Pilot Debrief

Aircraft near Tampa, FL — 2009-02-19

Final reportOPS09IA002
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Date
2009-02-19
Location
Tampa, FL, USA
Fatalities
0
Phase of flight
Taxi

Probable cause

The controller's issuance of an improper climb clearance to the pilot of Berry Aviation flight 510. Contributing to the incident was the controller's distraction while he searched for a misplaced flight progress strip.

NTSB narrative

An operational error occurred at Tampa Terminal Radar Approach Control that resulted in a loss of required separation between AirTran Airways flight 808 (TRS808) and Berry Aviation flight 510 (BYA510). TRS808 was operating as a scheduled 14 Code of Federal Regulations (CFR) Part 121 passenger flight between Pittsburgh International Airport, Pittsburgh, Pennsylvania and Tampa International Airport, Tampa Florida (TPA). BYA510 was operating as a 14 CFR Part 135 air taxi flight from MacDill Air Force Base (MCF), Tampa, Florida, to Jacksonville Naval Air Station (NIP), Jacksonville, Florida. BYA510 departed southbound from MCF beneath the final approach course for runway 36 at TPA. The pilot was erroneously cleared to climb to 5,000 feet in an area where local procedures required that aircraft level at 1,600 feet in order to avoid conflicts with aircraft landing at TPA. The controller stated that he was searching for BYA510's flight progress strip immediately before the flight passed about 200-250 feet below TRS808, after the pilot of TRS808 responded to a Traffic Collision Alerting System resolution advisory directing a climb to resolve the conflict. There were no injuries or damage reported to either aircraft. Following the incident, TRS808 landed uneventfully at TPA and BYA510 continued its flight to NIP.

Analysis

Primary failure mode
Human factors
First missed decision gate
Controller cleared BYA510 to climb to 5,000 feet instead of maintaining 1,600 feet.

NTSB coding

  • Air traffic event · Approach-IFR final approach
  • Attention / Monitoring

Evidence available

  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5