37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 372769 |
Time | |
Date | 199706 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Route In Use | departure other enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar pilot : instrument |
Experience | controller military : 3 controller radar : 17 flight time total : 450 |
ASRS Report | 372769 |
Person 2 | |
Affiliation | government : faa |
Function | oversight : coordinator |
Qualification | controller : radar |
Experience | controller radar : 13 flight time total : 120 |
ASRS Report | 372328 |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 7000 vertical : 600 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I was working manhattan radar (dr-1). Traffic was heavy and complex with numerous lax departures as well as numerous en route aircraft and several satellite departures. Near the time of the incident, a GA aircraft on the VOR 11L approach to toa wandered off course to the right toward higher terrain, was in MSAW alert, and was NORDO. Aircraft #1 departed the lax north complex and I climbed him to 5000 ft. Aircraft #2 departed the south complex a short time later and I climbed him to 4000 ft. I instructed aircraft #1 to turn left direct lax VOR and 'resume loop 9 departure, comply with altitude restrs.' I either thought I had given aircraft #1 an altitude of 15000 ft earlier or meant to in the second transmission. The audio tape recording indicates the only altitude I issued aircraft #1 was 5000 ft. As aircraft #1 turned east I observed his altitude readout indicate 5000 ft. I believed he was climbing to 15000 ft, so I issued aircraft #2 a new altitude assignment of 5000 ft. After the aircraft passed I observed that aircraft #1 appeared to still be at 5000 ft. I issued him clearance to 15000 ft. I was expecting to be relieved shortly. The traffic in my sector was very busy and I felt I should concentrate on working it. During this time the supervisor was discussing briefly combining sectors so that the parallel monitor position could be opened. I was unsure if separation had been lost, if so I suspected a pilot deviation. When I was relieved from the sector, I advised the supervisor of what I knew about the incident at that time.
Original NASA ASRS Text
Title: OPERROR LTSS BTWN ACR X AT 5000 FT AND ACR Y CLBING TO 5000 FT WITHOUT APPROPRIATE ALT LATERAL SEPARATION. RPTR THOUGHT ACR X HAD BEEN GIVEN CLB CLRNC TO 15000 FT AND WAS OUT OF 5000 FT IN THE CLB.
Narrative: I WAS WORKING MANHATTAN RADAR (DR-1). TFC WAS HVY AND COMPLEX WITH NUMEROUS LAX DEPS AS WELL AS NUMEROUS ENRTE ACFT AND SEVERAL SATELLITE DEPS. NEAR THE TIME OF THE INCIDENT, A GA ACFT ON THE VOR 11L APCH TO TOA WANDERED OFF COURSE TO THE R TOWARD HIGHER TERRAIN, WAS IN MSAW ALERT, AND WAS NORDO. ACFT #1 DEPARTED THE LAX N COMPLEX AND I CLBED HIM TO 5000 FT. ACFT #2 DEPARTED THE S COMPLEX A SHORT TIME LATER AND I CLBED HIM TO 4000 FT. I INSTRUCTED ACFT #1 TO TURN L DIRECT LAX VOR AND 'RESUME LOOP 9 DEP, COMPLY WITH ALT RESTRS.' I EITHER THOUGHT I HAD GIVEN ACFT #1 AN ALT OF 15000 FT EARLIER OR MEANT TO IN THE SECOND XMISSION. THE AUDIO TAPE RECORDING INDICATES THE ONLY ALT I ISSUED ACFT #1 WAS 5000 FT. AS ACFT #1 TURNED E I OBSERVED HIS ALT READOUT INDICATE 5000 FT. I BELIEVED HE WAS CLBING TO 15000 FT, SO I ISSUED ACFT #2 A NEW ALT ASSIGNMENT OF 5000 FT. AFTER THE ACFT PASSED I OBSERVED THAT ACFT #1 APPEARED TO STILL BE AT 5000 FT. I ISSUED HIM CLRNC TO 15000 FT. I WAS EXPECTING TO BE RELIEVED SHORTLY. THE TFC IN MY SECTOR WAS VERY BUSY AND I FELT I SHOULD CONCENTRATE ON WORKING IT. DURING THIS TIME THE SUPVR WAS DISCUSSING BRIEFLY COMBINING SECTORS SO THAT THE PARALLEL MONITOR POS COULD BE OPENED. I WAS UNSURE IF SEPARATION HAD BEEN LOST, IF SO I SUSPECTED A PLTDEV. WHEN I WAS RELIEVED FROM THE SECTOR, I ADVISED THE SUPVR OF WHAT I KNEW ABOUT THE INCIDENT AT THAT TIME.
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.