37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 350290 |
Time | |
Date | 199610 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lns |
State Reference | PA |
Altitude | agl bound lower : 100 agl bound upper : 100 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : lns |
Operator | general aviation : personal |
Make Model Name | Learjet 35 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground other : taxi landing other |
Flight Plan | VFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Bonanza 35 |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach landing : go around |
Flight Plan | VFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : ground oversight : supervisor |
Qualification | controller : radar |
Experience | controller non radar : 4 controller radar : 10 controller supervisory : 3 |
ASRS Report | 350290 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Events | |
Anomaly | non adherence : required legal separation non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Miss Distance | horizontal : 3000 vertical : 100 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error other |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
I was working ground control, flight data and controller in charge position from XF16Z to XJ03Z. At approximately XF30Z I observed a bonanza (small aircraft Y), descending and passing through the intersection of runway 8 and runway 13, attempting to land on runway 8. I scanned runway 8 and observed a lear (light transport X) still on runway 8, approximately 1000 ft from the turnoff at the end of the runway. I immediately instructed the controller on local control to send the bonanza around because the learjet was still on the runway. The local controller did so, issuing a right pattern for resequencing. I asked the local controller if the bonanza had been a low approach. The aircraft had appeared higher than normal for being so far down the runway. He did not respond. Shortly afterwards, the controller was relieved from local control. At that time I asked him what had happened with the bonanza and the learjet. The controller became loud and defensive. The controller replied, 'we have a displaced threshold here, don't you know where it is, the bonanza was over the displaced threshold when the learjet was exiting the runway.' I replied that that was not what I had seen. I asked the controller if the bonanza was cleared to land. The controller turned and left the tower cabin attendant, only to return very shortly requesting sick leave. I asked the controller what was the matter. He replied that his whole body hurt and that he had to leave as soon as possible. I approved the sick leave, leaving myself and 1 other atcs on position until relief arrived. At this point I called the facility manager at home for assistance. The manager arrived and before speaking to me, interviewed the controller who had relieved the local controller. This took place downstairs in the manager office. Shortly thereafter the facility manager returned to the tower cabin attendant, I had just been relieved and requested he and I go downstairs so that I could brief him on what I had seen happen. The manager now refused to go downstairs. So, in a low tone, I briefed him on what I had seen, that I had witnessed the bonanza passing through the runway intersection while the learjet was still on the runway, that I had instructed the local controller to send the bonanza around, and that the aircraft had returned and landed safely, that I had attempted an initial evaluation, but that the controller had requested sick leave and left. I told the manager that an operational error may have occurred and that I wanted to review the voice recording to see what could be determined. The manager at first did not believe an operational error could occur because the bonanza had not landed while the learjet was still on the runway and required me to show him the applicable section of the 7110.65. The manager then proceeded to question me about the previous saturday and asked me did I tell any controllers to send any aircraft around on saturday? Had I been sitting close behind the controllers watching their every move? Had I been writing notes about controllers while standing behind them looking over their shoulder on saturday? The facility manager at this point told me he had already spoke with the local controller today and that his account of this incident greatly differed from mine, and that he had also just spoken with his relief who left the facility in tears. I replied that I did not remember instructing anyone on saturday to issue a go around. I was not sitting or standing behind controllers writing notes, that I had listed some time on position times, on a pad in the back of the cabin attendant, but that I had left the pad on the counter for anyone to see. I asked the manager why the relief was upset, because I had just worked 2 hours on position right next to her and she was fine when she left the cabin attendant. I then proceeded downstairs. The manager followed. I told the manager that I had never done an operational error investigation. I asked him if he would help me. Could he stay and listen to the tape and make sure I was on the right track? He said he had to leave to go to a birthday party. The manager became very agitated and said, you are the supervisor, it is pretty black and white in the 7110.3, what has to be done, you had better call the regional communication center right away. At this point manager had heard both the controller and my recollections of what had happened and was aware that unless the voice recordings showed evidence to the contrary, that I would report what I had seen to the communication center. By XF00 I had called the communication center and had made all the required notifications and the operational error was reported.
