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|
Attributes | |
ACN | 489441 |
Time | |
Date | 200010 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : crw.airport |
State Reference | WV |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | Marginal |
Weather Elements | Rain other |
Light | Daylight |
Aircraft 1 | |
Operator | Other |
Aircraft 2 | |
Controlling Facilities | tower : crw.tower |
Operator | general aviation : personal |
Make Model Name | PA-31 Navajo Chieftan/Mojave/Navajo T1020 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : supervisor |
Qualification | controller : radar |
Experience | controller limited radar : 5 controller military : 3 controller radar : 8 controller time certified in position1 : 3 controller time certified in position2 : 6 |
ASRS Report | 489441 |
Person 2 | |
Affiliation | Other |
Function | other personnel |
Qualification | other other : faa mntnc |
Events | |
Anomaly | conflict : ground critical incursion : runway non adherence : clearance non adherence : required legal separation non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 2300 vertical : 0 |
Supplementary | |
Problem Areas | FAA ATC Facility ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Situations | |
ATC Facility | staffing : crw.tower |
Narrative:
In general, because we are understaffed, the tower controller-in-charge (controller in charge) is always working the flight data/clearance delivery position. This is not a good situation. A 3RD set of eyes is needed to afford proper safeguards (ie, the controller in charge should not be (combined with other position). Secondly the runway confign most commonly used at crw ILS runway 23/33. This confign has been an on-going problem since runway 33 was realigned yrs go. Pilots are constantly asked to restate their runway request and often read back the wrong runway. In addition, to these chronic problems, the tower cabin attendant is being refitted (as is the whole facility) and at the time of the incident, there was an flight engineer technician on a ladder at the local controller position, another spread eagle on the floor at (and under) the FD/clearance delivery/controller in charge position and an airways facility technician between the 2. They were troubleshooting an electrical problem that occurred during the refit and they were shouting back and forth at each other (this was necessary because 1 technician's head was up in the ceiling tiles and the other's head was in and under the tower console. As for the incident, an FAA vehicle was instructed to hold short of runway 33 for departing traffic (navajo). The vehicle read back runway 23 and crossed runway 33 in front of the navajo, which was rolling (but not yet rotated). Due to the inordinate background noise, obstructions to vision (the ladder) and several confusion, the local controller did not catch the erroneous readback. Had a third controller been present, this incident would most likely been prevented.
Original NASA ASRS Text
Title: TWR CTLR-IN-CHARGE (CIC) INVOLVED WITH RWY INCURSION WHEN LCL CTLR MISSES MAINT. VEHICLE INCORRECT READBACK DURING TWR RETROFIT CONSTRUCTION.
Narrative: IN GENERAL, BECAUSE WE ARE UNDERSTAFFED, THE TWR CTLR-IN-CHARGE (CIC) IS ALWAYS WORKING THE FLT DATA/CLRNC DELIVERY POS. THIS IS NOT A GOOD SIT. A 3RD SET OF EYES IS NEEDED TO AFFORD PROPER SAFEGUARDS (IE, THE CIC SHOULD NOT BE (COMBINED WITH OTHER POS). SECONDLY THE RWY CONFIGN MOST COMMONLY USED AT CRW ILS RWY 23/33. THIS CONFIGN HAS BEEN AN ON-GOING PROB SINCE RWY 33 WAS REALIGNED YRS GO. PLTS ARE CONSTANTLY ASKED TO RESTATE THEIR RWY REQUEST AND OFTEN READ BACK THE WRONG RWY. IN ADDITION, TO THESE CHRONIC PROBS, THE TWR CAB IS BEING REFITTED (AS IS THE WHOLE FACILITY) AND AT THE TIME OF THE INCIDENT, THERE WAS AN FE TECHNICIAN ON A LADDER AT THE LCL CTLR POS, ANOTHER SPREAD EAGLE ON THE FLOOR AT (AND UNDER) THE FD/CD/CIC POS AND AN AIRWAYS FACILITY TECHNICIAN BTWN THE 2. THEY WERE TROUBLESHOOTING AN ELECTRICAL PROB THAT OCCURRED DURING THE REFIT AND THEY WERE SHOUTING BACK AND FORTH AT EACH OTHER (THIS WAS NECESSARY BECAUSE 1 TECHNICIAN'S HEAD WAS UP IN THE CEILING TILES AND THE OTHER'S HEAD WAS IN AND UNDER THE TWR CONSOLE. AS FOR THE INCIDENT, AN FAA VEHICLE WAS INSTRUCTED TO HOLD SHORT OF RWY 33 FOR DEPARTING TFC (NAVAJO). THE VEHICLE READ BACK RWY 23 AND CROSSED RWY 33 IN FRONT OF THE NAVAJO, WHICH WAS ROLLING (BUT NOT YET ROTATED). DUE TO THE INORDINATE BACKGROUND NOISE, OBSTRUCTIONS TO VISION (THE LADDER) AND SEVERAL CONFUSION, THE LCL CTLR DID NOT CATCH THE ERRONEOUS READBACK. HAD A THIRD CTLR BEEN PRESENT, THIS INCIDENT WOULD MOST LIKELY BEEN PREVENTED.
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.