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|
Attributes | |
ACN | 331227 |
Time | |
Date | 199603 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : unz |
State Reference | GU |
Altitude | msl bound lower : 33000 msl bound upper : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : pgua |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Route In Use | enroute : other oceanic enroute : pacific enroute airway : pgua |
Flight Plan | IFR |
Aircraft 2 | |
Operator | other |
Make Model Name | Military Transport |
Operating Under FAR Part | other : other |
Flight Phase | cruise other |
Route In Use | enroute : other oceanic enroute : pacific |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 240 flight time total : 25000 flight time type : 875 |
ASRS Report | 331158 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 175 flight time total : 13000 flight time type : 255 |
ASRS Report | 331163 |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : took evasive action |
Consequence | Other |
Miss Distance | horizontal : 1500 vertical : 200 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
A military C9 at FL330 was sbound at owlss, time XA51Z. An air carrier aircraft was northbound at owlss, XA52Z, at FL330 -- wrong altitude for direction. Guam center had been given a xfer on the C9 at owlss (the xfer was made at approximately XA20Z). Guam center called at approximately XA30 with a xfer northbound of the air carrier at owlss, XA52Z, at FL310, requesting higher up to FL390. Guam was told to stand by to see if FL370 was available because FL330 and FL350 and FL390 were all blocked with traffic. Coordination was made with tokyo center for FL370, the altitude was approved. On the return call to guam center, the controller at oakland mistakenly stated FL330 was approved. Contributing factors: verbal coordination, all separation done on strips, looking at several different altitudes while making verbal coordination. Supplemental information from acn 332000: data person requested FL370, wrong altitude for direction, with ZOA. When ZOA called back they approved FL330 and also xfered another aircraft on same airway. Both controllers missed the confliction due to the number of aircraft, our bay was full, and the second aircraft's strip was not placed in the active bay. First aircraft was cleared to climb to FL330. I relieved the radar controller, was briefed on all traffic including first aircraft climbing to FL350 as approved. Upon seeing aircraft level at FL330 and checking active bay for conflictions or traffic calls and seeing none (second aircraft's strip was still not in active bay) I terminated radar with him. When the second aircraft checked in at FL330 the strip was in the active bay. A min after second aircraft checked in the first called back and said he had a TCASII alert and had to descend. Part of the problem arose due to the volume of work the data position must do when busy. He missed the altitudes because he had xfers to make, aircraft to release and estimated times to calculate. Additionally our bays are too small to hold all the active strips during a rush necessitating our placing active strips off to the side where they can be forgotten. This problem could have been avoided if we had a coordinator to handle some of the calls and a printer that prints our strips. We have to hand write strips now. Supplemental information from acn 331158: our flight was cruising at FL330 as assigned by guam center. Just past owlss waypoint we received a TCASII RA to 'descend, descend now.' as the captain started a 2000+ FPM descent, all 3 cockpit crew members saw crossing traffic from right to left at the 2 O'clock position at about 1/4 mi, FL330. Loss of altitude was between 250-350 ft. The captain contacted the crossing traffic on guam center frequency and confirmed the aircraft was a C9 military air evacuate/evacuation flight at FL330 that did not have visual contact with us. The C9 was inbound to guam on our track.
Original NASA ASRS Text
Title: SEPARATION WAS LOST BTWN A MIL C9 AND A DC10 WHILE OPPOSITE DIRECTION AT FL330, AND ON AN AIRWAY N OF UNZ, GU. THE DC10 FLC RESPONDED TO A TCASII RA AS A RESULT OF THE CLOSE PROX TO THE C9. FL370 (FOR THE DC10) HAD BEEN COORDINATED WITH TOKYO CTR, BUT WAS MISTAKENLY CALLED TO PGUA AT FL330, BY ZOA. THE PGUA CTLR TERMINATED RADAR WITH THE DC10 AND DIDN'T NOTICE THE CONFLICT PARTLY BECAUSE THE STRIP ON THE C9 WAS NOT IN THE BAY DURING A HVY WORKLOAD PERIOD.
