37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 379911 |
Time | |
Date | 199709 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dfw |
State Reference | TX |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : dfw |
Operator | common carrier : air carrier |
Make Model Name | Fokker 100 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : initial |
Route In Use | departure other enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Saab-Scania Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Qualification | controller : radar |
ASRS Report | 379911 |
Person 2 | |
Affiliation | government : faa |
Qualification | controller : radar |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Miss Distance | horizontal : 12000 vertical : 300 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | other |
Narrative:
I was working a departure position (DR3) at dfw regional approach when the following occurred: the dfw west tower called and coordinated a jet departing for the alliance airport (a satellite airport within our airspace). I instructed the tower to assign the jet 4000 ft and assign him the meacham north frequency, a satellite position that works the airspace that is surrounding the alliance airport. Note: at the time of this occurrence there is no 'set' procedure for these satellite departures, but there will be one in place on oct/xx/97. These instructions would allow the aircraft to come off dfw climbing straight ahead, and then the meacham north controller could turn him into his airspace that is directly west of the DR3 airspace, surface to 4000 ft. I then called the meacham north controller and coordinated that a 'jet' would be departing dfw to 4000 ft and straight to the meacham north frequency. Shortly thereafter, an air carrier X jet departed dfw on a meacham north tag, but on my frequency and climbing to 10000 ft. I slewed out to the data tag to pull it up on my scope. It showed that air carrier X was landing alliance. I then reassigned him 4000 ft, and at 5 mi north of the airport I turned him to a 280 degree heading to put him on a heading into the meacham north airspace. I observed that the meacham north controller had only traffic level at 3000 ft west of the airport heading nwbound. I then attempted to coordinate this action with the meacham north controller, but was not able to due to the high volume traffic that he was controling. I then switched him to the meacham north frequency. What I did not know was this: the local controller in the dfw west tower had mistakenly modified air carrier X's tag to an 'M.' when air carrier X got airborne and the meacham north controller saw the tag, he thought that was the jet that I had coordinated because I failed to mention the company name in my coordination. The data tag on air carrier X was overlapping another tag on the meacham north controller's scope and he tried to repos it. When doing so, he accidentally entered gibberish into the destination scratch pad, because he had tried to handoff some other jet to me, and because the automatic handoff parameters are wrong in that area, thejet he was attempting to handoff to me was already handed off to the center. Therefore the ARTS entry was still in the preview area, and went into the scratch pad of air carrier X. Seeing the bad data, the meacham north controller then amended the data tag 1 more time to show alliance as the destination, based on our previous coordination. All this took place in a few seconds before I had even pulled up the tag on my scope. Because the meacham north controller thinks this is a pre-coordinated alliance arrival, he expects him to be on runway heading as assigned by the tower, and not on the 280 degree heading that I assigned. I am thinking that the tower really had 2 aircraft bound for alliance and only told me about 1. (Here my attempts to coordinate are futile.) the meacham north controller then (thinking that air carrier X is on runway heading and not noticing the turn), attempting to climb a departing SF34, asks air carrier X to descend back to 3000 ft, and climbs the SF34 who was at 3000 ft, to 4000 ft. Instead of parallel courses, as planned, he now has 2 aircraft on converging courses, with no altitude separation established. The controller then noticing the situation, turns air carrier X and establishes visual separation. Meanwhile everyone is confused and as the air carrier Y jet departs dfw, the local controller calls me and tells me that he made a mistake and air carrier X is supposed to be going to las. I then try to coordinate with the meacham north controller, but he is too busy to talk, and I send a supervisor over to advise him of this new information. Conclusion: what started as a simple situation, developed into a very complicated problem. If the automatic handoff parameters would have been set correctly, the satellite jet departure being handed off to DR3 by meacham north would have been accomplished correctly, and the data tag on air carrier X would not have been inadvertently changed by the meacham north controller. If air carrier X would have departed on the wrong symbol, but with the appropriate destination, I would have questioned the pilot, and ascertained that the data tag was simply wrong, and would not have stopped his climb and handed him off to the meacham north controller. What started as a simple and seemingly harmless mistake by the west tower local controller, added with equipment malfunctions, and ineffective communication, could have resulted in a tragedy.
