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.

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