Northwest Airlines Flight 188 - overshot Minneapolis - AUDIO and RECORD transcripts

Northwest Airlines Flight 188

October 21, 2009

The October 21 flight from San Diego to Minneapolis (and beyond) carried 144 passengers for an extra hour and fifteen minutes. Lost to radio communications for 78 minutes, controllers at Minneapolis asked other Northwest flights to check Denver's frequency. When finally reached by controllers, the crew said, "we're good on fuel," adding that the aircraft was carrying more than two hours' worth. The FAA has classified the incident as a "pilot deviation" (similar to flying at the wrong altitude).

Updated: 12:59 pm ET November 25, 2009


Denver Air Route Traffic Control Center (Denver Center), Position 28R, Partial Transcript (PDF, 182 KB)
Denver Center, Position 28RA, Partial Transcript (PDF, 183 KB)
Denver Center, Position 30R, Partial Transcript (PDF, 171 KB)
Denver Center, Position 18R, Partial Transcript (PDF, 133 KB)
Denver Center, Position 08R, Partial Transcript (PDF, 129 KB)
Denver Center, Position 09R, Partial Transcript (PDF, 276 KB)
Audio (MP3, 2.12 MB)
Denver Center, Position 08D, Partial Transcript (PDF, 166 KB)
Denver Center, Position 18D, Partial Transcript (PDF, 167 KB)
Minneapolis Center, Position 29R, Partial Transcript (PDF, 84 KB)
Audio (MP3, 8.61 MB)
Minneapolis Center, Position 19R, Partial Transcript (PDF, 108 KB)
Audio (MP3, 5.36 MB)
Minneapolis Center, Position 13R, Partial Transcript (PDF, 94 KB)
Audio (MP3, 2.24 MB)
Minneapolis Center, Position 13D, Partial Transcript (PDF, 108 KB)
Audio (MP3, 2.38 MB)
Minneapolis Center, Position 16R, Partial Transcript (PDF, 133 KB)
Audio (MP3, 5.94 MB)
Minneapolis Center, Position 10R. Partial Transcript (PDF, 64 KB)
Audio (MP3, 3.51 MB)

Passengers overnight on board - Continental Airlines and ExpressJet Airlines

As he taxied to the terminal, the aircraft captain asked to deplane the passengers but the ground crew refused because there were no Transportation Security Administration staff in the airport at that hour. The captain tried several times but eventually had to take no for an answer even though TSA rules would have allowed the passengers to get off as long as they were kept in a sterile area of the airport. It's the first time airlines have been punished for a ramp delay, Lahood said.

Office of Public Affairs

DOT 182-09


Tuesday, November 24, 2009


Contact: Bill Mosley


Tel: (202) 366-4570

DOT Issues Precedent-Setting Fines for Rochester, MN Tarmac Delay Incident

The U.S. Department of Transportation today levied a total civil penalty of $100,000 against Continental Airlines and ExpressJet Airlines for their roles in causing the passengers on board Continental Express flight 2816 to remain on the aircraft at Rochester International Airport for an unreasonable period of time on Aug. 8, 2009. Continental also provided a full refund to each passenger and also offered each passenger additional compensation to tangibly acknowledge their time and discomfort. In addition, DOT assessed a civil penalty of $75,000 against Mesaba Airlines, which provided ground handling for the flight, for its role in the incident.

These precedent-setting enforcement actions involve consent orders that reflect a settlement by the carriers of violations alleged by DOT’s Aviation Enforcement Office. They are the first enforcement orders punishing carriers for extended tarmac delays, as well as the first time a carrier acting as a ground handler for another airline has been punished for failing to properly help passengers leave an aircraft during an unreasonably long tarmac delay.

“I hope that this sends a signal to the rest of the airline industry that we expect airlines to respect the rights of air travelers,” said U.S. Transportation Secretary Ray LaHood. “We will also use what we have learned from this investigation to strengthen protections for airline passengers subjected to long tarmac delays.”

The Aviation Enforcement Office’s investigation found that all three carriers violated the law that prohibits unfair and deceptive practices in air transportation for their respective roles in the incident, in which a Continental Express flight from Houston to Minneapolis/St. Paul operated by ExpressJet was diverted to Rochester due to bad weather in Minneapolis. The aircraft reached Rochester about 12:30 a.m. and the passengers were stranded aboard the aircraft until approximately 6:15 a.m. when they were finally deplaned into the terminal.

Prior to diverting to Rochester, ExpressJet contacted Mesaba personnel at Rochester to request assistance at the airport, which Mesaba, the only airline staffing the airport at the time, agreed to provide. Shortly after the flight arrived in Rochester, the ExpressJet captain asked the Mesaba employee handling the flight whether the passengers could deplane into the airport terminal. In response to this initial inquiry, and other subsequent inquiries, the captain was told that passengers could not enter the terminal because there were no Transportation Security Administration (TSA) screeners on duty at that hour, despite the fact that TSA rules would have allowed the passengers to enter the airport as long as they remained in a sterile area.

Continental and ExpressJet, in separate orders, were found to have violated the prohibition against unfair and deceptive practices in air transportation because ExpressJet failed to carry out a provision of Continental’s customer service commitment requiring that, if a ground delay is approaching three hours, its operations center will determine if departure is expected within a reasonable time, and if not the carrier will take action as soon as possible to deplane passengers. ExpressJet also failed to take timely actions required by its procedures, including notifying senior ExpressJet officials and providing appropriate Continental officials with notice of the delay. Continental was found to have engaged in an unfair and deceptive practice since, as the carrier marketing the flight 2816, Continental ultimately is responsible to its passengers on that flight.

