37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 784838 |
Time | |
Date | 200805 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : sfo.tower |
Operator | general aviation : corporate |
Make Model Name | HS 125 Series |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : radar |
Experience | controller limited radar : 16 controller non radar : 4 |
ASRS Report | 784838 |
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 none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 6000 vertical : 1000 |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I was working local control at sfo ATCT for 1 hour 30 mins. Landing runways 28; departing runways 1. I had traffic landing on both runways 28 with another pair of arrs approaching 2 mi final for runways 28L and 28R. Aircraft Y was holding in position on runway 1R. Air carrier X was holding in position on runway 1L with a wheels-up time (flow time) of XA01. I did not notice that air carrier X was an SFO8 departure over lin. This is the same departure SID that aircraft Y was on. There was no red 'left' on air carrier X strip to alert me that a right turn was at runway 1L; as required by SOP. Both aircraft Y and air carrier X had to hold in position on runways 1 while several aircraft landed on runways 28. The finals straightened out just in time to make the XA01 time for air carrier X. When the arrs cleared runway 1R I cleared aircraft Y for takeoff. A few seconds later the arrs cleared runway 1L and I cleared air carrier X for takeoff. I thought air carrier X was a PT3 departure; a left turn. A controller plugged in to relieve me so I began searching for the position relief briefing checklist. I began the position relief briefing checklist. I began the position relief briefing while I continued to work traffic. During the position relief briefing I shipped aircraft Y to departure. At the end of the position relief briefing I shipped air carrier X to departure. I noticed that air carrier X was still going straight out; they had not started a turn yet; about 1/2 mi off departure end. I changed places with the relieving controller and he began working the position. I moved back to the computer to make the changes to the duty board. When I returned I saw that air carrier X was now nebound. Chain of events: air carrier X was rerted from PT3 to SFO8. Air carrier X taxied to runway 1L by ground control but not marked with red 'left' (tmc working ground control). Air carrier X was issued XA01 wheels-up time. I loaded air carrier X on runway 1L without noticing that air carrier X was SFO8-lin. All I saw was XA01 wheels-up time and ZZZ destination. ZZZ flts usually get PT3 departure at sfo. My attention was primarily focused on the landing runways to ensure that they were clear and on finals. I cleared aircraft Y and air carrier X in a tight hole with landing traffic on a 2 mi final. I only cleared air carrier X because I wanted to make the XA01 wheels-up time. If there had been no wheels-up time I would surely have waited for a bigger hole.
Original NASA ASRS Text
Title: SFO CTLR EXPERIENCED OPERROR AFTER ISSUING TKOF CLRNC TO PARALLEL RWY DEPS; BOTH ASSIGNED THE SAME ROUTE; CITING SEVERAL CONTRIBUTING FACTORS.
Narrative: I WAS WORKING LCL CTL AT SFO ATCT FOR 1 HR 30 MINS. LNDG RWYS 28; DEPARTING RWYS 1. I HAD TFC LNDG ON BOTH RWYS 28 WITH ANOTHER PAIR OF ARRS APCHING 2 MI FINAL FOR RWYS 28L AND 28R. ACFT Y WAS HOLDING IN POS ON RWY 1R. ACR X WAS HOLDING IN POS ON RWY 1L WITH A WHEELS-UP TIME (FLOW TIME) OF XA01. I DID NOT NOTICE THAT ACR X WAS AN SFO8 DEP OVER LIN. THIS IS THE SAME DEP SID THAT ACFT Y WAS ON. THERE WAS NO RED 'L' ON ACR X STRIP TO ALERT ME THAT A R TURN WAS AT RWY 1L; AS REQUIRED BY SOP. BOTH ACFT Y AND ACR X HAD TO HOLD IN POS ON RWYS 1 WHILE SEVERAL ACFT LANDED ON RWYS 28. THE FINALS STRAIGHTENED OUT JUST IN TIME TO MAKE THE XA01 TIME FOR ACR X. WHEN THE ARRS CLRED RWY 1R I CLRED ACFT Y FOR TKOF. A FEW SECONDS LATER THE ARRS CLRED RWY 1L AND I CLRED ACR X FOR TKOF. I THOUGHT ACR X WAS A PT3 DEP; A L TURN. A CTLR PLUGGED IN TO RELIEVE ME SO I BEGAN SEARCHING FOR THE POS RELIEF BRIEFING CHKLIST. I BEGAN THE POS RELIEF BRIEFING CHKLIST. I BEGAN THE POS RELIEF BRIEFING WHILE I CONTINUED TO WORK TFC. DURING THE POS RELIEF BRIEFING I SHIPPED ACFT Y TO DEP. AT THE END OF THE POS RELIEF BRIEFING I SHIPPED ACR X TO DEP. I NOTICED THAT ACR X WAS STILL GOING STRAIGHT OUT; THEY HAD NOT STARTED A TURN YET; ABOUT 1/2 MI OFF DEP END. I CHANGED PLACES WITH THE RELIEVING CTLR AND HE BEGAN WORKING THE POS. I MOVED BACK TO THE COMPUTER TO MAKE THE CHANGES TO THE DUTY BOARD. WHEN I RETURNED I SAW THAT ACR X WAS NOW NEBOUND. CHAIN OF EVENTS: ACR X WAS RERTED FROM PT3 TO SFO8. ACR X TAXIED TO RWY 1L BY GND CTL BUT NOT MARKED WITH RED 'L' (TMC WORKING GND CTL). ACR X WAS ISSUED XA01 WHEELS-UP TIME. I LOADED ACR X ON RWY 1L WITHOUT NOTICING THAT ACR X WAS SFO8-LIN. ALL I SAW WAS XA01 WHEELS-UP TIME AND ZZZ DEST. ZZZ FLTS USUALLY GET PT3 DEP AT SFO. MY ATTN WAS PRIMARILY FOCUSED ON THE LNDG RWYS TO ENSURE THAT THEY WERE CLR AND ON FINALS. I CLRED ACFT Y AND ACR X IN A TIGHT HOLE WITH LNDG TFC ON A 2 MI FINAL. I ONLY CLRED ACR X BECAUSE I WANTED TO MAKE THE XA01 WHEELS-UP TIME. IF THERE HAD BEEN NO WHEELS-UP TIME I WOULD SURELY HAVE WAITED FOR A BIGGER HOLE.
Data retrieved from NASA's ASRS site as of May 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.