 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
An arc B737 blows tires and evacuate/evacuations passenger after tower instructs flight crew to abort at high speed due to a misunderstanding of the intentions of a government BE300 in a holding pattern over the OM to test the accuracy of the runway ILS ground transmitters. A lack of proper coordination between the approach and tower facilities are sighted as a causal factor in this incident.
| Attributes | |
| ACN | 354414 |
| Time | |
| Date | 199612 |
| Day | Tue |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : den |
| State Reference | CO |
| Altitude | msl bound lower : 7000 msl bound upper : 7000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : den tracon : ord |
| Operator | other |
| Make Model Name | Super King Air 300 |
| Operating Under FAR Part | Part 91 |
| Flight Phase | other |
| Flight Plan | VFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government other |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 4800 flight time type : 2600 |
| ASRS Report | 354414 |
| Person 2 | |
| Affiliation | government other |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial pilot : cfi pilot : atp |
| Experience | controller radar : 9 flight time last 90 days : 150 flight time total : 2700 flight time type : 650 |
| ASRS Report | 354330 |
| Events | |
| Anomaly | aircraft equipment problem : critical other anomaly other |
| Independent Detector | other controllera |
| Resolutory Action | flight crew : rejected takeoff other |
| Consequence | faa : investigated faa : reviewed incident with flight crew other |
| Miss Distance | horizontal : 3000 vertical : 1000 |
| Supplementary | |
| Primary Problem | ATC Human Performance |
| Air Traffic Incident | Inter Facility Coordination Failure |
| Situations | |
| ATC Facility | procedure or policy : unspecified |
Narrative:
Den approach cleared us to conduct holding patterns over the OM for ILS runway 25. (This is a normal flight inspection maneuver described in the FAA flight inspection order kept at each ATC facility.) runway 17L lies under and perpendicular to the runway 25 localizer course between the OM and threshold. At some point after we had crossed over the OM and were making a right turn as instructed, the tower ordered an air carrier X airliner departing on runway 17L to abort, causing tire blowouts and passenger evacuate/evacuation. I think the cause of this incident was ATC's lack of a clear understanding of flight inspection maneuvers along with an apparent lack of or improper coordination between the approach controller and tower controller. Had the tower controller been talking to us, he could have queried our intentions and or instructed us to abort our holding pattern.
Original NASA ASRS Text
Title: AN ARC B737 BLOWS TIRES AND EVACS PAX AFTER TWR INSTRUCTS FLC TO ABORT AT HIGH SPD DUE TO A MISUNDERSTANDING OF THE INTENTIONS OF A GOV BE300 IN A HOLDING PATTERN OVER THE OM TO TEST THE ACCURACY OF THE RWY ILS GND XMITTERS. A LACK OF PROPER COORD BTWN THE APCH AND TWR FACILITIES ARE SIGHTED AS A CAUSAL FACTOR IN THIS INCIDENT.
Narrative: DEN APCH CLRED US TO CONDUCT HOLDING PATTERNS OVER THE OM FOR ILS RWY 25. (THIS IS A NORMAL FLT INSPECTION MANEUVER DESCRIBED IN THE FAA FLT INSPECTION ORDER KEPT AT EACH ATC FACILITY.) RWY 17L LIES UNDER AND PERPENDICULAR TO THE RWY 25 LOC COURSE BTWN THE OM AND THRESHOLD. AT SOME POINT AFTER WE HAD CROSSED OVER THE OM AND WERE MAKING A R TURN AS INSTRUCTED, THE TWR ORDERED AN ACR X AIRLINER DEPARTING ON RWY 17L TO ABORT, CAUSING TIRE BLOWOUTS AND PAX EVAC. I THINK THE CAUSE OF THIS INCIDENT WAS ATC'S LACK OF A CLR UNDERSTANDING OF FLT INSPECTION MANEUVERS ALONG WITH AN APPARENT LACK OF OR IMPROPER COORD BTWN THE APCH CTLR AND TWR CTLR. HAD THE TWR CTLR BEEN TALKING TO US, HE COULD HAVE QUERIED OUR INTENTIONS AND OR INSTRUCTED US TO ABORT OUR HOLDING PATTERN.
Data retrieved from NASA's ASRS site as of July 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.