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|
Attributes | |
ACN | 469209 |
Time | |
Date | 200004 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : bum.vortac |
State Reference | MO |
Altitude | msl bound lower : 26500 msl bound upper : 28000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zkc.artcc |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : enroute altitude change |
Route In Use | arrival star : trake |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zkc.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Route In Use | enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller non radar : 17 controller radar : 15.5 controller time certified in position1 : 13.5 |
ASRS Report | 469209 |
Person 2 | |
Affiliation | government : faa |
Function | controller : handoff position |
Qualification | pilot : instrument |
Experience | controller radar : 18 flight time total : 5000 |
ASRS Report | 469210 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment : conflict alert aircraft equipment : tcas other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory flight crew : took evasive action |
Consequence | faa : investigated |
Miss Distance | horizontal : 17400 vertical : 300 |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Descended air carrier X to FL290. Air carrier Y was at FL280. Air carrier X read back that they were out of FL330 for FL240. Radios were scratchy, I missed the readback. The sector was very complex at the time. I had numerous aircraft on vectors for spacing for st louis. By the time I was aware that air carrier X had descended into air carrier Y's altitude, the aircraft had already responded to TCASII. Conflict alert did not activate until after the error occurred. The best way to help controllers with these types of errors, would be to make pilots accountable for listening to control instructions. It would give them more incentive to pay attention -- be a team player. Supplemental information from acn 460210: aircraft #2 was wbound at FL280. Aircraft #1 eastbound on trake 8 STAR was descended from FL330 to FL290. Pilot read back 'FL240' and descended into aircraft #2's altitude. Both aircraft responded to RA's. Supplemental information from acn 469760: I was the first officer (PF) on air carrier X from phx to stl. When we were approximately 100 mi west of bum at FL330, ZKC cleared us to FL240. At around FL265, we received a TCASII RA instructing us to climb for an aircraft ahead and 800-1000 ft below us. We climbed back up to about FL280. ZKC asked us why we did not level at FL290. The captain advised them we were cleared to FL240.
Original NASA ASRS Text
Title: MD80 AND B737, OPPOSITE DIRECTION, TAKE EVASIVE ACTION WHEN MD80 READS BACK INCORRECT DSCNT ALT, WHICH ZKC CTLRS DO NOT CATCH UNTIL BOTH ACFT INITIATE TCASII ACTION.
Narrative: DSNDED ACR X TO FL290. ACR Y WAS AT FL280. ACR X READ BACK THAT THEY WERE OUT OF FL330 FOR FL240. RADIOS WERE SCRATCHY, I MISSED THE READBACK. THE SECTOR WAS VERY COMPLEX AT THE TIME. I HAD NUMEROUS ACFT ON VECTORS FOR SPACING FOR ST LOUIS. BY THE TIME I WAS AWARE THAT ACR X HAD DSNDED INTO ACR Y'S ALT, THE ACFT HAD ALREADY RESPONDED TO TCASII. CONFLICT ALERT DID NOT ACTIVATE UNTIL AFTER THE ERROR OCCURRED. THE BEST WAY TO HELP CTLRS WITH THESE TYPES OF ERRORS, WOULD BE TO MAKE PLTS ACCOUNTABLE FOR LISTENING TO CTL INSTRUCTIONS. IT WOULD GIVE THEM MORE INCENTIVE TO PAY ATTN -- BE A TEAM PLAYER. SUPPLEMENTAL INFO FROM ACN 460210: ACFT #2 WAS WBOUND AT FL280. ACFT #1 EBOUND ON TRAKE 8 STAR WAS DSNDED FROM FL330 TO FL290. PLT READ BACK 'FL240' AND DSNDED INTO ACFT #2'S ALT. BOTH ACFT RESPONDED TO RA'S. SUPPLEMENTAL INFO FROM ACN 469760: I WAS THE FO (PF) ON ACR X FROM PHX TO STL. WHEN WE WERE APPROX 100 MI W OF BUM AT FL330, ZKC CLRED US TO FL240. AT AROUND FL265, WE RECEIVED A TCASII RA INSTRUCTING US TO CLB FOR AN ACFT AHEAD AND 800-1000 FT BELOW US. WE CLBED BACK UP TO ABOUT FL280. ZKC ASKED US WHY WE DID NOT LEVEL AT FL290. THE CAPT ADVISED THEM WE WERE CLRED TO FL240.
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.