Live-blogging: What happened on Flight 188

Posted at 9:28 AM on December 16, 2009 by Bob Collins (14 Comments)
Filed under: Northwest Airlines

Here's the live blog of the NTSB's release of 400 pages of evidence its gathered in its investigation into why the pilots of Northwest Airlines Flight 188 overshot their Minneapolis destination on October 21, 2009. It offers no conclusions as to what happened.

But it does shed an unfavorable light on the nation's air traffic control system, and the lack of procedures for recognizing a potential threat from the sky. As with most aircraft accidents, it also details a chain of failures, interrupted only by a flight attendant who asked when the plane will land.



Here's my appearance tonight on All Things Considered with Tom Crann:

I've written extensively about the incident:

What the tapes tell us (11/27)

FAA on Flight 188: "We could have done better" (11/13)

Was Flight 188 out of radio contact for three hours? Probably not. (11/5)

FAA smackdown (11/2)

General: Fighter jets should've been airborne over Minneapolis (10/29)

Flight 188: The explanation (10/26)

The 'What if?' scenario (10/23)

Flight 188: Making it add up (10/23)

---

Comments (14)

People are still covering this? It seems to me there are a lot bigger issues in the world right now.

Posted by Kathy | December 16, 2009 10:47 AM

---

Like what, Kathy?

As I've written before, this isn't really about two pilots, it's about an entire air traffic control system AND -- in particular -- the failure of the homeland defense system as it was established.

That's kind of a big deal seeing as how we're currently engaged in two wars because of that failure.

Posted by Bob Collins | December 16, 2009 12:22 PM

---

Summarizing what I got out of this:

-Plane out of contact for 77 minutes
-Pilots not aware of situation until inquiry from flight attendant
-Pilots distracted using laptop, figuring how to get favorable work schedule
-Military not notified until flight had passed Twin Cities
-Ground control shift changes may have clouded awareness of flight status
-Planes out of contact is a common occurence
-Procedures for checking in with ground control are not being followed

Thanks for the continued and in depth coverage. While the pop culture spotlight may be quick to move on, it is important to report on this failure of our security system.

Posted by kennedy | December 16, 2009 1:17 PM

---

I want to also give my thanks to MPR for continuing to cover this story.

Posted by Joseph | December 16, 2009 2:05 PM

---

My first comment was a little flippant, what I should have said was that the likelihood of another airplane attack is so remote that it doesn't really warrant more analysis than say, the health care bill, which will immediately affect everyone in this country and is being covered very poorly by all news outlets. To me it seems like you are covering Flight 188 extensively because of your personal interest in aviation.

And I wouldn't say we are in two wars because of the failure of the homeland defense system; these two wars are more a result of 60 years of questionable foreign policy practices.

Posted by Kathy | December 16, 2009 2:13 PM

---

Well, it's not either-or and MPR has devoted -- I'd guess -- hundreds of hours to the health care story. What in particular is not being covered satisfactorily .

And, yes, I acknowledge a personal interest in aviation. Others have a personal interest in politics so they cover things like governors going to NH. etc.

Although I prefer to look at it as expertise.

Look, there's significance in details other people think mean nothing. The first question after any major event happens --- say, two planes flying into the largest buildings in New York -- is "how could this happen?" Commissions are created, bureaucracies are built, constitutional rights are abridged, billions of dollars are spent and then we find out that nothing really changed.

Is that significant? I think it is, which is why I don't really care whether the pilots fell asleep or were arguing with each other.

What you describe is very much like what I heard in the aftermath of Watergate. Woodward and Bernstein incrementally found information that others would scream didn't matter and lambasted the Washington Post for spending months pursuing.

Now, I'm not Woodward and Bernstein and this story isn't Watergate but the process is the same. You ask questions until you get answers and you point out failures where failures shouldn't be tolerated. Change happens because people point out -- usually to the point of boring the listener -- that it needs to. Those who tolerate government failure and who don't want to be held accountable, depend on the short attention span of readers and the people whose job it is to tell them stuff that they might be sick of hearing. That's just the way it is.

As far as the breadth of subjects, at least five times a month, I post requests for information on stories people know about or want pursued. I don't recall ever hearing from you so I'm hoping you'll take the time to offer ideas and suggestions, and share your knowledge thereof.

Posted by Bob Collins | December 16, 2009 2:58 PM

---

your right, you are Bob Collins and this is about more than that other story.

2 Wars, countless wiretaps, restricted freedoms and more.

Posted by BJ | December 16, 2009 4:11 PM

---

I heard your piece on the news tonight. The word that came to my mind was "blather."

I a curious to know what your qualifications are to conclude that there are "far-reaching systemic problems," to criticize controller procedures, or to characterize ATC as a "rinky-dink system."

