37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 569792 |
Time | |
Date | 200301 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ryy.airport |
State Reference | GA |
Altitude | msl bound lower : 4000 msl bound upper : 5000 |
Environment | |
Flight Conditions | Marginal |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : corporate |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 27 |
Flight Phase | descent : approach |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : a80.tracon |
Operator | general aviation : personal |
Make Model Name | Bonanza 35 |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 27 |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Experience | controller radar : 20 controller time certified in position1 : 10 |
ASRS Report | 569792 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment : conflict alert atc equipment other atc equipment : radar other controllera other flight crewa other flight crewb other other : 4 |
Resolutory Action | controller : issued new clearance |
Consequence | faa : investigated Other |
Miss Distance | horizontal : 1500 vertical : 400 |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Both aircraft were inbound to ryy from the west. I had both aircraft on vectors for a north downwind to runway 27 ILS. Aircraft Y was at 4000 ft. Aircraft X was at 5000 ft. I instructed aircraft Y to descend to 3000 ft. Aircraft X read it back, which I didn't hear until the tape review. I observed aircraft descending through 4600 ft and told him to maintain 5000 ft. He said he had traffic to his right and had him in sight. I informed him that the descent was not for him. Pilots know they have no accountability for readback errors. They need to be reminded how important it is. I work in a very busy facility (atl/A80) and I have seen many, many controllers get dials because pilots making readback errors. Let's make them partly responsible. Maybe, we should call on them when we catch them (which is many times every day). Callback conversation with reporter revealed the following information: the reporter said she was very busy and did not hear the incorrect readback. She said it might have turned out differently if she had used aircraft type and full call sign in her communications with the pilots. She also said her communication technique has improved a lot since the incident.
Original NASA ASRS Text
Title: AN HS25 LNDG RYY ACKNOWLEDGED A DSCNT CLRNC INTENDED FOR A BE35 AHEAD AT A LOWER ALT. THE INCORRECT READBACK WAS NOT HEARD BY THE ATL CTLR.
Narrative: BOTH ACFT WERE INBOUND TO RYY FROM THE W. I HAD BOTH ACFT ON VECTORS FOR A N DOWNWIND TO RWY 27 ILS. ACFT Y WAS AT 4000 FT. ACFT X WAS AT 5000 FT. I INSTRUCTED ACFT Y TO DSND TO 3000 FT. ACFT X READ IT BACK, WHICH I DIDN'T HEAR UNTIL THE TAPE REVIEW. I OBSERVED ACFT DSNDING THROUGH 4600 FT AND TOLD HIM TO MAINTAIN 5000 FT. HE SAID HE HAD TFC TO HIS R AND HAD HIM IN SIGHT. I INFORMED HIM THAT THE DSCNT WAS NOT FOR HIM. PLTS KNOW THEY HAVE NO ACCOUNTABILITY FOR READBACK ERRORS. THEY NEED TO BE REMINDED HOW IMPORTANT IT IS. I WORK IN A VERY BUSY FACILITY (ATL/A80) AND I HAVE SEEN MANY, MANY CTLRS GET DIALS BECAUSE PLTS MAKING READBACK ERRORS. LET'S MAKE THEM PARTLY RESPONSIBLE. MAYBE, WE SHOULD CALL ON THEM WHEN WE CATCH THEM (WHICH IS MANY TIMES EVERY DAY). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID SHE WAS VERY BUSY AND DID NOT HEAR THE INCORRECT READBACK. SHE SAID IT MIGHT HAVE TURNED OUT DIFFERENTLY IF SHE HAD USED ACFT TYPE AND FULL CALL SIGN IN HER COMS WITH THE PLTS. SHE ALSO SAID HER COM TECHNIQUE HAS IMPROVED A LOT SINCE THE INCIDENT.
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.