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|
Attributes | |
ACN | 439858 |
Time | |
Date | 199906 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : zdv.artcc |
State Reference | CO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | Bonanza 35 |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level |
Flight Plan | None |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Experience | controller military : 4 controller radar : 10 |
ASRS Report | 439858 |
Events | |
Anomaly | aircraft equipment problem : recurrent event non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | none taken : unable none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Problem Areas | ATC Facility FAA ATC Human Performance |
Situations | |
ATC Facility | procedure or policy : d01.tracon |
Narrative:
The specific event is a fatal crash, but it brings attention to a procedure, or lack thereof, between ZDV and den approach that does not contribute to the overall safety of the airspace system. I was one of several controllers who provided flight following to this aircraft prior to its crash into a mountain. In the hour before the crash, flight following was terminated twice as a matter of common practice, the last time being only mins prior to impact. As this incident, like most others, is expected to go to court, we are all being nit-picked for what we said and how we said it, even though no services were being provided at the time of the incident. Ironically, there will probably be a large monetary award, not because certain rules were broken that directly contributed to the crash, but rather because of trivial matters that make controllers in general look stupid. One important problem that will probably never be mentioned, is the lack of automated handoffs between center and approach, but there should be, and in this case it might have helped if there was such a rule. As usual, the last controller in ZDV terminated flight following with this aircraft because the ability to hand it off to den approach is inhibited. I can only speculate as to why this is -- reasons may include: approach wants the ability to control workload by refusing flight following, no automatic traffic count is generated by a handoff like it would be by initiating a track, procedures have never been negotiated by LOA. Most controllers would prefer the automation to be activated, since almost no effort is required to take a handoff and acknowledge the aircraft when it checks on the frequency, whereas phone calls are over an open line and flight information has to be xferred and re-entered manually. Some center controllers bypass this problem by forcing a VFR handoff as if it was an IFR handoff and quickly coordinating by phone. Approach controllers do not have this option. When controllers are too busy to coordinate over the phone, most provide a suggested frequency for the adjacent facility, and the pilot does all the coordination over the frequency. One can only wonder how many aircraft are ignored when they attempt to reinitiate flight following due to workload, or elect not to continue flight following for some reason of their own. Whether this particular pilot attempted, or decided not to attempt to reinitiate flight following as he approached those particularly unfriendly looking mountains in less than ideal WX conditions is unknown. Having flown in that area, I can imagine that he was focused on the business of flying and didn't have a lot of time to wait for a chance to talk, ask for flight following, and then pass his flight information. It is impossible to say whether talking to a controller about terrain, WX, or anything else would have prevented the crash, but it certainly would not have hurt. There is simply no good reason for controllers and pilots to have to go through such a cumbersome ritual to maintain the continuity of flight following. Callback conversation with reporter revealed the following information: the reporter stated that den approach was written up recently by FAA evaluators for inhibiting their VFR handoff capability. Since then, approach has been very cooperative in taking the information on VFR aircraft. However, this information has to be given to them manually. There still is no automation handoff capability between both facilities for VFR aircraft. Reporter also stated that den approach generally terminates the radar on all VFR aircraft, and tells them to contact the center.
Original NASA ASRS Text
Title: RPTR ALLEGES THAT THERE SEEMS TO HAVE BEEN A LACK OF AUTOMATED HDOF AND PROCS ON VFR FLT FOLLOWING ACFT BTWN DEN APCH AND ZDV.
