ASRS Database Report Set - Controller Reports

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ASRS Database Report SetController ReportsReport Set Description .A sampling of reports from Air Traffic Controllers.Update Number .32.0Date of Update .April 30, 2019Number of Records in Report Set .50Number of New Records in Report Set .50Type of Records in Report Set.For each update, new records received at ASRS willdisplace a like number of the oldest records in theReport Set, with the objective of providing the fiftymost recent relevant ASRS Database records. Recordswithin this Report Set have been screened to assuretheir relevance to the topic.

National Aeronautics andSpace AdministrationAmes Research CenterMoffett Field, CA 94035-1000TH: 262-7MEMORANDUM FOR: Recipients of Aviation Safety Reporting System DataSUBJECT: Data Derived from ASRS ReportsThe attached material is furnished pursuant to a request for data from the NASA Aviation SafetyReporting System (ASRS). Recipients of this material are reminded when evaluating these dataof the following points.ASRS reports are submitted voluntarily. The existence in the ASRS database of reportsconcerning a specific topic cannot, therefore, be used to infer the prevalence of that problemwithin the National Airspace System.Information contained in reports submitted to ASRS may be amplified by further contact withthe individual who submitted them, but the information provided by the reporter is notinvestigated further. Such information represents the perspective of the specific individual who isdescribing their experience and perception of a safety related event.After preliminary processing, all ASRS reports are de-identified and the identity of the individualwho submitted the report is permanently eliminated. All ASRS report processing systems aredesigned to protect identifying information submitted by reporters; including names, companyaffiliations, and specific times of incident occurrence. After a report has been de-identified, anyverification of information submitted to ASRS would be limited.The National Aeronautics and Space Administration and its ASRS current contractor, BoozAllen Hamilton, specifically disclaim any responsibility for any interpretation which may bemade by others of any material or data furnished by NASA in response to queries of the ASRSdatabase and related materials.Becky L. Hooey, DirectorNASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATACertain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, andthus cannot be considered a measured random sample of the full population of like events. Forexample, we receive several thousand altitude deviation reports each year. This number maycomprise over half of all the altitude deviations that occur, or it may be just a small fraction oftotal occurrences.Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or otherparticipants in the aviation system are equally aware of the ASRS or may be equally willing toreport. Thus, the data can reflect reporting biases. These biases, which are not fully known ormeasurable, may influence ASRS information. A safety problem such as near midair collisions(NMACs) may appear to be more highly concentrated in area “A” than area “B” simply becausethe airmen who operate in area “A” are more aware of the ASRS program and more inclined toreport should an NMAC occur. Any type of subjective, voluntary reporting will have theselimitations related to quantitative statistical analysis.One thing that can be known from ASRS data is that the number of reports receivedconcerning specific event types represents the lower measure of the true number of suchevents that are occurring. For example, if ASRS receives 881 reports of track deviations in2010 (this number is purely hypothetical), then it can be known with some certainty that atleast 881 such events have occurred in 2010. With these statistical limitations in mind, webelieve that the real power of ASRS data is the qualitative information contained in reportnarratives. The pilots, controllers, and others who report tell us about aviation safetyincidents and situations in detail – explaining what happened, and more importantly, why ithappened. Using report narratives effectively requires an extra measure of study, but theknowledge derived is well worth the added effort.

Report Synopses

ACN: 1622395(1 of 50)SynopsisCenter Controller reported skydivers that were not supposed to be dropping out of the sky,close to an aircraft that reported the parachutes.ACN: 1616471(2 of 50)SynopsisController reported that a pilot reported encountering a drone while on a visual approachto New Orleans Lakefront airport.ACN: 1614559(3 of 50)SynopsisSLC Local Controller and B737 flight crew reported a runway incursion due to taxiwayconfusion.ACN: 1614554(4 of 50)SynopsisPSP Tower Controller reported issuing a Low Altitude Alert for an aircraft on a night timevisual approach.ACN: 1614326(5 of 50)SynopsisZHU Center Controller reported an unsafe situation when a military aircraft went No Radioand a carrier had to be vectored away from the No Radio aircraft.ACN: 1614325(6 of 50)SynopsisSDL Tower Controller reported an unsafe situation between two arrivals where bothaircraft executed a different sequence.ACN: 1613878(7 of 50)SynopsisIAD Tower Controller and pilot reported a near collision on the runway between the aircraftand a snow removal vehicle.ACN: 1613873Synopsis(8 of 50)

