37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 268779 |
Time | |
Date | 199404 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : etx |
State Reference | PA |
Altitude | msl bound lower : 13000 msl bound upper : 15000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Jetstream 31 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Route In Use | enroute : direct enroute airway : zny |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | DC-8 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar instruction : instructor |
Qualification | controller : radar |
Experience | controller radar : 14 |
ASRS Report | 269779 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar instruction : trainee |
Qualification | controller : developmental |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment other atc equipment : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 22200 vertical : 800 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
The sector was moderately busy volume with very complex traffic situation. There was training on the H (handoff asst position) and training on the right (radar position). About 1/2 of the sector traffic was on a non-standard route through the middle of the sector (including air carrier X) to accommodate spacing requirements to iad with other high altitude traffic that we don't talk to. There were about 5 phl departures that needed to be climbed above the iad traffic (including air carrier Y). Because of the heavy concentration of traffic in one area, the data blocks had to be constantly moved to prevent overlap. One time when the radar trainee was moving a data block, he accidently dropped air carrier X data block completely due to a keyboard sticking. I did not notice air carrier X data block drop off due to the other data block congestion. Air carrier Y was climbed from 13000 ft to 15000 ft without being given a restr to miss X at 14000 ft who had no data block and was not noticed. The conflict alert went off and I asked air carrier Y his altitude and he replied that he was level at 15000 ft. Contributing factors: sticking keyboard equipment is very old and sticky keys are generally accepted. The main and biggest problem was that there was training on the handoff position at the same time as the radar position. This requires the radar trainer to watch the radar trainee and coordinate with the radar trainee, the handoff trainee, and the handoff trainer, making it virtually impossible to see everything that is happening.
Original NASA ASRS Text
Title: ACR Y CLB THROUGH OCCUPIED ALT, HAD LTSS FROM ACR X. SYS ERROR.
Narrative: THE SECTOR WAS MODERATELY BUSY VOLUME WITH VERY COMPLEX TFC SIT. THERE WAS TRAINING ON THE H (HDOF ASST POS) AND TRAINING ON THE R (RADAR POS). ABOUT 1/2 OF THE SECTOR TFC WAS ON A NON-STANDARD RTE THROUGH THE MIDDLE OF THE SECTOR (INCLUDING ACR X) TO ACCOMMODATE SPACING REQUIREMENTS TO IAD WITH OTHER HIGH ALT TFC THAT WE DON'T TALK TO. THERE WERE ABOUT 5 PHL DEPS THAT NEEDED TO BE CLBED ABOVE THE IAD TFC (INCLUDING ACR Y). BECAUSE OF THE HVY CONCENTRATION OF TFC IN ONE AREA, THE DATA BLOCKS HAD TO BE CONSTANTLY MOVED TO PREVENT OVERLAP. ONE TIME WHEN THE RADAR TRAINEE WAS MOVING A DATA BLOCK, HE ACCIDENTLY DROPPED ACR X DATA BLOCK COMPLETELY DUE TO A KEYBOARD STICKING. I DID NOT NOTICE ACR X DATA BLOCK DROP OFF DUE TO THE OTHER DATA BLOCK CONGESTION. ACR Y WAS CLBED FROM 13000 FT TO 15000 FT WITHOUT BEING GIVEN A RESTR TO MISS X AT 14000 FT WHO HAD NO DATA BLOCK AND WAS NOT NOTICED. THE CONFLICT ALERT WENT OFF AND I ASKED ACR Y HIS ALT AND HE REPLIED THAT HE WAS LEVEL AT 15000 FT. CONTRIBUTING FACTORS: STICKING KEYBOARD EQUIP IS VERY OLD AND STICKY KEYS ARE GENERALLY ACCEPTED. THE MAIN AND BIGGEST PROB WAS THAT THERE WAS TRAINING ON THE HDOF POS AT THE SAME TIME AS THE RADAR POS. THIS REQUIRES THE RADAR TRAINER TO WATCH THE RADAR TRAINEE AND COORDINATE WITH THE RADAR TRAINEE, THE HDOF TRAINEE, AND THE HDOF TRAINER, MAKING IT VIRTUALLY IMPOSSIBLE TO SEE EVERYTHING THAT IS HAPPENING.
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.