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|
Attributes | |
ACN | 356197 |
Time | |
Date | 199612 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ral |
State Reference | CA |
Altitude | msl bound lower : 4000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ont tower : ral |
Operator | general aviation : personal |
Make Model Name | Sierra 24 |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Flight Plan | IFR |
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 : faa |
Function | controller : local |
Qualification | controller : non radar |
Experience | controller non radar : 2 |
ASRS Report | 356197 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : required legal separation non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Miss Distance | horizontal : 3000 vertical : 500 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Pilot Deviation Operational Error |
Narrative:
A BE24 called me on ral ATCT local frequency. He said he was on the localizer just outside of swan lake. I looked and saw nothing on the d-brite. My first thought was that the pilot was either lost or doing the approach VFR and had lost his transponder. (I had d-brite set on a 10 mi diameter around ral -- this includes about 4 mi west of swan lake.) I asked his position again and was told just outside of swan lake. I then asked how far outside of swan lake he was. He paused then said about 4-5 mi. ('Just outside' normally means 1- 2 mi.) I then expanded the radar and saw his data tag flashing to us in handoff mode. I took the handoff then asked him if approach had told him to contact me. (I asked because he had called me about 2-3 mi earlier than normal.) he answered in the affirmative saying approach had told him to contact me as soon as he was established on the localizer. I said 'roger' (thinking they sent him to me a little early, but since I saw no other traffic at the time, maybe they had other things to do and switched him early -- no problem). The pilot then asked if he was cleared for the approach. (I thought this was a strange question. If approach cleared you for the approach and sent you to me, obviously you're cleared for the approach. Then I thought with all the questions I had been asking him, maybe he was concerned that I didn't want him to continue with his approach because of some other factors, which wasn't the case at all.) I said once again, 'roger,' meaning to me that I understand if I made you hesitant to continue with all of my questions but it's ok, I'm not going to turn you away. At this time, he was just starting to appear on my d-brite when the conflict alert started going off. As he was on his descent out of 4000 ft, there was a B737 holding at 3000 ft. I called traffic and he reported the B737 in sight and said it was now behind him. Approach then called and asked if I was talking to the sierra. I said yes and they asked me to send the sierra back to them. I called out 2 other traffic calls for the sierra then sent him back to approach. Approximately one half mi west of ral, the sierra called again, still on an IFR tag, and reported 'agnes.' I gave him instructions on entering the pattern. When the sierra was on downwind, approach called and told me to have the sierra climb to 4000 ft and fly direct pdz. I relayed these instructions to the pilot only to have the pilot tell me he canceled IFR with approach. I told approach and cleared the sierra to land. In hindsight, I should have called approach as soon as I discovered sierra was on IFR flight plan and verified that they had sent him to me. Make no assumptions! This will be how I handle all similar sits in the future.
Original NASA ASRS Text
Title: AN IFR BE24 ON APCH AT 4000 FT MISINTERPS APCH CTL INSTRUCTION AND CHANGES TO TWR FREQ. THE LCL CTLR ASSUMES THAT APCH CTL HANDED OFF THE BE24 AND WAS #1 TO LAND. WHEN THE BE24 QUESTIONED IF HE WAS CLRED FOR THE APCH, THE LCL CTLR ACKNOWLEDGED 'ROGER.' APCH CTL HAD A B737 ON FREQ HOLDING AT 3000 FT IN FRONT OF THE BE24. LOSS OF SEPARATION OCCURRED WHEN THE BE24 STARTED DSCNT.