Original NASA ASRS Text
Title: TWR SUPVR WORKING A COMBINED POS OF GND CTL, FLT DATA AND CIC, OBSERVED THE LCL CTLR CLRING A BE35 TO LAND BEHIND A LR35 WHO WAS STILL ON THE RWY. THE SUPVR TOLD THE LCL CTLR TO SEND THE BE35 AROUND, WHICH HE DID. SUPVR CALLED A SYS ERROR ON LCL CTLR WHO THEN TOOK SICK LEAVE. FACILITY MGR WOULD NOT BACK THE SUPVR UP AND DOWNGRADED THE SYS ERROR TO A NON INCIDENT.
Narrative: I WAS WORKING GND CTL, FLT DATA AND CIC POS FROM XF16Z TO XJ03Z. AT APPROX XF30Z I OBSERVED A BONANZA (SMA Y), DSNDING AND PASSING THROUGH THE INTXN OF RWY 8 AND RWY 13, ATTEMPTING TO LAND ON RWY 8. I SCANNED RWY 8 AND OBSERVED A LEAR (LTT X) STILL ON RWY 8, APPROX 1000 FT FROM THE TURNOFF AT THE END OF THE RWY. I IMMEDIATELY INSTRUCTED THE CTLR ON LCL CTL TO SEND THE BONANZA AROUND BECAUSE THE LEARJET WAS STILL ON THE RWY. THE LCL CTLR DID SO, ISSUING A R PATTERN FOR RESEQUENCING. I ASKED THE LCL CTLR IF THE BONANZA HAD BEEN A LOW APCH. THE ACFT HAD APPEARED HIGHER THAN NORMAL FOR BEING SO FAR DOWN THE RWY. HE DID NOT RESPOND. SHORTLY AFTERWARDS, THE CTLR WAS RELIEVED FROM LCL CTL. AT THAT TIME I ASKED HIM WHAT HAD HAPPENED WITH THE BONANZA AND THE LEARJET. THE CTLR BECAME LOUD AND DEFENSIVE. THE CTLR REPLIED, 'WE HAVE A DISPLACED THRESHOLD HERE, DON'T YOU KNOW WHERE IT IS, THE BONANZA WAS OVER THE DISPLACED THRESHOLD WHEN THE LEARJET WAS EXITING THE RWY.' I REPLIED THAT THAT WAS NOT WHAT I HAD SEEN. I ASKED THE CTLR IF THE BONANZA WAS CLRED TO LAND. THE CTLR TURNED AND LEFT THE TWR CAB, ONLY TO RETURN VERY SHORTLY REQUESTING SICK LEAVE. I ASKED THE CTLR WHAT WAS THE MATTER. HE REPLIED THAT HIS WHOLE BODY HURT AND THAT HE HAD TO LEAVE ASAP. I APPROVED THE SICK LEAVE, LEAVING MYSELF AND 1 OTHER ATCS ON POS UNTIL RELIEF ARRIVED. AT THIS POINT I CALLED THE FACILITY MGR AT HOME FOR ASSISTANCE. THE MGR ARRIVED AND BEFORE SPEAKING TO ME, INTERVIEWED THE CTLR WHO HAD RELIEVED THE LCL CTLR. THIS TOOK PLACE DOWNSTAIRS IN THE MGR OFFICE. SHORTLY THEREAFTER THE FACILITY MGR RETURNED TO THE TWR CAB, I HAD JUST BEEN RELIEVED AND REQUESTED HE AND I GO DOWNSTAIRS SO THAT I COULD BRIEF HIM ON WHAT I HAD SEEN HAPPEN. THE MGR NOW REFUSED TO GO DOWNSTAIRS. SO, IN A LOW TONE, I BRIEFED HIM ON WHAT I HAD SEEN, THAT I HAD WITNESSED THE BONANZA PASSING THROUGH THE RWY INTXN WHILE THE LEARJET WAS STILL