Date: 201603
Local time of day: 1201-1800
Location: GFK.Tower, ND
Flight conditions: VMC
Light: Daylight
Aircraft: Skyhawk 172/Cutlass 172
Operator: FBO
Operating under: Part 91
Flight plan: VFR
Mission: Training
Flight phase: Initial Approach
Airspace: Class D GFK
ATC / advisory: TRACON GFK
Second aircraft: Skyhawk 172/Cutlass 172
Reporter organization: Government
Reporter function: Approach
Reporter qualification: Air Traffic Control Fully Certified
Human factors: Workload; Troubleshooting; Situational Awareness; Time Pressure; Training / Qualification; Communication Breakdown; Confusion; Distraction
Second reporter function: Instructor
Anomaly: ATC Issue All Types; Conflict Airborne Conflict; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Landing Without Clearance
Detector: Person Air Traffic Control
When detected: In-flight
Result: Air Traffic Control Issued New Clearance
Contributing factors: Human Factors; Procedure
Primary problem: Procedure

Narrative: Rwys 17R/17L in use. VFR weather. Multiple C172s in the VFR traffic pattern for RWY 17L. I was working Local Control 2. We use outer and inner VFR reporting points for VFR aircraft referred to as staged aircraft from RDR approach. There are no formal letters of agreement denoting this; and we use other forms of entry instructions for VFR itinerant aircraft not familiar with the airspace or unwritten procedures such as this. Aircraft X (the Aircraft X callsign indicates a first time solo or first time solo cross country student) called inbound from the outer reporting point of east ponds with no intentions on type of landing or anything. I told Aircraft X to report lagoon southbound expect runway 17 left and say type landing. Aircraft X reads back full stop with no other intentions of complying with the southbound outside the pattern instruction at lagoon. The reason for this southbound outside the pattern techniques is to eliminate the base entries when the pattern is saturated and sequence the southbound (or north; west; east-bound) outside the pattern aircraft with the aircraft that are entering the pattern on a downwind entry; essentially creating our own flow control procedure without ever saying anything about it on the ATIS. It seems to be this unwritten understood rule between us in the tower and UND however no one else is aware of the procedure and when a Aircraft X type or someone unfamiliar with it is given the south/north/east/westbound outside the pattern instruction and completely botches it; we have what happened to me here. Except next time it could potentially be fatal. Aircraft X was given two opportunities to read back my southbound outside the pattern instruction and the second time they got cut off because I had control instructions to issue to an aircraft on the runway that was taking too long and another aircraft on final that needed to be sent around due to improper runway separation. Therefore Aircraft X never read back southbound outside the pattern and once they called at lagoon; I told Aircraft X to fly southbound. Aircraft X proceeded inbound as if on a base entry and when Aircraft X finally decided to fly southbound they were already in the face of opposite direction traffic on the downwind for Runway 17L (Aircraft Y). I continued to tell Aircraft X to turn left and widen out to the east as they were on the downwind opposite direction of traffic coming right at them. Once again when Aircraft X did not acknowledge; I told him to turn left immediately. I then told Aircraft Y to turn right and fly west over the runway (17L). I had Aircraft Y continue westbound and contact tower; as the other controller indicated they could take that aircraft where they were as they had no conflicts. I shortly thereafter had Aircraft X continue on their left turn and re-enter the downwind for Runway 17 left similar to how a typical downwind entry would look. The only two things I could have possibly done differently were this:1. Reach out to the Aircraft X again to obtain the correct readback and reach out to them prior to them reaching lagoon to ensure they did what they were told2. Turn Aircraft Y immediately and let the Aircraft X continue on their improper course and issue traffic alerts to every aircraft that gets close to this green aircraft.What can [the FBO] and the tower and airport occupants do as a community to remedy this situation?1. Draft a LOA with [the FBO] and the ATCT about the reporting points and the flow control procedures used for VFR pattern entry.2. Publish in the A/FD how the pattern is run here at GFK and familiarize itinerants with this procedure as best as possible (FBO on field with pertinent info for pilots departing; etc.)[The FBO] needs to seriously evaluate all students based on their comprehension of ATC phraseology and the procedures utilized at this airport if they are to train here. They also need to be familiar with the English language and if they are uncomfortable with flying on their own they need to be restricted from flying solo until they can safely do so. To add to that; if the instructor has even the slightest inkling that the student will struggle when flying solo; they need to hold off certification until they can without a reasonable doubt guarantee their student will be safe and will comply with ATC instructions when told to. There are so many failures in this current system and there are many opportunities to fix the situation prior to it reaching the point it did in the narrative above. I strongly urge you in the committee to not just file this report and wait for another; because there will be more. Yet what I would encourage you to do is to take this report; review all necessary recordings and information; and help us make this facility and airspace safer than it ever has been before and fix this situation before it potentially becomes fatal.


Second narrative: I was in the downwind for 9 right. I was told by Tower to 'turn base; you are number 1'. We turn base and continue in to land. On short final I could not remember if Tower had given us a landing clearance. I ask Tower 'Are we cleared to land 9 right [callsign]'. Tower's response was '[callsign] affirmative'. We continued with the landing without further incident. Tower did not mention landing without a clearance or anything like that.I am not entirely sure; but I think the Tower has to say 'cleared to land' in order for it to be a proper clearance. The problem may have arose from the heavy traffic in the area. There was a lot of radio congestion from the multiple aircraft taking off or landing.


Synopsis: GFK Approach Controller reported of an operation at the airport that is not working correctly. Pilot attempted to enter the airspace; but does not respond in a timely manner and is a conflict with opposite direction traffic.