Accident Details
Probable Cause and Findings
The failure of the ACA795 flight crew to monitor and/or switch to the appropriate air traffic control frequency.
Aircraft Information
Registered Owner (Current)
Analysis
ACA795 departed Lester B. Pearson International Airport (CYYZ), Toronto, Canada at approximately 2010 eastern standard time, November 5, 2009 (0010 UTC on November 6, 2009) on a non-stop flight to Los Angeles International Airport (KLAX), Los Angeles, California. At 2115 MST, ACA795 checked in with ZDV at FL360. Aircraft radios were configured COMM1 on ATC frequency (ZDV), COMM2 on 121.5 MHZ. At 2134 ZDV radar sector 37 directed ACA795 to contact ZDV on frequency 132.87. ACA795 did not respond. ACA795 was NORDO for 37 minutes in ZDV and ZLA airspace.
The following timeline captures information provided by ZDV and the Canadian Transportation Safety Board regarding the chronological events pertaining to ACA795:
ACA795 Timeline
Time listed is MST on November 5, 2009
ACA795 – Air Canada Flight 795
ZDV- Denver Air Route Traffic Control Center
ZLA – Los Angeles Air Route Traffic Control Center
Dispatch – Air Canada Dispatch
Originator/ Time Action/Event
ATC Sector MST
ACA795 2055 Automated Aircraft Communications Addressing
and Reporting
System (ACARS) transmission from ACA795 to Air
Canada Maintenance via a Nebraska ARINC ground
station. This was the last communication
between ACARS and ACA795 before the NORDO
37R 2115 ACA795 checks in with ZDV at FL360 on frequency
125.67
37R 2134 ZDV directs ACA795 to contact ZDV (sector 24R)
on frequency 132.87
24R 2135 ZDV attempts two radio checks with ACA795 – no
response
25R 2135 ZDV directs ACA795 to contact ZDV on frequency
132.87 - no response
37R 2135 ZDV inter-facility coordination – 37R/37R
requests 30RA attempt to have ACA795 contact ZDV
on frequency 125.67
37R 2135 ZDV directs ACA795 to contact ZDV – no response
37R 2135 ZDV attempts radio check with ACA795 – no
response
25R 2136 ZDV attempts radio check with ACA795 – no
response
25R 2136 ZDV requests Frontier flight (FFT) 860 attempt
to contact ACA795 via air to air communications – negative result
30R 2136 ZDV makes multiple attempts to contact ACA795 on
frequency 125.67 – no response
ZDV 2137 ZDV request Air Canada dispatch send a message
to ACA795 via ACARS Air Canada sends the
message. The message was transmitted via a New
Mexico ground station. The airborne ACARS set
on ACA795 was on a frequency that was not
available at the New Mexico ground station.
Accordingly, the New Mexico ground station fails
to establish an uplink with ACA795. The air
dispatch system records the “no uplink” status
but does not report “no uplink” to Air Canada
dispatch for 30 minutes. The 30 minute system
configuration at Air Canada has since been
changed to 8 minutes.
30RA 2137 ZDV inter-facility coordination – 30RA advises
37R unable to establish communications with ACA795
on frequency 125.67
24R 2137 ZDV requests Frontier flight (FFT) 778 to contact
ACA795 via air to air communications on frequency
121.5 guard
25R 2138 ZDV requests FFT860 attempt to contact ACA795 via
air to air communications on frequency 121.5 guard
37R 2138 ZDV attempts radio check with ACA795 – no response
25R 2139 FFT860 reports unable to contact ACA795 on
frequency 121.5 guard
24R 2140 FFT788 reports unable to contact ACA795 on
frequency 121.5 guard
24R 2141 ZDV requests FFT780 attempt to contact ACA795 via
air to air communications on frequency 135.4
37R 2141 ZDV attempts radio check with ACA795 – no response
24R 2142 FFT780 reports unable to contact ACA795 on
frequency 135.4
24R 2143 ZDV attempts radio check with ACA795 – no response
25R 2143 ZDV requests Frontier flight (FFT) 266 attempt to
contact ACA795 via air to air communication on
frequency 127.07
ZDV 2144 ZDV advised the domestic events network (DEN) that
ACA795 is NORDO
24R 2144 ZDV requests ACA795 IDENT if receiving
transmission – no IDENT observed
25R 2145 FFT266 reports unable to contact ACA795 on
frequency 127.07
24R 2150 ZDV advised ZLA that ACA795, inbound to Los
Angeles, has been NORDO for 15 minutes
Dispatch 2150 Air Canada dispatch sends a second ACARS message
to ACA795 a total of five ACARS messages are sent
to ACA795. Air Canada dispatch also attempted to
contact ACA795 via selective-calling radio system
(SELCAL). ACA795 did not have HF SELCAL and the
VHF SELCAL notification did not have an audio
feature.
24R 2151 ZDV attempts radio check with ACA795 – no response
37R 2151 ZDV attempts radio check with ACA795 – no response
24R 2152 ZDV directs ACA795 to contact ZLA on frequency
127.35 – no response
25R 2153 ZDV requests FFT266 attempt to contact ACA795 on
frequency 133.325
25R 2154 FFT266 reports unable to contact ACA795 on
frequency 133.325
24R 2156 ZDV attempts radio check with ACA795 – no response
ACA795 2157 ACA795 uses ACARS to obtain LAX weather and LAX
automated terminal information service (ATIS)from
the ARINC server located at San Francisco
International Airport (SFO). This query did not
re-establish the ACARS link between Air Canada
dispatch and ACA795
24RA 2201 ZDV queries ZLA, sector 36R, to inquire if ACA795
had checked in on frequency 127.35 – negative
response
24R 2202 ZDV attempts radio check with ACA795 – no response
25R 2205 ZDV requests Continental flight (COA) 752 attempt
to contact ACA795 via air to air relay on
frequency 133.325
Dispatch 2207 Air Canada dispatch receives notification from
ARINC of “no uplink” failure for ACA795
25R 2211 ZDV requests COA752 attempt to contact ACA795 via
air to air relay on frequency 127.07
37R 2211 ZDV requests N613WF transmit to ACA795 to contact
ZLA on frequency 127.35
37R 2211 ACA795 receives N613WF transmission
37R 2212 N613WF reports that they had established
communications with ACA795
25R 2212 COA752 makes multiple attempts to contact ACA795
on Frequency 127.02
37R 2212 N613WF advises ACA795 that ATC has been trying to
reach them for 45 minutes
24RA 2214 ZLA advised ZDV that ACA795 reported that they
were on frequency 125.67 during the NORDO period
ACA795 2227 ACA795 begins descent into LAX triggering
automatic ACARS Reporting to the Air Canada ACARS
server. This re-establishes an ACARS link between
ACA795 and Air Canada dispatch resulting in the
release of the queued ACARS messages
Communications with ACA795 were re-established by ZDV R24 via air to air relay with N613WF at FL490. ACA795 was directed to contact Los Angeles ARTCC on frequency 127.35.
According to the FAA preliminary pilot deviation report, after landing, the pilot of ACA795 called the ZDV Operations Manager-in-Charge (OMIC) and explained that they were receiving static on frequency 121.5 and had turned the volume down. The pilot also stated that they had received ACARS messages after they had contacted ZLA.
National flight data center (FDC) notice to airman (NOTAM) 4/4386, special notice, states in part that all aircraft operating in the United States National Airspace, if capable, shall maintain a listening watch on VHF guard 121.5 or 243.0.
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# OPS10IA002