Narrative:

I am the controller who was working the north final position at the time of the incident. Aircraft west, cleared for NDB runway 14 approach at mtn, flew across the final approach course and required vectors to a second approach. During this time aircraft X was on a vector for ILS runway 28 approach at bwi. Aircraft X was not cleared for approach, so he flew across the localizer for runways 28 and 33L. Sep was lost between X and air carrier aircraft Y on final for runway 33L at bwi. During the time I was working on aircraft X, aircraft west came in close proximity to commuter Z who was eastbound for ILS 28 at bwi. I turned west northbound and Z southbound. West reported a near miss with a commuter aircraft, but said no evasive action was required. Factors contributing to situation: 1) it was near the end of shift and I was over 2 hours on this position west/O a break, working steady, heavy complex traffic. 2) equipment outage in the tower required manual and handoff on each bwi arrival, no handoff person was available to assist me. 3) I expected aircraft west pilot to be able to make a normal approach the first time he was cleared. The special attention that was required to assist this pilot in making his approach was the biggest factor leading up to the incident. 4) mtn was in an east operation and bwi in a west operation, which increases the north final workload tremendously. I was advised this will change in oct due to this occurrence. 5) the supervisor requested a 20 mi in trail and 250 KT restriction from ZDC due to personnel shortage and was overruled by mgt. Bwi needs more controllers. The hub and spoke system is a nightmare for ATC and the airline schedules should be spread out more evenly, no matter how much the airlines, or AOPA complains. I do not feel bwi's procedures are adequate to handle the number of aircraft they do, with the number of controllers they have. Bwi needs less airspace, fewer arrival routes, better flow control, more controllers and needs another jet runway before they allow any more airline expansion. Callback conversation with reporter revealed the following: reporter gave yrs in ATC. Described flight paths and altitudes of all 4 aircraft. Targets merged in both conflicts. Aircraft west and Z both at 2500'. Also aircraft X was at 2500' and south final controller stopped air carrier Y at 3000'. Aircraft west was given poor turn-on for NDB runway 14 at mtn and pilot was following proper procedure for that approach. WX was marginal and all aircraft were on IFR flight plan and making IFR approachs. Review board concluded that reporter had traffic which exceeded his capabilities. Had forgotten about aircraft X and after X conflict with air carrier Y the aircraft X was turned in behind Y for ILS 33L. Aircraft west and Z were in very close proximity to each other and we saw Z, but did not think evasive action was necessary. Reporter asked me to delete part of his narrative reference pilot of aircraft west not being able to fly NDB approach.

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Original NASA ASRS Text

Title: 4 ACFT INVOLVED IN 2 CASES OF LESS THAN STANDARD SEPARATION AT ABOUT THE SAME TIME. OPERATIONAL ERROR.

Narrative: I AM THE CTLR WHO WAS WORKING THE N FINAL POS AT THE TIME OF THE INCIDENT. ACFT W, CLRED FOR NDB RWY 14 APCH AT MTN, FLEW ACROSS THE FINAL APCH COURSE AND REQUIRED VECTORS TO A SECOND APCH. DURING THIS TIME ACFT X WAS ON A VECTOR FOR ILS RWY 28 APCH AT BWI. ACFT X WAS NOT CLRED FOR APCH, SO HE FLEW ACROSS THE LOC FOR RWYS 28 AND 33L. SEP WAS LOST BTWN X AND ACR ACFT Y ON FINAL FOR RWY 33L AT BWI. DURING THE TIME I WAS WORKING ON ACFT X, ACFT W CAME IN CLOSE PROX TO COMMUTER Z WHO WAS EBND FOR ILS 28 AT BWI. I TURNED W NBOUND AND Z SBND. W RPTED A NEAR MISS WITH A COMMUTER ACFT, BUT SAID NO EVASIVE ACTION WAS REQUIRED. FACTORS CONTRIBUTING TO SITUATION: 1) IT WAS NEAR THE END OF SHIFT AND I WAS OVER 2 HRS ON THIS POS W/O A BREAK, WORKING STEADY, HVY COMPLEX TFC. 2) EQUIP OUTAGE IN THE TWR REQUIRED MANUAL AND HDOF ON EACH BWI ARR, NO HDOF PERSON WAS AVAILABLE TO ASSIST ME. 3) I EXPECTED ACFT W PLT TO BE ABLE TO MAKE A NORMAL APCH THE FIRST TIME HE WAS CLRED. THE SPECIAL ATTN THAT WAS REQUIRED TO ASSIST THIS PLT IN MAKING HIS APCH WAS THE BIGGEST FACTOR LEADING UP TO THE INCIDENT. 4) MTN WAS IN AN E OPERATION AND BWI IN A W OPERATION, WHICH INCREASES THE N FINAL WORKLOAD TREMENDOUSLY. I WAS ADVISED THIS WILL CHANGE IN OCT DUE TO THIS OCCURRENCE. 5) THE SUPVR REQUESTED A 20 MI IN TRAIL AND 250 KT RESTRICTION FROM ZDC DUE TO PERSONNEL SHORTAGE AND WAS OVERRULED BY MGT. BWI NEEDS MORE CTLRS. THE HUB AND SPOKE SYS IS A NIGHTMARE FOR ATC AND THE AIRLINE SCHEDULES SHOULD BE SPREAD OUT MORE EVENLY, NO MATTER HOW MUCH THE AIRLINES, OR AOPA COMPLAINS. I DO NOT FEEL BWI'S PROCS ARE ADEQUATE TO HANDLE THE NUMBER OF ACFT THEY DO, WITH THE NUMBER OF CTLRS THEY HAVE. BWI NEEDS LESS AIRSPACE, FEWER ARR ROUTES, BETTER FLOW CTL, MORE CTLRS AND NEEDS ANOTHER JET RWY BEFORE THEY ALLOW ANY MORE AIRLINE EXPANSION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR GAVE YRS IN ATC. DESCRIBED FLT PATHS AND ALTS OF ALL 4 ACFT. TARGETS MERGED IN BOTH CONFLICTS. ACFT W AND Z BOTH AT 2500'. ALSO ACFT X WAS AT 2500' AND S FINAL CTLR STOPPED ACR Y AT 3000'. ACFT W WAS GIVEN POOR TURN-ON FOR NDB RWY 14 AT MTN AND PLT WAS FOLLOWING PROPER PROC FOR THAT APCH. WX WAS MARGINAL AND ALL ACFT WERE ON IFR FLT PLAN AND MAKING IFR APCHS. REVIEW BOARD CONCLUDED THAT RPTR HAD TFC WHICH EXCEEDED HIS CAPABILITIES. HAD FORGOTTEN ABOUT ACFT X AND AFTER X CONFLICT WITH ACR Y THE ACFT X WAS TURNED IN BEHIND Y FOR ILS 33L. ACFT W AND Z WERE IN VERY CLOSE PROX TO EACH OTHER AND WE SAW Z, BUT DID NOT THINK EVASIVE ACTION WAS NECESSARY. RPTR ASKED ME TO DELETE PART OF HIS NARRATIVE REF PLT OF ACFT W NOT BEING ABLE TO FLY NDB APCH.

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.