37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 356719 |
Time | |
Date | 199612 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : sns |
State Reference | CA |
Altitude | msl bound lower : 33000 msl bound upper : 34200 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa tracon : day |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : flight data controller : radar |
Qualification | controller : radar |
Experience | controller radar : 14 |
ASRS Report | 356719 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
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 : anomaly accepted |
Consequence | Other |
Miss Distance | horizontal : 23700 vertical : 1200 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
The bay approach was southeast confign. In this confign sector 13 works all the south departures off oak and sfo. In normal west confign, sector 14 works all the departures off oak and sfo on the flw's transition and point out the aircraft to sector 13. Invariably, it's not a normal procedure to point out to sector 14 and some pointouts are inadvertently missed. Case in point: I thought I had made the pointout to sector 14 (I was working sector 13 combined). My strips were late in coming to the sector, and I marked the strip pertaining to my aircraft that I had made the pointout to sector 14. At the time of the incident, I had already shipped my aircraft to ZLA. As stated earlier, usually sector 14 watches for the limited data blocks on the chance that sector 13 inadvertently omits a pointout. Why the limited data block was missed by the R14 controller, who knows, but sector 14's aircraft was descended through the limited data aircraft to crl other traffic that I had pointed out. Do we make sector 14 work the flw's transition aircraft and over saturate them? I'm not sure what the answer is. It was a mistake that shouldn't have happened, but that's exactly what it was - - a mistake -- a human error.
Original NASA ASRS Text
Title: CTLR WORKING SECTOR 13 IN A COMBINED CONFIGN (R&D) FAILED TO MAKE A POINTOUT ON A B737 TO THE ADJACENT SECTOR AND THAT CTLR DSNDED AN ACR B737 THROUGH A B737 THAT THE RPTR HAD ALREADY HANDED OFF TO ZLA. BAY AREA WAS IN THE SE CONFIGN AND THE RPTR JUST FORGOT ABOUT THE POINTOUT BEING NECESSARY. LIMITED DATA BLOCK ON THE ONE B737 APPARENTLY WAS NOT OBSERVED BY THE ADJACENT SECTOR.
Narrative: THE BAY APCH WAS SE CONFIGN. IN THIS CONFIGN SECTOR 13 WORKS ALL THE S DEPS OFF OAK AND SFO. IN NORMAL W CONFIGN, SECTOR 14 WORKS ALL THE DEPS OFF OAK AND SFO ON THE FLW'S TRANSITION AND POINT OUT THE ACFT TO SECTOR 13. INVARIABLY, IT'S NOT A NORMAL PROC TO POINT OUT TO SECTOR 14 AND SOME POINTOUTS ARE INADVERTENTLY MISSED. CASE IN POINT: I THOUGHT I HAD MADE THE POINTOUT TO SECTOR 14 (I WAS WORKING SECTOR 13 COMBINED). MY STRIPS WERE LATE IN COMING TO THE SECTOR, AND I MARKED THE STRIP PERTAINING TO MY ACFT THAT I HAD MADE THE POINTOUT TO SECTOR 14. AT THE TIME OF THE INCIDENT, I HAD ALREADY SHIPPED MY ACFT TO ZLA. AS STATED EARLIER, USUALLY SECTOR 14 WATCHES FOR THE LIMITED DATA BLOCKS ON THE CHANCE THAT SECTOR 13 INADVERTENTLY OMITS A POINTOUT. WHY THE LIMITED DATA BLOCK WAS MISSED BY THE R14 CTLR, WHO KNOWS, BUT SECTOR 14'S ACFT WAS DSNDED THROUGH THE LIMITED DATA ACFT TO CRL OTHER TFC THAT I HAD POINTED OUT. DO WE MAKE SECTOR 14 WORK THE FLW'S TRANSITION ACFT AND OVER SATURATE THEM? I'M NOT SURE WHAT THE ANSWER IS. IT WAS A MISTAKE THAT SHOULDN'T HAVE HAPPENED, BUT THAT'S EXACTLY WHAT IT WAS - - A MISTAKE -- A HUMAN ERROR.
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.