NTSB SAFETY RECOMMENDATION

FOR IMMEDIATE RELEASE: March 18, 2010
SB-10-08

NTSB SAYS NORTHWEST PILOTS’ DISTRACTION LED TO OVERFLIGHT OF MINNEAPOLIS, NOTES ATC SHORTCOMINGS; ISSUES RECOMMENDATIONS ON ATC PROCEDURES

Washington, DC – The National Transportation Safety Board has determined that Northwest Airlines flight 188 overflew its destination airport of Minneapolis by more than 100 miles and failed to maintain radio communications because the pilots became distracted by a conversation unrelated to the operation of the aircraft. The NTSB’s accident brief, released today, also note air traffic control shortcomings during the event, and the Board issued two safety recommendations to address those shortcomings.

On October 21, 2009, Northwest Airlines flight 188, an Airbus A320 (N374NW) operating as a scheduled flight between San Diego and Minneapolis, did not communicate with air traffic control for approximately one hour 17 minutes. While in this NORDO (no radio communications) state, it flew past its intended destination at a cruise altitude of 37,000 feet. The crew subsequently re-established radio communications and landed without further incident. There were no injuries.

The NTSB said that the pilots continued to fly through several air traffic control sectors without replying to any radio commands. The investigation found that the pilots had become engaged in a conversation dealing with the process by which pilots request flight schedules and during the conversation each was using his personal laptop computer, contrary to company policy. The pilots were not aware of the repeated attempts by air traffic controllers’ and the airline to contact them until a flight attendant used the intercom to inquire about the progress of the flight.

The NTSB also found that the lack of national requirements for recording ATC instructions when using automated flight tracking systems, such as directing an aircraft to switch frequencies or to indicate that an aircraft has checked in on an assigned frequency, was a factor in the controllers delay in performing necessary actions and notifications required by lost communications procedures. In addition, because NORDO events of a short duration are not uncommon, the Safety Board found that controllers and managers may have become complacent in completing necessary NORDO actions and required notifications in a timely manner.

As a result of deficiencies in ATC communications procedures revealed in this investigation and an accident involving a Pilatus PC-12/45 that crashed in Butte, Montana on March 22, 2009, the Safety Board is making recommendations to the FAA to address the following issues:

The lack of standard procedures for identifying flight crew-ATC communications in ATC facilities that use automated flight tracking systems.
The lack of standard phraseology for identifying the emergency nature of emergency ATC radio transmissions.
The Safety Board’s probable cause finding, with factual narrative, can be accessed at the following link on the Board’s website: http://www.ntsb.gov/ntsb/brief.asp?ev_id=20091022X00120&key=1

The Safety Recommendation letter can also be found on the Board’s website at: http://www.ntsb.gov/Recs/letters/2010/A10_42_43.pdf.

Previously, the Safety Board has addressed the potential hazards created by the use of personal electronic devices by transportation operators. Last month, following the Board’s investigation of the Colgan Air 3407 accident near Buffalo, NY, the Board issued a safety recommendation to the FAA to require all Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck. Details of Safety Recommendation A-10-30 can be accessed at: http://www.ntsb.gov/Recs/letters/2010/A10_10_34.pdf.

Recent accidents and incidents such as the midair collision over the Hudson River last August, Colgan Air flight 3407, and the Northwest pilot’s overflight of the Minnesota airport have demonstrated the clear hazards to aviation safety when pilots and air traffic controllers depart from standard operating procedures and established best practices.

The Safety Board will convene a 3-day public forum on professionalism in aviation to address methods for ensuring excellence in pilot and air traffic controller performance. The forum is intended to raise awareness by promoting an open discussion between the Safety Board and invited panelists drawn from industry, labor, academia, and government on the importance of developing and reinforcing professionalism in the aviation industry. The forum is scheduled for May 18-20, 2010. More information regarding the forum will be announced in the coming weeks.

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The NTSB is amending its regulations concerning notification
and reporting requirements regarding aircraft accidents or
incidents. In particular, the NTSB is adding regulations to require
operators to report certain incidents to the NTSB. The NTSB is also
amending existing regulations to provide clarity and ensure that
the appropriate means for notifying the NTSB of a reportable
incident is listed correctly in the regulation.

On October 7, 2008, the NTSB published an NPRM titled
“Notification and Reporting of Aircraft Accidents or Incidents and
Overdue Aircraft, and preservation of Aircraft Wreckage, Mail,
Cargo, and Records” in the Federal Register. This NPRM proposed,
and the final rule codifies the addition of five reportable
incidents, the reporting of which the NTSB believes will improve
aviation safety.

The operator of any civil aircraft, or any public aircraft not
operated by the Armed Forces or an intelligence agency of the
United States, or any foreign aircraft shall immediately, and by
the most expeditious means available, notify the nearest National
Transportation Safety Board (NTSB) office when an aircraft accident
or any of the following listed serious incidents occur:

• Failure of any internal turbine engine component that results
  in the escape of debris other than out the exhaust path.
• In-flight fire.
• Aircraft collision in flight.
• Release of all or a portion of a propeller blade from an
  aircraft, excluding release caused solely by ground contact.
• A complete loss of information, excluding flickering, from more
  than 50 percent of an aircraft’s cockpit displays known as
  Electronic Flight Instrument System (EFIS) displays, Engine
  Indication and Crew Alerting system (EICAS) displays, Electronic
  Centralized Aircraft Monitor (ECAM) displays, or other displays of
  this type, which generally include a primary flight display (PFD),
  primary navigation display (PND), and other integrated
  displays.
• Airborne Collision and Avoidance System (ACAS) resolution
  advisories issued either when an aircraft is being operated on an
  instrument flight rules flight plan and compliance with the
  advisory is necessary to avert a substantial risk of collision
  between two or more aircraft, or to an aircraft operating in class
  A airspace.
• Damage to helicopter tail or main rotor blades, including
  ground damage, that requires major repair or replacement of the
  blade(s).
• Any event in which an aircraft operated by an air carrier lands
  or departs on a taxiway, incorrect runway, or other area not
  designed as a runway, or experiences a runway incursion that
  requires the operator or the crew of another aircraft or vehicle to
  take immediate corrective
• action to avoid a collision.

The final rule was published in the Federal Register January
7th, and the revisions and additions published in this final rule
become effective March 8, 2010.

www.ntsb.gov