Northwest A320 overflies destination by 150 miles . . .

[robbreid]

NTSB ADVISORY

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National Transportation Safety Board

Washington, DC 20594





October 22, 2009





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NTSB INVESTIGATING FLIGHT THAT OVERFLEW INTENDED MINNEAPOLIS AIRPORT



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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.

[CD]

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.

[righthandman]

I guess I am in a writing sort of a mood today.

In light of all the security issues since 9/11, both real and imagined I guess this is a fairly serious event; even had 9/11 not happened I guess it could have still potentially been a very serious event.

I just can't help thinking that this is just one example of many where it could have easily happened to almost any one of us "out there", now reading about it.

It's amazing how when "cockpit discipline" breaks down just the tiniest wee bit, all hell can break loose. I feel bad for the crew. I imagine when they pull and listen to the CVR they will hear some very interesting reactions to their own errors.

[ywgflyboy]

I hope for their job that they are telling the truth and remembered there are CVR's!!!

Will we hear a heated argument and failed attempts to hear their call sign, ignoring calls from the FA's asking, "where are we?" are will we hear zzzzzzzzzzzzzzzzzzZzzzzzzzzZzzzzzzzZZzzzzzzzZZzzzzzz

[taylor498]

In regards to the CVR, I'm guessing the last 30 minutes of the flight were after they realized their mistake, and were headed back to the airport/landing/taxiing in.

[ywgflyboy]

right..... I am always amused at the fact with todays technology we have never extended that 30minutes just a tad further. Although most emergencies that they are needed in unfold in a matter of minutes, an hour of recordings could prove beneficial sometimes I think.

[Boeing boy]

"According to the Federal Administration (FAA) the crew was

interviewed by the FBI and airport police."

What exatly do the airport police have to do with a plane overflying its destination??

[whipline]

Most CVR's are 30 minutes, but technology can go severl layers deep. If they were chatting or sleeping the TSB will soon know. So much for the erase button.

[twinpratts]

Oh Crap...

[185/310]

Most CVRs are now digital, so the 30min rule no longer applies to some. For example the Colgan Q400 CVR into Buffalo showed there entire conversation from the gate or close to I believe.

[Changes in Latitudes]

Most CVRs are now digital, so the 30min rule no longer applies to some. For example the Colgan Q400 CVR into Buffalo showed there entire conversation from the gate or close to I believe.

Indeed most recorders go well beyond the bare minimums of FAR 23/25. The key reason being, quite often, the manufacturers can often prove a lot less liability for events when given access to greater amounts of information. Same can be said of FDR parameters these days.

Oh yea, and its also more "safe".

[Sidebar]

Many CVRs now provide 120 minutes of recording.

[Rockie]

I hope for their job that they are telling the truth and remembered there are CVR's!!!

Will we hear a heated argument and failed attempts to hear their call sign, ignoring calls from the FA's asking, "where are we?" are will we hear zzzzzzzzzzzzzzzzzzZzzzzzzzzZzzzzzzzZZzzzzzzzZZzzzzzz

I can't see this turning out well for them no matter what the cause, but both sleeping due to fatigue is the only cause that might deflect some of the attention away from them. If either of them were awake there is no possible excuse for that kind of inattention.

[ywgflyboy]

I am actually relativity surprised that jets where not scrambled. CBC reported 4 fighters were on stand-by but never took off. I assume they hold off until they see a change in HDG or ALT before giving the green light for an interception?

[tons-o-fun]

Wow I heard this first hand on Winnipeg centre ( I was enroute from YQT-YXL) It went something like this NW- " Uh Winnipeg centre I believe we overflew our destination and we're in canadian airspace??" (in a flustered tone of voice...my opinion) Cont- " confirm you overflew your destination??" NW- "I think so" (sqk ident and all that jazz) Cont- " negative i believe your still with minneapolis, contact on blah blah blah"

I remember it catching our attention and joking about it. Did they fall asleep? how does something like that happen? wierd oh well. we continued our flight uneventful and thought nothing of it until i seen it on CNN. I wonder if the controller @ winnipeg centre remembers this?

[Bushav8er]

Assuming that they were asleep, which is either more common or reported more now (perhaps both), don't blame the pilots - blame the regulators and companies that (legally) allow ridiculous duty times!

[snowshoe]

[quote="Boeing boy"]"According to the Federal Administration (FAA) the crew was

interviewed by the FBI and airport police."

What exatly do the airport police have to do with a plane overflying its destination?? [/quote]

Boeing boy:

They were probably out there for any possible honest to goodness scrap with a possible honest to goodness security "perpetrator". But, have a feeling the biggest shot of adrenalin they had was from getting the two drivers to blow into the balloon. If they failed, of course the entire incident is in their lap. If they passed , they're still in hot water,but, I have a feeling there will be some changes in the old ops dept after it gets hit with the sh-t storm of paper that's going to land on them.

[AEROBAT]

I remember a PWA 737 that overshot its destination by heck of a lot more than 150 miles. It was about 15 to 20 years ago. I think they ended up some where in the artic after departing Yellowknife.

