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|
Attributes | |
ACN | 738531 |
Time | |
Date | 200705 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : anc.airport |
State Reference | AK |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : a11.tracon |
Operator | common carrier : air carrier |
Make Model Name | Dash 8 Series Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : a11.tracon |
Operator | common carrier : air taxi |
Make Model Name | Cessna Single Turboprop Undifferentiated or Other Model |
Operating Under FAR Part | Part 135 |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach instruction : instructor |
Qualification | controller : radar |
Experience | controller non radar : 6 controller radar : 20 |
ASRS Report | 738531 |
Person 2 | |
Affiliation | government : faa |
Function | instruction : trainee |
Qualification | controller : developmental |
Experience | controller limited radar : 3 controller non radar : 3 controller radar : 0.5 |
ASRS Report | 738035 |
Events | |
Anomaly | conflict : airborne critical non adherence : required legal separation |
Independent Detector | atc equipment : conflict alert aircraft equipment : tcas other controllera other controllerb |
Resolutory Action | controller : issued alert controller : issued new clearance |
Consequence | faa : investigated |
Miss Distance | horizontal : 7000 vertical : 200 |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
When the fpl took the position he saw traffic orbiting over one of his gates at FL240; performed a flight plan check and saw that it was an H/E3; an unusual event. The trainee joined the fpl several mins later. A flight of 2 F15's with an unfamiliar call sign entered the same gate that the H/E3 was orbiting; another unusual situation. The fpl walked to the supervisor's desk and asked if an exercise was occurring. The supervisor said that there was; although no briefing by the agency had been provided. The trainee issued 3000 ft to the C208 that was level at 5000 ft and converging with DH8A at 4000 ft. At the time the fpl was querying the supervisor; and the fpl didn't hear the clearance. The fpl returned to the position with note paper; looked at the scope and saw nothing unusual (C208 had not begun descent); and began to write notes for the debrief with the trainee. The trainee issued a hard turn to the C208 at which time the fpl looked at the scope and saw the operational error and took the position. Causal factor #1: the lack of a briefing by the agency about the military exercise caused a distraction for the fpl. If a briefing had been made; the fpl would not have left the position to query the supervisor and would have corrected the 3000 ft clearance issued to the C208 in a timely manner. Causal factor #2: although part of the conflict alert software did activate and 'flash' on the scope; no aural alarm was activated. The aural alarm would have alerted the fpl to the situation and take over and would have prevented the DH8A from taking evasive action. Causal factor #3: the C208 had descended only 800 ft in 2 mins 20 seconds; but its climb/descent rate is 1400 FPM which is a violation of the aim. The C208 was not issued a pilot's discretion descent. The refusal to descend in accordance with the aim has been an ongoing problem for anchorage approach controllers with many air taxi operators that will hopefully be addressed by management now. Supplemental information from acn 738035: I was training on south radar when a DH8 departed anchorage sbound to ena. They checked in and I sent them direct ena at 4000 ft. A C208 checked in over napto at 5000 ft. I advised them to plan runway '7L.' a little later I descended the C208 to 3000 ft. Later I was scanning the scope and saw both aircraft opposite direction 2 mi apart; same altitude. I told the C208 to turn right heading 090 degrees. I told the DH8 to turn right heading 270 degrees. They said they were responding to a TCAS RA. I said roger. Then they said they were clear and I was unplugged and training was terminated at this point. Initially I kept the C208 at 5000 ft to keep above the DH8; but soon thought it would not have been a factor. The C208 descended at a really slow rate 800 ft in 2 mins and 20 seconds and I obviously didn't monitor the situation continuously. I had a few other aircraft on frequency but not too many to be a factor.
Original NASA ASRS Text
Title: A11 CTLR EXPERIENCED OPERROR AT 4000; DISTRACTED BY AN UNUSUAL NOT BRIEFED OPS; FAILED TO OBSERVE DEVELOPMENTAL ISSUED CONFLICT CLRNC.
