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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Air carrier misfiles flight plan and enters another oceanic route resulting in less than standard separation.
| Attributes | |
| ACN | 135883 |
| Time | |
| Date | 199002 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : dut |
| State Reference | AK |
| Altitude | msl bound lower : 37000 msl bound upper : 37000 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : foa |
| Operator | common carrier : air carrier |
| Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
| Navigation In Use | Other |
| Flight Phase | cruise other |
| Route In Use | enroute : other oceanic enroute : pacific |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
| Navigation In Use | Other |
| Flight Phase | cruise other |
| Route In Use | enroute : pacific enroute : other oceanic |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government : faa |
| Function | controller : non radar |
| Qualification | controller : non radar |
| ASRS Report | 135883 |
| Person 2 | |
| Affiliation | government : faa |
| Function | controller : non radar |
| ASRS Report | 135465 |
| Events | |
| Anomaly | non adherence : published procedure non adherence : required legal separation other anomaly other |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued new clearance |
| Consequence | faa : investigated |
| Miss Distance | horizontal : 99999 |
| Supplementary | |
| Primary Problem | ATC Human Performance |
| Air Traffic Incident | Operational Error |
Narrative:
Air carrier Y was on pacots 2 ( a notamed route between japan and USA) and air carrier X was on pacots 3 which is another laterally separated route, however air carrier X crossed from pacots 3 up to pacots 2 and back down to pacots 3. The mis-filed route was missed by several controllers until air carrier X reported over 45N/170W and the controller working at that time noticed the problem and re-established separation. Why the route was erroneous is still a mystery to me, but apparently oakland ARTCC mistyped several fixes when the NOTAM was sent out. The mistake was later caught by one of the airlines who called oakland to verify the accuracy of the NOTAM they received, oakland ARTCC then sent out a corrected NOTAM but the airline either did not receive it, or did not notice it as a change and filed via the original fixes. Supplemental information from acn 135624. An incorrect pacot NOTAM was issued from oakland center. 3 aircraft filed the incorrect route and two flew it west/O correction. While quality assurance was investigating one error they found this occurrence also. Incorrect NOTAM issued for 4 hours. No warning about NOTAM error given to oci sector. Prevention: 1) post the NOTAM routes at the sector for proposal strip xchk , 2) post the latitudes on the bay headers to xchk strips to routes, 3) notify sectors of possible errors in NOTAM's for a heads up on incorrect routes, 4)improve odaps to allow better information to NOTAM routes xchk to filed flight plans.
Original NASA ASRS Text
Title: ACR MISFILES FLT PLAN AND ENTERS ANOTHER OCEANIC ROUTE RESULTING IN LESS THAN STANDARD SEPARATION.
Narrative: ACR Y WAS ON PACOTS 2 ( A NOTAMED RTE BTWN JAPAN AND USA) AND ACR X WAS ON PACOTS 3 WHICH IS ANOTHER LATERALLY SEPARATED RTE, HOWEVER ACR X CROSSED FROM PACOTS 3 UP TO PACOTS 2 AND BACK DOWN TO PACOTS 3. THE MIS-FILED RTE WAS MISSED BY SEVERAL CTLRS UNTIL ACR X RPTED OVER 45N/170W AND THE CTLR WORKING AT THAT TIME NOTICED THE PROB AND RE-ESTABLISHED SEPARATION. WHY THE RTE WAS ERRONEOUS IS STILL A MYSTERY TO ME, BUT APPARENTLY OAKLAND ARTCC MISTYPED SEVERAL FIXES WHEN THE NOTAM WAS SENT OUT. THE MISTAKE WAS LATER CAUGHT BY ONE OF THE AIRLINES WHO CALLED OAKLAND TO VERIFY THE ACCURACY OF THE NOTAM THEY RECEIVED, OAKLAND ARTCC THEN SENT OUT A CORRECTED NOTAM BUT THE AIRLINE EITHER DID NOT RECEIVE IT, OR DID NOT NOTICE IT AS A CHANGE AND FILED VIA THE ORIGINAL FIXES. SUPPLEMENTAL INFO FROM ACN 135624. AN INCORRECT PACOT NOTAM WAS ISSUED FROM OAKLAND CENTER. 3 ACFT FILED THE INCORRECT RTE AND TWO FLEW IT W/O CORRECTION. WHILE QUALITY ASSURANCE WAS INVESTIGATING ONE ERROR THEY FOUND THIS OCCURRENCE ALSO. INCORRECT NOTAM ISSUED FOR 4 HRS. NO WARNING ABOUT NOTAM ERROR GIVEN TO OCI SECTOR. PREVENTION: 1) POST THE NOTAM ROUTES AT THE SECTOR FOR PROPOSAL STRIP XCHK , 2) POST THE LATITUDES ON THE BAY HEADERS TO XCHK STRIPS TO ROUTES, 3) NOTIFY SECTORS OF POSSIBLE ERRORS IN NOTAM'S FOR A HEADS UP ON INCORRECT ROUTES, 4)IMPROVE ODAPS TO ALLOW BETTER INFORMATION TO NOTAM ROUTES XCHK TO FILED FLT PLANS.
Data retrieved from NASA's ASRS site as of July 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.