Northwest Flight 188 - overshot destination - many alerts on flight deck

Wandering Flight Spurs Nap Probe

Weather condition

Traffic

Overshot

Track over destination

UPDATED TO NOV 17, 2009
FAA Administrator Randy Babbitt said in a news conference Friday that the FAA had not contacted NORAD soon enough regarding wayward Northwest Flight 188 - he also said things would change. Flight 188 last month went silent and overshot MSP by 150 miles, but the FAA did not notify other agencies about the loss of radio contact until one hour and nine minutes after last contact. In a news release, the FAA announced it "has taken steps to ensure more accurate preliminary information about air traffic events can be provided to top officials more quickly." As part of that push, the FAA will be updating its training and procedures for how controllers handle aircraft that have gone NORDO. The FAA says new incident notification procedures will be adopted by the end of the month and it will review changes to training and procedures by the end of January, 2010. The agency noted specific goals.


Changes target three areas. First it aims to ensure that air traffic controllers are armed with the knowledge, ability and tools to identify those aircraft that are in communication with ATC and when those communications have been interrupted. Second, it aims to ensure that coordination with other agencies regarding loss of communications is handled effectively and accurately. Third, the FAA aims to improve the accuracy of its preliminary investigations and the timely dissemination of information, internally.

NTSB preliminary findings have stated that the source of the distraction was not a "heated discussion of airline policy" as originally claimed, but the use of laptops in the cockpit, which can obscure the view of dashboard instruments and further distract pilots.

Descobertas preliminares da NTSB atestam que a fonte da distração não foi uma "discussão das diretrizes da empresa" como alegaram originalmente, mas o uso de LAPTOPS na cockpit, que pode encobrir a visão do painel de instrumentos e adicionalmente distrair pilotos.

FAA revokes wayward Northwest pilots' licenses

“You were disengaged and impervious to the serious threat to your own safety, as well as the safety of the people for whom you are responsible.”     the FAA said in a letter to the pilots.

FAA cancela licenças de pilotos da imprevisivel Northwest

"vocês estiveram descompromissados e indiferentes à ameaça séria a suas próprias segurança, assim como à segurança das pessoas para quais vocês são responsáveis"
O FAA disse numa carta para os pilotos

They were in violation of company policy, the NTSB said on Monday. The first officer was showing the captain how to use a new crew flight scheduling procedure, and both pilots said they lost track of time. During their discussion, they did not monitor the airplane or notice calls from ATC. Neither pilot was wearing a headset, but both said they heard conversation on the radio. Also, neither pilot noticed messages that were sent by company dispatchers. Neither pilot was aware of the airplane's position until a flight attendant called about five minutes before they were scheduled to land and asked for an ETA. The captain said at that point, he looked at his primary flight display and realized they had passed their destination, Minneapolis-St. Paul International Airport (MSP). They then made contact with ATC and were given vectors back to MSP.

Eles estiveram em violação das diretrizes da companhia, disse a NTSB na Segunda-feira. O co-piloto estava mostrando ao comandante como usar uma novo procedimento de horários de voo da tripulação,  e ambos pilotos disseram que eles ouviram conversas no rádio. Também, nenhum piloto notou as mensagens que foram enviadas pelos despachantes da companhia. Nenhum piloto esteve atento à posição do avião até que uma comissária de voo os chamou cinco minutos antes deles estarem no horário do pouso e indagaram a Hora Estimada de Chegada. O comandante disse que naquele ponto, ele olhou no seu PFD e percebeu que eles tinham passado o destino deles, o aeroporto internacional São Paulo em Minneapolis (KMSP). Eles então fizeram contato com o ATC e foram dados vetores para voltarem para Minneapolis.

