NTSB Wants Cockpit Conversations Monitored <


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NTSB Wants Cockpit Conversations Monitored

By Daniel Baxter

February 25, 2010 - In the wake of a number of airline accidents and incidents the NTSB is now calling for the FAA to put in place regulations that would require airlines to monitor cockpit conversations on a regular bias and provide for protection of those recordings from public disclosure.

"In the Colgan report, the Safety Board recommended that all available sources of information be downloaded and analyzed on a routine basis.  Numerous Safety Board investigations have identified the performance of the crew as causal or contributing to the accident. Over the last decade, data monitoring has resulted in measurable safety improvements for equipment and operations."

“Because FOQA has been credited with driving down the accident rates in commercial aviation, it is essential to understand what is going on in the cockpit if we are to achieve further reductions. The benefits attained from the CVR should not be limited to posthumous investigations,” said Debbie Hersman, Chair of the National Transportation Safety Board (NTSB).


On February 12, 2009, a Colgan Air, Bombardier DHC-8-400, N200WQ, operating as Continental Connection Flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post crash fire.

The National Transportation Safety Board determined that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.

The NTSB retrieved and analyzed the black box on Flight 3407. Voice recordings on the black box indicated both pilots engaged in conversations that were not appropriate, their conversation distracted them from being able to appropriately monitor aircraft systems and those conversations had taken place below 10,000 feet (Transcript Of Last Words Aboard Flight 3407). FAA regulations, part 135 section 100 (b) prohibit non-essential discussions when flying below 10,000 feet.


FAA Part 135.100 Flight crewmember duties.

(a) No certificate holder shall require, nor may any flight crewmember perform, any duties during a critical phase of flight except those duties required for the safe operation of the aircraft. Duties such as company required calls made for such nonsafety related purposes as ordering galley supplies and confirming passenger connections, announcements made to passengers promoting the air carrier or pointing out sights of interest, and filling out company payroll and related records are not required for the safe operation of the aircraft.

(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft.

(c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight.

On Wednesday, October 21, 2009, an Airbus A320, 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 144 passengers, 2 pilots and 3 flight attendants.

Both pilots were interviewed separately by NTSB investigators, the following is an overview of the interviews: Both pilots reported there was a distraction in the cockpit. The pilots said there was a concentrated period of discussion where they did not monitor the airplane or calls from ATC even though both stated they heard conversation on the radio. Also, neither pilot noticed messages that were sent by company dispatchers. They were discussing the new monthly crew flight scheduling system that was now in place as a result of the merger.

The discussion began at cruise altitude. Both said they lost track of time, each pilot accessed and used his personal laptop computer while they discussed the airline crew flight scheduling procedure. The first officer, who was more familiar with the procedure, was providing instruction to the captain. The use of personal computers on the flight deck is prohibited by company policy.

Neither pilot was aware of the airplane's position until a flight attendant called about 5 minutes before they were scheduled to land and asked, “what was their estimated time of arrival.” The captain told investigators, at that point, he looked at his primary flight display for an ETA and realized that they had passed MSP. They made contact with ATC and were given vectors back to MSP. At cruise altitude - the pilots stated they were using cockpit speakers to listen to radio communications, not their headsets.

When asked by ATC what the problem was, they replied, "just cockpit distraction" and, "dealing with company issues." Both pilots said there are no procedures for the flight attendants to check on the pilots during flight. The Safety Board interviewed the flight attendants and other company personnel. Air traffic control communications have been obtained analyzed. Data from the cockpit voice recorder (CVR) revealed the following:

The CVR recording was 1/2 hour in length. The cockpit area microphone channel was not working during this recording. However, the crew's headset microphones recorded their conversations. The CVR recording began during final approach, and continued while the aircraft was at the gate. During the hours immediately following the incident flight, routine aircraft maintenance provided power to the CVR for a few minutes on several occasions, likely recording over several minutes of the flight. The FDR captured the entire flight which contained several hundred aircraft parameters including the portion of flight where there was no radio communication from the flight crew.  (see Cockpit Voice Recorder Legislation Opposed By CAPA)

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