Monitoring What‘s Going On

The investigation into the Colgan Air accident, near Buffalo, N.Y., has spurred the NTSB to focus on ensuring professional discipline in pilots who hold advanced ratings and fly in air carrier crews. The Safety Board issued a safety recommendation to the FAA, pointing to failure on the part of the ATP-rated captain and commercial-rated first officer to properly monitor what was happening and pick up obvious information from the cockpit displays. The NTSB said the pilots failed to monitor the airplane's pitch attitude, power and, especially, its airspeed.

In 1994, the NTSB studied 37 major accidents; it found that in 31 instances, the pilots hadn't done an adequate job of monitoring or cross-checking. Pilots frequently failed to recognize and effectively draw attention to critical cues that led to the accident sequence. At the time of the study, the NTSB told the FAA that there was a need for enhanced training in pilot monitoring skills. After finding that a Cessna Citation crash in Pueblo, Colo., involved failure to properly monitor airspeed, the Safety Board asked the FAA to go one step further and mandate that pilots receive training emphasizing monitoring skills and workload management.

During public hearing testimony in the Colgan Air investigation, Dr. Robert Key Dismukes of NASA's Ames Research Center reported that people have limited attention and must select where in their environment to direct attention. Distractions and interruptions can increase workload and redirect attention, thus complicating the monitoring task. As a result, effective monitoring requires an active effort to seek information and ask questions. The NASA scientist testified that current training programs may tell pilots to be vigilant, but they don't provide explicit techniques.

Perhaps the most dramatic example of failure to monitor what's happening with an airplane occurred on Northwest Airlines Flight 188 on October 21, 2009. The Airbus A320 was out of contact with ATC for about one hour and 16 minutes. It flew past its intended destination, Minneapolis-St. Paul International Airport, at its cruise altitude of FL370 with two pilots, three flight attendants and 144 passengers.

The flight was operating from San Diego International Airport in San Diego, Calif., to Minneapolis. It took off at 2:59 p.m. PST, and the captain was the flying pilot. The takeoff, climb and initial cruise were normal. The flight crew indicated that the planned route programmed into the flight management computer (FMC) was flown during the climb and cruise portions of the flight.

At 6:46 p.m. CST, the flight was being handled by Denver Center, and one controller set up a handoff to another controller. The flight checked in with the second controller, and 10 minutes later, the second controller tried to hand off the flight to a third Denver controller with the radio transmission "one eighty eight contact Denver Center, one three two point one seven." When there was no response, the second Denver controller again directed the flight to "contact Denver Center, one three two point one seven."

At 6:57:01 p.m., the flight responded, "Okay, three two one seven, Northwest one eighty eight." This was the last ATC communication with the flight in Denver Center airspace. The airplane's flight data recorder (FDR) indicated that after this transmission, there was no radio microphone keying until 8:12:46 p.m.

The flight entered the third Denver sector's airspace, but didn't check in on the assigned frequency. The controllers for the fourth and fifth Denver sectors tried to raise the airplane, but it flew into their airspace with no radio contact. ATC radioed the flight to contact Minneapolis Center, but there was no response. Radio calls on several different frequencies were made by Denver and Minneapolis controllers attempting to establish contact, but nothing worked. ATC contacted the airline's dispatch center and had them send a text message to the airplane. The pilots of other aircraft were asked to contact Flight 188. Controllers transmitted in the blind on ATC sector frequencies and on emergency frequency 121.5 trying to raise the aircraft. They asked for an "ident" on the transponder if ATC could be heard. Controllers in other airspace sectors were advised that the airplane was "no radio" and would be landing at Minneapolis. At least four additional text messages were sent to the airplane by the airline's dispatchers.

At 8:12:46 p.m., the flight transmitted on frequency 132.125, and advised that they had overflown the destination and needed to turn around and head for Minneapolis. The pilots didn't know it at the time, but the frequency they used was for Canada's Winnipeg Area Control Center (YWG), Thunder Bay Low Sector. After establishing the flight's position over Eau Claire, Wis., at FL370, the YWG controller radioed that the flight was on the wrong frequency and directed the pilots to contact Minneapolis Center on 123.72. At 8:14:06 p.m., Flight 188 established communications with Minneapolis Center.

At 8:14:14 p.m., the flight radioed, "Roger, we got distracted and we've overflown Minneapolis. We're overhead Eau Claire and would like to make a 180 and do arrival from Eau Claire." They were then given radar vectors to set up for arrival. During the descent, controllers asked several times about the cause of the loss of contact, and each time the pilots indicated that they had "cockpit distractions."

The pilots told investigators that they hadn't fallen asleep. They said that two hours into the flight, a flight attendant brought meals to the cockpit. During that time, the captain took a lavatory break. For security reasons, the lead flight attendant stayed in the cockpit while the captain was absent. The first officer didn't leave the cockpit during the flight.

After eating, the pilots began conversing about the current preferential bidding system for crew scheduling. Delta's bidding system had been adopted after the Northwest and Delta merger. Both pilots characterized the system as confusing, and reported that their discussions concerned the captain's bid results for November. His results required him to commute to Minneapolis more often than in the past. The captain said that he pulled out his laptop to show the first officer his bid results. The first officer also pulled out his laptop. Both pilots stated that the first officer was tutoring the captain on the bidding system and process. The captain said the discussion lasted about 15 minutes.

The pilots stated that their first indication of anything unusual with the flight was when they received a call from a flight attendant asking about their arrival. The captain said that he then looked down at his multifunction control and display unit, and saw that there was no flight plan information depicted. Then, the captain looked at his navigation display and saw Duluth to his left and Eau Claire to his right.

The captain, age 53, held an ATP certificate with airplane multi-engine land, Boeing 727 and Airbus A320 ratings; a commercial pilot certificate with airplane single-engine land and sea ratings; and a flight engineer certificate (turbojet). He held a first-class medical certificate with the restriction that he "shall possess glasses for near/intermediate vision." According to airline records, he had 18,641 hours, of which 8,196 hours were as pilot in command.

The first officer, age 54, held an ATP certificate with airplane multi-engine land, Boeing 727 and Airbus A320 (second in command only) ratings and a flight engineer certificate (turbojet). He held a first-class medical certificate with the restriction that he "must have available glasses for near vision." According to airline records, he had 13,811 hours, of which 5,345 hours were as second in command in the A320.

The NTSB concluded that the first officer acknowledged but never completed an assigned radio frequency change due to interruptions, likely during the time that the flight attendant was in the cockpit and the captain was absent. Not complying with the ATC handoff was contrary to FARs and airline procedures. The NTSB also concluded that the controllers didn't follow procedures to ensure the flight was on the correct frequency, which delayed the identification of the flight as "no radio." Investigators found that ATC management didn't notify everyone they should have notified, in a timely manner, about the loss of contact with the flight. The Safety Board said that the FAA doesn't have national standardized procedures in use by ATC when flights are transferred from sector to sector using automation.

The NTSB determined that the probable cause of this incident was the flight crew's failure to monitor the airplane's radio, instruments and flight progress after becoming distracted by conversations and activities unrelated to the operation of the flight.