The consent order covering Mesaba finds that the carrier engaged in an unfair and deceptive practice when it provided inaccurate information to ExpressJet about deplaning passengers from flight 2816.

In November 2008, the Department proposed a rule to enhance airline passenger protections, including a provision that would require airlines to adopt contingency plans for lengthy tarmac delays and incorporate them in their contracts of carriage. A final rule is expected by the end of this calendar year.

Luxury Travel - New Cabins - Private Jet Flight - In-flight Live TV

TAM 3054 - Final Investigation Report - Pilot Interactive Computer Training

Centro de Treinamento da TAM em São Paulo

"TREINAMENTO FALHO"

O relatório aponta falhas no treinamento e instrução fornecidos pela TAM. O CENIPA diz que, a formação teórica dos pilotos usava apenas cursos interativos em computador, "o que permitia a formação massiva, mas não garantia a qualidade da instrução recebida". Além disso, a formação de Stefanini, o copiloto, contemplou apenas um tipo de certificação, o que se mostrou insuficiente para enfrentar aquela situação. Por fim, havia a percepção, entre os tripulantes, de que o treinamento vinha sendo abreviado, por causa da grande demanda advinda do crescimento da empresa. "

"Instrução: A formação teórica dos pilotos usava exclusivamente simulações em computador, o que não garantia a boa formação individual de cada um. Além disso, a formação do copiloto, Henrique Stefanini di Sacco, contemplou apenas um determinado tipo de certificação, que se mostrou insuficiente para enfrentar a situação. Havia a percepção entre os tripulantes, aliás, que o treinamento vinha sendo abreviado."

"Coordenação de cabine: O monitoramento do voo não se mostrou adequado, uma vez que a tripulação não percebia o que acontecia, o que impediu correções.

Pouca experiência do piloto: Apesar de sua larga experiência em grandes jatos comerciais, Di Sacco tinha apenas 200 horas de voo em jatos A320

Supervisão gerencial: A companhia aérea permitiu que a tripulação fosse composta por dois comandantes, mas Di Sacco havia realizado só um treinamento específico. A falta de coordenação entre os setores da empresa - especialmente Operações e Treinamento - levou a falhas na formação dos pilotos

Falta de percepção: A configuração e o funcionamento dos manetes não ajudaram os pilotos na identificação de dificuldades. E essa situação foi agravada pela falta de um alarme para indicar o erro na posição do instrumento

Perda de consciência situacional: Surgiu como consequência da falta de percepção dos pilotos. A automação da aeronave também não ofereceu aos tripulantes sinais de perigo"

Regulação: Embora a ANAC proibisse a operação com reverso (freio aerodinâmico) inoperante, a exigência só foi normatizada em 2008. Isso impediria o pouso com pista molhada

Projeto: Ficou constatado que é possível possível pousar com os manetes do A320 em posições distintas, sem que nenhum dispositivo alerte os pilotos.

FALHA EM AVISO SONORO

As simulações revelaram um dado preocupante: nem sempre o aviso sonoro "retard", que tem a função de advertir os pilotos sobre os procedimentos a serem adotados no momento do pouso, operou conforme o previsto. "Ficou constatado que, na aeronave A320, é possível, durante o pouso, posicionar um dos manetes de potência na posição reverso (frenagem) e outro na posição de subida (aceleração), sem que nenhum dispositivo alerte de modo eficiente os pilotos", diz a página 102. "Tal situação pode colocar a aeronave em condição crítica e, dependendo do tempo necessário para que a tripulação identifique essa configuração e dos parâmetros da pista de pouso, uma situação catastrófica poderá ocorrer", avisa o CENIPA.

Centro de Treinamento da TAM em São Paulo

US Airways Flight 1549 - 3D reconstruction - Hudson River Ditching

US Airways Flight 1549 reconstruction by EXO Esphere 3D

The NTSB released the public docket for Flight 1549 on June 9, 2009. The docket contains a wealth of information that can be utilized in a full 3D reconstruction of the accident. Our work goes deep into the underlying framework of information and encompasses the entire spectrum of accident information. Integrating all spatial and temporal data allows us to approach this accident from a never-before-seen perspective. All work you see on this page would withstand the rigors of qualification for presentation either as demonstrative evidence or, if sufficient witness testimony is available, real evidence. We have the capability to blend all of the information you see into any perceivable final product, depending on your specific visualization needs. The video below is best viewed full screen with HD enabled.
Most people don't realize this, but the birds were visible on radar, before the event occured. After integrating the raw radar data into our 3D environment and creating motion targets representing those radar returns associated with the flock of birds, our timeline clearly depicts the intersection of Flight 1549 with birds at a time of around 1527:10 (HHMM:SS). This coincides well with the CVR transcript which indicates loud "thumps" at 1527:11.4 (HHMM:SS.0). The NTSB Wildlife Factors Report has identified the feathers in the aircraft as Branta Canadensis (Canada Goose) by means of visual, microscopic and DNA analysis. Identification of the feathers was conducted by the Smithsonian Institute Feather Identification Laboratory. Though the errors may be intolerable, it is possible to pursue an altitude calculation for the birds by triangulation, this due to the fact that there are two separate radar facilities that reported data. We know the altitude of the birds at the time of impact, but it may also be helpful to determine their flight profile to understand where they were going or where they departed.. We will attempt this analysis as our work continues on the accident.

The illustration below presents a detailed view in the area of the bird strike and clearly shows motion, disorganization of the flock following the bird strike, and the subsequent re-organization of the flock(s) following the passage of a second aircraft, Eagle Flight 4718. Aircraft altitude is in 100's of feet, time lapse is set at 10x normal speed for this animaiton to aid in visualization. Eagle Flight 4718 actually came quite close to birds but luckily was not on an intersecting flightpath.