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|
Attributes | |
ACN | 98193 |
Time | |
Date | 198811 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : phx |
State Reference | AZ |
Altitude | msl bound lower : 8400 msl bound upper : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : phx |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, Low Wing, 1 Eng, Retractable Gear |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Experience | controller military : 7 controller non radar : 1 controller radar : 8 flight time last 90 days : 150 flight time total : 1500 |
ASRS Report | 98193 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 8000 |
ASRS Report | 97949 |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Miss Distance | horizontal : 16500 vertical : 600 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
As the radar controller, I was working the south departure sector at phx TRACON. I had an IFR small aircraft wbound IFR climbing to 10000' MSL. Tower called off 2 acrs, #1 on a stanfield departure, #2 on a mobie departure visual on #1. All 3 aircraft departed runway 26. The first air carrier checked in professionally with an altitude leaving and an altitude climbing to ('one-six-thousand'). I told air carrier #1 to amend altitude to maintain 6000' which the pilot read back. Small aircraft X was out of 7000', so air carrier #1 would pass below. Air carrier #2 reported airborne nonprofessionally with his altitude leaving (says nothing about assigned altitude [16000']). I told #2 to maintain 6000'. Crew read back slightly garbled but 6000' was received. #2 climbed through the altitude of small aircraft X causing loss of IFR sep. Contributing factors: air carrier #2 initially assigned 16000'. I instructed #2 to maintain 6000' west/O saying amend altitude. #2 did not, on initial contact, advise his altitude climbing to. When the pilot read back climbing to 16000', I did not hear the '1' and it is extremely garbled on the tape. Bottom line: my failure to not say 'amend altitude' and the crew having an assignment of 16000' but not advising me. Correcting the problem: have mandatory standard phraseology for pilots and crew just as for controllers. The pilot bears absolutely no responsibility for being required to hear me correctly. The controller is ultimately responsible though to hear the pilot's correct readback. Callback conversation with reporter revealed the following: reporter heard the tape of this incident shortly after he was removed from his position for recertification. He admits that the readback from the #2 air carrier was for an altitude of 'one six thousand,' and he missed the 'one.' his statement that he was being transferred to a VFR level ii tower for having this system error was not correct. He said that this incident was his third in 2 yrs and he told facility management that he would prefer to transfer to the VFR tower if they planned an extended period of 'humility training.' such was not the case, and he was returned to duty after recertification training was completed.
Original NASA ASRS Text
Title: ACR-LGT FLT CREW MISSED ALT CHANGE AND CTLR MISSED ERROR IN READBACK RESULTING IN LESS THAN STANDARD SEPARATION WHEN ACR-LGT CLIMBED THROUGH ALT OF SMA.
Narrative: AS THE RADAR CTLR, I WAS WORKING THE S DEP SECTOR AT PHX TRACON. I HAD AN IFR SMA WBOUND IFR CLBING TO 10000' MSL. TWR CALLED OFF 2 ACRS, #1 ON A STANFIELD DEP, #2 ON A MOBIE DEP VISUAL ON #1. ALL 3 ACFT DEPARTED RWY 26. THE FIRST ACR CHKED IN PROFESSIONALLY WITH AN ALT LEAVING AND AN ALT CLBING TO ('ONE-SIX-THOUSAND'). I TOLD ACR #1 TO AMEND ALT TO MAINTAIN 6000' WHICH THE PLT READ BACK. SMA X WAS OUT OF 7000', SO ACR #1 WOULD PASS BELOW. ACR #2 RPTED AIRBORNE NONPROFESSIONALLY WITH HIS ALT LEAVING (SAYS NOTHING ABOUT ASSIGNED ALT [16000']). I TOLD #2 TO MAINTAIN 6000'. CREW READ BACK SLIGHTLY GARBLED BUT 6000' WAS RECEIVED. #2 CLBED THROUGH THE ALT OF SMA X CAUSING LOSS OF IFR SEP. CONTRIBUTING FACTORS: ACR #2 INITIALLY ASSIGNED 16000'. I INSTRUCTED #2 TO MAINTAIN 6000' W/O SAYING AMEND ALT. #2 DID NOT, ON INITIAL CONTACT, ADVISE HIS ALT CLBING TO. WHEN THE PLT READ BACK CLBING TO 16000', I DID NOT HEAR THE '1' AND IT IS EXTREMELY GARBLED ON THE TAPE. BOTTOM LINE: MY FAILURE TO NOT SAY 'AMEND ALT' AND THE CREW HAVING AN ASSIGNMENT OF 16000' BUT NOT ADVISING ME. CORRECTING THE PROB: HAVE MANDATORY STANDARD PHRASEOLOGY FOR PLTS AND CREW JUST AS FOR CTLRS. THE PLT BEARS ABSOLUTELY NO RESPONSIBILITY FOR BEING REQUIRED TO HEAR ME CORRECTLY. THE CTLR IS ULTIMATELY RESPONSIBLE THOUGH TO HEAR THE PLT'S CORRECT READBACK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR HEARD THE TAPE OF THIS INCIDENT SHORTLY AFTER HE WAS REMOVED FROM HIS POS FOR RECERTIFICATION. HE ADMITS THAT THE READBACK FROM THE #2 ACR WAS FOR AN ALT OF 'ONE SIX THOUSAND,' AND HE MISSED THE 'ONE.' HIS STATEMENT THAT HE WAS BEING TRANSFERRED TO A VFR LEVEL II TWR FOR HAVING THIS SYS ERROR WAS NOT CORRECT. HE SAID THAT THIS INCIDENT WAS HIS THIRD IN 2 YRS AND HE TOLD FAC MGMNT THAT HE WOULD PREFER TO TRANSFER TO THE VFR TWR IF THEY PLANNED AN EXTENDED PERIOD OF 'HUMILITY TRNING.' SUCH WAS NOT THE CASE, AND HE WAS RETURNED TO DUTY AFTER RECERTIFICATION TRNING WAS COMPLETED.
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.