Northwest Flight Overshoots Destination by 150 Miles

[Matt Molnar]

NTSB is investigating why Wednesday's Northwest Flight 188 (http://flightaware.com/live/flight/NWA188/history/20091021/2135Z/KSAN/KMSP), flying from San Diego to Minneapolis, flew over MSP at 37,000 feet and continued another 150 miles before regaining radio contact and turning around.

NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
October 22, 2009

NTSB INVESTIGATING FLIGHT THAT OVERFLEW INTENDED MINNEAPOLIS AIRPORT

The National Transportation Safety Board is investigating an incident where an Airbus A320 overflew the Minneapolis-St Paul International/Wold-Chamberlain Airport (MSP).

On Wednesday, October 21, 2009, at 5:56 pm mountain daylight time, an Airbus A320, N03274, 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 147 passengers and unknown number of crew.

At 7:58 pm central daylight time (CDT), the aircraft flew over the destination airport and continued northeast for approximately 150 miles. The MSP center controller reestablished communications with the crew at 8:14 pm and reportedly stated that the crew had become distracted and had overflown MSP, and requested to return to MSP.

According to the Federal Administration (FAA) the crew was interviewed by the FBI and airport police. The crew stated they were in a heated discussion over airline policy and they lost situational awareness. The Safety Board is scheduling an interview with the crew.

The cockpit voice recorder (CVR) and flight data recorder (FDR) have been secured and are being sent to the NTSB laboratory in Washington, DC.

David Lawrence, the Investigator-in-Charge, is leading the team of 3 in investigating the incident.

Parties to the investigation are the FAA and Northwest Airlines.

-30-

NTSB Media Contact: Keith Holloway
[email protected]
(202) 314-6100

The CVR would seemingly answer exactly what happened pretty quickly. This afternoon WSJ reports (http://online.wsj.com/article/SB125623517851801783.html?mod=WSJ_hpp_MIDDLTopStor ies) the pilots may have fallen asleep.

[hiss srq]

Man, Delta pilots are just fumblin' and bumblin' all over the hub network arent they? Sounds like someone forgot to put a hold into the computer prior to TOD or at least over MSP to make it look like he was not sleeping at least. More fuel to the fire about why the FAA needs to create approved guidlines for naps.

[moose135]

http://online.wsj.com/article/SB1256235 ... TopStories (http://online.wsj.com/article/SB125623517851801783.html?mod=WSJ_hpp_MIDDLTopStor ies)


Airport Overshoot Prompts Pilot-Fatigue Probe
OCTOBER 22, 2009, 4:47 P.M. ET
By ANDY PASZTOR

A Northwest Airlines flight approaching Minneapolis Wednesday night lost contact with controllers for more than an hour and overshot its destination by about 150 miles before circling back to land. Federal safety regulators are investigating the incident as a possible case of pilots nodding off, according to government and airline-industry officials familiar with the matter.

Controllers at Minneapolis-St. Paul International Airport were able to re-establish contact with the Airbus A320, after a one hour and 18 minute lapse, before the plane, flight 188 en route from San Diego, landed safely and without injuries to the 147 passengers, according to a statement from the National Transportation Safety Board.

The NTSB said controllers lost contact with the aircraft while it was cruising at 37,000 feet, but didn't say how far from the airport the plane was at the time.

The NTSB said the pilots were interviewed after landing by Federal Bureau of Investigation agents and airport police. The pilots told law-enforcement officials they had been engaged in a "heated discussion over airline policy and they lost situational awareness," according to the NTSB. The Federal Aviation Administration is also investigating the incident.

Northwest is a unit of Delta Air Lines Inc.

"The safety of our passengers and crew is our top priority," Delta said in a statement. "We are cooperating with the FAA and NTSB in their investigation as well as conducting our own internal investigation. The pilots have been relieved from active flying pending the completion of these investigations. The incident comes as the FAA is seeking to update and rewrite decades-old rules governing how long commercial pilots can fly and remain on duty during a given period.

Wednesday night's incident is the second time in less than a week that a Delta cockpit crew was involved in a high-profile safety lapse. On Monday, a long-range Delta Boeing 767 en route from Brazil to Atlanta's Hartsfield International Airport landed on a taxiway, rather than the parallel runway. There were no injuries to any of the 182 passengers or 11 crew members.

The safety board is investigating whether pilot fatigue was an important factor. The crew had flown all night and was landing in darkness. The approach lights for the runway weren't turned on, however the lights on the runway surface were illuminated, according to the safety board.

Concerning the Minneapolis flight, it's not clear what the pilots' schedule was in the hours before it overshot the airport Wednesday night. But their work hours and sleep schedules in the preceding few days will be among the main issues examined by investigators.