N90 TRACON controllers reported another Controller was descending aircraft through theirairspace without coordination.ACN: 1613488(9 of 50)SynopsisTRACON Controller reported an aircraft descended quicker than anticipated and flew belowthe Minimum Vectoring Altitude.ACN: 1613487(10 of 50)SynopsisLocal Controller reported issuing a go around to an aircraft that appeared to be on shortfinal to a closed runway.ACN: 1612887(11 of 50)SynopsisSBN TRACON Controller reported assisting an aircraft with an equipment problem to a safelanding.ACN: 1612886(12 of 50)SynopsisSeattle TRACON Controller reported a loss of separation due to a rule being misapplied aswell as possible fatigue and distraction by the government furlough.ACN: 1612878(13 of 50)SynopsisDAB TRACON Controller reported an airborne conflict was exacerbated by faulty voicecommunications equipment.ACN: 1612876(14 of 50)SynopsisCleveland Center Controller reported an airspace deviation associated with a crossingrestriction that the pilot busted.ACN: 1612864(15 of 50)SynopsisNorCal TRACON Controller reported an airborne conflict with an arrival aircraft and a jetthat departed an uncontrolled airport.ACN: 1612862(16 of 50)

SynopsisSNA Local Controllers reported a NMAC due to a coordination/communication problem.ACN: 1612860(17 of 50)SynopsisZLA Front Line Manager reported a UAV was scheduled into an Altitude Reservation butknowledge of it was not posted nor were the Controllers informed.ACN: 1612859(18 of 50)SynopsisMemphis Center Controller reported an aircraft that descended below the Minimum SafeAltitude due to icing.ACN: 1612858(19 of 50)SynopsisTRACON Controller reported an airspace violation caused by distractions.ACN: 1612853(20 of 50)SynopsisMiami Center Controller reported a loss of separation due to different climb rates of twoaircraft and failing to notice due to distractions.ACN: 1612847(21 of 50)SynopsisDenver Tower Controller reported various complaints due to staffing, weather and thetraffic level.ACN: 1612594(22 of 50)SynopsisZMP Controller reported not having current approach plates due to the governmentshutdown and improvising using an expired plate.ACN: 1612592(23 of 50)SynopsisDenver Center Controller reported observing an aircraft that received a Minimum IFRAltitude alert and climbed the aircraft but pilot was slow to respond.ACN: 1612589(24 of 50)

SynopsisNew York Center Controller reported an airspace violation which reporter attributed todistractions.ACN: 1612587(25 of 50)SynopsisNew York TRACON Controller reported lack of communication from management about aRADAR site going out mid-shift causing confusion and panic.ACN: 1612585(26 of 50)SynopsisOntario Tower Controllers reported an unsafe situation between a departure and an arrivaldue to distractions.ACN: 1612577(27 of 50)SynopsisPhoenix TRACON Controller reported an unsafe operation due to low morale anddistractions.ACN: 1612268(28 of 50)SynopsisNew York Center Controllers reported a loss of separation, possibly due tomiscommunication, stress and distractions from the government shutdown.ACN: 1612267(29 of 50)SynopsisMaui Tower Controllers reported resolving a head-on conflict caused by untimelycoordination from HCF.ACN: 1612265(30 of 50)SynopsisHouston TRACON Controller reported climbing an aircraft too close through a heavy jet'swake turbulence due to distractions.ACN: 1612255(31 of 50)SynopsisPotomac TRACON Instructor reported a loss of separation while training due in part tofatigue and distractions.

ACN: 1612250(32 of 50)SynopsisChicago TRACON Controller reported adverse weather and a malfunctioning glideslopecaused aircraft to go around.ACN: 1611947(33 of 50)SynopsisZMA ARTCC Controller reported assigning an aircraft a higher altitude even though therewas converging traffic 1,000 feet above them.ACN: 1611942(34 of 50)SynopsisA Center Controller working a combined sector reported that they were distracted by aconversation with the Supervisor over pay issues and made a late point out to theadjacent facility.ACN: 1611940(35 of 50)SynopsisA Center Controller reported taking handoffs on two aircraft they did not recognize wereconverging at the same altitude due to stress from the government shutdown.ACN: 1611932(36 of 50)SynopsisA Center Controller reported an aircraft misunderstood their traffic information, possiblydue to poor radio coverage, and climbed above their assigned altitude into confliction withconverging traffic.ACN: 1611931(37 of 50)SynopsisMIA Approach Controller reported releasing departures from different airports onconverging headings into a confliction due to fatigue and stress over a governmentshutdown.ACN: 1611928(38 of 50)SynopsisTower Ground Controller reported incorrect coordination with Local Control that an aircrafton an IFR flight plan was a VFR flight due to being distracted by the governmentshutdown.

