Everyone makes mistakes. But it’s intolerable to see a situation where FAA managers don’t “practice what they preach” or worse yet believe they are above the standards they set for everyone else. After all these are the people that are supposed to be leading the organization. In the case of Northwest 188 they certainly didn’t lead by example.
The situation with Northwest 188 not being in contact with air traffic control snowballed in large part because of the failure of a few FAA managers to follow procedures.
Keep in mind these are the same FAA managers who mandate procedures and checklists for air traffic controllers. These are the same managers who mandate that all verbal air traffic exchanges, as well as position relief briefings to be recorded for later analysis.
But the investigation shows that numerous managers knowingly and willingly failed to follow procedure; Front Line Managers (FLMs) failed to follow through, Operations Managers (OMs) failed to follow checklists and give proper position relief briefings, and the position that oversees the entire operation of at least one facility (OM) isn’t required (and previously obviously didn’t believe it was necessary) to record their position relief briefings.
As the incident was unfolding several managers also abandoned their work areas to relay information to other managers face to face instead of using phone lines.
(I will sanitize this blog of complete names, but they are published in the NTSB’s documents should you care to read them yourself.)
The chain of events that led to the military not being notified of the problem with the flight started with the Denver Center (ZDV) Front Line Manger (FLM), Alex H., who “stated that at 0026 UTC on October 22nd, Mr. Michael R., sector 9 controller, called him via the voice switching communication systems (VSCS) advising him that NWA188 was not talking to him, and requested that he call company dispatch.” Mr. H. had some difficulty contacting Northwest dispatch but eventually was able to communicate with them.
However, procedure also states that the FLM is required to notify the facility OMIC of all NORDO aircraft.
At that time the flight was still about an hour from Minneapolis.
Alex H. “stated that he assumed the aircraft was now talking to ZMP, since ZMP had not called them with any inquiries about the aircraft. Mr. H. did not report the NORDO to the OMIC.”
So the first significant error was now made, and the Denver Center OMIC never was notified that the flight was NORDO, due to a FLM making an errant assumption and failing to follow procedure.
Now the flight was in Minneapolis Center’s (ZMP’s) airspace.
The next FLM’s statement was from Duane H.:
“…he was working as the FLM in area 5, when Mr. B., working sector 29, advised him that he (Mr. B.) had a NORDO aircraft (NWA188) from ZDV and that they were still looking for him. Mr. H. called NWA dispatch on a commercial non-recorded landline and was advised that they would send a message right up to NWA188.“
“Mr. H. stated that he was rather nonchalant about the issue…“
“Mr. H. had not called the OM at the watch desk to report the NORDO as required, and did not advise Ms. C. that he had not advised the OM of the NORDO.“
There’s nothing in his statement that indicates that Mr. H. was too busy to call the OM about the NORDO. He simply chose not to.
Eventually the third FLM involved (Ms. C.) followed proper procedure and notified the OM that the flight was NORDO. I guess one out of three FLMs doing their jobs isn’t too bad…
But she left her position in the area to do that, and advised the Operations Manager (OM) at the time, Mr. S., in person of the NORDO aircraft. Some time later when the flight was only 50 miles from its destination and still NORDO, Ms. C. walked back to the OMIC position and informed another OM, Ms. R., that the flight was still NORDO.
Why can controllers do their coordination regarding the safe separation of aircraft under their control via landlines but managers can’t do their coordination using the same? (The managers of the facility actually had a lame excuse as to why they choose to use unrecorded landlines, when they do use them at all, as noted further down in this entry.)
However, Ms. R. claims to have known nothing of the NORDO flight, because Mr. S. may have failed to convey that information to Ms. R. when she relieved him from position.
For the record Mr. S. said he “agreed to unofficially staff the watch desk.”
I’m not sure what “unofficially staff” means: you’re either on position performing the work of that position or you’re not. Is this an attempt to evade responsibility: “I was there, but not officially so I can’t be held responsible”?
Regardless of whether he was officially or unofficially staffing the watch desk, while he was there Mr. S. was the first OM that was notified of the NORDO flight and all he did was write the information on a notepad. He was relieved by Ms. R. about five minutes later (I can only assume he was “officially” relieved…).
He further stated that “if he had known that the flight had been NORDO for as long as it was, he would have done things differently, as per procedures, and contacted the DEN.” and “that in hindsight, he made a mistake in judgment.”
The FAA’s own Air Traffic Manual, the 7110.65 Section 10-4-4 states that all aircraft out of communications for longer than 5 minutes should be considered suspicious. By the time the OMIC is notified of a NORDO aircraft, it would be safe to assume that the aircraft would have been NORDO for more than five minutes by then. The OMIC would be notified by a FLM, who would be notified by a controller once he realized the aircraft was NORDO. That entire process would take several minutes at a bare minimum, and more than likely more than five minutes.
