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Attributes | |
ACN | 118855 |
Time | |
Date | 198908 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : pae |
State Reference | WA |
Altitude | msl bound lower : 2000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sea |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other enroute : direct enroute airway : sea enroute airway : zob |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : handoff position |
Qualification | controller : radar |
Experience | controller radar : 17 |
ASRS Report | 118855 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Events | |
Anomaly | non adherence : required legal separation non adherence : published procedure |
Independent Detector | other other : unspecified atc |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Deviation Intra Facility Coordination Failure Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
I answered the bfi ring line. Bfi tower had received a call from a helicopter somewhere northeast of bfi. The pilot apparently was lost and bfi had instructed him to contact dr-east. I acknowledged the information, wrote the acid on a flight progress strip and told the dr-east controller what bfi had reported. He indicated that he was already aware of the situation. I then answered the bfi ring line. Bfi wanted to coordinate for 2 air taxi aircraft to depart bfi and fly VFR to seatac. Seatac was metering arrs at the time so I told bfi to stand by while I coordinated with the area manager to see if our arrival sector could handle 2 more aircraft at that time. When I came off the bfi line, I overheard the dr-west controller say, 'small aircraft X, are you there?' I keyed the bfi voice line and asked bfi to send small aircraft X to our frequency again. Bfi acknowledged that they would. I came off the bfi voice line and answered the rnt ring line. Rnt wanted a release on the second aircraft. By this time it was past XX00Z. I was not sure if the airspace had been sterilized or not, I was not aware of DF-east's traffic picture, so I told rnt to hold the aircraft and I would have to call them back. Coordinating the air taxi departures and the second rnt departure took another several minutes. By the time I was able to redirect my attention to the dr-west controller his traffic picture had changed completely from when I had left it. I scanned the targets in his airspace and looked over the flight progress strips at his position. When I saw the flight progress strip on small aircraft X still sitting there (by this time bfi had been closed approximately 5 minutes) I concluded that bfi had been unable to depart small aircraft X before they had to close the airport. (I had completely forgotten my frequency change call). As it turned out, small aircraft X had departed. However, the pilot had in my opinion, made several errors. When he departed the pilot had the wrong transponder code set thus his alpha-numeric tag never acquired. His radio did not work on the dr-west frequency and when he returned to bfi tower frequency they told him to try the dr-east frequency. When he came up on the departure east frequency he told the controller he was 'out of 2100 for 4000'. (Remember bfi had assigned a 2000' restriction.) the dr-east controller, having no idea who the pilot was, asked small aircraft X his request and his position. The pilot said he was about 7 mi southwest of pae and would like a vector to fhr. The dr-east controller, still believing small aircraft X to be a VFR pop-up instructed the pilot to contact ZSE for service. The pilot complied and it wasn't until he reached fhr that the pilot mentioned anything about being on an IFR flight. Bfi has a requirement to notify the appropriate departure sector if an IFR target fails to acquire alpha-numerically within 2 mi off the end of their runway. They did make this notification and it was acknowledged by the dr-west controller. I had no knowledge of that conversation. In fact, if it weren't for the tape recording of my call to bfi requesting them to send small aircraft X to our frequency, I would have no post-departure recollection of involvement with this aircraft. Several factors led to this operational error. 1) it is unreasonable to expect any radar controller at a level 5 facility to work traffic without a staffed handoff position there to help him. 2) it is unreasonable to expect one person to adequately provide handoff assistance to two radar positions at the same time. 3) it is unreasonable to continue disrupting traffic in some of the country's most congested airspace during peak traffic periods to accommodate airshows. 4) no satellite airport should be allowed to release IFR aircraft without a void time constraint. 5) when bfi assigned the pilot of small aircraft X the dr-east frequency they should have notified the handoff controller. 6) the pilot of small aircraft X should not have vacated 2000' without a clearance. Had he stated to the dr-east controller that he was off bfi, leveling at 2000, it probably would have sent an entirely different message to the controller. 7) the dr-west controller should have monitored the traffic picture more closely and not have forgotten about small aircraft X. 8) the handoff controller should not have concluded that the aircraft had not departed just because he had no knowledge of the departure even though the airport had closed.
Original NASA ASRS Text
Title: FAILURE TO HANDOFF AND TRANSFER CTL OF SMA X FROM TRACON TO CENTER. PLT FAILURE TO COMPLY WITH ATC CLRNC. OPERATIONAL DEVIATION. PLT DEVIATION.
