4 ACFT INVOLVED IN 2 CASES OF LESS THAN STANDARD SEPARATION AT ABOUT THE SAME TIME. OPERATIONAL ERROR.

Date: 1988-09 · Aircraft: Small Transport; Low Wing; 2 Turboprop Eng

Anomalies: atc-issue-all-types|conflict-airborne-conflict

Synopsis

4 ACFT INVOLVED IN 2 CASES OF LESS THAN STANDARD SEPARATION AT ABOUT THE SAME TIME. OPERATIONAL ERROR.

Narrative

I AM THE CTLR WHO WAS WORKING THE N FINAL POS AT THE TIME OF THE INCIDENT. ACFT W; CLRED FOR NDB RWY 14 APCH AT MTN; FLEW ACROSS THE FINAL APCH COURSE AND REQUIRED VECTORS TO A SECOND APCH. DURING THIS TIME ACFT X WAS ON A VECTOR FOR ILS RWY 28 APCH AT BWI. ACFT X WAS NOT CLRED FOR APCH; SO HE FLEW ACROSS THE LOC FOR RWYS 28 AND 33L. SEP WAS LOST BTWN X AND ACR ACFT Y ON FINAL FOR RWY 33L AT BWI. DURING THE TIME I WAS WORKING ON ACFT X; ACFT W CAME IN CLOSE PROX TO COMMUTER Z WHO WAS EBND FOR ILS 28 AT BWI. I TURNED W NBOUND AND Z SBND. W RPTED A NEAR MISS WITH A COMMUTER ACFT; BUT SAID NO EVASIVE ACTION WAS REQUIRED. FACTORS CONTRIBUTING TO SITUATION: 1) IT WAS NEAR THE END OF SHIFT AND I WAS OVER 2 HRS ON THIS POS W/O A BREAK; WORKING STEADY; HVY COMPLEX TFC. 2) EQUIP OUTAGE IN THE TWR REQUIRED MANUAL AND HDOF ON EACH BWI ARR; NO HDOF PERSON WAS AVAILABLE TO ASSIST ME. 3) I EXPECTED ACFT W PLT TO BE ABLE TO MAKE A NORMAL APCH THE FIRST TIME HE WAS CLRED. THE SPECIAL ATTN THAT WAS REQUIRED TO ASSIST THIS PLT IN MAKING HIS APCH WAS THE BIGGEST FACTOR LEADING UP TO THE INCIDENT. 4) MTN WAS IN AN E OPERATION AND BWI IN A W OPERATION; WHICH INCREASES THE N FINAL WORKLOAD TREMENDOUSLY. I WAS ADVISED THIS WILL CHANGE IN OCT DUE TO THIS OCCURRENCE. 5) THE SUPVR REQUESTED A 20 MI IN TRAIL AND 250 KT RESTRICTION FROM ZDC DUE TO PERSONNEL SHORTAGE AND WAS OVERRULED BY MGT. BWI NEEDS MORE CTLRS. THE HUB AND SPOKE SYS IS A NIGHTMARE FOR ATC AND THE AIRLINE SCHEDULES SHOULD BE SPREAD OUT MORE EVENLY; NO MATTER HOW MUCH THE AIRLINES; OR AOPA COMPLAINS. I DO NOT FEEL BWI'S PROCS ARE ADEQUATE TO HANDLE THE NUMBER OF ACFT THEY DO; WITH THE NUMBER OF CTLRS THEY HAVE. BWI NEEDS LESS AIRSPACE; FEWER ARR ROUTES; BETTER FLOW CTL; MORE CTLRS AND NEEDS ANOTHER JET RWY BEFORE THEY ALLOW ANY MORE AIRLINE EXPANSION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR GAVE YRS IN ATC. DESCRIBED FLT PATHS AND ALTS OF ALL 4 ACFT. TARGETS MERGED IN BOTH CONFLICTS. ACFT W AND Z BOTH AT 2500'. ALSO ACFT X WAS AT 2500' AND S FINAL CTLR STOPPED ACR Y AT 3000'. ACFT W WAS GIVEN POOR TURN-ON FOR NDB RWY 14 AT MTN AND PLT WAS FOLLOWING PROPER PROC FOR THAT APCH. WX WAS MARGINAL AND ALL ACFT WERE ON IFR FLT PLAN AND MAKING IFR APCHS. REVIEW BOARD CONCLUDED THAT RPTR HAD TFC WHICH EXCEEDED HIS CAPABILITIES. HAD FORGOTTEN ABOUT ACFT X AND AFTER X CONFLICT WITH ACR Y THE ACFT X WAS TURNED IN BEHIND Y FOR ILS 33L. ACFT W AND Z WERE IN VERY CLOSE PROX TO EACH OTHER AND WE SAW Z; BUT DID NOT THINK EVASIVE ACTION WAS NECESSARY. RPTR ASKED ME TO DELETE PART OF HIS NARRATIVE REF PLT OF ACFT W NOT BEING ABLE TO FLY NDB APCH.

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