1990 — Dec 3, fog, runway collision/fire, Northwest 1482 & 299, DTW AP, Romulus MI– 8
–8 NTSB AAR. Airlines, Inc., Flights 1482 and 299 Runway Incursion…Collision… 1991, p11.
–8 Sturkey. Mid-Air: Accident Reports and Voice Transcripts… 2008, p. 358.[1]
Narrative Information
NTSB Factual Information:
“1.1 History of the Flights
“1.1.1 General
“On December 3, 1990, at 1345 [1:45] eastern standard time, Northwest Airlines (NWA) flight 1482, a McDonnell Douglas DC-9, and Northwest Airlines flight 299, a Boeing 727 (B-727), collided near the intersection of runways 09/27 and 03C/21C at Detroit Metropolitan/Wayne County Airport (DTW), Romulus, Michigan. The DC-9 was to be a regularly scheduled passenger flight to Pittsburgh, Pennsylvania, and the B-727 was to be a regularly scheduled passenger flight to Memphis, Tennessee. Both airplanes were operating under Federal Aviation Regulations (FAR) Part 121 and instrument meteorological conditions prevailed at the time at DTW. The B-727 was on its takeoff roll on runway 3C at the time of the collision, and the DC-9 had taxied onto the runway just prior to the accident. The B-727 was substantially damaged, and the DC-9 was destroyed during the collision and subsequent fire. Of the 40 passengers and 4 crewmembers aboard the DC-9, 7 passengers and 1 flight attendant received fatal injuries. None of the 146 passengers and 8 crewmembers on the B-727 were injured.
“1.1.2 B-727 Taxi and Takeoff Activity
“Flight 299 was initially scheduled to depart at 1210, but an airplane change delayed the flightcrew from boarding the incoming airplane until 1245 at Gate F11. Following normal turnaround procedures, the flight was pushed back for taxi around 1331. The flight was initially cleared by the west ground controller to runway 3C via a right turn from the gate, and to gold short of Oscar 7, a taxiway just short of the C concourse…The flightcrew noted that the visibility was ¾ mile, as reported on Automatic Terminal Information Service (ATIS) information Delta. They also noted that the visibility was deteriorating as they began taxiing.
“The flightcrew of the B-727 was instructed to contact the east ground controller near Oscar 9 and was then instructed to taxi to runway 3C via Oscar 6, to Foxtrot taxiway, and to advise the east ground controller when crossing runway 9/27. The captain then asked the first officer to monitor the radio for updated ATIS information and to check the company [end of p.1] takeoff visibility minimums for runway 3C. The takeoff minimum for runway 3C was ¼ mile visibility, which coincided with the ¼ mile visibility when being broadcast as part of the new ATIS information Echo. As they taxied through the Oscar 6 area, the flightcrew observed an NWA DC-9 taxiing eastbound on the Outer taxiway toward Oscar 4. This airplane was NWA flight 1482, the DC-9 involved in this accident. The B-727 captain stated, ‘I lost sight of this aircraft as it taxied away from me. It appeared to be entering an area of lower visibility.’ Shortly thereafter, they also heard a discussion on east ground control frequency concerning a taxiing airplane missing the Oscar 6 intersection.
“The B-727 then crossed runway 9/27 and the crew reported to the ground controller that they were clear of that runway. They continued taxiing along Foxtrot taxiway as the No. 3 engine was started. As they turned onto Xray taxiway, ground control requested their position, then cleared them to the local control frequency. At this time, the captain noted that he could see, ‘…the end of the apron of 3X…,’ a distance of approximately 1,800 feet. The second officer commented around that time that the weather was deteriorating significantly. The B-727 then stopped at the hold line for runway 3C and reported to the local controller at 1344:08 that they were ready for takeoff. The flight was cleared for takeoff at 1344:15. Power was advanced at 1345:03, 48 seconds after the receipt of takeoff clearance. The captain later testified at the Safety Board’s public hearing that since the ATIS was reporting ¼ mile visibility and he had adequate visual references to maintain the runway centerline, he believed that his decision to take off was correct.
