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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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| Attributes | |
| ACN | 136866 |
| Time | |
| Date | 199002 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : mcw |
| State Reference | IA |
| Altitude | msl bound lower : 3000 msl bound upper : 3500 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zmp artcc : zkc |
| Operator | common carrier : air carrier |
| Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
| Flight Phase | climbout : initial |
| Route In Use | enroute : on vectors |
| Flight Plan | IFR |
| Aircraft 2 | |
| Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
| Flight Phase | cruise other |
| Route In Use | approach : straight in enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government : faa |
| Function | controller : radar |
| Qualification | controller : radar |
| Experience | controller radar : 19 |
| ASRS Report | 136866 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | conflict : airborne less severe non adherence : clearance non adherence : published procedure other spatial deviation |
| Independent Detector | other controllera |
| Resolutory Action | flight crew : returned to intended course or assigned course other |
| Consequence | Other |
| Miss Distance | horizontal : 30000 vertical : 0 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation Operational Deviation |
Narrative:
Air carrier X was cleared to depart runway 35, turn right to 060 degree heading, maintain 5000'. He rogered clearance, but did not repeat runway or heading. I did not catch the readback or assumed that I heard it verbatim (mistake #1). At the time aircraft Y was on an ILS 35 approach to report OM inbound (3 min departure rule). Aircraft Y reported OM. Aircraft Y issued left turn heading 180 degrees, maintain 3000'. Air carrier X acknowledged and reported off 35 seconds later, turning left out of 3500'. I asked air carrier X again direction of turn. Air carrier X said left. I then reissued right heading 060 degrees. Air carrier X said he thought I said left turn on departure heading 160 degrees (mistake #2). Both mistakes are what we want to hear, not what is said. Situation could have resulted in a mid-air collision, if not for having aircraft Y established southbound before air carrier X departed. I was at fault for not listening for the readback or thinking I heard complete readback. Pilot of air carrier X was at fault for not verifying the heading or giving a complete readback. Moral of story: when in doubt, ask again, and give complete readbacks. For both myself and pilot of air carrier X, we were assuming, and that is not conducive to a safe ATC system.
Original NASA ASRS Text
Title: ACR X FAILED TO COMPLY WITH ATC CLRNC. OPERATIONAL DEVIATION. ARTCC RADAR CTLR FAILED TO HEAR ACR X ACKNOWLEDGE A CLRNC FOR ACFT Y.
Narrative: ACR X WAS CLRED TO DEPART RWY 35, TURN RIGHT TO 060 DEG HDG, MAINTAIN 5000'. HE ROGERED CLRNC, BUT DID NOT REPEAT RWY OR HDG. I DID NOT CATCH THE READBACK OR ASSUMED THAT I HEARD IT VERBATIM (MISTAKE #1). AT THE TIME ACFT Y WAS ON AN ILS 35 APCH TO RPT OM INBND (3 MIN DEP RULE). ACFT Y RPTED OM. ACFT Y ISSUED LEFT TURN HDG 180 DEGS, MAINTAIN 3000'. ACR X ACKNOWLEDGED AND RPTED OFF 35 SECS LATER, TURNING LEFT OUT OF 3500'. I ASKED ACR X AGAIN DIRECTION OF TURN. ACR X SAID LEFT. I THEN REISSUED RIGHT HDG 060 DEGS. ACR X SAID HE THOUGHT I SAID LEFT TURN ON DEP HDG 160 DEGS (MISTAKE #2). BOTH MISTAKES ARE WHAT WE WANT TO HEAR, NOT WHAT IS SAID. SITUATION COULD HAVE RESULTED IN A MID-AIR COLLISION, IF NOT FOR HAVING ACFT Y ESTABLISHED SBND BEFORE ACR X DEPARTED. I WAS AT FAULT FOR NOT LISTENING FOR THE READBACK OR THINKING I HEARD COMPLETE READBACK. PLT OF ACR X WAS AT FAULT FOR NOT VERIFYING THE HDG OR GIVING A COMPLETE READBACK. MORAL OF STORY: WHEN IN DOUBT, ASK AGAIN, AND GIVE COMPLETE READBACKS. FOR BOTH MYSELF AND PLT OF ACR X, WE WERE ASSUMING, AND THAT IS NOT CONDUCIVE TO A SAFE ATC SYS.
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.