Northwest was recently acquired by Delta, which prompted the change in rules that the pilots were discussing. In a statement issued on Monday, Delta said the two pilots in command of Northwest Flight 188 are suspended until the conclusion of the investigations, but added that using laptops in the cockpit is strictly against the airline's flight deck policies, "and violations of that policy will result in termination." The NTSB said the captain, age 53, has been with Northwest since 1985 and has a total flight time of about 20,000 hours. The F/O, age 54, was hired in 1997, and has a total flight time of about 11,000 hours. Both pilots said they had never had an accident, incident or violation; neither reported any ongoing medical conditions, and both said they were not fatigued. They were both commuters, but they had a 19-hour layover in San Diego just prior to the incident flight. NTSB will analyze data from the flight data recorder to see if any information regarding crew activity during the portion of flight where radio contact was lost can be obtained.


A Northwest foi recentemnte comprada pela DELTA, a qual efetuou a imediata mudança nas regras que os pilotos estavam discutindo. Numa declaração emitida na Segunda-feira, a DELTA disse que os dois pilotos em comando do voo 188 da Northwest estavam suspensos até a conclusão das investigações, mas acrescentou que usar NOTEBOOK na cockpit é estritamente contra as diretrizes da cabine dos pilotos na empresa, "e violações desta diretriz resultariam em demissão".
A NTSB disse que o comandante, 53 anos, estava na Northwest desde 1985 e tem um total de cerca de  20.000 horas de voo. O Primeiro-Oficial, 54 anos, foi contratado em 1997 e tem um total de cerca de 11.000 horas de voo. Ambos pilotos disseram que eles nunca tiveram um acidente, incidente ou violação; nem relataram quaisquer condições médicas em andamento, e ambos disseram que eles não estavam fatigados. Eles ambos estavam em jornada de voo, mas eles tiveram um repouso de 19 horas em San Diego logo antes do voo do incidente. A NTSB analisará os dados do Gravador de Dados de Voo para ver se qualquer informação a respeito da atividade da tripulação   durante a porção do voo onde o contato pelo rádio foi perdido possa ser obtida.

The National Transportation Safety Board is investigating, among other things, whether the two pilots fell asleep at the controls. The pair told law-enforcement officials who interviewed them upon landing in Minneapolis - and apparently told fellow pilots later - that they had been engaged in a "heated discussion over airline policy and they lost situational awareness," according to the NTSB.

O NTSB está investigando, entre outras coisas, se os dois pilotos cochilaram nos controles. Os pilotos contaram aos investigadores que os intrevistaram após o pouso em Minneapolis e aparentemente contaram a pilotos colegas mais tarde, que eles tinham estado empenhados numa "calorosa discussão acerca das diretrizes da empresa de linha aérea e eles perderam a consciência situacional", de acordo como NTSB.

Teria qualquer dos pilotos "distraídos" (cochilando!) inserido no FMS a CHEGADA EAU CLAIRE 8 em vez da SKETER 3?

O resultado seria o FMS ter calculado o T/D [Top Of  Descend = ponto ideal de descida] para 19 milhas náuticas DEPOIS de Minneapolis.

  

EAU CLAIRE 8 ARRIVAL

SKETER 3 ARRIVAL

Route to be flown

Pilots napping in the cockpit - getting beyond their control

"My eyelids on slow motion closure sounded on my head like those cartoon cats napping"

"The instruments panel fade in and out".

Pilots, Airlines Push For Nap Time

FAA rules on how many hours an airline pilot may fly or be on duty before he must rest have been virtually unchanged for nearly a half-century. If airlines had to allow their crews more rest, they would have to hire more crews.

The practice of catching a nap while serving on the flight deck is not currently approved by the FAA, but citing supporting evidence, pilot unions and airlines say it may be time for the FAA to embrace the idea. British Airways, Qantas and others have for some years allowed one pilot to sleep during the cruise portion of some flights and some studies indicate it makes crew more alert during critical phases of flight. "It may seem counterintuitive to folks in the back of the plane, but it's the right thing to do," Bill Voss, president of the Flight Safety Foundation, told The Wall Street Journal. Besides, pilots do nap en route, according to a recent survey of commuter pilots referenced by the Journal, which also stated simply that "pilots say naps not only make sense, but that they also already take them." And fatigue has long been among the top concerns of aviation safety authorities, having been cited as a contributing factor in more than 250 aviation fatalities since 1990.

