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Attributes | |
ACN | 504536 |
Time | |
Date | 200103 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : w45.airport |
State Reference | VA |
Altitude | msl bound lower : 5100 msl bound upper : 7000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog Rain |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | general aviation : personal |
Make Model Name | Baron 58/58TC |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level cruise : enroute altitude change |
Route In Use | approach : instrument non precision arrival other enroute airway : v286.airway |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | general aviation : personal |
Make Model Name | Caravan 1 208A |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level |
Route In Use | enroute airway : v286.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar pilot : instrument |
Experience | controller radar : 13.5 controller time certified in position1 : 1.15 flight time total : 325 |
ASRS Report | 504536 |
Person 2 | |
Affiliation | government : faa |
Function | controller : handoff position |
Qualification | controller : radar |
Events | |
Anomaly | conflict : airborne critical inflight encounter : weather non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment : conflict alert atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : separated traffic controller : issued new clearance |
Consequence | faa : investigated |
Miss Distance | horizontal : 5000 vertical : 0 |
Supplementary | |
Problem Areas | ATC Human Performance Weather |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Intra Facility Coordination Failure Operational Error |
Narrative:
Widespread IFR day across entire control area, rain and icing reports earlier in the shift. Now that sun had set, fog moving in. Another operational error occurred in my area of specialization -- bay 3 -- about 3 hours before, resulting in 3 fpl's and 1 developmental being removed from staffing due to investigation. I came back from a break and started to relieve the controller at the R05 and R02 combined position. Even though a checklist was used, the briefing was rushed and not in a continuous flight. We kept being interrupted by several aircraft with requests and by controllers attempting to coordinate with us. I hastily accepted the position and started issuing clrncs. More calls from other controllers came. Then, aircraft #1 at 7000 ft requested an approach. I did not understand him and asked him to repeat his request. It was only then that I realized aircraft #1 was landing at an airport within my jurisdiction, and he was only 7 mi south of that airport. I knew that the procedure turn would take the aircraft close to an adjacent approach controller's airspace, but was not sure if it was a right turn or left turn. I stood up and searched for the reference book, so that I could verify the approach. As my d-side and I searched for the approach plate, a small group of controllers and supervisors gathered 4-5 ft behind me. They were discussing the ongoing investigation of the operational error that had occurred earlier. With all of the distrs, both on the radar and in my surrounding environment, I never gained a complete and thorough picture of my traffic. When aircraft #1 asked for lower, I descended him from 7000 ft to 5100 ft, my minimum IFR altitude. I continued issuing clrncs to other aircraft, scanning the whole sector now, when I realized that aircraft #1 had aircraft #2 underneath him at 6000 ft less than 2 mi west of his position. The conflict alert activated and I turned aircraft #1 to a 090 degree heading, which was approximately a 60 degree turn to the right. Due to the proximity to the arrival airport, aircraft #1 was descending rapidly, so I chose not to stop his descent, but let him continue to 5100 ft to get below aircraft #2. I did not try to climb him back to 7000 ft, fearing that separation would be lost a second time. Separation was regained laterally and I was relieved from the position. In reviewing this error, I now see many contributing factors. First, the poor WX and incoming fog influenced me to rush the approach so that aircraft #1 could get on the ground as soon as possible. Secondly, the reduced staffing, due to the other operational error, had meant longer time on position that evening -- fatigue was setting in. The third factor was my having to issue multiple clrncs and receive multiple coords, as soon as I took the sector distracting me from correlating data blocks and flight plan information as I normally do. Another contributing factor was my inability to comprehend the pilot's request, and then being unfamiliar with the full approach. I should have fully absorbed the information before I issued the descent clearance. Additionally, having another operational error that evening, and listening to the speculation and rumors caused all of bay 3 to be on edge. Discussing it on the control room floor created a lot of backgnd noise. The new dsr rooms have sectors much closer to each other, so normal tone of voice appears to be amplified. I was unable to tune that noise out. Lastly, and most importantly, I assumed responsibility of the radar position prematurely before I had the complete picture in my mind. The rushed relief briefing started the error chain. Had I taken the time and developed a full understanding of all of the traffic, this operational error could have been avoided.
Original NASA ASRS Text
Title: ZDC CTLR OBTAINS AN INCOMPLETE POS RELIEF BRIEFING AND BECOMES INVOLVED IN A LOSS OF SEPARATION WHEN HE ISSUES A DSCNT CLRNC TO A BE58 THROUGH A C208 1000 FT BENEATH.
