In its continuing investigation of an Airbus A320 that overflew the Minneapolis-St Paul International/Wold-Chamberlain Airport (MSP), the National Transportation Safety Board has developed the following factual information: On Wednesday, October 21, 2009, at 5:56 pm mountain daylight time, an Airbus A320, operating as Northwest Airlines (NWA) flight 188, became a NORDO (no radio communications) flight at 37,000 feet. The flight was operating as a Part 121 flight from San Diego International Airport, San Diego, California (SAN) to MSP with 144 passengers, 2 pilots and 3 flight attendants.

Both pilots were interviewed separately by NTSB investigators yesterday in Minnesota. The following is an overview of the interviews:

The first officer and the captain were interviewed for over 5 hours combined.
The Captain, 53 years old, was hired in 1985. His total flight time is about 20,000 hours, about 10,000 hours of A-320 time of which about 7,000 was as pilot in command.
The First Officer, 54 years old, was hired in 1997. His total flight time is about 11,000 hours, and has about 5,000 hours on the A-320.
Both pilots said they had never had an accident, incident or violation.
Neither pilot reported any ongoing medical conditions.
Both pilots stated that they were not fatigued. They were both commuters, but they had a 19-hour layover in San Diego just prior to the incident flight. Both said they did not fall asleep or doze during the flight.
Both said there was no heated argument.
Both stated there was a distraction in the cockpit. The pilots said there was a concentrated period of discussion where they did not monitor the airplane or calls from ATC even though both stated they heard conversation on the radio. Also, neither pilot noticed messages that were sent by company dispatchers. They were discussing the new monthly crew flight scheduling system that was now in place as a result of the merger. The discussion began at cruise altitude.
Both said they lost track of time.
Each pilot accessed and used his personal laptop computer while they discussed the airline crew flight scheduling procedure. The first officer, who was more familiar with the procedure was providing instruction to the captain. The use of personal computers on the flight deck is prohibited by company policy.
Neither pilot was aware of the airplane’s position until a flight attendant called about 5 minutes before they were scheduled to land and asked what was their estimated time of arrival (ETA). The captain said, at that point, he looked at his primary flight display for an ETA and realized that they had passed MSP. They made contact with ATC and were given vectors back to MSP.
At cruise altitude – the pilots stated they were using cockpit speakers to listen to radio communications, not their headsets.
When asked by ATC what the problem was, they replied “just cockpit distraction” and “dealing with company issues”.
Both pilots said there are no procedures for the flight attendants to check on the pilots during flight.
The Safety Board is interviewing the flight attendants and other company personnel today. Air traffic control communications have been obtained and are being analyzed. Preliminary data from the cockpit voice recorder (CVR) revealed the following:

The CVR recording was 1/2 hour in length.
The cockpit area microphone channel was not working during this recording. However, the crew’s headset microphones recorded their conversations.
The CVR recording began during final approach, and continued while the aircraft was at the gate.
During the hours immediately following the incident flight, routine aircraft maintenance provided power to the CVR for a few minutes on several occasions, likely recording over several minutes of the flight.
The FDR captured the entire flight which contained several hundred aircraft parameters including the portion of flight where there was no radio communication from the flight crew. Investigators are examining the recorded parameters to see if any information regarding crew activity during the portion of flight where radio contact was lost can be obtained.

The Safety Board’s investigation continues.

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NTSB Media Contact: Keith Holloway
hollowk@ntsb.gov
(202) 314-6100

FOR IMMEDIATE RELEASE: March 5, 2010 Washington, DC – National Transportation Safety Board Chairman Deborah A.P. Hersman today encouraged the sleep research and healthcare community to continue their efforts to educate transportation policy makers of the dangers of fatigue in all modes of transportation.

Speaking before the annual conference of the National Sleep Foundation in Washington, D.C., Chairman Hersman remarked that fatigue has been a concern for the Board since the creation of the agency in 1967 and it has been an issue on the Board’s Most Wanted List of Transportation Safety Improvements since the list was established in 1990.

“The work of the National Sleep Foundation and other organizations and individuals is critical to improving transportation safety policy,” said Chairman Hersman. “The NTSB is interested and willing to partner with you in developing a greater awareness of fatigue.”

Hersman highlighted a number of accident investigations across all transportation modes that included fatigue as the probable cause or a contributing factor to accidents. As a result, the Board has made safety recommendations that range from deploying fatigue detection systems to reduce the occurrence of accidents to installing electronic on-board recorders that collect and maintain hours of service data on vehicle operators.

“We can’t always prove fatigue as a cause of an accident, but the frequency with which we now routinely document the presence of fatigue-related factors in transportation operations is alarming,” Hersman stated.

Hersman remarked that while there are still no definitive tools to conclusively identify the degree to which a person is fatigued, the major challenge is to ensure that all those in transportation report to work rested and fit for duty — for their own safety and for the safety of those they are transporting.

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