You obviously have no air traffic control experience. Do you have experience as a commercial pilot? Do you routinely fly in the system? How much time have you spent plugged in with a sector controller at Minneapolis Center? Have you ever been through the door of an ARTCC? Do you even know what ARTCC stands for?

Mistakes were made. Procedures will be improved. Life will go on.

We already have a vast surplus of unqualified people dispensing nonsense with great conviction to a public that is unqualified to judge it. We don't need any more. Please stick to reporting facts and leave the conclusions to be made by people who are competent in the subject matter.

Posted by Airedale | December 16, 2009 6:01 PM

---

//We already have a vast surplus of unqualified people dispensing nonsense with great conviction to a public that is unqualified to judge it. We don't need any more. Please stick to reporting facts and leave the conclusions to be made by people who are competent in the subject matter.

If I misspell a word, do you have to be an English major to point it out? You obviously haven't read anything of what I've written so far. I would encourage you to take the time to do so.

If you're going to say I got this wrong, then I would challenge you to point out where. I suspect your indignation isn't that I don't know what I'm talking about, nor that I got it wrong. I suspect your indignation is because I got it right and pointed it out.

Your comment "mistakes were made and procedures will be changed" confirms what I've already written: That procedures were inadequate and changes need to be made. The biggest "change", however, is that procedures already in place need to be followed. That wasn't done here. Particularly in the area of the air defense notification, that wasn't done even though the procedures for doing so were created after the deaths of 3,000 people.

If you'd read the material I'd written, you would know that it was AIR TRAFFIC CONTROLLERS who pointed out the flaws and listed their complaints with the their inability to keep track of whether they established communications with a plane entering their sector. If that's not true, that's something you should take up with them.

So, sure, you can call me names and tell me I don't know what *I'm* talking about, but what you're really saying here is that the people you work with, your superiors, the head of the FAA also don't know what they're talking about.

After this incident, your superiors sent out memos, and held meetings and acknowledged the systemic failure that was illuminated by this incident. The head of the FAA came out last month and said the same thing. The reminders were to follow the procedures THAT ARE ALREADY IN PLACE.

Look, I know that being an air traffic controller is tough work but in this day and age -- particularly in this day and age -- the job includes the responsibility to follow procedures and alert authorities under certain situations, and that's just the way it is. Controllers didn't do that in this case. You failed. That happens, true, but it doesn't disguise the fact the system failed, and no amount of rhetoric can distract people from the fact that the system -- not just the pilots -- failed that evening.

There are a lot of people whose lives depend on controllers doing their job. Don't ever tell us we don't have a right to point out when you don't.

Posted by Bob Collins | December 16, 2009 6:08 PM

---

Patrick Smith, a pilot and columnist over at Salon.com has a pretty succinct breakdown of how the incident occured based on a his conversation with an acquaintance of one of the pilots. Admittedly its third hand, but Patrick has been writing about aviation for a while and is a pretty straight up guy.

Assuming that Patrick's story is accurate, it does show what is often the case in airline incidents... its not one thing that goes wrong, its a nasty concantenation of little problems that add up to a big problem.

http://www.salon.com/news/air_travel/index.html?story=/tech/col/smith/2009/12/10/askthepilot344

Posted by Ken Stieer | December 16, 2009 7:48 PM

---

What a hoot!

1) I'd still be curious to know the answers to my questions regarding your qualifications.

2) I am not a controller. I do, however, fly in the system and have spent a number of hours plugged in (on headsets) sitting with controllers in order to better understand their end of the game and to improve on my end. I have a great deal of respect for the system and the people who make it work. In fact, I frequently bet my life on it.

3) "I suspect your indignation is because I got it right and pointed it out." Maybe I should have used the phrase "self-important" in addition to "unqualified?"

4) "If you're going to say I got this wrong, then I would challenge you to point out where." Not difficult: Your hyperbole. There are not ""far-reaching systemic problems" and the system is not "rinky-dink." People did not react as desired to this one-in-a-hundred-million event. (That is not hyperbole, btw. It actually may be a low-side estimate. As I type this, flightaware.com says there are 4,572 flights being handled by ATC. 46,420 arrivals in the past 24 hours.)

But ... maybe I'm all wrong. Maybe I jumped to an erroneous conclusion just as you do when you attack me as an air traffic controller. Maybe you have a lot of training and experience upon which to base your judgments. Second request: Please tell us.

Posted by Airedale | December 16, 2009 8:11 PM

---

//Your hyperbole. There are not ""far-reaching systemic problems"

That's the second time you've quoted me as saying that. What I said was "What we learned today is how far-reaching the systemic failures were in the air traffic control system."

