37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 799060 |
Time | |
Date | 200808 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : rdu.airport |
State Reference | NC |
Altitude | msl single value : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : rdu.tracon |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : pack |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller radar : 25 controller time certified in position1 : 8 |
ASRS Report | 799060 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | airspace violation : entry altitude deviation : overshoot non adherence : required legal separation non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : investigated |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was working rdu departure. Aircraft X checked in off of runway 5R reporting leaving 2600 ft for 7000 ft. I radar idented the aircraft and issued a left turn heading 240 degrees; resume the PACK6 departure; climb and maintain 12000 ft. The aircraft read back heading 240 degrees; resume the PACK6; maintain 16000 ft. I caught the incorrect altitude. About 30 seconds later the pilot requested a heading verification. I informed the aircraft I was more concerned with the incorrect altitude readback than his heading. The aircraft read back 12000 ft. I noticed the aircraft in a right turn (they were instructed to turn left) and instructed the aircraft to continue the right turn to a heading of 140 degrees and again to maintain 12000 ft. The pilot acknowledged with a correct readback. It appeared that the aircraft began a left turn and I asked what heading they were turning to. The pilot reads back 240 degrees (was assigned 140 degrees) and says we've got it under control. The pilot then comes back and asks for a heading and altitude verification again. I instructed the aircraft to continue the right turn to a 230 degree heading. The tower beeped in my ear with coordination as the aircraft read back his heading of 230 degrees and 'maintain 16000 ft.' I missed the altitude readback due to coordination with the tower. The aircraft had already acknowledged 12000 ft on 2 previous occasions and then reverts back to 16000 ft for some reason. The pilot asks me if he was to turn to azell intersection and resume the departure; and I informed the pilot he was on an assigned vector of 230 degrees. I was busy working several other departures during this time and 2 overflt aircraft. I observed the aircraft had climbed through his last assigned altitude and instructed the aircraft to maintain 12000 ft and I then coordination with the overlying center. The aircraft never leveled and continued to climb. The aircraft was then assigned FL230 and advised of a possible pilot deviation. I later learned that the tower had to issue the initial heading to the same aircraft 2 times due to incorrect readbacks. The flight crew's inattentiveness caused undue stress and additional workload and could have caused a serious accident had the incorrect headings; turns; and altitudes conflicted with another aircraft.
Original NASA ASRS Text
Title: RDU CTLR DESCRIBED OPDEV WHEN ACR DEP FAILED TO COMPLY WITH ALT RESTRICTION; ENTERING ADJACENT AIRSPACE WITHOUT HDOF.
Narrative: I WAS WORKING RDU DEP. ACFT X CHKED IN OFF OF RWY 5R RPTING LEAVING 2600 FT FOR 7000 FT. I RADAR IDENTED THE ACFT AND ISSUED A L TURN HDG 240 DEGS; RESUME THE PACK6 DEP; CLB AND MAINTAIN 12000 FT. THE ACFT READ BACK HDG 240 DEGS; RESUME THE PACK6; MAINTAIN 16000 FT. I CAUGHT THE INCORRECT ALT. ABOUT 30 SECONDS LATER THE PLT REQUESTED A HDG VERIFICATION. I INFORMED THE ACFT I WAS MORE CONCERNED WITH THE INCORRECT ALT READBACK THAN HIS HDG. THE ACFT READ BACK 12000 FT. I NOTICED THE ACFT IN A R TURN (THEY WERE INSTRUCTED TO TURN L) AND INSTRUCTED THE ACFT TO CONTINUE THE R TURN TO A HDG OF 140 DEGS AND AGAIN TO MAINTAIN 12000 FT. THE PLT ACKNOWLEDGED WITH A CORRECT READBACK. IT APPEARED THAT THE ACFT BEGAN A L TURN AND I ASKED WHAT HDG THEY WERE TURNING TO. THE PLT READS BACK 240 DEGS (WAS ASSIGNED 140 DEGS) AND SAYS WE'VE GOT IT UNDER CTL. THE PLT THEN COMES BACK AND ASKS FOR A HDG AND ALT VERIFICATION AGAIN. I INSTRUCTED THE ACFT TO CONTINUE THE R TURN TO A 230 DEG HDG. THE TWR BEEPED IN MY EAR WITH COORD AS THE ACFT READ BACK HIS HDG OF 230 DEGS AND 'MAINTAIN 16000 FT.' I MISSED THE ALT READBACK DUE TO COORD WITH THE TWR. THE ACFT HAD ALREADY ACKNOWLEDGED 12000 FT ON 2 PREVIOUS OCCASIONS AND THEN REVERTS BACK TO 16000 FT FOR SOME REASON. THE PLT ASKS ME IF HE WAS TO TURN TO AZELL INTXN AND RESUME THE DEP; AND I INFORMED THE PLT HE WAS ON AN ASSIGNED VECTOR OF 230 DEGS. I WAS BUSY WORKING SEVERAL OTHER DEPS DURING THIS TIME AND 2 OVERFLT ACFT. I OBSERVED THE ACFT HAD CLBED THROUGH HIS LAST ASSIGNED ALT AND INSTRUCTED THE ACFT TO MAINTAIN 12000 FT AND I THEN COORD WITH THE OVERLYING CTR. THE ACFT NEVER LEVELED AND CONTINUED TO CLB. THE ACFT WAS THEN ASSIGNED FL230 AND ADVISED OF A POSSIBLE PLTDEV. I LATER LEARNED THAT THE TWR HAD TO ISSUE THE INITIAL HDG TO THE SAME ACFT 2 TIMES DUE TO INCORRECT READBACKS. THE FLT CREW'S INATTENTIVENESS CAUSED UNDUE STRESS AND ADDITIONAL WORKLOAD AND COULD HAVE CAUSED A SERIOUS ACCIDENT HAD THE INCORRECT HDGS; TURNS; AND ALTS CONFLICTED WITH ANOTHER ACFT.
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.