37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 544054 |
Time | |
Date | 200204 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : elm.airport |
State Reference | NY |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : elm.tower |
Operator | general aviation : personal |
Make Model Name | Skyhawk 172/Cutlass 172 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : initial |
Aircraft 2 | |
Controlling Facilities | tower : elm.tower |
Operator | common carrier : air carrier |
Make Model Name | Do 328 TP (Turboprop) |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : supervisor instruction : instructor |
Qualification | controller : radar |
Experience | controller military : 5 controller radar : 20 controller supervisory : 15 controller time certified in position1 : 16 |
ASRS Report | 544054 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local instruction : trainee |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other controllera other controllerb other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was conducting a certification check on a new FAA controller. He was doing an excellent job but as is the case something came up that was different from what I thought to be correct. Traffic was light so I picked up the ATP (mistake #1 distraction). While I was researching, my trainee cleared a cessna 172 for takeoff, then put a D328 into position to hold while the C172 cleared the departure corridor. The trainee coordinated a release and a heading with departure control. As the trainee turned back to issue the departure clearance and heading to the D328 he was amazed to see the D328 rotating in his takeoff roll. He responded quickly to issue the heading assigned by radar and continued to handle the flight as normal. We informed the pilot to call the tower as required and switched him to departure. The coordination with radar took 15-30 seconds before the rescan caught the D328 rotating, that's a long time in this business. On the bright side it presented me with the opportunity to observe the trainee handle unusual sits. Not that looking in a book caused or not looking could have prevented the misident but doing anything other than your primary job in this profession is potentially hazardous. Supplemental information from acn 543896: both pilots were sure of the takeoff clearance when indeed the aircraft was cleared into position and hold. There was a potential conflict with a previous departure but the conflict was avoided by an ATC vector. ATC reviewed the tape which showed that the crew was in error. Normally when a clearance is in question the pilot communicating with ATC will clarify with ATC. This did not happen in this instance. The PF did question the clearance but did not verify with ATC via the PNF.
Original NASA ASRS Text
Title: SUPERVISORY CTLR CONDUCTING A CERTIFICATION CHK ON A NEW CTLR BECAME DISTRACTED AND DID NOT NOTICE AN ACFT DEPART WITHOUT A CLRNC.
Narrative: I WAS CONDUCTING A CERTIFICATION CHK ON A NEW FAA CTLR. HE WAS DOING AN EXCELLENT JOB BUT AS IS THE CASE SOMETHING CAME UP THAT WAS DIFFERENT FROM WHAT I THOUGHT TO BE CORRECT. TFC WAS LIGHT SO I PICKED UP THE ATP (MISTAKE #1 DISTR). WHILE I WAS RESEARCHING, MY TRAINEE CLRED A CESSNA 172 FOR TKOF, THEN PUT A D328 INTO POS TO HOLD WHILE THE C172 CLRED THE DEP CORRIDOR. THE TRAINEE COORDINATED A RELEASE AND A HEADING WITH DEP CTL. AS THE TRAINEE TURNED BACK TO ISSUE THE DEP CLRNC AND HEADING TO THE D328 HE WAS AMAZED TO SEE THE D328 ROTATING IN HIS TKOF ROLL. HE RESPONDED QUICKLY TO ISSUE THE HEADING ASSIGNED BY RADAR AND CONTINUED TO HANDLE THE FLT AS NORMAL. WE INFORMED THE PLT TO CALL THE TWR AS REQUIRED AND SWITCHED HIM TO DEP. THE COORD WITH RADAR TOOK 15-30 SECONDS BEFORE THE RESCAN CAUGHT THE D328 ROTATING, THAT'S A LONG TIME IN THIS BUSINESS. ON THE BRIGHT SIDE IT PRESENTED ME WITH THE OPPORTUNITY TO OBSERVE THE TRAINEE HANDLE UNUSUAL SITS. NOT THAT LOOKING IN A BOOK CAUSED OR NOT LOOKING COULD HAVE PREVENTED THE MISIDENT BUT DOING ANYTHING OTHER THAN YOUR PRIMARY JOB IN THIS PROFESSION IS POTENTIALLY HAZARDOUS. SUPPLEMENTAL INFO FROM ACN 543896: BOTH PLTS WERE SURE OF THE TKOF CLRNC WHEN INDEED THE ACFT WAS CLRED INTO POS AND HOLD. THERE WAS A POTENTIAL CONFLICT WITH A PREVIOUS DEP BUT THE CONFLICT WAS AVOIDED BY AN ATC VECTOR. ATC REVIEWED THE TAPE WHICH SHOWED THAT THE CREW WAS IN ERROR. NORMALLY WHEN A CLRNC IS IN QUESTION THE PLT COMMUNICATING WITH ATC WILL CLARIFY WITH ATC. THIS DID NOT HAPPEN IN THIS INSTANCE. THE PF DID QUESTION THE CLRNC BUT DID NOT VERIFY WITH ATC VIA THE PNF.
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.