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Attributes | |
ACN | 381849 |
Time | |
Date | 199710 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sfo airport : hwd |
State Reference | CA |
Altitude | msl bound lower : 3000 msl bound upper : 3200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | general aviation : corporate |
Make Model Name | Sabreliner 265 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | descent other |
Route In Use | arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : cfi pilot : atp pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 2400 flight time type : 250 |
ASRS Report | 381849 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation non adherence : published procedure non adherence : far |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Miss Distance | horizontal : 8000 vertical : 200 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
The initial clearance was runway heading to 400 ft then a left turn to heading 160 degrees. After completing this, departure said light transport X left turn to 060 degrees and climb to 3000 ft. At 3000 ft and passing about 110 degree heading, I saw an aircraft at 12 O'clock. I immediately steepened my turn to about 80 degrees of bank, let my nose go through the horizon and descended to 2000 ft. Simultaneously, a new controller shouted for light transport X to descend to 2000 ft. The B737 passed above our right side uneventfully. After talking with the supervisor from ATC, he apologized and said I shouldn't hear anything else about this. The only thing I take away from this incident is the need for a SID for jet aircraft leaving hwd airport. If no SID will be developed some training and planning needs to be done by controllers taking into account larger turn radius for jet aircraft in close proximity to the oak approach corridor. Supplemental information from acn 381851: I was receiving OJT on AR1&2 combined, at bay TRACON. I released an IFR departure from hwd airport, light transport X, an N265, on the standard departure from hwd (turn left heading 160 degrees, radar vectors to the first fix, lin, climb and maintain 2000 ft). The aircraft departed hwd and checked in with me 'in the left turn leaving 1500 ft.' light transport X was radar idented and mode C verified. As the sabreliner continued its climb to 2000 ft a vector was issued, turn left heading 060 degrees, traffic was issued at 12 O'clock, 4 mi, 3500 ft, on final to sfo, air carrier Y B737. It appeared to both me and my instructor that the sabreliner was making a very wide (maybe a half standard rate) turn. I instructed the aircraft to continue the left turn heading 010 degrees, climb and maintain 3000 ft, then in the same transmission corrected the altitude to maintain 2000 ft. The sabreliner reported the traffic in sight, and indicated he was in the turn, climbing to 3000 ft. Both my instructor and I were 'scrambling' to point out the sabreliner to the sfo arrival sector and we both missed the pilot's readback. I observed the sabreliner's mode C above 2000 ft, however, my instructor intervened at this point and attempted to resolve the situation by instructing the sabreliner to maintain 2000 ft. I was informed that the hwd departure should have been restr to 200 KTS or 210 KTS, to assist in keeping the initial turn tight. The departure procedure itself is inherently dangerous. I believe it is designed and works well with small single engine aircraft and most twins. It is not a procedure that works well with high performance twins and jets. The bottom line: this error was caused by the following factors: 1) we missed the altitude readback. 2) a poorly designed departure procedure for jets off of hwd. 3) failure to restrict the departure to a speed that appears to me to be in violation of the ATC handbook. 4) instructor's failure to adequately monitor a developmental's actions. Supplemental information from acn 382067: I instructed the developmental to leave aircraft at 2000 ft. In the same clearance that light transport X was given 3000 ft it was corrected to climb and maintain 2000 ft. The pilot read back '2 -- 3000.' the developmental and myself both missed the pilot's readback. The turn rate and speed of the light transport X put it in close proximity to the sfo 095 degree radial, an air carrier Y B737 was on final and descending for approach. Approximately altitude 3100 ft. What I believe caused the error: 1) missed readback by controller (me). 2) the initial issuance of climb and maintain 3000 ft correction climb and maintain 2000 ft, should never have been issued, due to light transport X location and turn rate. 3) another factor, I believe light transport X was not complying with far 91.117. Ground speed indicated approximately 250 KTS, the clean stall speed for light transport X is 117 KTS -- well below the 200 KT restr while flying under class B.
Original NASA ASRS Text
Title: A SABRELINER CLBING OFF HWD ON AN ASSIGNED HDG AT A FAST SPD HAD LTSS OCCUR WITH AN ACR B737 INBOUND TO SFO. CTLR TRAINING IN PROGRESS AT THE TRACON AND NEITHER THE TRAINEE OR THE INSTRUCTOR CAUGHT THE IMPROPER READBACK ON AN AMENDED ALT CLRNC GIVEN TO THE SABRELINER. SABRELINER WAS ALLEGEDLY MAKING A NON STANDARD RATE TURN AND EXCEEDING THE SPD BELOW THE CLASS B AIRSPACE PER FAR 91 PT 117(C).
