37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 618167 |
Time | |
Date | 200405 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : buf.vortac |
State Reference | NY |
Altitude | msl bound lower : 3000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : buf.tracon |
Operator | general aviation : personal |
Make Model Name | Cessna 340/340A |
Operating Under FAR Part | Part 91 |
Navigation In Use | other vortac |
Flight Phase | cruise : level |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : buf.tracon |
Operator | common carrier : charter |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Experience | controller radar : 18 controller time certified in position2 : 2 |
ASRS Report | 618167 |
Person 2 | |
Affiliation | other |
Function | flight crew : single pilot |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment : conflict alert other controllera |
Resolutory Action | controller : issued alert controller : issued new clearance flight crew : took evasive action |
Consequence | faa : investigated |
Miss Distance | horizontal : 21000 vertical : 900 |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Intra Facility Coordination Failure |
Narrative:
I had just come to work. The briefing controller told me the C340 at 4000 ft 'was direct buf VOR, then direct iag,' I think. Just prior to briefing controller unplugging, local called to 'apreq' a turn to heading 090 degrees for departing buf B190, climbing to 10000 ft. Since direct buf VOR for C340 would keep C340 about 6 mi southeast of buf airport, I approved the turn. As B190 was climbing through 28000 ft, I observed C340 east of buf VOR approximately heading 320 degrees toward B190. I called B190 traffic out to C340, who replied 'I have him in sight.' as I was doing this, the conflict alert went off. I told C340 to maintain visual separation, then told B190 of traffic and B190 said he saw C340. After the situation cleared, I asked C340 if he was direct buf VOR. He said no, he was direct iag, about a 310 degree heading. I then turned C340 to 270 degree heading to keep aircraft clear for buf airport departures. Mistake #1: not confirming C340's actual clearance and heading, especially because aircraft was close to the departure corridor and at low altitude of 4000 ft. Mistake #2: not just stopping departure (B190) at 3000 ft to ensure separation. That's my job. I failed and I won't get caught like that again. I mistakenly believed the 2 aircraft were not in confliction because of diverging headings. Wrong! Mistake #3: my judgement was based on potentially incorrect information during my briefing. I failed to make sure the information was accurate, especially when briefing included the words 'I think.' mistake #4: yrs of experience helped to prevent a bad situation from getting worse. But those same yrs sometimes fog the person's judgement to get the situation correct. The situation was something I should have been right on top of, not being nonchalant because 'I've seen it all.' I fell into a trap, but should have seen it coming. I always try to learn from my mistakes, so I don't repeat them. This was a dumb mistake on my part.
Original NASA ASRS Text
Title: BUF TRACON CTLR RESOLVED A DEVELOPING CONFLICT WITH 2 DEP ACFT.
Narrative: I HAD JUST COME TO WORK. THE BRIEFING CTLR TOLD ME THE C340 AT 4000 FT 'WAS DIRECT BUF VOR, THEN DIRECT IAG,' I THINK. JUST PRIOR TO BRIEFING CTLR UNPLUGGING, LCL CALLED TO 'APREQ' A TURN TO HDG 090 DEGS FOR DEPARTING BUF B190, CLBING TO 10000 FT. SINCE DIRECT BUF VOR FOR C340 WOULD KEEP C340 ABOUT 6 MI SE OF BUF ARPT, I APPROVED THE TURN. AS B190 WAS CLBING THROUGH 28000 FT, I OBSERVED C340 E OF BUF VOR APPROX HDG 320 DEGS TOWARD B190. I CALLED B190 TFC OUT TO C340, WHO REPLIED 'I HAVE HIM IN SIGHT.' AS I WAS DOING THIS, THE CONFLICT ALERT WENT OFF. I TOLD C340 TO MAINTAIN VISUAL SEPARATION, THEN TOLD B190 OF TFC AND B190 SAID HE SAW C340. AFTER THE SIT CLRED, I ASKED C340 IF HE WAS DIRECT BUF VOR. HE SAID NO, HE WAS DIRECT IAG, ABOUT A 310 DEG HDG. I THEN TURNED C340 TO 270 DEG HDG TO KEEP ACFT CLR FOR BUF ARPT DEPS. MISTAKE #1: NOT CONFIRMING C340'S ACTUAL CLRNC AND HDG, ESPECIALLY BECAUSE ACFT WAS CLOSE TO THE DEP CORRIDOR AND AT LOW ALT OF 4000 FT. MISTAKE #2: NOT JUST STOPPING DEP (B190) AT 3000 FT TO ENSURE SEPARATION. THAT'S MY JOB. I FAILED AND I WON'T GET CAUGHT LIKE THAT AGAIN. I MISTAKENLY BELIEVED THE 2 ACFT WERE NOT IN CONFLICTION BECAUSE OF DIVERGING HDGS. WRONG! MISTAKE #3: MY JUDGEMENT WAS BASED ON POTENTIALLY INCORRECT INFO DURING MY BRIEFING. I FAILED TO MAKE SURE THE INFO WAS ACCURATE, ESPECIALLY WHEN BRIEFING INCLUDED THE WORDS 'I THINK.' MISTAKE #4: YRS OF EXPERIENCE HELPED TO PREVENT A BAD SIT FROM GETTING WORSE. BUT THOSE SAME YRS SOMETIMES FOG THE PERSON'S JUDGEMENT TO GET THE SIT CORRECT. THE SIT WAS SOMETHING I SHOULD HAVE BEEN RIGHT ON TOP OF, NOT BEING NONCHALANT BECAUSE 'I'VE SEEN IT ALL.' I FELL INTO A TRAP, BUT SHOULD HAVE SEEN IT COMING. I ALWAYS TRY TO LEARN FROM MY MISTAKES, SO I DON'T REPEAT THEM. THIS WAS A DUMB MISTAKE ON MY PART.
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.