“Five seconds into the takeoff roll the first officer stated, ‘Definitely not a quarter mile, but ah, at least they’re callin’ it.’ According to the flightcrew, the airplane entered an area of reduced visibility as it accelerated through about 100 knots. The captain stated that the DC-9 suddenly appeared on the right side of the runway in the path of the right wing of the airplane. He then shouted and moved his body to the left while moving the yoke to the left and slightly aft. Following the impact at 1345:40, he rejected the takeoff and stopped the airplane using maximum braking. The collision occurred 1 minute and 25 seconds after the tower cleared the B-727 for takeoff.
“1.1.3 DC-9 Preflight Activity
“This flight was the captain’s first without supervision after extended period off flying status for medical reasons….[p.4]
“1.1.4 DC-9 Taxi Activity
“At 1335:31, the DC-9 was cleared to taxi from Gate C18 by the west ground controller with the following instructions:
1482, right turn out of parking, taxi runway 3 Center, exit ramp at Oscar 6, contact ground now 119.45.
“The captain stated that the visibility was deteriorating as they began taxiing, but he was able [to] find and follow the ‘yellow line’ {the taxiway centerline}. The captain testified that he intercepted the taxiway centerline at or near the point where it forks to the left to become the centerline of the Outer taxiway heading east. About this time, the first officer stated, ‘Hey , it looks like it’s goin’ zero zero out here.’ Shortly thereafter, ground control requested their position. The first officer reported that they were abeam the fire station. At this time, they were given an additional taxi clearance: ‘Roger, Northwest 1482, taxi Inner, Oscar 6, Fox, report making the, ah, right turn on Xray.’ About ½ minute later, the first officer stated, ‘Guess we turn left here.’ When the captain expressed some doubt about this left turn, the first officer replied, ‘Near as I can tell. Man, I can’t see [expletive] out here.’
“At 1339:22, the captain stated, ‘Well anyway, flaps twenty and takeoff check when you get the time.’ The first six items on the takeoff checklist were then completed by the crew.
“In a subsequent discussion with ground control about their position, the first officer stated to the controller: ‘approaching the parallel runway on Oscar 6…headed eastbound on Oscar 6 here…’ He then said that they had missed Oscar 6 and that they ‘…see a sign here that says, ah, the arrows to Oscar 5. Think we’re on Foxtrot now.’ According to the first officer, he realized that they had missed taxiway Oscar 6 after he observed the sign for that taxiway behind him. The controller then stated ‘Northwest 1482, ah, you just approach[ed] Oscar 5 and you are you on the Outer?’ The first officer responded ‘yeah, that’s right.’
“Ground control then gave the additional taxi instruction: Northwest 1482, continue to Oscar 4, then turn right on Xray.
“The captain continued to taxi eastbound on the Outer taxiway at a very slow rate. The first officer estimated later that during this period the visibility was about 500 to 600 feet… [end p. 5]
“Beginning at 1342:00, as the airplane was nearing the Outer/Oscar 4 intersection, the following dialogue occurred between the captain and first officer (F/O):
Captain: This, this a right turn here, Jim?
F/O: That’s the runway.
Captain: Okay, we’re goin’ right over here then [possible query].
F/O: Yeah, that way. [pause of 21 seconds] Well, wait a minute. Oh, # this, uh,
- [pause of 8 seconds] I think we’re on ah, Xray here now.
Captain: Give him a call and tell him that, ah….
F/O: Yeah, this is nine. We’re facing one six zero yeah. Cleared to cross it.
Captain: When I cross this which way do I go? Right?
F/O: Yeah.
Captain: This, this is the active runway here, isn’t it?
F/O: This is, should be nine and two seven. [pause of 5 seconds] It is. [pause of
3 seconds] Yeah, this is nine two seven.
Captain: Follow this. [Unintelligible word] we’re cleared to cross this thing. You
sure?
F/O: That’s what he said, yea. [pause of 2 seconds] But this taxi light takes
us….[pause of 2 seconds]. Is there a taxiway over there?
