37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 354651 |
Time | |
Date | 199611 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : shb |
State Reference | IN |
Altitude | msl bound lower : 16700 msl bound upper : 17000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zid |
Operator | common carrier : air carrier |
Make Model Name | L-1011 Tri-Star All Series |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Electra L-188 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller radar : 7 |
ASRS Report | 354651 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : required legal separation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Miss Distance | horizontal : 10200 vertical : 700 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Narrative:
Air carrier X en route to cvg issued clearance to 17000 ft. Air carrier X read back 16000 ft. Air carrier X was observed going through 16800 ft and control instructions were reissued to maintain 17000 ft, turn 30 degrees right, current altimeter, and then to state altitude. Traffic was issued to the air carrier X and assigned altitude was requested. Air carrier X stated '17000 ft, previously issued 16000 ft.' conflict alert activated only seconds after air carrier X descended through 17000 ft. Not giving any warning of possible resolution to error prior to loss of separation. The air carrier X had already entered the receiving controller's airspace but was not switched so that traffic could be called. At the time the traffic call was to be made, a 'green light coordination' call occurred and therefore the opportunity to alert air carrier X to his traffic was missed.
Original NASA ASRS Text
Title: ARTCC RADAR CTLR DSNDED AN ACR L1011 TO 17000 FT. FLC READ BACK THE WRONG ALT AND THE CTLR DIDN'T CATCH THE ERROR UNTIL THE L1011 WENT THROUGH 17000 FT AND THE CONFLICT ALERT ACTIVATED SHOWING LTSS OCCURRING WITH AN ACR L188 AT 16000 FT.
Narrative: ACR X ENRTE TO CVG ISSUED CLRNC TO 17000 FT. ACR X READ BACK 16000 FT. ACR X WAS OBSERVED GOING THROUGH 16800 FT AND CTL INSTRUCTIONS WERE REISSUED TO MAINTAIN 17000 FT, TURN 30 DEGS R, CURRENT ALTIMETER, AND THEN TO STATE ALT. TFC WAS ISSUED TO THE ACR X AND ASSIGNED ALT WAS REQUESTED. ACR X STATED '17000 FT, PREVIOUSLY ISSUED 16000 FT.' CONFLICT ALERT ACTIVATED ONLY SECONDS AFTER ACR X DSNDED THROUGH 17000 FT. NOT GIVING ANY WARNING OF POSSIBLE RESOLUTION TO ERROR PRIOR TO LOSS OF SEPARATION. THE ACR X HAD ALREADY ENTERED THE RECEIVING CTLR'S AIRSPACE BUT WAS NOT SWITCHED SO THAT TFC COULD BE CALLED. AT THE TIME THE TFC CALL WAS TO BE MADE, A 'GREEN LIGHT COORD' CALL OCCURRED AND THEREFORE THE OPPORTUNITY TO ALERT ACR X TO HIS TFC WAS MISSED.
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.