EVASIVE ACTION REQUIRED TO PREVENT COLLISION WHEN ACR-MLG OVERTAKES VFR CPR-SMT ON FINAL APCH COURSE.
Synopsis
EVASIVE ACTION REQUIRED TO PREVENT COLLISION WHEN ACR-MLG OVERTAKES VFR CPR-SMT ON FINAL APCH COURSE.
Narrative
ACFT #1 (SMT) WAS BEING VECTORED FOR ILS 33 FINAL APCH COURSE AT JST. CURRENT HDG 230 DEGS; ALT 7000 TO 5000'. ACFT #2 (MLG) WAS 4 MI IN TRAIL ON SAME HDG; ALT 8000'. TRANSPONDER ON SMT X FAILS AND RADAR CTLR A LOSES RADAR CONTACT. MLG Y IS THEN DSNDED TO 6000'; CAUSING A POSSIBLE OPERROR BECAUSE SMT X'S POS AND ALT WAS NOW UNKNOWN. SMT X CANCELS IFR; BUT REMAINS ON FREQ FOR VFR ADVISORIES. CTLR A DOES NOT RE-ESTABLISH RADAR IDENT OF SMT X. CTLR B ARRIVED TO ASSUME CTL RESPONSIBILITY. AFTER AN INCOMPLETE SECTOR BRIEFING WHERE CTLR A STATED THAT SMT X HAD CANCELLED; CTLR A DEPARTED THE SECTOR (END OF CTLR A'S SHIFT). CTLR B IS NOW RESPONSIBLE FOR SECTION OPERATION. CTLR B TURNED MLG Y TO HDG 315 DEGS. CTLR B THEN OBSERVED A PRIMARY RADAR RETURN W OF LOC AND AT 12 O'CLOCK POS OF MLG Y AT 3 MI. ASSUMING PRIMARY RETURN TO BE THAT OF SMT X CTLR CALLS TFC FOR BOTH ACFT. THE ASSUMPTION WAS CORRECT AND SMT X VISUALLY ACQUIRED MLG Y. SMT X THEN STATES THAT MLG Y B 'COMING DIRECTLY AT US.' SMT X INSTRUCTS MLG Y TO INITIATE A LEFT TURN (EVASIVE MANEUVER) WITH NO REPLY. SMT X AGAIN INSTRUCTED MLG Y TO MAKE A LEFT TURN. CTLR THEN INSTRUCTED MLG Y TO TURN LEFT TO HDG OF 270 DEGS; WHICH RESULTED IN SEP AND AVERTED COLLISION. CONTRIBUTING FACTORS: 1) LOW VIS; 2) FAILURE OF CTLR A TO MAINTAIN POSITIVE RADAR IDENT OF SMT X; 3) LOW EXPERIENCE AND SKILL LEVEL OF CTLR A (TOTAL RADAR CERTIFIED TIME 6-8 WKS); 4) INCOMPLETE SECTOR RELIEF BRIEFING; 5) FAILURE TO RE-IDENT THE SMT X; 6) CTLR A'S BELIEF THAT WHEN AN ACFT CANCELS IFR; NO FURTHER CONSIDERATION FOR SEP EXISTS; REGARDLESS OF ARPT PROX OR ACFT PROX; 7) INADEQUATE TRNING ON NON RADAR PROCS OF CTLR A AND FAILURE TO ADHERE TO NATIONAL AND FAC TRNING GUIDELINES; 8) RADAR CERTIFICATION OF CTLR A PRIOR TO THIS INDIVIDUAL BEING CAPABLE OF SATISFACTORY PERFORMANCE; AND OVER THE OBJECTION OF SEVERAL FPL'S; 9) INEXPERIENCED CTLR WORKING 3 SECTORS IN A COMBINED CONFIGN (WESTMORELAND; TYRONE AND INDIANHEAD SECTORS #54; 52 AND 53 RESPECTIVELY); 10) UNWILLINGNESS OF SUPERVISORY PERSONNEL TO INITIATE INVESTIGATION UPON NOTIFICATION OF THE ABOVE INCIDENT (INDIRECTLY A FACTOR). TO PREVENT RECURRENCE: DE-CERTIFICATION OF RADAR CTLR A AND RETRAINING; INCLUDING LOST RADAR CONTACT PROCS; SECTOR RELIEF BRIEFING; TFC ADVISORIES; REQUIREMENTS TO ENSURE THAT NATIONAL/FAC TRNING GUIDELINES ARE FOLLOWED WRITTEN RULES TO PROHIBIT A NEW CTLR FROM WORKING COMBINED CONFIGN UNTIL ATTAINING A PREDETERMINED AMOUNT OF HRS AT EACH SECTOR INDIVIDUALLY.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.