“At this point, the captain of the DC-9 set the parking brake. Also at this time, 1343:24, the B-727 crewmembers were performing their takeoff checklist and were 1 minute and 36 seconds from beginning their takeoff roll. Intracockpit dialogue in the DC-9 continued:
Captain: Nah, I don’t see one. [pause of 11 seconds] Give him a call and tell him that, ah, we can’t see nothin’ out here.[2] [pause of 32 seconds until the captain released the parking brake, followed by 16 second pause] Now what runway is this? [pause of 7 seconds] This is a runway.
F/O: Yeah, turn left over there. Nah, that’s a runway too. [end of p. 7]
Captain: Well tell him we’re out here. We’re stuck.
F/O: That’s zero nine.
“At this time, 1344:40, the B-727 flight engineer was calling the takeoff checklist complete, and the airplane was about 24 seconds from beginning its takeoff roll. At 1344:47, the captain of the DC-9 attempted to contact ground control. However, because he was initially transmitting on some unknown frequency or over the interphone, he was unable to make contact until 11 seconds later. The dialogue in the cockpit of the DC-9 and radio transmissions beginning at 1344:47 are as follows:
Captain to ground: Hey, ground, 1482. We’re out here we’re stuck….we can’t see
anything out her. [lapse of 8 seconds] ah, ground, 1482. [unsuccessful transmissions]
Ground control: Northwest 1482, just to verify, you are proceeding southbound on Xray now and you are across nine two seven.
Captain to ground: Ah, we’re not sure, it’s so foggy out here we’re completely stuck here.
Ground control: Okay, ah, are you on a ru- taxiway or on a runway?
Captain to ground: We’re on a runway we’re right by ah zero four.
Ground control: Yeah, Northwest 1482 roger, are you clear of runway 3 Center?
F/O [to captain]: We’re on runway 21 Center.
Captain to ground: Yeah, it looks like we’re on 21 Center here.
Captain or F/O: [expletive]
[Pause of 10 seconds from captain’s last transmission to ground control.]
Ground control: Northwest 1482, y’say you are on 21 Center?
Captain to ground: I believe we are, we’re not sure.
F/O [to captain]: Yes we are.
[Pause of 5 seconds from captain’s last transmission to ground control.] [end of p. 8]
Ground control: Northwest 1482 roger, if you are on 21 Center exit that runway immediately sir.
“The two airplanes collided 7 seconds after this last instruction from the ground controller….
“Following the collision, the captain shut off the fuel control levers. The first officer stated that he instinctively ducked over to the left as the B-727 wing tip grazed his side of the cockpit. An evacuation of passengers was ordered immediately over the airplane public address system by the captain. The tail cone exit was not opened during the evacuation. The external tail cone release was not activated by any flight crewmember or airport rescue and fire fighting (ARFF) personnel. The internal tail cone release mechanism was later found to have been mechanically inoperable. A flight attendant and a passenger succumbed in the tail cone. [end of p. 9] ….
“…DC-9…General Damage Description
“The interior of the passenger cabin was extensively damaged by the fire. All cabin sidewall and ceiling panels, stowage bins and seat cushions, except for some small pieces, were destroyed by fire….
“The airplane’s fuselage was cut in a straight line just below the bottom of the windows on the right side of the airplane. The cut line remained along the right side of the fuselage, and the fuselage structure above this cut line to the top was destroyed by fire. The majority of the fuselage was burned from just aft of the cockpit to just forward of the aft bulkhead, from the top to just above the window line on the left side of the airplane.
“The accessory compartment between the aft pressure bulkhead and the fiberglass tail cone contained considerable amounts of soot. Plastic electrical wiring support loops and insulation on some small wires in that area had melted…. [p. 26]
“1.13.3 Injury and Fatality Descriptions
“No persons on the B-727 were injured. Seven passengers and one flight attendant on the DC-9 died. The flight attendant was found face down on the tail cone catwalk with her head directly under the tail-cone release handle and the male passenger who had sustained a minor head injury was found aft of the tail cone slide pack… Both victims died of asphyxia secondary to smoke and soot inhalation and both were within reach of the tail-cone emergency release handle.