The system as a whole is not rinky dink per se, but some of the elements of the system are. Using Google to track airplanes? Critical communications that have to take place on personal cellphones? Look, it's the safest system on the plant. The equipment is -- in many ways -- woeful and obsolete. My source is one of the people who repair as well as controller testimony. Just a few weeks ago when the flight planning computer went down, do you know why it went down? Because there's only one part to swap out (it was a router) and one guy had a key to the closet where it's kept and he wasn't at work.

Was it a one in a million event? Perhaps. But I didn't create the air traffic security system on the basis of the one-in-a-million scenarios. The government did. What are the odds a bottle of mouthwash will be used as a weapon, or the old lady in the wheelchair who has to get rousted at security is housing a weapon. Pretty high, and yet there we all are.

I didn't make the government invent a system where an airplane heading for a major city out of contact for 1:17 should lead to a series of events and procedures. The government did. It's the government who created the protocols that controllers are required to follow. It's not my *DESIRE* that they be employed. It's their REQUIREMENT that they be employed. It's not an option; it's a requirement of the job. Procedures are either followed, or they're not. Equipment either works or it doesn't. Someone answers a phone that supposed to be answered, or they don't. The FARs are adhered to, or they're not. There's no gray area here that you get live in because you know the people. That's the job. It's not easy. It's not pretty, but that's the job.

And I have every right to examine the actions of the government.

So what are my requirements to be a controller? None. I'm a pilot and I'm in the system from the other end, and yes, I toured Farmington 4 years ago, I believe. The only controllers I know are the ones I hang out with Oshkosh. But I couldn't sit down at a console tonight and guide a flight. Then, again, that's not my job. My job is to examine the statements of the people whose job it is and relay them accurately.

But you're suggesting that one must BE a controller or have put on a headset to be able to relay what the government has already confirmed were systemic failures in the system. I didn't make that up.

When you read what I've written above, that should be obvious to you. When you look at the documentation; that should be obvious to you, too.

If you don't want to listen to me; that's fine. But you should listen to them because they're IN the system and they're pointing out and acknowledging obvious -- and fixa ble -- flaws.

And you have too. So you can't on the one hand say I'm not qualified to point out the obvious flaws they're pointing out, and at the same time acknowledge the obvious flaws.

As far as 46,240 flights handled, no one argues that the controllers are not experienced and proficient. That's not the issue and it was never the assertion. But your comment reminds me of the comment of a Northwest Airlines spokesman a few decades ago when a DC-9 crashed on takeoff in Detroit.

When we contacted the company, the spokesman said, "now, we had ,1,000 flights today that ended successfully, why don't we talk about THOSE."

So what's happened because of that one flight? The sterile cockpit, among other things.

So what will happen because of this one in a million incident? The same thing that happened after all the other one-in-a-million incidents in which people have lost their lives. Changes that are required will be made, just as you acknowledge. That's the "FARs written in blood" cliche which I'm sure you've heard before.

I pointed out those changes are required because the people in the system has pointed out those changes are required.

If you spend just a few minutes actually reading the data that I've read, you'll see that, too. If you believe I've erred, you need only pull out the mistakes line by line as I've written them and provide the proper information. (I'll give you one: it was Barb Logan, not Bonnie Nashopulos who called the flight deck. The pilots said it was Bonnie but in her deposition, Logan said it was her)

I appreciate your taking the time to write and I appreciate your passion and obvious professionalism.

Posted by Bob Collins | December 16, 2009 10:58 PM

---

Thanks, Ken. He's right. I wrote about the same thing in the transcript above:

"If things had not gone well with this flight. If it had run out of fuel, the story we'd be telling you today is the same one we tell whenever there's an accident. It's never one particular thing that dooms a flight. It's a series of faults -- a chain of failure, as it's called. If you break any part of the chain, people survive.

In this case, you start with two pilots who aren't paying attention, throw in a messaging system that doesn't have a simple bell, add a dispatcher that doesn't answer the phone, mix in the lack of procedures for recognizing when a flight is out of touch, and you've got the makings of a disaster. "

Posted by Bob Collins | December 16, 2009 11:00 PM

---

Airedale,

I'm not sure where you got that chip on your shoulder, but get over it. Security failures make headlines. That plane flew almost directly over my house and no one on the ground knew who was at the controls. I appreciate that the NTSB recognizes the failure and is basically doing a root cause failure analysis. Once they know what went wrong they can implement fixes.

Ignoring the issue will not make it go away.

Posted by kennedy | December 17, 2009 1:53 PM

---

• E-mail this page
• Print this page
• Tweet this page
• Share this

Services

• Hourly Newscast
• HD Radio
• iPhone App / Mobile
• E-mail newsletters
• RSS feeds
• Podcasts
• Submit your photos
• Videos
• Weather
• Most e-mailed stories