National Transportation Safety Board
Washington, DC 20594
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
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.
