Narrative:

I was working an extremely busy arrival period vectoring to runway 27R at fll, final approximately 25 miles long. Aircraft X was on an ILS approach. Approximately 7 mi final aircraft X received a TCAS climb for unknown VFR traffic, indicated that they had climbed to 2500 ft, were too high for the approach and requested a 360 degree turn to get down. I told the pilot I was too busy for a 360 degree, and issued a right turn to 30 degree, maintain at or below 3000 ft for resequencing. Shortly thereafter, I turned aircraft X right heading 80 degrees. I worked on making a hole on final for aircraft X, so they wouldn't have to go out to 25 miles to get in line, at this point aircraft X was about 10 miles northeast of fll heading 80 degrees assigned (I assumed). There was a B190 commuter on an 8 mi final talking to the tower, and aircraft Y an A320, on a 13 mi final (on my frequency cleared for an ILS approach. I had made a hole for aircraft X behind aircraft Y. The frequency was very busy and I made several xmissions/vectors to other aircraft after giving aircraft X the 80 degree heading, as I went to issue the aircraft Y traffic/sequence to aircraft X. I saw aircraft X had turned base leg and I couldn't believe my eyes. To verify, I asked aircraft X if they had in fact turned base and they stumbled on frequency (realizing their error) and said they were turning back to an 80 degree heading. I told them no-do not turn back, continue on the base and pointed out the B190 traffic-2 O'clock and 1 mi, aircraft X called the traffic in sight and I told aircraft X to follow the B190 and cleared them for a visual approach. I then went immediately to aircraft Y and cancelled their approach clearance and told them to maintain 3000 ft on the localizer. Next, I notice aircraft X turning away from the airport and asked if they were inbound as there was straight in traffic on the localizer (aircraft Y). Aircraft X replied that they had already started returning to the assigned 80 degree heading, but were turning back. These back to back erroneous actions by aircraft X (from a 180 degree heading or so base that they turned on their own, to a left turn to 80 degrees-basically outbnd on the localizer-caused not only a loss of separation with aircraft Y, but necessitated me pulling the aircraft Z behind aircraft Y off the localizer for resequencing, at a time I was so busy, I didn't need to be sequencing aircraft twice. I think there were multiple causes for this situation, and many lessons to be learned. 1) I think the aircraft X crew was perturbed that the VFR traffic that caused the TCAS climb was not issued. I was vectoring non-stop and didn't see or issue the traffic before they had already initiated their climb. 2) I think the crew chose not to continue their approach to show their displeasure with my not issuing the traffic. After the TCAS traffic had passed, aircraft X was on a 6-7 mi final at 2400 ft only about 500 ft above the glideslope. On a clear VMC day it made no sense to me that they wouldn't continue the approach. 3) I'm sure there's an FMS issue here. The crew answered for, and was observed heading 80 degrees. The crew was also observed on the south (base leg) heading they initiated. The crew was told specifically to not turn from the base leg back to an 80 degrees heading, called the B190 in sight, was told to follow the B190 an acknowledged, yet mysteriously turned left to 80 degrees anyway compounding an already dicey situation. The big lesson I would like to communicate with pilots, particularly air carrier crews is this: 1) we all make mistakes! 99 percent of them can be fixed without incident if we all just fess up to it. 2) ATC and controllers are not 'out to get pilots'. In my 21 yrs of ATC, I have seen air carrier pilots turn simple screw ups into major events in their attempt to keep from getting in trouble. Did this aircraft X crew (and many others) think that in this day and age, in a radar environment, that they can turn from an 80 degree heading to a 180 degree heading, fly for 3 or 4 miles, realize their error, turn back to an 80 degree heading and a) no one will notice, B) it won't affect other traffic! 3) every action this crew took on their own, I was immediately trying to salvage the situation at hand and make it work, when crews aren't honest with me, or continue to try and 'correct' their error, they are only compounding the problem--usually (as was in this case) making it far worse than the first mistake was by a long shot. In this scenario, when aircraft X turned base by mistake, all I had to do was cancel aircraft Y's approach clearance and give them an s-turn off the localizer to follow aircraft X in their 'zeal' to fix their mistake, aircraft X caused not only aircraft Y, but aircraft Z to come off the localizer completely and have to go back out to a 30 mi final, but I had to have miami center (ZMA) put subsequent arrivals into holding because I ran out of airspace and couldn't accept any more arrivals. We all need to be honest with each other and communicate, acknowledge when we make a mistake so we can fix it and help each other. I am sure the aircraft X crew will be sending you their own NASA report with their perspective on this event. Separation never would have been lost if aircraft X had just said 'yes, we turned base by mistake, sorry, what do you want us to do?' callback conversation with reporter revealed the following information: the reporter restated the facts outlined in the report as to the sequence of events. He reaffirmed his assumption that FMS played a key role in this incident. The reporter believes that the original 80 degree heading was still selected in the FMS when the aircraft was on the incorrect 180 degree heading and that the 80 degree heading was selected and somehow activated via the FMS initiating the eastbound turn.

