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|
Attributes | |
ACN | 728905 |
Time | |
Date | 200701 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ord.airport |
State Reference | IL |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | Marginal |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach ground : maintenance |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : c90.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-82 |
Operating Under FAR Part | Part 121 |
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 : 20 |
ASRS Report | 728905 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation |
Independent Detector | atc equipment : conflict alert other controllera |
Resolutory Action | controller : issued new clearance controller : issued alert flight crew : took evasive action |
Consequence | faa : investigated |
Supplementary | |
Problem Areas | ATC Human Performance FAA |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Situations | |
ATC Facility | staffing : c90.tracon |
Narrative:
(I observed the situation and tried to intervene to help salvage the situation.) the 1ST aircraft; aircraft X; was turned south by arrival controller directly at traffic at same altitude (4000 ft) on runway 27R arrival to ord. The controller had inadvertently issued a 180 degree heading rather than the 90 degree heading he thought he had given. I am convinced that everyone's reaction time was significantly delayed and that; the initial mistake and subsequent slow reactions were entirely due to controller fatigue. The error occurred within the last 30 mins of a long workweek. Management's mandatory 'time on position' was a direct safety issue and will continue to be; at least at a facility such as C90. Such 'blanket' policies of management are latently hostile and short-sighted. Local management should be allowed to dictate its own policies in order to procure the safest work conditions. This is not factory work -- or office work. Decisions are made continually on position approximately every 3 seconds. Finally; the controller who had the error had personally confided in me his fatigue shortly before the error occurred.
Original NASA ASRS Text
Title: C90 CTLR WITNESS OPERROR AT 4000 WHEN ANOTHER CTLR INADVERTENTLY TURNED AN ARR TO THE WRONG HEADING; CITING FATIGUE AS A MAJOR FACTOR.
Narrative: (I OBSERVED THE SITUATION AND TRIED TO INTERVENE TO HELP SALVAGE THE SITUATION.) THE 1ST ACFT; ACFT X; WAS TURNED S BY ARR CTLR DIRECTLY AT TFC AT SAME ALT (4000 FT) ON RWY 27R ARR TO ORD. THE CTLR HAD INADVERTENTLY ISSUED A 180 DEG HDG RATHER THAN THE 90 DEG HDG HE THOUGHT HE HAD GIVEN. I AM CONVINCED THAT EVERYONE'S REACTION TIME WAS SIGNIFICANTLY DELAYED AND THAT; THE INITIAL MISTAKE AND SUBSEQUENT SLOW REACTIONS WERE ENTIRELY DUE TO CTLR FATIGUE. THE ERROR OCCURRED WITHIN THE LAST 30 MINS OF A LONG WORKWEEK. MGMNT'S MANDATORY 'TIME ON POS' WAS A DIRECT SAFETY ISSUE AND WILL CONTINUE TO BE; AT LEAST AT A FACILITY SUCH AS C90. SUCH 'BLANKET' POLICIES OF MGMNT ARE LATENTLY HOSTILE AND SHORT-SIGHTED. LCL MGMNT SHOULD BE ALLOWED TO DICTATE ITS OWN POLICIES IN ORDER TO PROCURE THE SAFEST WORK CONDITIONS. THIS IS NOT FACTORY WORK -- OR OFFICE WORK. DECISIONS ARE MADE CONTINUALLY ON POS APPROX EVERY 3 SECONDS. FINALLY; THE CTLR WHO HAD THE ERROR HAD PERSONALLY CONFIDED IN ME HIS FATIGUE SHORTLY BEFORE THE ERROR OCCURRED.
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.