NTSB: Better communication needed after Northwest flight overshoots airport by 100 miles

NTSB seeks better communications after NWA mishap

MINNEAPOLIS — Federal safety officials recommended Thursday that better communications procedures be adopted in the wake of a fatal Montana plane crash and a Northwest Airlines flight that overshot the Minneapolis airport by more than 100 miles last year.

The National Transportation Safety Board issued its recommendations to the Federal Aviation Administration, which runs the nation’s air traffic control system. The report comes after the board investigated the Northwest flight, whose pilots failed to talk to air traffic controllers for more than an hour, and the Montana crash that killed 14 people.

One recommendation called for controllers to better document their communication with pilots to ensure that critical information gets passed from one controller to another. The board also said controllers should always begin transmissions on emergency frequencies by saying “on guard.” Although a common practice, the phrasing isn’t required.

Doug Church, a spokesman for the National Air Traffic Controllers Association, said the union declined immediate comment because officials had not had a chance to closely review the report.

The pilots of Northwest Flight 188 failed to communicate with controllers for about 77 minutes before discovering they were over Wisconsin in October. The pilots, whose licenses were revoked, said they became distracted while working on laptop computers.

Although the NTSB officially ruled Thursday that the probable cause of the incident was “the flight crew’s failure to monitor the airplane’s radio and instruments,” it found room for improvement on the ground.

The crew lost contact when a controller in Denver told them to change frequencies as the plane moved into different airspace. The handoff came during a shift change, and the plane’s crew failed to contact controllers on the new frequency. A Minneapolis controller tried unsuccessfully to contact the plane on the emergency frequency.

Both the Denver and Minneapolis control facilities used automated systems to track and hand off flights between controllers, but they weren’t required to document that the flight crew had been told — but failed — to contact the next sector, the NTSB report said.

Had a standardized procedure been in place, the controller who was coming on duty likely would have quickly discovered that the plane was out of radio contact, the report said. It also suggested that an explicit identification of emergency transmissions may have broken the pilots’ distraction.

In the Montana crash, the report said documentation procedure deficiencies likely did not cause the accident but the investigation indicated that controllers were not documenting — and thus not ensuring — that pilots obtained critical weather and safety information for destination airports. There was a controller shift change during the incident.

The private flight from Oroville, Calif., was destined for Bozeman but the pilot requested clearance to divert to Butte. The NTSB hasn’t determined why the pilot wanted to divert or why the Pilatus PC-12/45 crashed into a cemetery near the Butte airport’s runway on March 22, 2009. The preliminary accident report indicates weather conditions at both airports were satisfactory.

On the Net:

The NTSB announcement is at: www.ntsb.gov/Pressrel/2010/100318.html