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Attributes | |
ACN | 610445 |
Time | |
Date | 200402 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : slc.airport |
State Reference | UT |
Altitude | msl bound lower : 8000 msl bound upper : 8400 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Snow |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : slc.tracon tracon : s56.tracon |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : s56.tracon tower : slc.tower |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Experience | controller radar : 20 controller time certified in position1 : 19 |
ASRS Report | 610445 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Events | |
Anomaly | conflict : airborne critical conflict : ground critical inflight encounter : weather non adherence : required legal separation non adherence : published procedure other spatial deviation other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued new clearance flight crew : executed go around flight crew : exited adverse environment flight crew : took evasive action |
Consequence | faa : investigated |
Miss Distance | horizontal : 12000 vertical : 600 |
Supplementary | |
Problem Areas | ATC Human Performance Weather FAA |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure Operational Error |
Situations | |
ATC Facility | procedure or policy : slc.tower |
Narrative:
The problem arose because slc tower was trying to depart with inadequate spacing on final. 1) successive arrival spacing had decreased below applicable minima X and Y. 2) the departure (Z) release was with less than applicable minima for 1/4 - 1/2 mi visibility -- 2 mi increasing to 3 mi within 1 min. 3) when the aircraft (west) went missed approach, he executed the published missed procedure and turned into the departure traffic with less than applicable separation minima. After resolving that situation, the tower controller issued a wrong direction of turn that placed CRJ7 (west) in an unsafe proximity to higher terrain. The aircraft entered a 9000 ft and 10000 ft MVA at 8000 ft. The aircraft entered an 11000 ft MVA at 8400 ft after being climbed out of 8000 ft, the assigned missed approach altitude. Corrective actions: this facility chose to cover-up the above incidents by misrepresenting the facts and events. Basically eliminating the process to learn and correct deficiencies openly and undermining our mission for safety, and compromising almost every applicable FAA directive. Not an exaggeration/very near disaster/catastrophe. FAA hotline called. Some changes being made in outcome. Callback conversation with reporter revealed the following information: reporter perceives that tower management has not correctly evaluated this event. Reporter alleges that TRACON facility management has failed to challenge tower management to ensure that tower controllers apply correct arrival/departure handbook ATC procedures. Reporter alleges tower management only looked into the event after someone called the FAA hotline to report the multiple aircraft conflict.
Original NASA ASRS Text
Title: S56 DEP CTLR QUESTIONS SLC LCL CTLR DECISIONS IN TWO SUCCESSIVE EVENTS RESULTING IN A LOSS OF SEPARATION, INCORRECT HDG ASSIGNED DURING A GAR AND PUTTING AN ACR INTO CLOSE PROX OF HIGH TERRAIN -- THE RESULT OF INCORRECT APPLICATION OF GAR PROCS.
Narrative: THE PROB AROSE BECAUSE SLC TWR WAS TRYING TO DEPART WITH INADEQUATE SPACING ON FINAL. 1) SUCCESSIVE ARR SPACING HAD DECREASED BELOW APPLICABLE MINIMA X AND Y. 2) THE DEP (Z) RELEASE WAS WITH LESS THAN APPLICABLE MINIMA FOR 1/4 - 1/2 MI VISIBILITY -- 2 MI INCREASING TO 3 MI WITHIN 1 MIN. 3) WHEN THE ACFT (W) WENT MISSED APCH, HE EXECUTED THE PUBLISHED MISSED PROC AND TURNED INTO THE DEP TFC WITH LESS THAN APPLICABLE SEPARATION MINIMA. AFTER RESOLVING THAT SIT, THE TWR CTLR ISSUED A WRONG DIRECTION OF TURN THAT PLACED CRJ7 (W) IN AN UNSAFE PROX TO HIGHER TERRAIN. THE ACFT ENTERED A 9000 FT AND 10000 FT MVA AT 8000 FT. THE ACFT ENTERED AN 11000 FT MVA AT 8400 FT AFTER BEING CLBED OUT OF 8000 FT, THE ASSIGNED MISSED APCH ALT. CORRECTIVE ACTIONS: THIS FACILITY CHOSE TO COVER-UP THE ABOVE INCIDENTS BY MISREPRESENTING THE FACTS AND EVENTS. BASICALLY ELIMINATING THE PROCESS TO LEARN AND CORRECT DEFICIENCIES OPENLY AND UNDERMINING OUR MISSION FOR SAFETY, AND COMPROMISING ALMOST EVERY APPLICABLE FAA DIRECTIVE. NOT AN EXAGGERATION/VERY NEAR DISASTER/CATASTROPHE. FAA HOTLINE CALLED. SOME CHANGES BEING MADE IN OUTCOME. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR PERCEIVES THAT TWR MGMNT HAS NOT CORRECTLY EVALUATED THIS EVENT. RPTR ALLEGES THAT TRACON FACILITY MGMNT HAS FAILED TO CHALLENGE TWR MGMNT TO ENSURE THAT TWR CTLRS APPLY CORRECT ARR/DEP HANDBOOK ATC PROCS. RPTR ALLEGES TWR MGMNT ONLY LOOKED INTO THE EVENT AFTER SOMEONE CALLED THE FAA HOTLINE TO RPT THE MULTIPLE ACFT CONFLICT.
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.