ACN: 1611925(39 of 50)SynopsisTower Controller reported Quality Assurance staff suggested a pilot initiated go-arounddue to preceding traffic was an ATC Operational Error.ACN: 1611072(40 of 50)SynopsisTraffic Management Coordinator reported that an unqualified Supervisor working severalpositions created significant traffic problems.ACN: 1611071(41 of 50)SynopsisSFO Ground Controller reported a pilot was confused by the departure clearance receivedvia CPDLC.ACN: 1611067(42 of 50)SynopsisA TRACON Controller without an Assist reported an unidentified VFR aircraft climbed intotraffic on a final approach course and another aircraft deviated from their course into ahigher Minimum Vectoring Altitude Area.ACN: 1611052(43 of 50)SynopsisZNY Center Controller reported an airspace violation due to external distractions.ACN: 1611048(44 of 50)SynopsisPalm Springs Tower Controller reported an unsafe approach due to weather and possiblepiloting issues.ACN: 1611038(45 of 50)SynopsisRSW TRACON Controller reported NMAC with an airliner and a VFR aircraft due in part tobeing distracted.ACN: 1610816Synopsis(46 of 50)

ZNY Controller reported an airborne conflict which was avoided by climbing an aircraft intoanother sectors airspace without a correct point-out. Reporter stated fatigue issues relatedto the government shutdown.ACN: 1610813(47 of 50)SynopsisTRACON Controller reported no response from a military aircraft until using guardfrequency. Flight was then switched to UHF and turned before entering a higher MVA.ACN: 1610808(48 of 50)SynopsisTower Controller reported rushing to clear the runway of vehicles for landing traffic whiletraining.ACN: 1610372(49 of 50)SynopsisSFO Tower Controller reported simultaneous go-arounds, one associated with a loss ofcommunication.ACN: 1610370(50 of 50)SynopsisZMP Center Controller reported an unsafe procedure that was resolved, but was not whatthe center controller wanted, which would have led to an operational error.

Report Narratives

ACN: 1622395(1 of 50)Time / DayDate : 201902Local Time Of Day : 1201-1800PlaceLocale Reference.ATC Facility : ZAB.ARTCCState Reference : NMAltitude.MSL.Single Value : 8000Aircraft : 1Reference : XATC / Advisory.Center : ZABMake Model Name : Small AircraftFlight Plan : IFRFlight Phase : CruiseRoute In Use.Airway : V105Aircraft : 2Reference : YATC / Advisory.Center : ZABAircraft Operator : MilitaryMake Model Name : Military TransportCrew Size.Number Of Crew : 4Operating Under FAR Part : Part 91Mission : SkydivingPersonReference : 1Location Of Person.Facility : ZAB.ARTCCReporter Organization : GovernmentFunction.Air Traffic Control : EnrouteQualification.Air Traffic Control : Fully CertifiedASRS Report Number.Accession Number : 1622395Human Factors : Situational AwarenessEventsAnomaly.ATC Issue : All TypesAnomaly.Conflict : Airborne ConflictAnomaly.Deviation - Procedural : Published Material / PolicyAnomaly.Deviation - Procedural : FARAnomaly.Inflight Event / Encounter : ObjectDetector.Person : Flight CrewMiss Distance.Horizontal : 0When Detected : In-flightResult.Air Traffic Control : Provided AssistanceAssessments

Contributing Factors / Situations : Human FactorsPrimary Problem : Human FactorsNarrative: 1Aircraft X reported there are parachutes off his left side less than half a mile at hisaltitude. He reported about a dozen parachutes. He adjusted his course to the right tomiss them. He said that if he had stayed on V105 he would have hit them. We were nottalking to any jump aircraft at AZ04 at the time. We then noticed a 1200 codemaneuvering at 175. We tracked the aircraft and another IFR aircraft into TUS had toadjust his course to miss the aircraft and he reported that it was an [Aircraft Y]. I calledthe ZZZ jump school who told me that [Aircraft Y] had flown in yesterday. [Jump School]briefed them for operations at ZZZ and then the pilot told them that they would bedropping at AZ04. [Jump school] told them that they needed to contact ZAB for operationsat AZ04. I asked him if he had a contact number for the pilot. He said that he would try tohave them contact us. We were able to have the pilot call the Operations Manager. Thepilot admitted to doing a HAHO [High Altitude High Opening] drop at AZ04 without talkingto ZAB. This pilot violated several FAR's and created a near mid-air with a nonparticipating aircraft operating IFR in the NAS. The number, frequency, several locationsand type of jump operations in Sector 46 is by far more than anywhere else in the world.The FAR's were never created for these types of operations. These operations, on aneveryday basis, at several locations, create a very real hazard to the NAS. Every singlecontroller that tries to maintain some sort of safety on that sector will tell you that the FAAwill not take action to address the jump operations until someone dies. There will be afatality in that sector due to jump operations in the very near future if these types ofoperations are allowed to continue. The FAR's need to be changed. There needs to beregulation in place that ensures that jump operations are contained in a TFR, warning areaor restricted airspace. Aircraft should not be allowed to throw objects out the back of anairplane that will collide with other non-participating aircraft.SynopsisCenter Controller reported skydivers that were not supposed to be dropping out of the sky,close to an aircraft that reported the parachutes.

