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|
Attributes | |
ACN | 89020 |
Time | |
Date | 198806 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sie |
State Reference | NJ |
Altitude | msl bound lower : 35000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ewr |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | cruise other |
Route In Use | enroute airway : b24 enroute airway : a300 |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : flight data |
Qualification | controller : developmental |
Experience | controller non radar : 3 |
ASRS Report | 89020 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 15000 |
ASRS Report | 88849 |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 1500 vertical : 0 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
The problem began at about XA01 local time when I, a non radar controller at the ny ARTCC, approved FL350 northbound on the amber 300 route (A300) for heavy transport Y. I was working sector D88/89 at the time for about 2 hours and 25 mins and was feeling slightly fatigued, both mentally and physically. Approximately 10 mins later I was relieved for my lunch break. During the course of giving my position relief briefing, I noticed my failure to mark all 3 of my flight progress strips on heavy transport Y at FL350 (the computer generated and printed altitude of FL310 was in the altitude box on my other 2 strips). I then marked the strips properly but forgot to coordinate the changed altitude to the next sector, D82, and failed to point this out to the controller relieving me. This is where the error initially occurred, and the following events just compounded it. When I returned from lunch I relieved the controller at sector D82. I worked this sector from approximately XB10 local to XC15 local and during that time was training another deviation. At about XB30 local, bermuda control called my sector with an estimate on large transport X. Traveling nwbnd on B24. FL350 was approved on this flight, thinking that he didn't have any traffic because heavy transport Y was being incorrectly shown at FL310. At about XB50 local time I noticed the controller working D88/89 was very busy and that his progress reports that we receive via printer from radio were beginning to pile up. I got up from my sector and proceeded to help him by doing his progress reports. One of the reports I did was heavy transport Y by the last reporting point in D88/89 (catch intersection). I failed to transfer the estimate for the champ intersection to my sector at that time assuming that I would receive the estimate on the D82 printer. As it turns out, I never did receive the estimate on the D82 printer. At about XC10 local time I noticed that I did not forward a pilot estimate to the radar sector R65 that is adjacent to D82. My trnee and I got up and checked the copy on the D88/89 printer to check the estimate, but failed to notice the different altitude. A system error then occurred as the 2 aircraft xed each other at FL350 at the champ intersection. The error was not discovered until the pilot of large transport X told the controller working R65 that they had just missed heavy transport Y. In retrospect I realize that I was working D88/89 for too long a period of time west/O a break. I also was working my sixth straight day and was working a day shift after working a night shift the night before I also feel that something should be done about the method of ATC being used over the ny oceanic control area. The present system was developed at a time when there wasn't many aircraft and they didn't go as fast and fly as high as they do now. This system is ancient and should be changed immediately before many people get killed and 1 air traffic controller's life gets ruined.
Original NASA ASRS Text
Title: TWO ACR'S PASS IN CLOSE PROX ON CONVERGING COURSES AT THE SAME ALT IN OCEANIC AIRSPACE.
Narrative: THE PROB BEGAN AT ABOUT XA01 LCL TIME WHEN I, A NON RADAR CTLR AT THE NY ARTCC, APPROVED FL350 NBOUND ON THE AMBER 300 ROUTE (A300) FOR HVT Y. I WAS WORKING SECTOR D88/89 AT THE TIME FOR ABOUT 2 HRS AND 25 MINS AND WAS FEELING SLIGHTLY FATIGUED, BOTH MENTALLY AND PHYSICALLY. APPROX 10 MINS LATER I WAS RELIEVED FOR MY LUNCH BREAK. DURING THE COURSE OF GIVING MY POSITION RELIEF BRIEFING, I NOTICED MY FAILURE TO MARK ALL 3 OF MY FLT PROGRESS STRIPS ON HVT Y AT FL350 (THE COMPUTER GENERATED AND PRINTED ALT OF FL310 WAS IN THE ALT BOX ON MY OTHER 2 STRIPS). I THEN MARKED THE STRIPS PROPERLY BUT FORGOT TO COORDINATE THE CHANGED ALT TO THE NEXT SECTOR, D82, AND FAILED TO POINT THIS OUT TO THE CTLR RELIEVING ME. THIS IS WHERE THE ERROR INITIALLY OCCURRED, AND THE FOLLOWING EVENTS JUST COMPOUNDED IT. WHEN I RETURNED FROM LUNCH I RELIEVED THE CTLR AT SECTOR D82. I WORKED THIS SECTOR FROM APPROX XB10 LCL TO XC15 LCL AND DURING THAT TIME WAS TRNING ANOTHER DEV. AT ABOUT XB30 LCL, BERMUDA CTL CALLED MY SECTOR WITH AN ESTIMATE ON LGT X. TRAVELING NWBND ON B24. FL350 WAS APPROVED ON THIS FLT, THINKING THAT HE DIDN'T HAVE ANY TFC BECAUSE HVT Y WAS BEING INCORRECTLY SHOWN AT FL310. AT ABOUT XB50 LCL TIME I NOTICED THE CTLR WORKING D88/89 WAS VERY BUSY AND THAT HIS PROGRESS RPTS THAT WE RECEIVE VIA PRINTER FROM RADIO WERE BEGINNING TO PILE UP. I GOT UP FROM MY SECTOR AND PROCEEDED TO HELP HIM BY DOING HIS PROGRESS RPTS. ONE OF THE RPTS I DID WAS HVT Y BY THE LAST RPTING POINT IN D88/89 (CATCH INTXN). I FAILED TO TRANSFER THE ESTIMATE FOR THE CHAMP INTXN TO MY SECTOR AT THAT TIME ASSUMING THAT I WOULD RECEIVE THE ESTIMATE ON THE D82 PRINTER. AS IT TURNS OUT, I NEVER DID RECEIVE THE ESTIMATE ON THE D82 PRINTER. AT ABOUT XC10 LCL TIME I NOTICED THAT I DID NOT FORWARD A PLT ESTIMATE TO THE RADAR SECTOR R65 THAT IS ADJACENT TO D82. MY TRNEE AND I GOT UP AND CHKED THE COPY ON THE D88/89 PRINTER TO CHK THE ESTIMATE, BUT FAILED TO NOTICE THE DIFFERENT ALT. A SYSTEM ERROR THEN OCCURRED AS THE 2 ACFT XED EACH OTHER AT FL350 AT THE CHAMP INTXN. THE ERROR WAS NOT DISCOVERED UNTIL THE PLT OF LGT X TOLD THE CTLR WORKING R65 THAT THEY HAD JUST MISSED HVT Y. IN RETROSPECT I REALIZE THAT I WAS WORKING D88/89 FOR TOO LONG A PERIOD OF TIME W/O A BREAK. I ALSO WAS WORKING MY SIXTH STRAIGHT DAY AND WAS WORKING A DAY SHIFT AFTER WORKING A NIGHT SHIFT THE NIGHT BEFORE I ALSO FEEL THAT SOMETHING SHOULD BE DONE ABOUT THE METHOD OF ATC BEING USED OVER THE NY OCEANIC CTL AREA. THE PRESENT SYS WAS DEVELOPED AT A TIME WHEN THERE WASN'T MANY ACFT AND THEY DIDN'T GO AS FAST AND FLY AS HIGH AS THEY DO NOW. THIS SYS IS ANCIENT AND SHOULD BE CHANGED IMMEDIATELY BEFORE MANY PEOPLE GET KILLED AND 1 AIR TFC CTLR'S LIFE GETS RUINED.
Data retrieved from NASA's ASRS site as of August 2007 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.