Narrative: I ANSWERED THE BFI RING LINE. BFI TWR HAD RECEIVED A CALL FROM A HELI SOMEWHERE NE OF BFI. THE PLT APPARENTLY WAS LOST AND BFI HAD INSTRUCTED HIM TO CONTACT DR-EAST. I ACKNOWLEDGED THE INFORMATION, WROTE THE ACID ON A FLT PROGRESS STRIP AND TOLD THE DR-EAST CTLR WHAT BFI HAD REPORTED. HE INDICATED THAT HE WAS ALREADY AWARE OF THE SITUATION. I THEN ANSWERED THE BFI RING LINE. BFI WANTED TO COORDINATE FOR 2 AIR TAXI ACFT TO DEPART BFI AND FLY VFR TO SEATAC. SEATAC WAS METERING ARRS AT THE TIME SO I TOLD BFI TO STAND BY WHILE I COORDINATED WITH THE AREA MGR TO SEE IF OUR ARR SECTOR COULD HANDLE 2 MORE ACFT AT THAT TIME. WHEN I CAME OFF THE BFI LINE, I OVERHEARD THE DR-WEST CTLR SAY, 'SMA X, ARE YOU THERE?' I KEYED THE BFI VOICE LINE AND ASKED BFI TO SEND SMA X TO OUR FREQ AGAIN. BFI ACKNOWLEDGED THAT THEY WOULD. I CAME OFF THE BFI VOICE LINE AND ANSWERED THE RNT RING LINE. RNT WANTED A RELEASE ON THE SECOND ACFT. BY THIS TIME IT WAS PAST XX00Z. I WAS NOT SURE IF THE AIRSPACE HAD BEEN STERILIZED OR NOT, I WAS NOT AWARE OF DF-EAST'S TFC PICTURE, SO I TOLD RNT TO HOLD THE ACFT AND I WOULD HAVE TO CALL THEM BACK. COORDINATING THE AIR TAXI DEPS AND THE SECOND RNT DEP TOOK ANOTHER SEVERAL MINUTES. BY THE TIME I WAS ABLE TO REDIRECT MY ATTN TO THE DR-WEST CTLR HIS TFC PICTURE HAD CHANGED COMPLETELY FROM WHEN I HAD LEFT IT. I SCANNED THE TARGETS IN HIS AIRSPACE AND LOOKED OVER THE FLT PROGRESS STRIPS AT HIS POSITION. WHEN I SAW THE FLT PROGRESS STRIP ON SMA X STILL SITTING THERE (BY THIS TIME BFI HAD BEEN CLOSED APPROX 5 MINUTES) I CONCLUDED THAT BFI HAD BEEN UNABLE TO DEPART SMA X BEFORE THEY HAD TO CLOSE THE ARPT. (I HAD COMPLETELY FORGOTTEN MY FREQ CHANGE CALL). AS IT TURNED OUT, SMA X HAD DEPARTED. HOWEVER, THE PLT HAD IN MY OPINION, MADE SEVERAL ERRORS. WHEN HE DEPARTED THE PLT HAD THE WRONG XPONDER CODE SET THUS HIS ALPHA-NUMERIC TAG NEVER ACQUIRED. HIS RADIO DID NOT WORK ON THE DR-WEST FREQ AND WHEN HE RETURNED TO BFI TWR FREQ THEY TOLD HIM TO TRY THE DR-EAST FREQ. WHEN HE CAME UP ON THE DEP EAST FREQ HE TOLD THE CTLR HE WAS 'OUT OF 2100 FOR 4000'. (REMEMBER BFI HAD ASSIGNED A 2000' RESTRICTION.) THE DR-EAST CTLR, HAVING NO IDEA WHO THE PLT WAS, ASKED SMA X HIS REQUEST AND HIS POSITION. THE PLT SAID HE WAS ABOUT 7 MI SW OF PAE AND WOULD LIKE A VECTOR TO FHR. THE DR-EAST CTLR, STILL BELIEVING SMA X TO BE A VFR POP-UP INSTRUCTED THE PLT TO CONTACT ZSE FOR SERVICE. THE PLT COMPLIED AND IT WASN'T UNTIL HE REACHED FHR THAT THE PLT MENTIONED ANYTHING ABOUT BEING ON AN IFR FLT. BFI HAS A REQUIREMENT TO NOTIFY THE APPROPRIATE DEP SECTOR IF AN IFR TARGET FAILS TO ACQUIRE ALPHA-NUMERICALLY WITHIN 2 MI OFF THE END OF THEIR RWY. THEY DID MAKE THIS NOTIFICATION AND IT WAS ACKNOWLEDGED BY THE DR-WEST CTLR. I HAD NO KNOWLEDGE OF THAT CONVERSATION. IN FACT, IF IT WEREN'T FOR THE TAPE RECORDING OF MY CALL TO BFI REQUESTING THEM TO SEND SMA X TO OUR FREQ, I WOULD HAVE NO POST-DEP RECOLLECTION OF INVOLVEMENT WITH THIS ACFT. SEVERAL FACTORS LED TO THIS OPERATIONAL ERROR. 1) IT IS UNREASONABLE TO EXPECT ANY RADAR CTLR AT A LEVEL 5 FAC TO WORK TFC WITHOUT A STAFFED HANDOFF POSITION THERE TO HELP HIM. 2) IT IS UNREASONABLE TO EXPECT ONE PERSON TO ADEQUATELY PROVIDE HANDOFF ASSISTANCE TO TWO RADAR POSITIONS AT THE SAME TIME. 3) IT IS UNREASONABLE TO CONTINUE DISRUPTING TFC IN SOME OF THE COUNTRY'S MOST CONGESTED AIRSPACE DURING PEAK TFC PERIODS TO ACCOMMODATE AIRSHOWS. 4) NO SATELLITE ARPT SHOULD BE ALLOWED TO RELEASE IFR ACFT WITHOUT A VOID TIME CONSTRAINT. 5) WHEN BFI ASSIGNED THE PLT OF SMA X THE DR-EAST FREQ THEY SHOULD HAVE NOTIFIED THE HANDOFF CTLR. 6) THE PLT OF SMA X SHOULD NOT HAVE VACATED 2000' WITHOUT A CLRNC. HAD HE STATED TO THE DR-EAST CTLR THAT HE WAS OFF BFI, LEVELING AT 2000, IT PROBABLY WOULD HAVE SENT AN ENTIRELY DIFFERENT MESSAGE TO THE CTLR. 7) THE DR-WEST CTLR SHOULD HAVE MONITORED THE TFC PICTURE MORE CLOSELY AND NOT HAVE FORGOTTEN ABOUT SMA X. 8) THE HANDOFF CTLR SHOULD NOT HAVE CONCLUDED THAT THE ACFT HAD NOT DEPARTED JUST BECAUSE HE HAD NO KNOWLEDGE OF THE DEP EVEN THOUGH THE ARPT HAD CLOSED.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.