B757 TCASII RA CLB HAD LTSS FROM DSNDING B757. SYS ERROR.

Date: 1995-07 · Aircraft: B757 Undifferentiated or Other Model · Phase: climb

Anomalies: atc-issue-all-types|conflict-airborne-conflict|deviation-discrepancy-procedural-published-material-policy

Synopsis

B757 TCASII RA CLB HAD LTSS FROM DSNDING B757. SYS ERROR.

Narrative

APCH CTL WAS COMBINED AT ONE POS; F1 (POS SYMBOL W). TRAINING WAS IN PROGRESS AT F1. DEP CTL WAS COMBINED AT ONE POS; KRANT (POS SYMBOL S). I WAS ORIGINALLY TOLD TO DECOMBINE THE E APCH POS; F2 (POS SYMBOL E); FROM F1; BUT DUE TO THE LIGHT TFC; THE INSTRUCTOR AND TRAINEE REQUESTED THE POS REMAINED COMBINED. THEREFORE; I WAS INSTRUCTED TO RELIEVE THE CTLR AT THE KRANT DEP POS. ACFT #1; A B757; DEPARTED WASHINGTON SBOUND ON THE DCA 185 DEG RADIAL. I INITIALLY CLRED ACFT #1 TO 6000 FT; THE VERT LIMIT OF MY AIRSPACE. AS ACFT #1 APCHED OXXON NDB (5 NM S OF DCA); I COORDINATED FOR FURTHER CLB. THE APPROPRIATE SECTOR TO COORDINATE A CLB WITH WOULD NORMALLY BE F2; BUT; BELIEVING THE POS TO STILL BE COMBINED; I COORDINATED WITH F1; SAYING 'AT OXXON DIRECT DAILY; CLBING TO 10; (CALL SIGN).' F1 RESPONDED 'APPROVED.' I WAS AWARE ACFT #2; A B757 INBOUND TO BWI; WAS TFC FOR ACFT #1; AND CALLED THE TFC TO ACFT #1 AS 'A B757; 1 O'CLOCK AND 15 MI; NEBOUND; DSNDING TO 11000 FT.' I EXPECTED F1 TO STOP ACFT #2 AT 11000 FT. DUE TO WX IN THE VICINITY OF OTT; ACFT #1 WAS DEVIATING ON A SBOUND HDG DURING HIS CLB TO 10000 FT. ACFT #2 WAS TRACKING NEBOUND TOWARDS OTT. AS ACFT #1 WAS CLBING THROUGH 9600 FT; ACFT #2 DSNDED THROUGH 11000 FT. AT THIS POINT; THE OJT INSTRUCTOR ASKED; 'WHAT ARE YOU DOING WITH THAT GUY?' I RESPONDED; 'CLBING TO 10000 FT LIKE I COORDINATED.' THE ACFT WERE APPROX 5 MI APART AT THIS TIME. I IMMEDIATELY TOLD ACFT #1 THAT THE TFC WAS DSNDING THROUGH 11000 FT AND TO CLB AND MAINTAIN FL190. AT THIS POINT I TURNED AROUND TO LOOK AT THE F1 POS AND DISCOVERED THAT F2 HAD BEEN OPENED WITHOUT MY KNOWLEDGE. F2 TURNED ACFT #2 EBOUND; AND ACFT #1 PASSED BEHIND ACFT #2. I WOULD ESTIMATE THE CLOSEST POINT OF APCH TO BE LESS THAN 1 MI AND LESS THAN 300 FT. IN HIS INVESTIGATION OF THE INCIDENT; THE SUPVR DETERMINED GO-BEHIND SEPARATION HAD BEEN ESTABLISHED BY F2 TURNING ACFT #2 EBOUND; WITH ACFT #1 HDG SBOUND. ACFT #1 ASKED ME IF I HAD BEEN TALKING TO THE OTHER ACFT AND WHERE HE CAME FROM. I EXPLAINED THAT THE OTHER ACFT WAS ON ANOTHER FREQ; THAT THERE HAD BEEN A MISCOM BTWN ATC; AND THAT THE ACFT HAD BEEN DSNDED BELOW 11000 FT. ACFT #1 ADVISED THAT HE HAD RECEIVED A TCASII RA TO CLB AND THAT THE OTHER ACFT WAS 'RIGHT THERE.' WHAT HAPPENED? THERE WERE BASICALLY 3 MISTAKES MADE HERE. FIRST; THE INSTRUCTOR AND TRAINEE FAILED TO NOTIFY ME THEY WERE OPENING THE F2 POS. SECONDLY; F1 INCORRECTLY APPROVED A POINT ON ACFT #1 CLBING SBOUND FROM OXXON; INTO AIRSPACE BELONGING TO F2. FINALLY; I FAILED TO REALIZE FROM THE POS SYMBOL E DISPLAYED ON THE SCOPE THAT F2 HAD BEEN OPENED. I BELIEVE THIS SIT WOULD HAVE BEEN AVOIDED IF ANY OF THE FOLLOWING HAD OCCURRED: F2 ADVISES KRANT IT IS OPEN; F1 DOES NOT APPROVE THE POINT AND INSTEAD TELLS KRANT F2 IS OPEN; KRANT RECOGNIZES FROM THE RADAR DISPLAY THAT F2 IS OPEN. IT ALSO SHOULD BE STATED THAT THIS OCCURRED AT THE BEGINNING OF THE DAY SHIFT; ON OUR FIRST DAY BACK TO WORK; AFTER A BEAUTIFUL WX WEEKEND. IT IS POSSIBLE THAT THE LEVEL OF ALERTNESS DISPLAYED BY ALL CTLRS INVOLVED WAS LESS THAN NORMAL. I KNOW THAT I WAS CERTAINLY NOT 100 PERCENT AT THE TIME OF THE INCIDENT. I DID NOT FEEL I HAD GOTTEN A GOOD NIGHT'S SLEEP THE NIGHT BEFORE. I DID NOT; HOWEVER; REALIZE THE IMPACT IT HAD ON MY AWARENESS OF SURROUNDING ACTIVITIES. I DID NOT HEAR THE F2 POS CTLRS MOVE TO THE F2 POS; NOR DID I RECOGNIZE THE VOICE OF F1 AS SOMEONE OTHER THAN THE TRAINEE I THOUGHT WAS WORKING F1. I BELIEVE THESE HUMAN PERFORMANCE FACTORS PLAYED A ROLE IN THIS INCIDENT.

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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.