In the case of the Delta crew that landed on the taxiway in Atlanta, the safety board said Wednesday that a third pilot aboard the twin-engine Boeing 767 had fallen ill during the flight and "was relocated to the cabin" before landing. The board said there was 10-miles visibility when the big jet touched down on the taxiway.

Earlier media reports indicated that the crew of the Boeing 767 had been temporarily removed from flying duties.

I'm not sure what "airline policy" is so controversial that it results in an hour-long "heated discussion" that causes you to ignore radio calls and overfly your destination by 150 miles. It's probably a good thing for the flight crew that the CVR has a 30 minute loop...


More fuel to the fire about why the FAA needs to create approved guidlines for naps.
On my KC-135 crew, the rule was "Last one awake has to wake up someone else". :wink:

[USAF Pilot 07]

zZzZzZzZzZzZzZz

Wonder if the aircraft CVR is still available. Sounds stupid of the pilots to claim they were in a heated debate about airline policy if the CVR is later pulled and it turns out they were sound asleep... Not good...

[PhilDernerJr]

They were definitely sleeping.

YA FIRED!

[SengaB]

Check out the flight path.
http://www.nycaviation.com/hosting/nwa18801.jpg

http://www.nycaviation.com/hosting/nwa18802.jpg

Senga

[Vidiot]

Too bad it wasn't United. Channel 9 on that flight would be interesting...

[moose135]

Wonder if the aircraft CVR is still available. Sounds stupid of the pilots to claim they were in a heated debate about airline policy if the CVR is later pulled and it turns out they were sound asleep... Not good...
Per the FARs, the CVR only is required to store the prior 30 minutes of audio, so it's quite possible the portion that would show what happened was overwritten as the flight made its return to MSP.

[moose135]

Something else to consider here - it is reported that the crew has been questioned by the FBI and local law enforcement, and will, no doubt, face questioning from the FAA and/or the NTSB in short order. If it is found that they did fall asleep, and weren't involved in a "heated discussion" as they claim, not only will they lose their jobs, and quite possibly their pilot licenses, they could also face federal charges for providing false information in an investigation. That always looks good on a resume! :wink:

[NIKV69]

Yea not these two pilots are basically toast. What a terrible situation. Still can't believe two guys wouldn't have enough rest to make a 4-6 hour flight without falling asleep.

[mirrodie]

Actually, they were indeed in a heated debate over this subject.

http://www.airliners.net/aviation-forum ... n/2139789/ (http://www.airliners.net/aviation-forums/non_aviation/read.main/2139789/)

[Art at ISP]

I find this so hard to believe on a number of levels--such as how such an automated aircraft can do this--if they had programmed the STAR properly, it would call for altitude changes, and send an alarm at some point--if they were sleeping it would be a DEEP sleep....

I am still shaking my head in disbelief.

[Matt Molnar]

Actually, they were indeed in a heated debate over this subject.

http://www.airliners.net/aviation-forum ... n/2139789/ (http://www.airliners.net/aviation-forums/non_aviation/read.main/2139789/)
Well I think they should be given a pass if that's the case.

[Matt Molnar]

Apparently the CVR is only going to arrive at the NTSB in Washington today. Did they deliver it on horseback?

[cancidas]

i still think they were kidnapped by aliens, enjoyed the experiments that were performed on them and flew the extra mileage to overwrite the CVR and FDR....



ok, so i've had too much caffeine today. i admit it.

[Matt Molnar]

Devil's advocate: maybe an outside source caused them to fall asleep...i.e. fumes from the lav, elevated carbon monoxide levels, or below normal oxygen levels.

[NIKV69]

MSNBC reports it is an old model CVR only last 30 min of flight is recorded so it will only reveal the part of the flight after they discovered their error.

[PhilDernerJr]

The CVR was probably first recorded by the airline before handing it in to the investigators.

[moose135]

Devil's advocate: maybe an outside source caused them to fall asleep...i.e. fumes from the lav, elevated carbon monoxide levels, or below normal oxygen levels.
And those fumes caused them to think they had a heated discussion? Maybe somebody pumped some hallucinogens into the cockpit? :shock:


The CVR was probably first recorded by the airline before handing it in to the investigators.
I would be very surprised if that happened. I assume these units are sealed to detect tampering, I don't think DL would want to open that can of worms!

[PhilDernerJr]

I could be wrong, but I thought the CVR was actually airline property. The CVR can be used for the airline to do their own investigations when behavioral issues arise or whatever they feel. Argument with ATC? Pull the CVR. Sexual harassment with an F/A? Pull the CVR.

[Matt Molnar]

Devil's advocate: maybe an outside source caused them to fall asleep...i.e. fumes from the lav, elevated carbon monoxide levels, or below normal oxygen levels.
And those fumes caused them to think they had a heated discussion? Maybe somebody pumped some hallucinogens into the cockpit? :shock:
Not super likely, but definitely possible.

