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|
Attributes | |
ACN | 291847 |
Time | |
Date | 199412 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : iiu |
State Reference | KY |
Altitude | msl bound lower : 25300 msl bound upper : 25600 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zid |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | oversight : supervisor |
Qualification | controller : radar |
Experience | controller radar : 3 controller supervisory : 5 |
ASRS Report | 291847 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : required legal separation other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 18000 vertical : 700 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Narrative:
An operational error occurred due to misunderstood clearance by a pilot, and a missed readback by the controller. Aircraft was issued a climb to FL250. The pilot acknowledged. The controller issued a turn 'fly heading 270, direct pxv when able, rest of route unchanged.' the pilot readback 'climb to 270, direct pxv.' the aircraft then continued through FL250, TCASII initiated an RA. Aircraft 1 descended back to FL250. Aircraft 2 climbed to FL265. Aedp activated approximately 2 seconds prior to aci reporting level. Although the controller did not hear the readback 'climb' by the pilot, the pilot did not understand or follow the controller's clearance. If the pilot of aircraft 1 had used the 'flight level' in his readback, this would have triggered the controller's ear to the misunderstanding.
Original NASA ASRS Text
Title: CTLR SUPVR RPT REF CLRNC CONFUSION. ALTDEV AND TCASII RA.
Narrative: AN OPERROR OCCURRED DUE TO MISUNDERSTOOD CLRNC BY A PLT, AND A MISSED READBACK BY THE CTLR. ACFT WAS ISSUED A CLB TO FL250. THE PLT ACKNOWLEDGED. THE CTLR ISSUED A TURN 'FLY HDG 270, DIRECT PXV WHEN ABLE, REST OF RTE UNCHANGED.' THE PLT READBACK 'CLB TO 270, DIRECT PXV.' THE ACFT THEN CONTINUED THROUGH FL250, TCASII INITIATED AN RA. ACFT 1 DSNDED BACK TO FL250. ACFT 2 CLBED TO FL265. AEDP ACTIVATED APPROX 2 SECONDS PRIOR TO ACI RPTING LEVEL. ALTHOUGH THE CTLR DID NOT HEAR THE READBACK 'CLB' BY THE PLT, THE PLT DID NOT UNDERSTAND OR FOLLOW THE CTLR'S CLRNC. IF THE PLT OF ACFT 1 HAD USED THE 'FLT LEVEL' IN HIS READBACK, THIS WOULD HAVE TRIGGERED THE CTLR'S EAR TO THE MISUNDERSTANDING.
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.