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Original NASA ASRS Text

Title: MIA APCH CTLR EXPERIENCED LOSS OF SEPARATION ON FLL FINAL.

Narrative: I WAS WORKING AN EXTREMELY BUSY ARR PERIOD VECTORING TO RWY 27R AT FLL, FINAL APPROX 25 MILES LONG. ACFT X WAS ON AN ILS APCH. APPROX 7 MI FINAL ACFT X RECEIVED A TCAS CLB FOR UNKNOWN VFR TFC, INDICATED THAT THEY HAD CLBED TO 2500 FT, WERE TOO HIGH FOR THE APCH AND REQUESTED A 360 DEG TURN TO GET DOWN. I TOLD THE PLT I WAS TOO BUSY FOR A 360 DEG, AND ISSUED A R TURN TO 30 DEG, MAINTAIN AT OR BELOW 3000 FT FOR RESEQUENCING. SHORTLY THEREAFTER, I TURNED ACFT X R HDG 80 DEGS. I WORKED ON MAKING A HOLE ON FINAL FOR ACFT X, SO THEY WOULDN'T HAVE TO GO OUT TO 25 MILES TO GET IN LINE, AT THIS POINT ACFT X WAS ABOUT 10 MILES NE OF FLL HDG 80 DEGS ASSIGNED (I ASSUMED). THERE WAS A B190 COMMUTER ON AN 8 MI FINAL TALKING TO THE TWR, AND ACFT Y AN A320, ON A 13 MI FINAL (ON MY FREQ CLRED FOR AN ILS APCH. I HAD MADE A HOLE FOR ACFT X BEHIND ACFT Y. THE FREQ WAS VERY BUSY AND I MADE SEVERAL XMISSIONS/VECTORS TO OTHER ACFT AFTER GIVING ACFT X THE 80 DEG HDG, AS I WENT TO ISSUE THE ACFT Y TFC/SEQUENCE TO ACFT X. I SAW ACFT X HAD TURNED BASE LEG AND I COULDN'T BELIEVE MY EYES. TO VERIFY, I ASKED ACFT X IF THEY HAD IN FACT TURNED BASE AND THEY STUMBLED ON FREQ (REALIZING THEIR ERROR) AND SAID THEY WERE TURNING BACK TO AN 80 DEG HDG. I TOLD THEM NO-DO NOT TURN BACK, CONTINUE ON THE BASE AND POINTED OUT THE B190 TFC-2 O'CLOCK AND 1 MI, ACFT X CALLED THE TFC IN SIGHT AND I TOLD ACFT X TO FOLLOW THE B190 AND CLRED THEM FOR A VISUAL APCH. I THEN WENT IMMEDIATELY TO ACFT Y AND CANCELLED THEIR APCH CLRNC AND TOLD THEM TO MAINTAIN 3000 FT ON THE LOCALIZER. NEXT, I NOTICE ACFT X TURNING AWAY FROM THE ARPT AND ASKED IF THEY WERE INBND AS THERE WAS STRAIGHT IN TFC ON THE LOCALIZER (ACFT Y). ACFT X REPLIED THAT THEY HAD ALREADY STARTED RETURNING TO THE ASSIGNED 80 DEG HDG, BUT WERE TURNING BACK. THESE BACK TO BACK ERRONEOUS ACTIONS BY ACFT X (FROM A 180 DEG HDG OR SO BASE THAT THEY TURNED ON THEIR OWN, TO A L TURN TO 80 DEGS-BASICALLY OUTBND ON THE LOCALIZER-CAUSED NOT ONLY A LOSS OF SEPARATION WITH ACFT Y, BUT NECESSITATED ME PULLING THE ACFT Z BEHIND ACFT Y OFF THE LOCALIZER FOR RESEQUENCING, AT A TIME I WAS SO BUSY, I DIDN'T NEED TO BE SEQUENCING ACFT TWICE. I THINK THERE WERE MULTIPLE CAUSES FOR THIS SIT, AND MANY LESSONS TO BE LEARNED. 