37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 556331 |
Time | |
Date | 200208 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfb.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sfb.tower |
Operator | general aviation : personal |
Make Model Name | Cessna Stationair/Turbo Stationair 6 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : taxi |
Flight Plan | VFR |
Aircraft 2 | |
Controlling Facilities | tower : sfb.tower |
Operator | general aviation : instructional |
Make Model Name | Skyhawk 172/Cutlass 172 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : takeoff |
Flight Plan | VFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : radar |
Experience | controller limited radar : 17 controller radar : 3 |
ASRS Report | 556331 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : radar |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : published procedure non adherence : required legal separation other anomaly other |
Independent Detector | other controllera other controllerb |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 1000 vertical : 100 |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Intra Facility Coordination Failure |
Narrative:
At sfb, ground controller had 4 other position combined with ground controller at the time. Ground controller had 6-10 aircraft calling for taxi. Normal procedure is to write a half strip and place on local controller board, taxi to runway 9L at B1. When sending aircraft to intersection other than B1, to notify local controller, obtain acknowledgement and write intersection and runway on strip (ground controller never obtained acknowledgement. The strip was placed in bin with other strips -- no special, i.e., cocking and/or upside down treatment of the strip.) trying to depart as many small aircraft prior to heavy jet inbound. Departed 1 aircraft, taxied another into position, another calls inbound, another calls ready, clear #2, taxied into position #3, #4 calls ready at intersection right (I did not 'register 'right'). Cleared #3, and told #4 to taxi into position at 'B1' and be ready, heavy jet 6 mi final. At same time, relieving controller was plugged in, awaiting briefing, which was being done as #4 taxied onto runway at 'right' (B1 to right approximately 6500 ft). #3 was airborne approximately 3000 ft prior to intersection. If relieving ground controller had been able to pay attention to ground controller and not answering phones, NOTAMS, etc, and had they got an acknowledgement or cocked the strip or highlighted the intersection, it could have prevented occurrence. Had I 'heard' #4 call at 'right,' it would not have happened. Had I seen 'right' scribbled on strip, it would not have happened. Too many people trying to do too many things too fast contributed. The controller in charge (who was the ground controller) was notified.
Original NASA ASRS Text
Title: SFB LCL CTLR INSTRUCTS ACFT DOWNFIELD INTO POS WITH TFC DEPARTING FROM THE APCH END OF RWY RESULTING IN A RWY INCURSION.
Narrative: AT SFB, GND CTLR HAD 4 OTHER POS COMBINED WITH GND CTLR AT THE TIME. GND CTLR HAD 6-10 ACFT CALLING FOR TAXI. NORMAL PROC IS TO WRITE A HALF STRIP AND PLACE ON LCL CTLR BOARD, TAXI TO RWY 9L AT B1. WHEN SENDING ACFT TO INTXN OTHER THAN B1, TO NOTIFY LCL CTLR, OBTAIN ACKNOWLEDGEMENT AND WRITE INTXN AND RWY ON STRIP (GND CTLR NEVER OBTAINED ACKNOWLEDGEMENT. THE STRIP WAS PLACED IN BIN WITH OTHER STRIPS -- NO SPECIAL, I.E., COCKING AND/OR UPSIDE DOWN TREATMENT OF THE STRIP.) TRYING TO DEPART AS MANY SMALL ACFT PRIOR TO HVY JET INBOUND. DEPARTED 1 ACFT, TAXIED ANOTHER INTO POS, ANOTHER CALLS INBOUND, ANOTHER CALLS READY, CLR #2, TAXIED INTO POS #3, #4 CALLS READY AT INTXN R (I DID NOT 'REGISTER 'R'). CLRED #3, AND TOLD #4 TO TAXI INTO POS AT 'B1' AND BE READY, HVY JET 6 MI FINAL. AT SAME TIME, RELIEVING CTLR WAS PLUGGED IN, AWAITING BRIEFING, WHICH WAS BEING DONE AS #4 TAXIED ONTO RWY AT 'R' (B1 TO R APPROX 6500 FT). #3 WAS AIRBORNE APPROX 3000 FT PRIOR TO INTXN. IF RELIEVING GND CTLR HAD BEEN ABLE TO PAY ATTN TO GND CTLR AND NOT ANSWERING PHONES, NOTAMS, ETC, AND HAD THEY GOT AN ACKNOWLEDGEMENT OR COCKED THE STRIP OR HIGHLIGHTED THE INTXN, IT COULD HAVE PREVENTED OCCURRENCE. HAD I 'HEARD' #4 CALL AT 'R,' IT WOULD NOT HAVE HAPPENED. HAD I SEEN 'R' SCRIBBLED ON STRIP, IT WOULD NOT HAVE HAPPENED. TOO MANY PEOPLE TRYING TO DO TOO MANY THINGS TOO FAST CONTRIBUTED. THE CIC (WHO WAS THE GND CTLR) WAS NOTIFIED.
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.