37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 390989 |
Time | |
Date | 199801 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
Altitude | msl bound lower : 5000 msl bound upper : 6500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ord tower : ord tracon : mci |
Operator | general aviation : corporate |
Make Model Name | Fokker 50 |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : clearance delivery |
Qualification | controller : non radar controller : developmental |
Experience | controller military : 4 controller non radar : 7 flight time total : 150 |
ASRS Report | 390989 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : published procedure non adherence : required legal separation other anomaly other |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Miss Distance | horizontal : 6000 vertical : 300 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Falcon jet called clearance delivery for outbound IFR clearance. Clearance was issued including SID departure to maintain 5000 ft. Pilot read back 'one five thousand.' readback of wrong altitude not detected. Falcon jet departed, began climbing to 15000 ft (instead of 5000 ft). Air carrier arrival southwest of airport presently level at 7000 ft inbound on vectors. Falcon jet went over to departure control, still climbing. Departure controller did not catch right away that pilot was climbing through 5000 ft. Falcon jet at 6700 ft and 1 mi away from air carrier at closest point. Falcon jet said later he had the air carrier in sight at all times. Factors: falcon jet not a regular user of this airport, possibly unfamiliar with the SID. Clearance delivery missed readback of wrong altitude. Departure controller initially missed the fact the aircraft climbed through 5000 ft. It is required at this airport that when issuing the SID (which is issued to all IFR departures at 5000 ft and above) the controller state 'maintain 5000 ft.' the SID also clearly states that all aircraft are to maintain 5000 ft and expect further clearance 10 mins after departure.
Original NASA ASRS Text
Title: A CTLR WORKING CLRNC DELIVERY POS ISSUED AN IFR CLRNC TO AN FK50 WITH A CLB TO 5000 FT. THE PLT READ BACK CLB TO 15000 FT. THE ERROR WAS NOT CAUGHT BY THE CTLR. AFTER TKOF, THE FK50 RPTED ON INITIAL CONTACT WITH DEP CTL THAT THEY WERE CLBING TO 15000 FT. AGAIN THE INCORRECT READBACK WENT UNDETECTED. SEPARATION LOSS OCCURRED SHORTLY THEREAFTER WITH AN ARRIVING ACR AT 7000 FT.
Narrative: FALCON JET CALLED CLRNC DELIVERY FOR OUTBOUND IFR CLRNC. CLRNC WAS ISSUED INCLUDING SID DEP TO MAINTAIN 5000 FT. PLT READ BACK 'ONE FIVE THOUSAND.' READBACK OF WRONG ALT NOT DETECTED. FALCON JET DEPARTED, BEGAN CLBING TO 15000 FT (INSTEAD OF 5000 FT). ACR ARR SW OF ARPT PRESENTLY LEVEL AT 7000 FT INBOUND ON VECTORS. FALCON JET WENT OVER TO DEP CTL, STILL CLBING. DEP CTLR DID NOT CATCH RIGHT AWAY THAT PLT WAS CLBING THROUGH 5000 FT. FALCON JET AT 6700 FT AND 1 MI AWAY FROM ACR AT CLOSEST POINT. FALCON JET SAID LATER HE HAD THE ACR IN SIGHT AT ALL TIMES. FACTORS: FALCON JET NOT A REGULAR USER OF THIS ARPT, POSSIBLY UNFAMILIAR WITH THE SID. CLRNC DELIVERY MISSED READBACK OF WRONG ALT. DEP CTLR INITIALLY MISSED THE FACT THE ACFT CLBED THROUGH 5000 FT. IT IS REQUIRED AT THIS ARPT THAT WHEN ISSUING THE SID (WHICH IS ISSUED TO ALL IFR DEPS AT 5000 FT AND ABOVE) THE CTLR STATE 'MAINTAIN 5000 FT.' THE SID ALSO CLRLY STATES THAT ALL ACFT ARE TO MAINTAIN 5000 FT AND EXPECT FURTHER CLRNC 10 MINS AFTER DEP.
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.