Narrative: THE SPECIFIC EVENT IS A FATAL CRASH, BUT IT BRINGS ATTN TO A PROC, OR LACK THEREOF, BTWN ZDV AND DEN APCH THAT DOES NOT CONTRIBUTE TO THE OVERALL SAFETY OF THE AIRSPACE SYS. I WAS ONE OF SEVERAL CTLRS WHO PROVIDED FLT FOLLOWING TO THIS ACFT PRIOR TO ITS CRASH INTO A MOUNTAIN. IN THE HOUR BEFORE THE CRASH, FLT FOLLOWING WAS TERMINATED TWICE AS A MATTER OF COMMON PRACTICE, THE LAST TIME BEING ONLY MINS PRIOR TO IMPACT. AS THIS INCIDENT, LIKE MOST OTHERS, IS EXPECTED TO GO TO COURT, WE ARE ALL BEING NIT-PICKED FOR WHAT WE SAID AND HOW WE SAID IT, EVEN THOUGH NO SVCS WERE BEING PROVIDED AT THE TIME OF THE INCIDENT. IRONICALLY, THERE WILL PROBABLY BE A LARGE MONETARY AWARD, NOT BECAUSE CERTAIN RULES WERE BROKEN THAT DIRECTLY CONTRIBUTED TO THE CRASH, BUT RATHER BECAUSE OF TRIVIAL MATTERS THAT MAKE CTLRS IN GENERAL LOOK STUPID. ONE IMPORTANT PROB THAT WILL PROBABLY NEVER BE MENTIONED, IS THE LACK OF AUTOMATED HDOFS BTWN CTR AND APCH, BUT THERE SHOULD BE, AND IN THIS CASE IT MIGHT HAVE HELPED IF THERE WAS SUCH A RULE. AS USUAL, THE LAST CTLR IN ZDV TERMINATED FLT FOLLOWING WITH THIS ACFT BECAUSE THE ABILITY TO HAND IT OFF TO DEN APCH IS INHIBITED. I CAN ONLY SPECULATE AS TO WHY THIS IS -- REASONS MAY INCLUDE: APCH WANTS THE ABILITY TO CTL WORKLOAD BY REFUSING FLT FOLLOWING, NO AUTOMATIC TFC COUNT IS GENERATED BY A HDOF LIKE IT WOULD BE BY INITIATING A TRACK, PROCS HAVE NEVER BEEN NEGOTIATED BY LOA. MOST CTLRS WOULD PREFER THE AUTOMATION TO BE ACTIVATED, SINCE ALMOST NO EFFORT IS REQUIRED TO TAKE A HDOF AND ACKNOWLEDGE THE ACFT WHEN IT CHKS ON THE FREQ, WHEREAS PHONE CALLS ARE OVER AN OPEN LINE AND FLT INFO HAS TO BE XFERRED AND RE-ENTERED MANUALLY. SOME CTR CTLRS BYPASS THIS PROB BY FORCING A VFR HDOF AS IF IT WAS AN IFR HDOF AND QUICKLY COORDINATING BY PHONE. APCH CTLRS DO NOT HAVE THIS OPTION. WHEN CTLRS ARE TOO BUSY TO COORDINATE OVER THE PHONE, MOST PROVIDE A SUGGESTED FREQ FOR THE ADJACENT FACILITY, AND THE PLT DOES ALL THE COORD OVER THE FREQ. ONE CAN ONLY WONDER HOW MANY ACFT ARE IGNORED WHEN THEY ATTEMPT TO REINITIATE FLT FOLLOWING DUE TO WORKLOAD, OR ELECT NOT TO CONTINUE FLT FOLLOWING FOR SOME REASON OF THEIR OWN. WHETHER THIS PARTICULAR PLT ATTEMPTED, OR DECIDED NOT TO ATTEMPT TO REINITIATE FLT FOLLOWING AS HE APCHED THOSE PARTICULARLY UNFRIENDLY LOOKING MOUNTAINS IN LESS THAN IDEAL WX CONDITIONS IS UNKNOWN. HAVING FLOWN IN THAT AREA, I CAN IMAGINE THAT HE WAS FOCUSED ON THE BUSINESS OF FLYING AND DIDN'T HAVE A LOT OF TIME TO WAIT FOR A CHANCE TO TALK, ASK FOR FLT FOLLOWING, AND THEN PASS HIS FLT INFO. IT IS IMPOSSIBLE TO SAY WHETHER TALKING TO A CTLR ABOUT TERRAIN, WX, OR ANYTHING ELSE WOULD HAVE PREVENTED THE CRASH, BUT IT CERTAINLY WOULD NOT HAVE HURT. THERE IS SIMPLY NO GOOD REASON FOR CTLRS AND PLTS TO HAVE TO GO THROUGH SUCH A CUMBERSOME RITUAL TO MAINTAIN THE CONTINUITY OF FLT FOLLOWING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT DEN APCH WAS WRITTEN UP RECENTLY BY FAA EVALUATORS FOR INHIBITING THEIR VFR HDOF CAPABILITY. SINCE THEN, APCH HAS BEEN VERY COOPERATIVE IN TAKING THE INFO ON VFR ACFT. HOWEVER, THIS INFO HAS TO BE GIVEN TO THEM MANUALLY. THERE STILL IS NO AUTOMATION HDOF CAPABILITY BTWN BOTH FACILITIES FOR VFR ACFT. RPTR ALSO STATED THAT DEN APCH GENERALLY TERMINATES THE RADAR ON ALL VFR ACFT, AND TELLS THEM TO CONTACT THE CTR.
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.