Narrative: WHEN THE FPL TOOK THE POS HE SAW TFC ORBITING OVER ONE OF HIS GATES AT FL240; PERFORMED A FLT PLAN CHK AND SAW THAT IT WAS AN H/E3; AN UNUSUAL EVENT. THE TRAINEE JOINED THE FPL SEVERAL MINS LATER. A FLT OF 2 F15'S WITH AN UNFAMILIAR CALL SIGN ENTERED THE SAME GATE THAT THE H/E3 WAS ORBITING; ANOTHER UNUSUAL SITUATION. THE FPL WALKED TO THE SUPVR'S DESK AND ASKED IF AN EXERCISE WAS OCCURRING. THE SUPVR SAID THAT THERE WAS; ALTHOUGH NO BRIEFING BY THE AGENCY HAD BEEN PROVIDED. THE TRAINEE ISSUED 3000 FT TO THE C208 THAT WAS LEVEL AT 5000 FT AND CONVERGING WITH DH8A AT 4000 FT. AT THE TIME THE FPL WAS QUERYING THE SUPVR; AND THE FPL DIDN'T HEAR THE CLRNC. THE FPL RETURNED TO THE POS WITH NOTE PAPER; LOOKED AT THE SCOPE AND SAW NOTHING UNUSUAL (C208 HAD NOT BEGUN DSCNT); AND BEGAN TO WRITE NOTES FOR THE DEBRIEF WITH THE TRAINEE. THE TRAINEE ISSUED A HARD TURN TO THE C208 AT WHICH TIME THE FPL LOOKED AT THE SCOPE AND SAW THE OPERROR AND TOOK THE POS. CAUSAL FACTOR #1: THE LACK OF A BRIEFING BY THE AGENCY ABOUT THE MIL EXERCISE CAUSED A DISTR FOR THE FPL. IF A BRIEFING HAD BEEN MADE; THE FPL WOULD NOT HAVE LEFT THE POS TO QUERY THE SUPVR AND WOULD HAVE CORRECTED THE 3000 FT CLRNC ISSUED TO THE C208 IN A TIMELY MANNER. CAUSAL FACTOR #2: ALTHOUGH PART OF THE CONFLICT ALERT SOFTWARE DID ACTIVATE AND 'FLASH' ON THE SCOPE; NO AURAL ALARM WAS ACTIVATED. THE AURAL ALARM WOULD HAVE ALERTED THE FPL TO THE SITUATION AND TAKE OVER AND WOULD HAVE PREVENTED THE DH8A FROM TAKING EVASIVE ACTION. CAUSAL FACTOR #3: THE C208 HAD DSNDED ONLY 800 FT IN 2 MINS 20 SECONDS; BUT ITS CLB/DSCNT RATE IS 1400 FPM WHICH IS A VIOLATION OF THE AIM. THE C208 WAS NOT ISSUED A PLT'S DISCRETION DSCNT. THE REFUSAL TO DSND IN ACCORDANCE WITH THE AIM HAS BEEN AN ONGOING PROB FOR ANCHORAGE APCH CTLRS WITH MANY AIR TAXI OPERATORS THAT WILL HOPEFULLY BE ADDRESSED BY MGMNT NOW. SUPPLEMENTAL INFO FROM ACN 738035: I WAS TRAINING ON S RADAR WHEN A DH8 DEPARTED ANCHORAGE SBOUND TO ENA. THEY CHKED IN AND I SENT THEM DIRECT ENA AT 4000 FT. A C208 CHKED IN OVER NAPTO AT 5000 FT. I ADVISED THEM TO PLAN RWY '7L.' A LITTLE LATER I DSNDED THE C208 TO 3000 FT. LATER I WAS SCANNING THE SCOPE AND SAW BOTH ACFT OPPOSITE DIRECTION 2 MI APART; SAME ALT. I TOLD THE C208 TO TURN R HDG 090 DEGS. I TOLD THE DH8 TO TURN R HDG 270 DEGS. THEY SAID THEY WERE RESPONDING TO A TCAS RA. I SAID ROGER. THEN THEY SAID THEY WERE CLR AND I WAS UNPLUGGED AND TRAINING WAS TERMINATED AT THIS POINT. INITIALLY I KEPT THE C208 AT 5000 FT TO KEEP ABOVE THE DH8; BUT SOON THOUGHT IT WOULD NOT HAVE BEEN A FACTOR. THE C208 DSNDED AT A REALLY SLOW RATE 800 FT IN 2 MINS AND 20 SECONDS AND I OBVIOUSLY DIDN'T MONITOR THE SITUATION CONTINUOUSLY. I HAD A FEW OTHER ACFT ON FREQ BUT NOT TOO MANY TO BE A FACTOR.
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.