIS TRANSFER. ZSE WAS WORKING THIS ACFT BUT HAD NO TFC ON HIM. I BELIEVE THE CAUSE OF THIS ERROR TO BE THE FACT THE SECTOR WAS UNMANAGEABLE DUE TO SECTOR SATURATION. THE ODAPS COMPUTER HAD GONE DOWN AND JUST COME UP APPROX 40 MINS PRIOR TO THE DEV. WHEN I CAME UP TO THE SECTOR, I WAS IN AWE. THERE WERE STRIPS EVERYWHERE! MOST FLT PLANS HAD 2 SETS OF STRIPS. ONE FROM PRIOR TO ODAPS GOING DOWN, AND THE FLT PLANS THAT WERE BEING ACTIVATED AFTER ODAPS CAME BACK UP. THIS OUTAGE OCCURRED DURING A BUSY TIME OF THE DAY FOR OC7. I CAN HONESTLY SAY THAT THIS WAS THE BUSIEST PERIOD I CAN REMEMBER WORKING IN MY YRS OF ATC. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: RPTR STATED THAT THERE WAS NO LOSS OF SEPARATION IN THIS INCIDENT. THE ACR ENTERED ADJACENT FACILITY AIRSPACE WITHOUT A HDOF. A REVIEW BOARD MEETING WAS SET UP BY THE FACILITY TO DISCUSS ALL THE FACTS AND TO SEE HOW A SIMILAR INCIDENT IN THE FUTURE CAN BE AVOIDED. THE BOARD DETERMINED THAT THE RPTR WAS NOT AT FAULT SINCE THE MISTAKE OCCURRED PRIOR TO HIM TAKING THE SECTOR. IN ADDITION, THE ACR ACFT HAD BEEN IN RADAR CONTACT BY THE ADJACENT FACILITY AND THEY WERE EXPECTING THE ACFT. RPTR SAID THAT THE FACILITY IS IN THE PROCESS OF RECLASSIFYING THIS AS A NON OCCURRENCE INSTEAD OF A SYS DEV. RPTR ALSO SAID THAT THE ODAPS HAS BEEN CAUSING THEM PROBS EVER SINCE IT WAS INSTALLED. SUPPLEMENTAL INFORMATION FROM ACN 258193: INCLUDED IS A COPY OF MY STATEMENT FOR THE OPERATIONAL ERROR REVIEW BOARD. TFC AT THE SECTOR WAS DETERMINED TO BE MODERATE TO HVY AND COMPLEX. ODAPS WAS TAKEN DOWN DUE TO A FAILURE OF A NEW TEST VERSION OF ODAPS (1.2). I WAS WORKING OC7 DURING THE PEAK EBOUND FLOW. SOON AFTER SITTING DOWN I HAD TO GO TO A BACKBOARD. OC1 WAS HAVING TROUBLE RUNNING FLT PLANS BEYOND 160W AND WAS PASSING ME HANDWRITTEN 160W STRIPS. ODAPS WAS TAKEN DOWN. I WAS EXTREMELY BUSY. THE SUPVR SAID HE WOULD GET ME SOME HELP. I INTERPRETED THIS AS ANOTHER PAIR OF EYES. I HAD TO WAIT UNTIL ODAPS WAS RESTARTED TO GET HELP. I DID NOT PRESS FOR HELP BECAUSE THE SUPVR HAD TOLD ME THAT WE WERE DOWN 3 PEOPLE DUE TO SICK LEAVE. I EXPECTED I WAS GOING TO GET ANOTHER PAIR OF EYES AS SOON AS THEY WERE AVAILABLE. TWR BEGAN INPUTTING FLT PLANS (STARTING WITH THE S TRACKS). I WAS WORKING THE SECTOR AND INPUTTING FLT PLANS AS TIME PERMITTED. WHILE INPUTTING AN ACR MY CRT MALFUNCTIONED. I INFORMED THE SUPVR OF THE PROB. I WAS ABLE TO CLR MY CRT. BUT I STOPPED INPUTTING FLT PLANS BECAUSE I DID NOT HAVE TIME TO WASTE ON MALFUNCTIONING EQUIP. I GAVE THE ACR TO TWR TO INPUT. MEANWHILE, MR. Z PLUGGED IN TO RELIEVE ME. SINCE THE SECTOR WAS IN NO CONDITION TO BE PASSED TO A SINGLE PERSON I ASKED MR. Z TO START SEQUENCING THE RE-INPUT FLT PLANS. AT SOME POINT, MR. Z AND I SWITCHED PLACES AND HE BEGAN PROCESSING MESSAGES WHILE I SEQUENCED STRIPS. SOON AFTER THIS MR. Z NOTICED ACR X INSIDE ZSE'S AIRSPACE WITHOUT A MANUAL TRANSFER. MR. Z THEN COORDINATED WITH SEATTLE.
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.