ON THE RWY, THAT I HAD INSTRUCTED THE LCL CTLR TO SEND THE BONANZA AROUND, AND THAT THE ACFT HAD RETURNED AND LANDED SAFELY, THAT I HAD ATTEMPTED AN INITIAL EVALUATION, BUT THAT THE CTLR HAD REQUESTED SICK LEAVE AND LEFT. I TOLD THE MGR THAT AN OPERROR MAY HAVE OCCURRED AND THAT I WANTED TO REVIEW THE VOICE RECORDING TO SEE WHAT COULD BE DETERMINED. THE MGR AT FIRST DID NOT BELIEVE AN OPERROR COULD OCCUR BECAUSE THE BONANZA HAD NOT LANDED WHILE THE LEARJET WAS STILL ON THE RWY AND REQUIRED ME TO SHOW HIM THE APPLICABLE SECTION OF THE 7110.65. THE MGR THEN PROCEEDED TO QUESTION ME ABOUT THE PREVIOUS SATURDAY AND ASKED ME DID I TELL ANY CTLRS TO SEND ANY ACFT AROUND ON SATURDAY? HAD I BEEN SITTING CLOSE BEHIND THE CTLRS WATCHING THEIR EVERY MOVE? HAD I BEEN WRITING NOTES ABOUT CTLRS WHILE STANDING BEHIND THEM LOOKING OVER THEIR SHOULDER ON SATURDAY? THE FACILITY MGR AT THIS POINT TOLD ME HE HAD ALREADY SPOKE WITH THE LCL CTLR TODAY AND THAT HIS ACCOUNT OF THIS INCIDENT GREATLY DIFFERED FROM MINE, AND THAT HE HAD ALSO JUST SPOKEN WITH HIS RELIEF WHO LEFT THE FACILITY IN TEARS. I REPLIED THAT I DID NOT REMEMBER INSTRUCTING ANYONE ON SATURDAY TO ISSUE A GAR. I WAS NOT SITTING OR STANDING BEHIND CTLRS WRITING NOTES, THAT I HAD LISTED SOME TIME ON POS TIMES, ON A PAD IN THE BACK OF THE CAB, BUT THAT I HAD LEFT THE PAD ON THE COUNTER FOR ANYONE TO SEE. I ASKED THE MGR WHY THE RELIEF WAS UPSET, BECAUSE I HAD JUST WORKED 2 HRS ON POS RIGHT NEXT TO HER AND SHE WAS FINE WHEN SHE LEFT THE CAB. I THEN PROCEEDED DOWNSTAIRS. THE MGR FOLLOWED. I TOLD THE MGR THAT I HAD NEVER DONE AN OPERROR INVESTIGATION. I ASKED HIM IF HE WOULD HELP ME. COULD HE STAY AND LISTEN TO THE TAPE AND MAKE SURE I WAS ON THE RIGHT TRACK? HE SAID HE HAD TO LEAVE TO GO TO A BIRTHDAY PARTY. THE MGR BECAME VERY AGITATED AND SAID, YOU ARE THE SUPVR, IT IS PRETTY BLACK AND WHITE IN THE 7110.3, WHAT HAS TO BE DONE, YOU HAD BETTER CALL THE REGIONAL COM CTR RIGHT AWAY. AT THIS POINT MGR HAD HEARD BOTH THE CTLR AND MY RECOLLECTIONS OF WHAT HAD HAPPENED AND WAS AWARE THAT UNLESS THE VOICE RECORDINGS SHOWED EVIDENCE TO THE CONTRARY, THAT I WOULD RPT WHAT I HAD SEEN TO THE COM CTR. BY XF00 I HAD CALLED THE COM CTR AND HAD MADE ALL THE REQUIRED NOTIFICATIONS AND THE OPERROR WAS RPTED.
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.