Original NASA ASRS Text
Title: CTLR RELAYED INCOMPLETE INFO TO ADJACENT CTLR RESULTING IN A POTENTIAL CONFLICT SIT. THE CTLR REALIZED THE ERROR AND WAS ABLE TO ESTABLISH VISUAL SEPARATION BEFORE RADAR SEPARATION WAS LOST.
Narrative: I WAS WORKING A DEP POS (DR3) AT DFW REGIONAL APCH WHEN THE FOLLOWING OCCURRED: THE DFW W TWR CALLED AND COORDINATED A JET DEPARTING FOR THE ALLIANCE ARPT (A SATELLITE ARPT WITHIN OUR AIRSPACE). I INSTRUCTED THE TWR TO ASSIGN THE JET 4000 FT AND ASSIGN HIM THE MEACHAM N FREQ, A SATELLITE POS THAT WORKS THE AIRSPACE THAT IS SURROUNDING THE ALLIANCE ARPT. NOTE: AT THE TIME OF THIS OCCURRENCE THERE IS NO 'SET' PROC FOR THESE SATELLITE DEPS, BUT THERE WILL BE ONE IN PLACE ON OCT/XX/97. THESE INSTRUCTIONS WOULD ALLOW THE ACFT TO COME OFF DFW CLBING STRAIGHT AHEAD, AND THEN THE MEACHAM N CTLR COULD TURN HIM INTO HIS AIRSPACE THAT IS DIRECTLY W OF THE DR3 AIRSPACE, SURFACE TO 4000 FT. I THEN CALLED THE MEACHAM N CTLR AND COORDINATED THAT A 'JET' WOULD BE DEPARTING DFW TO 4000 FT AND STRAIGHT TO THE MEACHAM N FREQ. SHORTLY THEREAFTER, AN ACR X JET DEPARTED DFW ON A MEACHAM N TAG, BUT ON MY FREQ AND CLBING TO 10000 FT. I SLEWED OUT TO THE DATA TAG TO PULL IT UP ON MY SCOPE. IT SHOWED THAT ACR X WAS LNDG ALLIANCE. I THEN REASSIGNED HIM 4000 FT, AND AT 5 MI N OF THE ARPT I TURNED HIM TO A 280 DEG HDG TO PUT HIM ON A HDG INTO THE MEACHAM N AIRSPACE. I OBSERVED THAT THE MEACHAM N CTLR HAD ONLY TFC LEVEL AT 3000 FT W OF THE ARPT HDG NWBOUND. I THEN ATTEMPTED TO COORDINATE THIS ACTION WITH THE MEACHAM N CTLR, BUT WAS NOT ABLE TO DUE TO THE HIGH VOLUME TFC THAT HE WAS CTLING. I THEN SWITCHED HIM TO THE MEACHAM N FREQ. WHAT I DID NOT KNOW WAS THIS: THE LCL CTLR IN THE DFW W TWR HAD MISTAKENLY MODIFIED ACR X'S TAG TO AN 'M.' WHEN ACR X GOT AIRBORNE AND THE MEACHAM N CTLR SAW THE TAG, HE THOUGHT THAT WAS THE JET THAT I HAD COORDINATED BECAUSE I FAILED TO MENTION THE COMPANY NAME IN MY COORD. THE DATA TAG ON ACR X WAS OVERLAPPING ANOTHER TAG ON THE MEACHAM N CTLR'S SCOPE AND HE TRIED TO REPOS IT. WHEN DOING SO, HE ACCIDENTALLY ENTERED GIBBERISH INTO THE DEST SCRATCH PAD, BECAUSE HE HAD TRIED TO HDOF SOME OTHER JET TO ME, AND BECAUSE THE AUTO HDOF PARAMETERS ARE WRONG