In other words the OMIC should automatically notify the DEN the moment they hear of a NORDO aircraft.
They’ve told controllers time and time again that management wants to know of all NORDO air carrier aircraft ASAP. So controllers pass the information on and then a manager might choose to sit on it?!
There’s nothing in the order that says managers can use their best judgment in determining whether or not to call the DEN, but that’s what this manager chose to do. He flat-out admitted that he “he would have done things differently, as per procedures“.
So this manager knew what the procedure was, but chose to ignore it, apparently because he believed that the procedures, rules and orders didn’t apply to him, or that he could otherwise interpret them to his liking.
Are you starting to see a pattern here with the way the managers responded to this problem?
For whatever reason they just didn’t seem to care that much; at least not enough to follow procedures properly, or they were under the impression that all the procedures were somehow subject to their own personal interpretations.
“When asked if he conducted a position relief briefing after Ms. R. returned, Mr. S. responded that he did not use the OMIC checklist to brief Ms. R. because of the short duration of time he had been there.”
So Mr. S. admits that he chose to ignore another order that mandates the use of checklists during position relief briefings too.
Later Ms. R. stated:
“Ms. R. acknowledged that it was possible that Mr. S. had advised her of the NORDO but she did not recall being advised.” and “that she expected a more structured OM position relief briefs, and she had been told that they were considering recording the OM position relief brief…”
Why don’t they routinely use a checklist like all the other operational positions are required to? Why is the OM position the only operational position in the facility that isn’t required to record position relief briefings?
Because they didn’t use a position relief checklist and because they didn’t record the briefing we’ll never know what really happened.
After Ms. R. finally heard of the NORDO flight she notified the DEN. But then she left the OMIC position apparently without anyone in her stead, because “while away from the OM desk coordinating with the FLM’s, the DEN had been calling for the OM.”
So the situation is developing where a airliner is approaching a major metropolitan area out of communications for about an hour; no one is sure of whether or not the flight has been hijacked; they are thinking of scrambling military fighters to intercept (whose notification was made incredibly late to start with) and the manager at the facility overseeing the situation walks away from her position?!
Back in July of 2007 I filed an Unsatisfactory Condition Report (UCR) concerning a violation of the FAA’s 7210.3 Order that states in paragraph 2-6-2 “Watch Supervision Assignments”:
“An individual is considered available for watch supervision when he/she is physically present in the operational area and is able to perform the primary duties of the function. If the supervisor/CIC leaves the operational area or is engaged in an activity which will interfere with or preclude the performance of watch supervision duties, then another qualified individual must be designated to supervise the watch.”
My complaint was that our Front Line Managers were routinely leaving the operational area for five minutes or more and failing to designate someone else to supervise the watch.
The UCR was closed on August 1st 2007, coincidentally by the same person who was recently promoted to the facility manager position (head of the facility), who stated that “The item described in UCR 521747 does not meet the “covered conditions” requirements for filing a UCR.” and “We consider this UCR closed.”
There is no mention of whether or not the concerns I raised in my UCR were even investigated.
At my facility FAA managers still routinely abandon their watch supervision positions without designating someone else to supervise the watch (or giving a recorded position relief briefing). FAA management has clearly shown in the past that it considers it acceptable for its managers to ignore that particular order.
So the OM walked away from her position while the DEN was trying to call because that’s what operations managers do all the time, in spite of it not conforming to the FAA’s own orders.
On page 3 of the NTSB report the managers allege that the line to the DEN at the Operations Manager’s (OM) desk doesn’t allow them to leave their position to “coordinate and communicate with several areas requiring her to be away from the single site DEN speaker and handset.”
Again, why don’t the managers use the landlines like controllers do to accomplish their coordination?!
On page 3 the report states that:
“The first problem was that despite numerous efforts, they have not been able to get their landlines recorded. Controllers and managers, when required to transmit urgent time critical information, use the speed dial function of a land line versus the cumbersome VSCS.”
“The cumbersome VSCS”?! “Time critical information”?!
VSCS (Voice Control Switching System) is actually the only communication system air traffic controllers use in the sector to talk to airplanes and each other to perform their air traffic duties. So VSCS is good enough for controllers to use to keep airplanes apart, but it’s too “cumbersome” for managers to use?!
Don’t forget, all the VSCS communications are recorded, but the regular telephone land lines are not. And the non-recorded system is the one that the managers choose to use (that is when they’re not wandering away from their positions to coordinate face to face with each other).
And that “time critical information” is the stuff in this case several managers chose to not pass on in a timely manner in accordance with procedures and orders.
I’m not sure which is worse: the poor judgment these managers exhibited or their lame excuses.
Are these managers examples of the “higher standard” that FAA management claims they’re held to?
This big cluster fxck brought to you by FAA management.
It’s no wonder the FAA is so screwed up…