The strategies supported by the airlines and unions are referred to as controlled napping, and are seen as fatigue-mitigation strategies. Public perception is cited as the biggest obstacle in implementing those strategies. The balance of safety, profitability and work rules makes the issue complex. The FAA is expected to review crew rest rules, and napping is expected to be part of the conversation if not the final regulations.

Crowded skies and exhausted pilots are a bad mix, the airline industry and pilot unions agree, but they're struggling over what to do about it.

"We have many experiences of the flight crew, the cabin crew, who in cases of emergency were just so numb they couldn't respond instantly to a tragedy at hand."

Corporate Airlines Flight 5966 was preparing to land on Oct. 19, 2004, when the twin-engine turboprop slammed into trees. The pilots and 11 passengers were killed. Two injured passengers survived by jumping from the plane moments before it was engulfed in flames.


The NTSB said the pilots failed to notice that their plane had descended too quickly because they didn't follow procedures and engaged in unprofessional cockpit banter. But the board also said the captain and first officer probably were exhausted - they were completing their sixth flight of the day, had been on duty more than 14 hours and had flown three trips the day before.

Studies show exhaustion can impair a pilot's judgment in much the same way alcohol does. It's not uncommon for overtired pilots to focus on a conversation or a single chore and miss other things going on around them, including critical flight information. In a few cases, they've just fallen asleep.

Last year, two pilots conked out for at least 18 minutes during a midmorning flight from Honolulu to Hilo, Hawaii, as their plane continued to cruise past its destination and out to sea. Air traffic controllers were finally able to raise the pilots, who turned around the plane with its 40 passengers and landed it safely.

It's not clear where the captain of Flight 3407 slept the night before the crash, but it appears he may have tried to nap in a busy airport crew room where his company - regional carrier Colgan Air Inc. of Manassas, Va., which operated the flight for Continental - kept bright lights on to discourage extended sleeping. The first officer commuted overnight from her home near Seattle to Newark, N.J., to make the flight to Buffalo.


A brief review of US Federal Aviation Administration (FAA) flight time and rest rules for scheduled domestic commercial carriers (US Code Title 14, part 121.471) are as follows:

Crewmember total flying time maximum of:

1000 hours in any calendar year

100 hours in any calendar month

30 hours in any 7 consecutive days

8 hours between required rest periods

Rest for scheduled flight during the 24 hours preceding the completion of any flight segment:

9 consecutive of hours rest for less than 8 hours scheduled flight time

10 hours rest for 8 hours or more, but less than 9 hours scheduled flight time

11 hours rest for 9 hours or more scheduled flight time

Read the entire section for exceptions (18).

The flight crew duty day starts with check-in, and is considered concluded at block-in plus 15 minutes for that day’s final flight. Rest periods are times when the crewmember is not scheduled for flying duty. These are not periods of restful sleep. Adequate restful sleep, however, must be achievable during these rest periods. In addition to FAA regulations, company rules and practices also influence crew scheduling and rest issues. Company contracts with pilots, scheduling practices for bids and reserve, and productivity demands all play a part in the balance between work requirements and crew rest.

When flight crewmembers find themselves flying when fatigued several warning signals should alert them of a dangerous situation. These include:


Eyes going in and out of focus

Head bobs involuntarily

Persistent yawning

Wandering or poorly organized thoughts

Spotty near term memory

Missed or erroneous performance of routine procedures

Degradation of control accuracy (19)
 
REFERENCES:
18. Code of Federal Regulations, Title 14, Vol. 2 (revised 2002), 14CFR121.471.


19. Caldwell JA, (2002) Asleep at the Throttle. US Air Force Research Laboratory Pamphlet.