IN THAT AREA, THEJET HE WAS ATTEMPTING TO HDOF TO ME WAS ALREADY HANDED OFF TO THE CTR. THEREFORE THE ARTS ENTRY WAS STILL IN THE PREVIEW AREA, AND WENT INTO THE SCRATCH PAD OF ACR X. SEEING THE BAD DATA, THE MEACHAM N CTLR THEN AMENDED THE DATA TAG 1 MORE TIME TO SHOW ALLIANCE AS THE DEST, BASED ON OUR PREVIOUS COORD. ALL THIS TOOK PLACE IN A FEW SECONDS BEFORE I HAD EVEN PULLED UP THE TAG ON MY SCOPE. BECAUSE THE MEACHAM N CTLR THINKS THIS IS A PRE-COORDINATED ALLIANCE ARR, HE EXPECTS HIM TO BE ON RWY HDG AS ASSIGNED BY THE TWR, AND NOT ON THE 280 DEG HDG THAT I ASSIGNED. I AM THINKING THAT THE TWR REALLY HAD 2 ACFT BOUND FOR ALLIANCE AND ONLY TOLD ME ABOUT 1. (HERE MY ATTEMPTS TO COORDINATE ARE FUTILE.) THE MEACHAM N CTLR THEN (THINKING THAT ACR X IS ON RWY HDG AND NOT NOTICING THE TURN), ATTEMPTING TO CLB A DEPARTING SF34, ASKS ACR X TO DSND BACK TO 3000 FT, AND CLBS THE SF34 WHO WAS AT 3000 FT, TO 4000 FT. INSTEAD OF PARALLEL COURSES, AS PLANNED, HE NOW HAS 2 ACFT ON CONVERGING COURSES, WITH NO ALT SEPARATION ESTABLISHED. THE CTLR THEN NOTICING THE SIT, TURNS ACR X AND ESTABLISHES VISUAL SEPARATION. MEANWHILE EVERYONE IS CONFUSED AND AS THE ACR Y JET DEPARTS DFW, THE LCL CTLR CALLS ME AND TELLS ME THAT HE MADE A MISTAKE AND ACR X IS SUPPOSED TO BE GOING TO LAS. I THEN TRY TO COORDINATE WITH THE MEACHAM N CTLR, BUT HE IS TOO BUSY TO TALK, AND I SEND A SUPVR OVER TO ADVISE HIM OF THIS NEW INFO. CONCLUSION: WHAT STARTED AS A SIMPLE SIT, DEVELOPED INTO A VERY COMPLICATED PROB. IF THE AUTO HDOF PARAMETERS WOULD HAVE BEEN SET CORRECTLY, THE SATELLITE JET DEP BEING HANDED OFF TO DR3 BY MEACHAM N WOULD HAVE BEEN ACCOMPLISHED CORRECTLY, AND THE DATA TAG ON ACR X WOULD NOT HAVE BEEN INADVERTENTLY CHANGED BY THE MEACHAM N CTLR. IF ACR X WOULD HAVE DEPARTED ON THE WRONG SYMBOL, BUT WITH THE APPROPRIATE DEST, I WOULD HAVE QUESTIONED THE PLT, AND ASCERTAINED THAT THE DATA TAG WAS SIMPLY WRONG, AND WOULD NOT HAVE STOPPED HIS CLB AND HANDED HIM OFF TO THE MEACHAM N CTLR. WHAT STARTED AS A SIMPLE AND SEEMINGLY HARMLESS MISTAKE BY THE W TWR LCL CTLR, ADDED WITH EQUIP MALFUNCTIONS, AND INEFFECTIVE COM, COULD HAVE RESULTED IN A TRAGEDY.
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.