1) I THINK THE ACFT X CREW WAS PERTURBED THAT THE VFR TFC THAT CAUSED THE TCAS CLB WAS NOT ISSUED. I WAS VECTORING NON-STOP AND DIDN'T SEE OR ISSUE THE TFC BEFORE THEY HAD ALREADY INITIATED THEIR CLB. 2) I THINK THE CREW CHOSE NOT TO CONTINUE THEIR APCH TO SHOW THEIR DISPLEASURE WITH MY NOT ISSUING THE TFC. AFTER THE TCAS TFC HAD PASSED, ACFT X WAS ON A 6-7 MI FINAL AT 2400 FT ONLY ABOUT 500 FT ABOVE THE GLIDESLOPE. ON A CLR VMC DAY IT MADE NO SENSE TO ME THAT THEY WOULDN'T CONTINUE THE APCH. 3) I'M SURE THERE'S AN FMS ISSUE HERE. THE CREW ANSWERED FOR, AND WAS OBSERVED HDG 80 DEGS. THE CREW WAS ALSO OBSERVED ON THE S (BASE LEG) HDG THEY INITIATED. THE CREW WAS TOLD SPECIFICALLY TO NOT TURN FROM THE BASE LEG BACK TO AN 80 DEGS HDG, CALLED THE B190 IN SIGHT, WAS TOLD TO FOLLOW THE B190 AN ACKNOWLEDGED, YET MYSTERIOUSLY TURNED L TO 80 DEGS ANYWAY COMPOUNDING AN ALREADY DICEY SIT. THE BIG LESSON I WOULD LIKE TO COMMUNICATE WITH PLTS, PARTICULARLY ACR CREWS IS THIS: 1) WE ALL MAKE MISTAKES! 99 PERCENT OF THEM CAN BE FIXED WITHOUT INCIDENT IF WE ALL JUST FESS UP TO IT. 2) ATC AND CTLRS ARE NOT 'OUT TO GET PLTS'. IN MY 21 YRS OF ATC, I HAVE SEEN ACR PLTS TURN SIMPLE SCREW UPS INTO MAJOR EVENTS IN THEIR ATTEMPT TO KEEP FROM GETTING IN TROUBLE. DID THIS ACFT X CREW (AND MANY OTHERS) THINK THAT IN THIS DAY AND AGE, IN A RADAR ENVIRONMENT, THAT THEY CAN TURN FROM AN 80 DEG HDG TO A 180 DEG HDG, FLY FOR 3 OR 4 MILES, REALIZE THEIR ERROR, TURN BACK TO AN 80 DEG HDG AND A) NO ONE WILL NOTICE, B) IT WON'T AFFECT OTHER TFC! 3) EVERY ACTION THIS CREW TOOK ON THEIR OWN, I WAS IMMEDIATELY TRYING TO SALVAGE THE SIT AT HAND AND MAKE IT WORK, WHEN CREWS AREN'T HONEST WITH ME, OR CONTINUE TO TRY AND 'CORRECT' THEIR ERROR, THEY ARE ONLY COMPOUNDING THE PROB--USUALLY (AS WAS IN THIS CASE) MAKING IT FAR WORSE THAN THE FIRST MISTAKE WAS BY A LONG SHOT. IN THIS SCENARIO, WHEN ACFT X TURNED BASE BY MISTAKE, ALL I HAD TO DO WAS CANCEL ACFT Y'S APCH CLRNC AND GIVE THEM AN S-TURN OFF THE LOCALIZER TO FOLLOW ACFT X IN THEIR 'ZEAL' TO FIX THEIR MISTAKE, ACFT X CAUSED NOT ONLY ACFT Y, BUT ACFT Z TO COME OFF THE LOCALIZER COMPLETELY AND HAVE TO GO BACK OUT TO A 30 MI FINAL, BUT I HAD TO HAVE MIAMI CENTER (ZMA) PUT SUBSEQUENT ARRIVALS INTO HOLDING BECAUSE I RAN OUT OF AIRSPACE AND COULDN'T ACCEPT ANY MORE ARRIVALS. WE ALL NEED TO BE HONEST WITH EACH OTHER AND COMMUNICATE, ACKNOWLEDGE WHEN WE MAKE A MISTAKE SO WE CAN FIX IT AND HELP EACH OTHER. I AM SURE THE ACFT X CREW WILL BE SENDING YOU THEIR OWN NASA RPT WITH THEIR PERSPECTIVE ON THIS EVENT. SEPARATION NEVER WOULD HAVE BEEN LOST IF ACFT X HAD JUST SAID 'YES, WE TURNED BASE BY MISTAKE, SORRY, WHAT DO YOU WANT US TO DO?' CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR RESTATED THE FACTS OUTLINED IN THE RPT AS TO THE SEQUENCE OF EVENTS. HE REAFFIRMED HIS ASSUMPTION THAT FMS PLAYED A KEY ROLE IN THIS INCIDENT. THE RPTR BELIEVES THAT THE ORIGINAL 80 DEG HDG WAS STILL SELECTED IN THE FMS WHEN THE ACFT WAS ON THE INCORRECT 180 DEG HDG AND THAT THE 80 DEG HDG WAS SELECTED AND SOMEHOW ACTIVATED VIA THE FMS INITIATING THE EBND TURN.

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.