37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 642024 |
Time | |
Date | 200412 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : hio.airport |
State Reference | OR |
Altitude | msl single value : 2800 |
Environment | |
Flight Conditions | IMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : p80.tracon |
Operator | general aviation : corporate |
Make Model Name | Learjet 31 |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Experience | controller radar : 21 controller time certified in position1 : 12 |
ASRS Report | 642024 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | non adherence : required legal separation non adherence : published procedure non adherence : clearance non adherence other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : investigated |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I vectored a lear 31 to the final approach course for the ILS runway 12 at hio. The aircraft was at 5000 ft MSL. When I issued the clearance to 'descend and maintain three thousand five hundred.' the pilot readback 'down to twenty-five.' it was a very fast readback and I missed the 'twenty' portion of the readback. The MVA in the area is 3500 ft. I noticed the aircraft going through 3300 ft and at 3200 ft, I again issued the clearance 'maintain three thousand five hundred.' the pilot responded 'roger, down to twenty-five.' again, very fast, but this time I caught the readback. I again issued 'climb and maintain three thousand five hundred.' the pilot readback 'up to thirty-five now, but I read back twenty-five.' the act descended as low as 2800 ft before climbing back up. The pilot's insistence on short, group form readbacks, ie, 'down to twenty-five, up to thirty-five,' was a major contributor to this error. I doubt I would have missed a proper readback of 'two thousand five hundred,' or 'three thousand five hundred.'
Original NASA ASRS Text
Title: P80 CTLR CHRONICLES READBACK HEARBACK ERROR THAT CAUSED ACFT TO DSND BELOW MVA.
Narrative: I VECTORED A LEAR 31 TO THE FINAL APCH COURSE FOR THE ILS RWY 12 AT HIO. THE ACFT WAS AT 5000 FT MSL. WHEN I ISSUED THE CLRNC TO 'DSND AND MAINTAIN THREE THOUSAND FIVE HUNDRED.' THE PLT READBACK 'DOWN TO TWENTY-FIVE.' IT WAS A VERY FAST READBACK AND I MISSED THE 'TWENTY' PORTION OF THE READBACK. THE MVA IN THE AREA IS 3500 FT. I NOTICED THE ACFT GOING THROUGH 3300 FT AND AT 3200 FT, I AGAIN ISSUED THE CLRNC 'MAINTAIN THREE THOUSAND FIVE HUNDRED.' THE PLT RESPONDED 'ROGER, DOWN TO TWENTY-FIVE.' AGAIN, VERY FAST, BUT THIS TIME I CAUGHT THE READBACK. I AGAIN ISSUED 'CLB AND MAINTAIN THREE THOUSAND FIVE HUNDRED.' THE PLT READBACK 'UP TO THIRTY-FIVE NOW, BUT I READ BACK TWENTY-FIVE.' THE ACT DSNDED AS LOW AS 2800 FT BEFORE CLBING BACK UP. THE PLT'S INSISTENCE ON SHORT, GROUP FORM READBACKS, IE, 'DOWN TO TWENTY-FIVE, UP TO THIRTY-FIVE,' WAS A MAJOR CONTRIBUTOR TO THIS ERROR. I DOUBT I WOULD HAVE MISSED A PROPER READBACK OF 'TWO THOUSAND FIVE HUNDRED,' OR 'THREE THOUSAND FIVE HUNDRED.'
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.