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|
Attributes | |
ACN | 91474 |
Time | |
Date | 198807 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : ont |
State Reference | CA |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ont tracon : sna |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
ASRS Report | 91474 |
Person 2 | |
Affiliation | government : faa |
Function | controller : handoff position |
Qualification | controller : radar |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 15000 vertical : 0 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Inter Facility Coordination Failure |
Narrative:
At XA00Z, medium large transport X checked in with me at sli 145 degree right/10 DME heading 020 degrees at 5000' MSL, landing sna. This was during heavy traffic conditions with a handoff person. The next transmission from medium large transport X was at XA06Z, 10 mi southwest of ont at 5000'. There was no ARTS tag or transponder at this position, only a primary radar presentation. A pointout was made from coast to ont. Ont did not observe a target or transponder at this point. The strip was located in the file box. Transponder code was verified, and transponder reappeared at this time. Then ont TRACON responded to finding this transponder code. Pilot stated there had been a problem with transponder in morning. Circumstances: failed transponder, strip accidentally filed away by handoff person, handoff dropped from coast tab list, heavy traffic, radar person was in his fifth hour of his sixth day of 6 days scheduled--this sixth day was his fifteenth scheduled overtime in a row. His last 2 day weekend was the first week in april while on vacation. That's 25 overtime days since 1/88, ont TRACON did not protect 5000' after the incident reported, resulting in operational error with an small aircraft Y at 5000' (2 1/2 mi, same altitude). Callback conversation with reporter revealed the following: when the ARTS handoff was taken by the reporter, everything about the ARTS tag was normal. Almost immediately, the transponder of the air carrier medium large transport failed and the ARTS tag went into coast and into the coast list. The handoff controller saw the identification in the coast list. He assumed that the controller had cleared the aircraft for approach and given a frequency chg to sna tower. He then took the flight progress strip for the flight and filed it away. With no strip in front of him and no ARTS tag on the medium large transport target, reporter forgot about the flight until the pilot called to ask about a turn to the final approach course. Reporter stated that the traffic vol was very high at the time, and that he did not have time to devote much attention to the medium large transport.
Original NASA ASRS Text
Title: ACR MLG ENTERED ADJACENT CTLR'S AIRSPACE WITHOUT COORD OR HANDOFF AND CONFLICTED WITH TRAFFIC IN THAT CTLR'S SECTOR.
Narrative: AT XA00Z, MLG X CHKED IN WITH ME AT SLI 145 DEG R/10 DME HDG 020 DEGS AT 5000' MSL, LNDG SNA. THIS WAS DURING HVY TFC CONDITIONS WITH A HDOF PERSON. THE NEXT XMISSION FROM MLG X WAS AT XA06Z, 10 MI SW OF ONT AT 5000'. THERE WAS NO ARTS TAG OR TRANSPONDER AT THIS POS, ONLY A PRIMARY RADAR PRESENTATION. A POINTOUT WAS MADE FROM COAST TO ONT. ONT DID NOT OBSERVE A TARGET OR TRANSPONDER AT THIS POINT. THE STRIP WAS LOCATED IN THE FILE BOX. TRANSPONDER CODE WAS VERIFIED, AND TRANSPONDER REAPPEARED AT THIS TIME. THEN ONT TRACON RESPONDED TO FINDING THIS TRANSPONDER CODE. PLT STATED THERE HAD BEEN A PROB WITH TRANSPONDER IN MORNING. CIRCUMSTANCES: FAILED TRANSPONDER, STRIP ACCIDENTALLY FILED AWAY BY HDOF PERSON, HDOF DROPPED FROM COAST TAB LIST, HVY TFC, RADAR PERSON WAS IN HIS FIFTH HR OF HIS SIXTH DAY OF 6 DAYS SCHEDULED--THIS SIXTH DAY WAS HIS FIFTEENTH SCHEDULED OVERTIME IN A ROW. HIS LAST 2 DAY WEEKEND WAS THE FIRST WK IN APRIL WHILE ON VACATION. THAT'S 25 OVERTIME DAYS SINCE 1/88, ONT TRACON DID NOT PROTECT 5000' AFTER THE INCIDENT RPTED, RESULTING IN OPERROR WITH AN SMA Y AT 5000' (2 1/2 MI, SAME ALT). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: WHEN THE ARTS HDOF WAS TAKEN BY THE RPTR, EVERYTHING ABOUT THE ARTS TAG WAS NORMAL. ALMOST IMMEDIATELY, THE TRANSPONDER OF THE ACR MLG FAILED AND THE ARTS TAG WENT INTO COAST AND INTO THE COAST LIST. THE HDOF CTLR SAW THE ID IN THE COAST LIST. HE ASSUMED THAT THE CTLR HAD CLRED THE ACFT FOR APCH AND GIVEN A FREQ CHG TO SNA TWR. HE THEN TOOK THE FLT PROGRESS STRIP FOR THE FLT AND FILED IT AWAY. WITH NO STRIP IN FRONT OF HIM AND NO ARTS TAG ON THE MLG TARGET, RPTR FORGOT ABOUT THE FLT UNTIL THE PLT CALLED TO ASK ABOUT A TURN TO THE FINAL APCH COURSE. RPTR STATED THAT THE TFC VOL WAS VERY HIGH AT THE TIME, AND THAT HE DID NOT HAVE TIME TO DEVOTE MUCH ATTN TO THE MLG.
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.