|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0601 To 1200|
|Locale Reference||airport : mdh|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Controlling Facilities||tower : mdh|
|Make Model Name||Small Transport, Low Wing, 2 Recip Eng|
|Flight Phase||descent : approach|
|Route In Use||approach : straight in|
|Make Model Name||Small Aircraft, High Wing, 1 Eng, Fixed Gear|
|Flight Phase||ground other : taxi|
|Affiliation||government : faa|
|Function||controller : local|
|Qualification||controller : non radar|
|Function||oversight : supervisor|
|Qualification||controller : non radar|
|Anomaly||incursion : landing without clearance|
non adherence : published procedure
|Independent Detector||other controllera|
|Resolutory Action||none taken : insufficient time|
|Consequence||faa : investigated|
|Primary Problem||ATC Human Performance|
|Air Traffic Incident||Intra Facility Coordination Failure|
Small transport xaa, called cabbi (OM) inbound on a practice ILS, requesting a full stop. I asked whether he could land on runway 18 to hold short of runway 24 for landing traffic. I told him 2930' of runway was available to him, and I issued the wind, which was very light. He said there would be no problem. I then told him to report the middle marker inbound, straight in for runway 18. I had several aircraft in the pattern for runway 24 and a few departures. Runway 24 was the designated active--runway 18 was ground control's jurisdiction. As I saw the small transport approximately over the middle marker, I cleared him to land runway 18 to hold short of runway 24, however unfortunately I used the wrong call sign calling him xxb, another small transport on the field. When he did not respond, I repeated the clearance, again using the wrong call sign. About that time I noticed small aircraft X crossing runway 18 at the runway 24 parallel taxiway, and it was then that I realized I failed to coordinate the runway 18 landing with ground control. I could tell, however, that small aircraft X would be across the runway before the small transport xed the runway threshold. On very short final, the small transport said 'confirm XXX cleared to land.' I cleared him to land, using his correct call sign, giving him the full length of the runway. The small aircraft was clear. At that time I belatedly coordinated the runway 18 landing with ground control. About 15 mins later I was removed from position and decertified, initially being charged with committing a system error because the supervisor didn't believe small aircraft X was across the runway when the small transport xed the threshold. That was changed to an operational deviation when the pilot of small transport xxa confirmed by telephone the runway was clear when he xed the threshold. The operational deviation was because I failed to coordinate the runway 18 landing with ground control. I will readily admit this situation involved human errors on my part, but one of the things that makes the ATC system work so well is redundancies. At carbondale tower we have a cabin attendant coordination position. A controller plugged into the cabin attendant coordination position assists the local controller in spotting traffic, and points out to the controller if he makes a mistake or overlooks something, so it can be corrected before it is too late. On this day, the supervisor was plugged into the cabin attendant controller position, but was apparently not trying to help me work the traffic, but merely monitoring my performance. I believe all ATC employees should be on the same team--that is, doing the job of ensuring air safety. In this case, the redundancies in the system didn't work. The supervisor should have coordinated the runway 18 landing with ground control, as I also should have. We both failed.
Original NASA ASRS Text
Title: ACFT CLEARED TO LAND ON RWY RELEASED TO GND CTL.
Narrative: SMT XAA, CALLED CABBI (OM) INBND ON A PRACTICE ILS, REQUESTING A FULL STOP. I ASKED WHETHER HE COULD LAND ON RWY 18 TO HOLD SHORT OF RWY 24 FOR LNDG TFC. I TOLD HIM 2930' OF RWY WAS AVAILABLE TO HIM, AND I ISSUED THE WIND, WHICH WAS VERY LIGHT. HE SAID THERE WOULD BE NO PROB. I THEN TOLD HIM TO RPT THE MIDDLE MARKER INBND, STRAIGHT IN FOR RWY 18. I HAD SEVERAL ACFT IN THE PATTERN FOR RWY 24 AND A FEW DEPS. RWY 24 WAS THE DESIGNATED ACTIVE--RWY 18 WAS GND CTL'S JURISDICTION. AS I SAW THE SMT APPROX OVER THE MIDDLE MARKER, I CLRED HIM TO LAND RWY 18 TO HOLD SHORT OF RWY 24, HOWEVER UNFORTUNATELY I USED THE WRONG CALL SIGN CALLING HIM XXB, ANOTHER SMT ON THE FIELD. WHEN HE DID NOT RESPOND, I REPEATED THE CLRNC, AGAIN USING THE WRONG CALL SIGN. ABOUT THAT TIME I NOTICED SMA X XING RWY 18 AT THE RWY 24 PARALLEL TXWY, AND IT WAS THEN THAT I REALIZED I FAILED TO COORDINATE THE RWY 18 LNDG WITH GND CTL. I COULD TELL, HOWEVER, THAT SMA X WOULD BE ACROSS THE RWY BEFORE THE SMT XED THE RWY THRESHOLD. ON VERY SHORT FINAL, THE SMT SAID 'CONFIRM XXX CLRED TO LAND.' I CLRED HIM TO LAND, USING HIS CORRECT CALL SIGN, GIVING HIM THE FULL LENGTH OF THE RWY. THE SMA WAS CLR. AT THAT TIME I BELATEDLY COORDINATED THE RWY 18 LNDG WITH GND CTL. ABOUT 15 MINS LATER I WAS REMOVED FROM POS AND DECERTIFIED, INITIALLY BEING CHARGED WITH COMMITTING A SYS ERROR BECAUSE THE SUPVR DIDN'T BELIEVE SMA X WAS ACROSS THE RWY WHEN THE SMT XED THE THRESHOLD. THAT WAS CHANGED TO AN OPDEV WHEN THE PLT OF SMT XXA CONFIRMED BY TELEPHONE THE RWY WAS CLR WHEN HE XED THE THRESHOLD. THE OPDEV WAS BECAUSE I FAILED TO COORDINATE THE RWY 18 LNDG WITH GND CTL. I WILL READILY ADMIT THIS SITUATION INVOLVED HUMAN ERRORS ON MY PART, BUT ONE OF THE THINGS THAT MAKES THE ATC SYS WORK SO WELL IS REDUNDANCIES. AT CARBONDALE TWR WE HAVE A CAB COORD POS. A CTLR PLUGGED INTO THE CAB COORD POS ASSISTS THE LCL CTLR IN SPOTTING TFC, AND POINTS OUT TO THE CTLR IF HE MAKES A MISTAKE OR OVERLOOKS SOMETHING, SO IT CAN BE CORRECTED BEFORE IT IS TOO LATE. ON THIS DAY, THE SUPVR WAS PLUGGED INTO THE CAB CTLR POS, BUT WAS APPARENTLY NOT TRYING TO HELP ME WORK THE TFC, BUT MERELY MONITORING MY PERFORMANCE. I BELIEVE ALL ATC EMPLOYEES SHOULD BE ON THE SAME TEAM--THAT IS, DOING THE JOB OF ENSURING AIR SAFETY. IN THIS CASE, THE REDUNDANCIES IN THE SYS DIDN'T WORK. THE SUPVR SHOULD HAVE COORDINATED THE RWY 18 LNDG WITH GND CTL, AS I ALSO SHOULD HAVE. WE BOTH FAILED.
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.