[co-joe]

A prof I had in college told us a story about a bizjet crew going yyc to lax and both pilots waking up having flown far enough past LA that all they could see was ocean in every direction. oopsies

[CAL]

hmmm I think they might have been sleeping....to do something like that awake would have been a complete disregard for what they were doing...I cant imagine they were awake..unless it was a Delta and NW pilot together:)...not sure which is worse but surely more like to keep their jobs if they were alseep...
Dont be fooled by that 30 mins thing...I fly an older machine and I have been told they can get more if they want...

[mabcan]

We have 30 minutes only because the regulation says it so : this is not a limitation coming from the technology, they just have to change the duration for the CVR.
On an A320, you have around 40 hours of flight datas (more than 100 parameters) on a simple 128 mb disc coming from the QAR, which is way above the requirements from the regulation.

[c-fhbc]

I have been out of the loop for awhile and no experience with the latest FMS and all the magic. Why did the auto pilot fly past the I assume destination of Minni? Should it not have entered a hold or would on station passage just gone dead reconning?? Just an old guy wondering!!!

[Inverted2]

I have been out of the loop for awhile and no experience with the latest FMS and all the magic. Why did the auto pilot fly past the I assume destination of Minni? Should it not have entered a hold or would on station passage just gone dead reconning?? Just an old guy wondering!!!

I dont fly the 320 but I assume their AP is similar to other jets. In ours, if we fly past a waypoint, the AP will continue along in the same track as it was to the last waypoint. So sort of dead reckonning in a way....

[Changes in Latitudes]

What does the FA call sound like in the 320? Apparently the FA's made numerous attempts to contact the flight deck with no response. Pretty hard to talk over that call chime in the aircraft I fly.

[sky's the limit]

Posted by Solaris in General Airline Comments. I tried to merge the threads but made a total hash of it... so I just cut and paste. Some days the mouse is your friend, others it just ain't....

stl

By CBC News, cbc.ca, Updated: October 23, 2009 11:04 AMJet that overshot destination by 240 km investigated

The U.S. National Transportation Safety Board is investigating how a Northwest Airlines flight on Wednesday managed to overshoot its destination by more than 240 kilometres before turning back.

Northwest Flight 188 was en route from San Diego to Minneapolis on Wednesday evening when air traffic controllers lost contact with the plane for more than an hour.

Four military fighter jets were readied to chase down the plane before contact with the Airbus 320 was re-established. By that time, the plane had overshot its destination and flown across the state line into Wisconsin airspace.

When the plane landed in Minneapolis, the crew told airline and security officials that it lost "situational awareness" during a spirited discussion about airline policy.

Suspicions pilots were asleep

But there are suspicions that the pilots were asleep. On Thursday investigators had yet to question the pilots and as such had no insights on whether it was possible they had fallen asleep, NTSB spokesman Keith Holloway said. The pilots have been suspended from flying by their airline while it, too, investigates.

The airline has not released names or details about the crew members in question.

Investigators hope the plane's cockpit voice recorder will help get to the bottom of the matter.

Aviation experts say the pilots should have had numerous warnings as they approached and passed Minneapolis: cockpit displays, controllers trying repeatedly to reach them, the city lights twinkling below.

Yet the pilots didn't discover their mistake until a flight attendant in the cabin contacted them by intercom, a source close to the investigation who spoke on condition of anonymity said.

"It just doesn't make any sense," said Bill Voss, president of the Flight Safety Foundation in Alexandria, Va. "The pilots are saying they were involved in a heated conversation. Well, that was a very long conversation."

Ben Berman, an airline pilot and former chief of major accident investigations at the NTSB, said it becomes second nature for pilots to know when they need to begin landing preparations.

Those preparations should have begun when the flight was still 160 kilometres or more away from Minneapolis, he said. It would require a fairly dramatic event to lose track of that kind of awareness, so shop talk "pretty clearly wasn't all that was going on," Berman said.

While the passengers were apparently unaware what was happening as they passed their destination, police on the ground were preparing for the worst and the Air National Guard had put fighter jets on alert at two locations.

Passenger Andrea Allmon didn't know anything was amiss.

"Everybody got up to get their luggage, and the plane was swarmed by police as we were getting our bags down from the overhead bins," she said.

She said they were kept on the plane briefly while police talked to the crew. Allmon said she was "horrified" to learn what had happened and it was "unbelievable to me that they weren't paying attention. Just not paying attention."

The FAA is updating rules governing how many hours commercial pilots may fly and remain on duty. The NTSB also cautioned government agencies this week about the risks of sleep apnea contributing to transportation accidents.

In January 2008, two Go! Airlines pilots fell asleep for at least 18 minutes during a midmorning flight from Honolulu to Hilo, Hawaii. The plane passed its destination and was heading out over open ocean before controllers raised the pilots. The captain was later diagnosed with sleep apnea.

In the incident Wednesday night, air traffic controllers in Denver had been in contact with the Northwest pilots as they flew over the Rockies, FAA spokeswoman Laura Brown said. But as the plane got closer to Minneapolis, she said, "the Denver centre tried to contact the flight but couldn't get anyone."

That was just before 8 p.m.

Nobody had any contact with the plane for the next 78 minutes.

With files from The Associated Press