ACN: 1616471(2 of 50)Time / DayDate : 201902Local Time Of Day : 0001-0600PlaceLocale Reference.Airport : NEW.AirportState Reference : LAAltitude.AGL.Single Value : 500Aircraft : 1Reference : XATC / Advisory.Tower : NEWMake Model Name : M-20 Series Undifferentiated or Other ModelCrew Size.Number Of Crew : 1Operating Under FAR Part : Part 91Flight Plan : VFRFlight Phase : Final ApproachRoute In Use : Visual ApproachAirspace.Class D : NEWAircraft : 2Reference : YAircraft Operator : PersonalMake Model Name : UAV - Unpiloted Aerial VehicleCrew Size.Number Of Crew : 1Operating Under FAR Part.OtherFlight Phase.OtherAirspace.Class D : NEWPersonReference : 1Location Of Person.Facility : NEW.TowerFunction.Air Traffic Control : Other / UnknownQualification.Air Traffic Control : Fully CertifiedASRS Report Number.Accession Number : 1616471EventsAnomaly.Conflict : NMACDetector.Person : Air Traffic ControlWhen Detected : In-flightResult.General : None Reported / TakenAssessmentsContributing Factors / Situations : Airspace StructurePrimary Problem : Airspace StructureNarrative: 1

Aircraft was on about a 1/2 mile right base for RWY 36R and cleared to land. As he wasturning final, he reported a drone sighting about 400-500 ft. away from his aircraft. Do notallow any drone activity in any controlled airspace, regardless of altitude.SynopsisController reported that a pilot reported encountering a drone while on a visual approachto New Orleans Lakefront airport.

ACN: 1614559(3 of 50)Time / DayDate : 201902Local Time Of Day : 1801-2400PlaceLocale Reference.Airport : SLC.AirportState Reference : UTAltitude.AGL.Single Value : 0EnvironmentFlight Conditions : VMCLight : DaylightAircraft : 1Reference : XATC / Advisory.Tower : SLCAircraft Operator : Air CarrierMake Model Name : B737-800Crew Size.Number Of Crew : 2Operating Under FAR Part : Part 121Flight Plan : IFRMission : PassengerNav In Use : FMS Or FMCFlight Phase : LandingRoute In Use : Visual ApproachAircraft : 2Reference : YMake Model Name : Any Unknown or Unlisted Aircraft ManufacturerFlight Plan : IFRRoute In Use : VectorsPerson : 1Reference : 1Location Of Person.Facility : SLC.TowerReporter Organization : GovernmentFunction.Air Traffic Control : LocalQualification.Air Traffic Control : Fully CertifiedExperience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 1ASRS Report Number.Accession Number : 1614559Human Factors : Situational AwarenessPerson : 2Reference : 2Location Of Person.Aircraft : XLocation In Aircraft : Flight DeckReporter Organization : Air CarrierFunction.Flight Crew : Pilot Not Flying

Function.Flight Crew : First OfficerQualification.Flight Crew : Air Transport Pilot (ATP)Qualification.Flight Crew : InstrumentQualification.Flight Crew : MultiengineASRS Report Number.Accession Number : 1614801Person : 3Reference : 3Location Of Person.Aircraft : XLocation In Aircraft : Flight DeckReporter Organization : Air CarrierFunction.Flight Crew : Pilot FlyingFunction.Flight Crew : CaptainQualification.Flight Crew : Air Transport Pilot (ATP)Qualification.Flight Crew : MultiengineQualification.Flight Crew : InstrumentASRS Report Number.Accession Number : 1614813Human Factors : Situational AwarenessHuman Factors : TroubleshootingEventsAnomaly.Conflict : Ground Conflict, Less SevereAnomaly.Deviation - Procedural : ClearanceAnomaly.Ground Incursion : RunwayDetector.Person : Air Traffic ControlWhen Detected : TaxiResult.Flight Crew : Returned To ClearanceResult.Air Traffic Control : Provided AssistanceAssessmentsContributing Factors / Situations : AirportContributing Factors / Situations : Human FactorsPrimary Problem : Human FactorsNarrative: 1Aircraft X was cleared to land on runway 16L with Aircraft Y holding short of 16L waiting todepart. Another aircraft was crossing a 4.5NM final for 16L and Aircraft X was told toexpedite to H4 (a high speed taxiway) to clear the runway and taxi to their gate. Aircraft Ywas instructed to line up and wait on 16L. Aircraft X turned early at H5 but was observedclearing the runway; Aircraft

database and related materials. Becky L. Hooey, Director NASA Aviation Safety Reporting System. CAVEAT REGARDING USE OF ASRS DATA . Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For

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