“Three male passengers who occupied seats 7F, 9F, and 12F were the only persons to die from massive blunt force trauma. A female passenger seated in 6F and a male passenger originally seated in 12D died of asphyxia secondary to smoke and soot inhalation. The male was found in the aisle at row 11, and both of these victims were severely burned. A male passenger assigned to seat 10D, who was found in the aisle at row 9, died of thermal injuries; no traumatic injuries or smoke and soot inhalation were detected….
“The cabin of the DC-9 was consumed by fire. The fuel vent surge tank in the right wing of the B-727 was probably ruptured as the wing sliced through the fuselage of the DC-9….
“The passenger in seat 11D stated that flames erupted ‘almost immediately.’ The passenger in seat 6B said that after the impact he saw a flame that looked like a ‘blow torch’ coming into the cabin at the right rear. The passenger in seat 15A saw flames along the right side of the fuselage immediately after impact. [end of p. 34]
“1.14.3 Fire Fighting….
“…the Fire Chief stated that he decided not to have his fire fighters attempt to jettison the DC-9 tail-cone externally because the cabin was totally engulfed in fire and the cabin environment appeared to be nonsurvivable. He also said that flames on the ground in the area of the tail-cone presented an unacceptable risk to his fire fighters. At the public hearing for this investigation, he stated that another reason why he did not want the tail-cone jettisoned was because it would vent the fire within the fuselage…. [p. 36]
Analysis
“2.1 General
“The investigation clearly indicated that when the accident occurred the DC-9 was positioned on active runway 3C/21/C and the B-727 was on its takeoff roll.
“The Safety Board…concludes that the visibility was so poor at the runway intersection that neither airplane had time to visually acquire and evade the other prior to the collision…. [p. 50]
“2.2.2 Role Reversal in Cockpit
“The Safety Board believes that a nearly complete and unintentional reversal of command roles took place in the cockpit of the DC-9 shortly after taxiing began. The result was that the captain became overly reliant on the first officer. The captain essentially acquiesced to the first officer’s assumption of leadership. This role reversal contributed significantly to the eventual runway incursion…. [p. 53]
“….by the time the airplane was on the Outer taxiway, the captain apparently believed that the first officer knew what he was doing and where the airplane was located. Unfortunately, as was revealed later, the first officer was not aware of his location and did not inform the captain of this problem. The Safety Board believes that if the pilots had admitted to themselves that they were lost at that point, and if they had acknowledged this to the ground controller around 1339, they might have prompted the controllers to take appropriate action, which could have prevented the accident. The captain, however, apparently believed that the first officer knew where he was, and the first officer apparently could not bring himself to admit, or was not aware, that his assertive directions had placed the airplane in this predicament…. [p. 55]
“At 1340, the ground controller transmitted: ‘Northwest 1482, continue to Oscar 4 then turn right on Xray.’ This transmission, in retrospect, may have confused the flightcrew and adversely affected their subsequent actions because they did not have to go as far as the centerline for taxiway Oscar 4 to turn right onto taxiway Xray…. [p. 56]
“2.3.2 Ground Controller’s Actions
“In analyzing this accident in retrospect, the Safety Board examined the actions that could have been taken by the ground controller to prevent the runway incursion….he could have requested to local controller to suspend takeoff activity until he was certain that the DC-9 was in fact across runway 9/27 of the Oscar 4 area and established on taxiway Xray…. [p. 61]
“3.2 Probable Cause
“The National Transportation Safety Board determines that the probable cause of this accident was a lack of proper crew coordination, including a virtual reversal of roles by the DC-9 pilots, which led to their failure to stop taxiing their airplane and alert the ground controller of their positional uncertainty in a timely manner before and after intruding onto the active runway.
“Contributing to the cause of the accident were (1) deficiencies in the air traffic control services provided by the Detroit tower, including failure of the ground controller to take timely action to alert the local controller to the possible runway incursion, inadequate visibility observations, failure to use progressive taxi instructions in low-visibility conditions, and issuance of inappropriate and confusing taxi instructions compounded by inadequate backup supervision for the level of experience of the staff on duty; (2) deficiencies in the surface markings, signage, and lighting at the airport and the failure of Federal Aviation Administration surveillance to detect or correct any of these deficiencies; and (3) failure of Northwest Airlines, Inc., to provide adequate cockpit resource management training to their aircrews.
