37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 657172 |
Time | |
Date | 200505 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : maf.airport |
State Reference | TX |
Altitude | msl single value : 5000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : maf.tracon |
Operator | other |
Make Model Name | Beechjet 400 |
Operating Under FAR Part | Part 91 |
Flight Phase | landing : missed approach |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : maf.tracon |
Operator | general aviation : personal |
Make Model Name | Baron 58/58TC |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Experience | controller military : 8 controller radar : 15 |
ASRS Report | 657172 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : investigated |
Miss Distance | horizontal : 6000 vertical : 200 |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Maf ATCT is filing a pilot deviation on a military aircraft. Events leading to this pilot deviation also encompass a controller operational error/operational deviation and a system error that are not being reported. The military pilot was conducting multiple practice approachs; being issued alternate missed approach instructions. After one approach where the pilot was not issued alternate missed approach instructions; he flew the last assigned missed approach instead of the published miss. This caused a loss of separation with another IFR baron on approach to a secondary airport. Local order requires that we enter approach information and alternate missed approach instructions in the ARTS scratch pad for quick look purposes. This was accomplished with an alternate miss that would not have been a conflict to the second aircraft. The controller never actually issued the entered miss to the aircraft. A new controller relieved the working controller but was not briefed that the non conflicting missed approach had not yet been issued. The relieving controller assumed the alternate miss had been issued; not having been briefed that it had not. In the end; the military BE40 was 1 mi and 200 ft from the IFR baron.
Original NASA ASRS Text
Title: MAF CTLR DESCRIBES LOSS OF SEPARATION AT 5000 FT AS RELIEVING CTLR ASSUMED AUTOMATED CLRNC DATA HAD BEEN ISSUED TO THE MIL ACFT.
Narrative: MAF ATCT IS FILING A PLTDEV ON A MIL ACFT. EVENTS LEADING TO THIS PLTDEV ALSO ENCOMPASS A CTLR OPERROR/OPDEV AND A SYS ERROR THAT ARE NOT BEING RPTED. THE MIL PLT WAS CONDUCTING MULTIPLE PRACTICE APCHS; BEING ISSUED ALTERNATE MISSED APCH INSTRUCTIONS. AFTER ONE APCH WHERE THE PLT WAS NOT ISSUED ALTERNATE MISSED APCH INSTRUCTIONS; HE FLEW THE LAST ASSIGNED MISSED APCH INSTEAD OF THE PUBLISHED MISS. THIS CAUSED A LOSS OF SEPARATION WITH ANOTHER IFR BARON ON APCH TO A SECONDARY ARPT. LCL ORDER REQUIRES THAT WE ENTER APCH INFO AND ALTERNATE MISSED APCH INSTRUCTIONS IN THE ARTS SCRATCH PAD FOR QUICK LOOK PURPOSES. THIS WAS ACCOMPLISHED WITH AN ALTERNATE MISS THAT WOULD NOT HAVE BEEN A CONFLICT TO THE SECOND ACFT. THE CTLR NEVER ACTUALLY ISSUED THE ENTERED MISS TO THE ACFT. A NEW CTLR RELIEVED THE WORKING CTLR BUT WAS NOT BRIEFED THAT THE NON CONFLICTING MISSED APCH HAD NOT YET BEEN ISSUED. THE RELIEVING CTLR ASSUMED THE ALTERNATE MISS HAD BEEN ISSUED; NOT HAVING BEEN BRIEFED THAT IT HAD NOT. IN THE END; THE MIL BE40 WAS 1 MI AND 200 FT FROM THE IFR BARON.
Data retrieved from NASA's ASRS site as of January 2009 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.