NTSB -- NTSB SAYS NORTHWEST PILOTS' DISTRACTION LED TO OVERFLIGHT OF MINNEAPOLIS, NOTES ATC SHORTCOMINGS; ISSUES RECOMMENDATIONS ON ATC PROCEDURES

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NTSB PRESS RELEASE

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National Transportation Safety Board

Washington, DC 20594

FOR IMMEDIATE RELEASE: March 18, 2010

SB-10-08

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NTSB SAYS NORTHWEST PILOTS' DISTRACTION LED TO

OVERFLIGHT OF MINNEAPOLIS, NOTES ATC SHORTCOMINGS; ISSUES

RECOMMENDATIONS ON ATC PROCEDURES

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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.

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NTSB Media Contact: Keith Holloway

hollow@xxxxxxxx

(202) 314-6100

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