“Contributing to the fatalities in the accident was the inoperability of the DC-9 internal tail-cone release mechanism. Contributing to the number and severity of injuries was the failure of the crew of the DC-9 to properly execute the passenger evacuation.
- Recommendations
“As a result of this investigation, the National Transportation Safety Board makes the following recommendations:
–to the Federal Aviation Administration:
Improve standards for airport marking and lighting during low-visibility conditions, such as standards for more conspicuous marking and lighting; evaluation of unidirectional taxi lines for use on acute angle taxiways; and requirements for stop-bars or position-hold lights at all taxiways that intersect active runways. (Class II, Priority Action) (A-91-54)
Identify, at all 14 CFR 139 certificated airports, complex intersections, where a potential for pilot confusion exists. Where needed, require additional lighting and signs. (Class II, Priority Action) (A-91-55)
Require that CFR 139 certificated airports use reflectorized paint for airport surface markings. (Class II, Priority Action) (A-91-56) [end of p. 79]
Require that CFR 139 certificated airports install semi-flush runway edge lights in accordance with Advisory Circular 150/5340-24. (Class II, Priority Action) (A-91-57)
….
Include guidance in Advisory Circular 150/5220-4, Water Supply Systems for Aircraft Fire and Rescue Protection, that addresses the need for fire departments to be notified in a timely manner when hydrants and water supply systems used for fire fighting are inoperable. (Class II, Priority Action) (A-91-59)
….
Require that air traffic control tower managers reemphasize the concept and use of progressive taxi/progressive ground movement instructions during low-visibility ground operations in local Operations Position Standards Handbooks. (Class II, Priority Action) (A-91-61)
Require that air traffic control tower managers emphasize to local controllers the need for positive determination of airplane departures in IFR[3] conditions when direct visual observations of departing airplanes are not possible. (Class II, Priority Action) (A-91-62)
…. [p. 80] ….
–to Northwest Airlines, Inc.:
Immediately institute comprehensive line crewmember Cockpit Resource Management training as a part of Northwest Airlines’ Line-Oriented Flight Training and coordinated crew training programs. (Class II, Priority Action) (A-91-69)
….
“Jim Burnett, Member [NTSB] filed the following concurring statement:
“I concur with the final report but would have preferred to include as part of the final report two findings and one recommendation which were a part of the staff’s draft report but which were not adopted by the full Board.
“The two findings are:
The local controller, realizing that an aircraft might be on the active runway, failed to issue a safety alert or other advisory about this possibility to the flightcrew of the B-727.
The DC-9 tail-cone was not jettisoned by the fire fighters; and the possible hazard, as well as the potential for fire ventilation, did not justify this lack of action….” [p. 82]
(NTSB. Aircraft Accident Report. Northwest Airlines, Inc., Flights 1482 and 299 Runway Incursion and Collision, Detroit Metropolitan/Wayne County Airport, Romulus, Michigan. 1991)
Sources
National Transportation Safety Board. Aircraft Accident Report. Northwest Airlines, Inc., Flights 1482 and 299 Runway Incursion and Collision, Detroit Metropolitan/Wayne County Airport, Romulus, Michigan (NTSB/AAR/91/05). Washington, DC: Adopted 6-25-1991, 178 pp. Accessed 8-29-2018 at: https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9105.pdf
Sturkey, Marion F. Mid-Air: Accident Reports and Voice Transcripts from Military and Airline Mid-Air Collisions. Plum Branch, SC: Heritage Press International, 2008.
[1] Section heading is: “Lost in Blinding Fog.”
[2] At page 57 the NTSB report notes: “The first officer did not comply with this order and, after a lapse of about 13 seconds, responded incorrectly to another ground control request for their position.” The Safety Board believes that if the first officer had obeyed the captain immediately, the air traffic controllers might have taken more timely action to stop the B-727 takeoff.”
[3] Instrument Flight Rules.