Narrative: A BE24 CALLED ME ON RAL ATCT LCL FREQ. HE SAID HE WAS ON THE LOC JUST OUTSIDE OF SWAN LAKE. I LOOKED AND SAW NOTHING ON THE D-BRITE. MY FIRST THOUGHT WAS THAT THE PLT WAS EITHER LOST OR DOING THE APCH VFR AND HAD LOST HIS XPONDER. (I HAD D-BRITE SET ON A 10 MI DIAMETER AROUND RAL -- THIS INCLUDES ABOUT 4 MI W OF SWAN LAKE.) I ASKED HIS POS AGAIN AND WAS TOLD JUST OUTSIDE OF SWAN LAKE. I THEN ASKED HOW FAR OUTSIDE OF SWAN LAKE HE WAS. HE PAUSED THEN SAID ABOUT 4-5 MI. ('JUST OUTSIDE' NORMALLY MEANS 1- 2 MI.) I THEN EXPANDED THE RADAR AND SAW HIS DATA TAG FLASHING TO US IN HDOF MODE. I TOOK THE HDOF THEN ASKED HIM IF APCH HAD TOLD HIM TO CONTACT ME. (I ASKED BECAUSE HE HAD CALLED ME ABOUT 2-3 MI EARLIER THAN NORMAL.) HE ANSWERED IN THE AFFIRMATIVE SAYING APCH HAD TOLD HIM TO CONTACT ME AS SOON AS HE WAS ESTABLISHED ON THE LOC. I SAID 'ROGER' (THINKING THEY SENT HIM TO ME A LITTLE EARLY, BUT SINCE I SAW NO OTHER TFC AT THE TIME, MAYBE THEY HAD OTHER THINGS TO DO AND SWITCHED HIM EARLY -- NO PROB). THE PLT THEN ASKED IF HE WAS CLRED FOR THE APCH. (I THOUGHT THIS WAS A STRANGE QUESTION. IF APCH CLRED YOU FOR THE APCH AND SENT YOU TO ME, OBVIOUSLY YOU'RE CLRED FOR THE APCH. THEN I THOUGHT WITH ALL THE QUESTIONS I HAD BEEN ASKING HIM, MAYBE HE WAS CONCERNED THAT I DIDN'T WANT HIM TO CONTINUE WITH HIS APCH BECAUSE OF SOME OTHER FACTORS, WHICH WASN'T THE CASE AT ALL.) I SAID ONCE AGAIN, 'ROGER,' MEANING TO ME THAT I UNDERSTAND IF I MADE YOU HESITANT TO CONTINUE WITH ALL OF MY QUESTIONS BUT IT'S OK, I'M NOT GOING TO TURN YOU AWAY. AT THIS TIME, HE WAS JUST STARTING TO APPEAR ON MY D-BRITE WHEN THE CONFLICT ALERT STARTED GOING OFF. AS HE WAS ON HIS DSCNT OUT OF 4000 FT, THERE WAS A B737 HOLDING AT 3000 FT. I CALLED TFC AND HE RPTED THE B737 IN SIGHT AND SAID IT WAS NOW BEHIND HIM. APCH THEN CALLED AND ASKED IF I WAS TALKING TO THE SIERRA. I SAID YES AND THEY ASKED ME TO SEND THE SIERRA BACK TO THEM. I CALLED OUT 2 OTHER TFC CALLS FOR THE SIERRA THEN SENT HIM BACK TO APCH. APPROX ONE HALF MI W OF RAL, THE SIERRA CALLED AGAIN, STILL ON AN IFR TAG, AND RPTED 'AGNES.' I GAVE HIM INSTRUCTIONS ON ENTERING THE PATTERN. WHEN THE SIERRA WAS ON DOWNWIND, APCH CALLED AND TOLD ME TO HAVE THE SIERRA CLB TO 4000 FT AND FLY DIRECT PDZ. I RELAYED THESE INSTRUCTIONS TO THE PLT ONLY TO HAVE THE PLT TELL ME HE CANCELED IFR WITH APCH. I TOLD APCH AND CLRED THE SIERRA TO LAND. IN HINDSIGHT, I SHOULD HAVE CALLED APCH AS SOON AS I DISCOVERED SIERRA WAS ON IFR FLT PLAN AND VERIFIED THAT THEY HAD SENT HIM TO ME. MAKE NO ASSUMPTIONS! THIS WILL BE HOW I HANDLE ALL SIMILAR SITS IN THE FUTURE.
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.