Narrative: THE INITIAL CLRNC WAS RWY HDG TO 400 FT THEN A L TURN TO HDG 160 DEGS. AFTER COMPLETING THIS, DEP SAID LTT X L TURN TO 060 DEGS AND CLB TO 3000 FT. AT 3000 FT AND PASSING ABOUT 110 DEG HDG, I SAW AN ACFT AT 12 O'CLOCK. I IMMEDIATELY STEEPENED MY TURN TO ABOUT 80 DEGS OF BANK, LET MY NOSE GO THROUGH THE HORIZON AND DSNDED TO 2000 FT. SIMULTANEOUSLY, A NEW CTLR SHOUTED FOR LTT X TO DSND TO 2000 FT. THE B737 PASSED ABOVE OUR R SIDE UNEVENTFULLY. AFTER TALKING WITH THE SUPVR FROM ATC, HE APOLOGIZED AND SAID I SHOULDN'T HEAR ANYTHING ELSE ABOUT THIS. THE ONLY THING I TAKE AWAY FROM THIS INCIDENT IS THE NEED FOR A SID FOR JET ACFT LEAVING HWD ARPT. IF NO SID WILL BE DEVELOPED SOME TRAINING AND PLANNING NEEDS TO BE DONE BY CTLRS TAKING INTO ACCOUNT LARGER TURN RADIUS FOR JET ACFT IN CLOSE PROX TO THE OAK APCH CORRIDOR. SUPPLEMENTAL INFO FROM ACN 381851: I WAS RECEIVING OJT ON AR1&2 COMBINED, AT BAY TRACON. I RELEASED AN IFR DEP FROM HWD ARPT, LTT X, AN N265, ON THE STANDARD DEP FROM HWD (TURN L HDG 160 DEGS, RADAR VECTORS TO THE FIRST FIX, LIN, CLB AND MAINTAIN 2000 FT). THE ACFT DEPARTED HWD AND CHKED IN WITH ME 'IN THE L TURN LEAVING 1500 FT.' LTT X WAS RADAR IDENTED AND MODE C VERIFIED. AS THE SABRELINER CONTINUED ITS CLB TO 2000 FT A VECTOR WAS ISSUED, TURN L HDG 060 DEGS, TFC WAS ISSUED AT 12 O'CLOCK, 4 MI, 3500 FT, ON FINAL TO SFO, ACR Y B737. IT APPEARED TO BOTH ME AND MY INSTRUCTOR THAT THE SABRELINER WAS MAKING A VERY WIDE (MAYBE A HALF STANDARD RATE) TURN. I INSTRUCTED THE ACFT TO CONTINUE THE L TURN HDG 010 DEGS, CLB AND MAINTAIN 3000 FT, THEN IN THE SAME XMISSION CORRECTED THE ALT TO MAINTAIN 2000 FT. THE SABRELINER RPTED THE TFC IN SIGHT, AND INDICATED HE WAS IN THE TURN, CLBING TO 3000 FT. BOTH MY INSTRUCTOR AND I WERE 'SCRAMBLING' TO POINT OUT THE SABRELINER TO THE SFO ARR SECTOR AND WE BOTH MISSED THE PLT'S READBACK. I OBSERVED THE SABRELINER'S MODE C ABOVE 2000 FT, HOWEVER, MY INSTRUCTOR INTERVENED AT THIS POINT AND ATTEMPTED TO RESOLVE THE SIT BY INSTRUCTING THE SABRELINER TO MAINTAIN 2000 FT. I WAS INFORMED THAT THE HWD DEP SHOULD HAVE BEEN RESTR TO 200 KTS OR 210 KTS, TO ASSIST IN KEEPING THE INITIAL TURN TIGHT. THE DEP PROC ITSELF IS INHERENTLY DANGEROUS. I BELIEVE IT IS DESIGNED AND WORKS WELL WITH SMALL SINGLE ENG ACFT AND MOST TWINS. IT IS NOT A PROC THAT WORKS WELL WITH HIGH PERFORMANCE TWINS AND JETS. THE BOTTOM LINE: THIS ERROR WAS CAUSED BY THE FOLLOWING FACTORS: 1) WE MISSED THE ALT READBACK. 2) A POORLY DESIGNED DEP PROC FOR JETS OFF OF HWD. 3) FAILURE TO RESTRICT THE DEP TO A SPD THAT APPEARS TO ME TO BE IN VIOLATION OF THE ATC HANDBOOK. 4) INSTRUCTOR'S FAILURE TO ADEQUATELY MONITOR A DEVELOPMENTAL'S ACTIONS. SUPPLEMENTAL INFO FROM ACN 382067: I INSTRUCTED THE DEVELOPMENTAL TO LEAVE ACFT AT 2000 FT. IN THE SAME CLRNC THAT LTT X WAS GIVEN 3000 FT IT WAS CORRECTED TO CLB AND MAINTAIN 2000 FT. THE PLT READ BACK '2 -- 3000.' THE DEVELOPMENTAL AND MYSELF BOTH MISSED THE PLT'S READBACK. THE TURN RATE AND SPD OF THE LTT X PUT IT IN CLOSE PROX TO THE SFO 095 DEG RADIAL, AN ACR Y B737 WAS ON FINAL AND DSNDING FOR APCH. APPROX ALT 3100 FT. WHAT I BELIEVE CAUSED THE ERROR: 1) MISSED READBACK BY CTLR (ME). 2) THE INITIAL ISSUANCE OF CLB AND MAINTAIN 3000 FT CORRECTION CLB AND MAINTAIN 2000 FT, SHOULD NEVER HAVE BEEN ISSUED, DUE TO LTT X LOCATION AND TURN RATE. 3) ANOTHER FACTOR, I BELIEVE LTT X WAS NOT COMPLYING WITH FAR 91.117. GND SPD INDICATED APPROX 250 KTS, THE CLEAN STALL SPD FOR LTT X IS 117 KTS -- WELL BELOW THE 200 KT RESTR WHILE FLYING UNDER CLASS B.
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.