A jetBlue f/a friend of mine told me a story a few years ago (maybe I've posted it here before)...On a redeye to JFK, the smoke alarm for the front lav went off a couple of times, but for whatever reason (it was dark, etc) the person made it back to their seat before the crew could determine who had caused it and they didn't want to make a fuss while everyone was sleeping. After they get to the gate and clear everyone out, a passenger asks to get back on the plane to retrieve something from the forward lav. Of course they don't let him do that, but they offer to get it for him. He's very insistent that he get it himself, which of course raises the crew's suspicion so they go inspect. In the garbage bin they find a crack pipe fashioned out of a Coke can...apparently the guy got scared and tossed it when the smoke alarm went off.

On the A320 (maybe other types as well) the ventilation for the forward lav is connected to the vents in the cockpit, so they decide to drug test the pilots just in case. Sure enough, they tested positive for crack and weren't allowed to fly for about a week.

[hiss srq]

That JetBlue story is actually fact too. I have heard it from a few sources. And yes, on the Airbus, the forward lav's outflow is into the cockpit.

[USAF Pilot 07]

I could be wrong, but I thought the CVR was actually airline property. The CVR can be used for the airline to do their own investigations when behavioral issues arise or whatever they feel. Argument with ATC? Pull the CVR. Sexual harassment with an F/A? Pull the CVR.


It may be, but I'd think once the FAA or feds get involved the airline loses it's "rights" to the CVR. They can probably request a copy from the FAA or NTSB after the data is extracted by them (before its released to the public) so that they can start their own investigation. I would imagine a FAA "representative" or officer was there to meet the plane when it pulled into the gate to make sure no funny business was being pulled.

I mean maybe the airlines could refuse to give it to the FAA, but then the FAA would probably just de-certify the airline and ground their whole operation.

When it comes to disputes with ATC, I think the tapes are usually marked (either requested by the pilots or done by ATC).

In my jet the CVR has several different channels which record inter-aircraft communication and communication between ATC and the aircraft. The whole unit starts recording once the parking brake is released so you can't control which channel is recording or anything like that.

[hiss srq]

It is engaged based on a sqwat switch in the parking brakes system. Similarly to the wat ACARS engages.

[coachrowsey]

I find this so hard to believe on a number of levels--such as how such an automated aircraft can do this--if they had programmed the STAR properly, it would call for altitude changes, and send an alarm at some point--if they were sleeping it would be a DEEP sleep....

I am still shaking my head in disbelief.


Wouldn't we all love to know what really happened

[USAF Pilot 07]

I find this so hard to believe on a number of levels--such as how such an automated aircraft can do this--if they had programmed the STAR properly, it would call for altitude changes, and send an alarm at some point--if they were sleeping it would be a DEEP sleep....



Even with a STAR with all altitude restrictions loaded in the box, the indication that the aircraft was at the TOD may only be a flashing symbol on the EHSI or EADI (if that) which would require their eyes be open, lol. Since they were at cruise their cruising altitude was probably captured coupled with their FMS NAV, so the autopilot would not automatically descend at the TOD (but it would continue to fly the lateral route on the FP).

Most STARS end with "expect radar vectors", so in the FMS flightplan you will load the STAR and the expected runway, but there will be a discontinuity between the last point on the STAR and a point on the approach. Before you reach the last point on the STAR you will usually get radar vectors off of the STAR to final, during which you can switch over the NAV sources on your EHSI to the localizer freq and inbound course of the arrival being flown and/or update the box to go direct to a point (usually the FAF) on the approach.

In this case, once they reached the final approach on the STAR their FMS sequenced to the discontinuity and had nowhere to fly so it maintained their current heading, and since no one had physically forced the aircraft to descend they were still at cruise altitude.

I believe some airlines have a policy in which the F/A are required to check-in up front every so often, but maybe DL/NWA doesn't, it wasn't done (busy cabin) or maybe eventually it was the F/As who woke up the pilots. If they had a ground speed of 600NM/HR it would mean they only overflew the airport by 15 minutes, and assuming they would have started their descent 150 miles from the airport, another 15 minutes from when they should have started that (30 minutes total).

The only aural warnings they may have had would be from ATC and who knows how loud they had their radios turned up. Both pilots were probably pretty sound asleep though...

[Matt Molnar]

As widely expected, the FAA just announced they have revoked the licenses of both pilots. They have 10 days to appeal.

[Big Tim #70]

As widely expected, the FAA just announced they have revoked the licenses of both pilots. They have 10 days to appeal.


Would they revoke their commercial rating or their pilots license all together?

[moose135]

Would they revoke their commercial rating or their pilots license all together?
Probably be their license all together.