|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : azo|
|Operator||common carrier : air carrier|
|Make Model Name||B737-200|
|Operating Under FAR Part||Part 121|
|Navigation In Use||Other|
|Flight Phase||ground : preflight|
|Affiliation||government : faa|
|Function||controller : ground|
controller : local
|Qualification||controller : radar|
|Experience||controller military : 4|
controller radar : 16
|Affiliation||government : faa|
|Function||controller : clearance delivery|
|Qualification||controller : non radar|
|Anomaly||non adherence : published procedure|
other anomaly other
|Independent Detector||other controllera|
|Resolutory Action||controller : issued new clearance|
|Primary Problem||ATC Human Performance|
|Air Traffic Incident||other|
Air carrier X called clearance delivery for IFR to ord. Clearance delivery specialist was on telephone, conversing about an automatic insurance claim. Air carrier X filed direct ord and 14000 ft, air carrier X used the full call sign on initial contact. Clearance delivery specialist assumed that air carrier Y called for IFR to ord (also proposed). She told air carrier Y that she had an xyz and was that him. Air carrier X insisted that he was indeed abc. Clearance delivery specialist changed air carrier X's flight plan to read abc and issued the IFR clearance to air carrier X assuming that it was air carrier Y to ord 'as filed' to maintain 3000 ft and expect 8000 ft within 10 mins. Air carrier X read back the clearance to maintain 2000 ft and expect 8000 ft within 10 mins. The readback error was not caught by clearance delivery. (MVA at airport is 2500 ft.) local control and ground control specialist advised the clearance delivery specialist that the pilot had read back 2000 ft in error. The clearance delivery specialist either didn't hear or ignored local control and ground control and went back to the outside phone conversation with the insurance agent. The clearance (route) issued to air carrier X should have reflected a STAR or proper routing as per pertinent loas. The route issued 'as filed' was direct ord. The situation was resolved by the succeeding clearance delivery specialist and the local control and ground control specialist who witnessed the errors. I believe that the incorrect routing, altitude issued, readback, and the transposed call sign would not have happened if the clearance delivery specialist issuing the clearance had not been distracted (voluntarily) by making outside telephone calls for personal business while assigned an ATC position of operation, in violation of facility telephone usage policy.
Original NASA ASRS Text
Title: CLRNC DELIVERY TRANSPOSES CALL SIGNS AND ISSUES WRONG CLNRC AND MISSES ALT READBACK ERROR. SIT WAS RESOLVED BY THE RELIEVING CLRNC DELIVERY AND THE LCL-GND CTLR WHO WITNESSED THE ERRORS. VIOLATION OF FACILITY PHONE USAGE POLICY. DISTR.
Narrative: ACR X CALLED CLRNC DELIVERY FOR IFR TO ORD. CLRNC DELIVERY SPECIALIST WAS ON TELEPHONE, CONVERSING ABOUT AN AUTO INSURANCE CLAIM. ACR X FILED DIRECT ORD AND 14000 FT, ACR X USED THE FULL CALL SIGN ON INITIAL CONTACT. CLRNC DELIVERY SPECIALIST ASSUMED THAT ACR Y CALLED FOR IFR TO ORD (ALSO PROPOSED). SHE TOLD ACR Y THAT SHE HAD AN XYZ AND WAS THAT HIM. ACR X INSISTED THAT HE WAS INDEED ABC. CLRNC DELIVERY SPECIALIST CHANGED ACR X'S FLT PLAN TO READ ABC AND ISSUED THE IFR CLRNC TO ACR X ASSUMING THAT IT WAS ACR Y TO ORD 'AS FILED' TO MAINTAIN 3000 FT AND EXPECT 8000 FT WITHIN 10 MINS. ACR X READ BACK THE CLRNC TO MAINTAIN 2000 FT AND EXPECT 8000 FT WITHIN 10 MINS. THE READBACK ERROR WAS NOT CAUGHT BY CLRNC DELIVERY. (MVA AT ARPT IS 2500 FT.) LCL CTL AND GND CTL SPECIALIST ADVISED THE CLRNC DELIVERY SPECIALIST THAT THE PLT HAD READ BACK 2000 FT IN ERROR. THE CLRNC DELIVERY SPECIALIST EITHER DIDN'T HEAR OR IGNORED LCL CTL AND GND CTL AND WENT BACK TO THE OUTSIDE PHONE CONVERSATION WITH THE INSURANCE AGENT. THE CLRNC (RTE) ISSUED TO ACR X SHOULD HAVE REFLECTED A STAR OR PROPER ROUTING AS PER PERTINENT LOAS. THE RTE ISSUED 'AS FILED' WAS DIRECT ORD. THE SIT WAS RESOLVED BY THE SUCCEEDING CLRNC DELIVERY SPECIALIST AND THE LCL CTL AND GND CTL SPECIALIST WHO WITNESSED THE ERRORS. I BELIEVE THAT THE INCORRECT ROUTING, ALT ISSUED, READBACK, AND THE TRANSPOSED CALL SIGN WOULD NOT HAVE HAPPENED IF THE CLRNC DELIVERY SPECIALIST ISSUING THE CLRNC HAD NOT BEEN DISTRACTED (VOLUNTARILY) BY MAKING OUTSIDE TELEPHONE CALLS FOR PERSONAL BUSINESS WHILE ASSIGNED AN ATC POS OF OP, IN VIOLATION OF FACILITY TELEPHONE USAGE POLICY.
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.