Narrative: WIDESPREAD IFR DAY ACROSS ENTIRE CTL AREA, RAIN AND ICING RPTS EARLIER IN THE SHIFT. NOW THAT SUN HAD SET, FOG MOVING IN. ANOTHER OPERROR OCCURRED IN MY AREA OF SPECIALIZATION -- BAY 3 -- ABOUT 3 HRS BEFORE, RESULTING IN 3 FPL'S AND 1 DEVELOPMENTAL BEING REMOVED FROM STAFFING DUE TO INVESTIGATION. I CAME BACK FROM A BREAK AND STARTED TO RELIEVE THE CTLR AT THE R05 AND R02 COMBINED POS. EVEN THOUGH A CHKLIST WAS USED, THE BRIEFING WAS RUSHED AND NOT IN A CONTINUOUS FLT. WE KEPT BEING INTERRUPTED BY SEVERAL ACFT WITH REQUESTS AND BY CTLRS ATTEMPTING TO COORDINATE WITH US. I HASTILY ACCEPTED THE POS AND STARTED ISSUING CLRNCS. MORE CALLS FROM OTHER CTLRS CAME. THEN, ACFT #1 AT 7000 FT REQUESTED AN APCH. I DID NOT UNDERSTAND HIM AND ASKED HIM TO REPEAT HIS REQUEST. IT WAS ONLY THEN THAT I REALIZED ACFT #1 WAS LNDG AT AN ARPT WITHIN MY JURISDICTION, AND HE WAS ONLY 7 MI S OF THAT ARPT. I KNEW THAT THE PROC TURN WOULD TAKE THE ACFT CLOSE TO AN ADJACENT APCH CTLR'S AIRSPACE, BUT WAS NOT SURE IF IT WAS A R TURN OR L TURN. I STOOD UP AND SEARCHED FOR THE REF BOOK, SO THAT I COULD VERIFY THE APCH. AS MY D-SIDE AND I SEARCHED FOR THE APCH PLATE, A SMALL GROUP OF CTLRS AND SUPVRS GATHERED 4-5 FT BEHIND ME. THEY WERE DISCUSSING THE ONGOING INVESTIGATION OF THE OPERROR THAT HAD OCCURRED EARLIER. WITH ALL OF THE DISTRS, BOTH ON THE RADAR AND IN MY SURROUNDING ENVIRONMENT, I NEVER GAINED A COMPLETE AND THOROUGH PICTURE OF MY TFC. WHEN ACFT #1 ASKED FOR LOWER, I DSNDED HIM FROM 7000 FT TO 5100 FT, MY MINIMUM IFR ALT. I CONTINUED ISSUING CLRNCS TO OTHER ACFT, SCANNING THE WHOLE SECTOR NOW, WHEN I REALIZED THAT ACFT #1 HAD ACFT #2 UNDERNEATH HIM AT 6000 FT LESS THAN 2 MI W OF HIS POS. THE CONFLICT ALERT ACTIVATED AND I TURNED ACFT #1 TO A 090 DEG HDG, WHICH WAS APPROX A 60 DEG TURN TO THE R. DUE TO THE PROX TO THE ARR ARPT, ACFT #1 WAS DSNDING RAPIDLY, SO I CHOSE NOT TO STOP HIS DSCNT, BUT LET HIM CONTINUE TO 5100 FT TO GET BELOW ACFT #2. I DID NOT TRY TO CLB HIM BACK TO 7000 FT, FEARING THAT SEPARATION WOULD BE LOST A SECOND TIME. SEPARATION WAS REGAINED LATERALLY AND I WAS RELIEVED FROM THE POS. IN REVIEWING THIS ERROR, I NOW SEE MANY CONTRIBUTING FACTORS. FIRST, THE POOR WX AND INCOMING FOG INFLUENCED ME TO RUSH THE APCH SO THAT ACFT #1 COULD GET ON THE GND ASAP. SECONDLY, THE REDUCED STAFFING, DUE TO THE OTHER OPERROR, HAD MEANT LONGER TIME ON POS THAT EVENING -- FATIGUE WAS SETTING IN. THE THIRD FACTOR WAS MY HAVING TO ISSUE MULTIPLE CLRNCS AND RECEIVE MULTIPLE COORDS, AS SOON AS I TOOK THE SECTOR DISTRACTING ME FROM CORRELATING DATA BLOCKS AND FLT PLAN INFO AS I NORMALLY DO. ANOTHER CONTRIBUTING FACTOR WAS MY INABILITY TO COMPREHEND THE PLT'S REQUEST, AND THEN BEING UNFAMILIAR WITH THE FULL APCH. I SHOULD HAVE FULLY ABSORBED THE INFO BEFORE I ISSUED THE DSCNT CLRNC. ADDITIONALLY, HAVING ANOTHER OPERROR THAT EVENING, AND LISTENING TO THE SPECULATION AND RUMORS CAUSED ALL OF BAY 3 TO BE ON EDGE. DISCUSSING IT ON THE CTL ROOM FLOOR CREATED A LOT OF BACKGND NOISE. THE NEW DSR ROOMS HAVE SECTORS MUCH CLOSER TO EACH OTHER, SO NORMAL TONE OF VOICE APPEARS TO BE AMPLIFIED. I WAS UNABLE TO TUNE THAT NOISE OUT. LASTLY, AND MOST IMPORTANTLY, I ASSUMED RESPONSIBILITY OF THE RADAR POS PREMATURELY BEFORE I HAD THE COMPLETE PICTURE IN MY MIND. THE RUSHED RELIEF BRIEFING STARTED THE ERROR CHAIN. HAD I TAKEN THE TIME AND DEVELOPED A FULL UNDERSTANDING OF ALL OF THE TFC, THIS OPERROR COULD HAVE BEEN AVOIDED.
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.