Narrative: A MIL C9 AT FL330 WAS SBOUND AT OWLSS, TIME XA51Z. AN ACR ACFT WAS NBOUND AT OWLSS, XA52Z, AT FL330 -- WRONG ALT FOR DIRECTION. GUAM CTR HAD BEEN GIVEN A XFER ON THE C9 AT OWLSS (THE XFER WAS MADE AT APPROX XA20Z). GUAM CTR CALLED AT APPROX XA30 WITH A XFER NBOUND OF THE ACR AT OWLSS, XA52Z, AT FL310, REQUESTING HIGHER UP TO FL390. GUAM WAS TOLD TO STAND BY TO SEE IF FL370 WAS AVAILABLE BECAUSE FL330 AND FL350 AND FL390 WERE ALL BLOCKED WITH TFC. COORD WAS MADE WITH TOKYO CTR FOR FL370, THE ALT WAS APPROVED. ON THE RETURN CALL TO GUAM CTR, THE CTLR AT OAKLAND MISTAKENLY STATED FL330 WAS APPROVED. CONTRIBUTING FACTORS: VERBAL COORD, ALL SEPARATION DONE ON STRIPS, LOOKING AT SEVERAL DIFFERENT ALTS WHILE MAKING VERBAL COORD. SUPPLEMENTAL INFO FROM ACN 332000: DATA PERSON REQUESTED FL370, WRONG ALT FOR DIRECTION, WITH ZOA. WHEN ZOA CALLED BACK THEY APPROVED FL330 AND ALSO XFERED ANOTHER ACFT ON SAME AIRWAY. BOTH CTLRS MISSED THE CONFLICTION DUE TO THE NUMBER OF ACFT, OUR BAY WAS FULL, AND THE SECOND ACFT'S STRIP WAS NOT PLACED IN THE ACTIVE BAY. FIRST ACFT WAS CLRED TO CLB TO FL330. I RELIEVED THE RADAR CTLR, WAS BRIEFED ON ALL TFC INCLUDING FIRST ACFT CLBING TO FL350 AS APPROVED. UPON SEEING ACFT LEVEL AT FL330 AND CHKING ACTIVE BAY FOR CONFLICTIONS OR TFC CALLS AND SEEING NONE (SECOND ACFT'S STRIP WAS STILL NOT IN ACTIVE BAY) I TERMINATED RADAR WITH HIM. WHEN THE SECOND ACFT CHKED IN AT FL330 THE STRIP WAS IN THE ACTIVE BAY. A MIN AFTER SECOND ACFT CHKED IN THE FIRST CALLED BACK AND SAID HE HAD A TCASII ALERT AND HAD TO DSND. PART OF THE PROB AROSE DUE TO THE VOLUME OF WORK THE DATA POS MUST DO WHEN BUSY. HE MISSED THE ALTS BECAUSE HE HAD XFERS TO MAKE, ACFT TO RELEASE AND ESTIMATED TIMES TO CALCULATE. ADDITIONALLY OUR BAYS ARE TOO SMALL TO HOLD ALL THE ACTIVE STRIPS DURING A RUSH NECESSITATING OUR PLACING ACTIVE STRIPS OFF TO THE SIDE WHERE THEY CAN BE FORGOTTEN. THIS PROB COULD HAVE BEEN AVOIDED IF WE HAD A COORDINATOR TO HANDLE SOME OF THE CALLS AND A PRINTER THAT PRINTS OUR STRIPS. WE HAVE TO HAND WRITE STRIPS NOW. SUPPLEMENTAL INFO FROM ACN 331158: OUR FLT WAS CRUISING AT FL330 AS ASSIGNED BY GUAM CTR. JUST PAST OWLSS WAYPOINT WE RECEIVED A TCASII RA TO 'DSND, DSND NOW.' AS THE CAPT STARTED A 2000+ FPM DSCNT, ALL 3 COCKPIT CREW MEMBERS SAW XING TFC FROM R TO L AT THE 2 O'CLOCK POS AT ABOUT 1/4 MI, FL330. LOSS OF ALT WAS BTWN 250-350 FT. THE CAPT CONTACTED THE XING TFC ON GUAM CTR FREQ AND CONFIRMED THE ACFT WAS A C9 MIL AIR EVAC FLT AT FL330 THAT DID NOT HAVE VISUAL CONTACT WITH US. THE C9 WAS INBOUND TO GUAM ON OUR TRACK.
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.