ADVISORY, CONSULTING AND
Delta near-miss crew was flying without charts
Safety board says procedures ignored on flight to Cincinnati
THE CINCINNATI ENQUIRER and ENQUIRER NEWS SERVICE - September 4, 1987
WASHINGTON - The Delta Air Lines pilots en route to Cincinnati who strayed off course over the North Atlantic and came within 30 feet of colliding with another jumbo jet were flying without oceanic charts and had made no attempt to verify their location.
The National Transportation Safety, Board said Thursday the Delta crew had performed only one of six possible navigational procedures available to pilots who make transoceanic flights.
60 miles off course
The incident occurred July 8 when the Delta L-1011 jet, en route from London to Cincinnati, flew 60 miles off course and almost collided with a Continental Airlines 747 flying from London to Newark. The two jetliners were carrying nearly 600 people.
William Berry, a Delta spokesman, told the Associated Press that Delta procedures were not observed "in certain elements of the flight," but declined to elaborate. Berry said, however, that it was his understanding that Delta flight crews are supplied with plotting charts and also have a "very in-depth, detailed flight plan."
The airline suspended the crew without pay. The captain, who was making his 11th ocean crossing, was suspended for a year, the co-pilot for three months and the flight engineer for two months.
Immediately after the incident, it was widely reported that the two jetliners missed each other by 100 feet, but the joint U.S.-Canadian investigation revealed that the .jets came as close as 30 feet Canada investigated because the incident occurred off the coast of Newfoundland, which is the first point at which the jets would have been tracked by air traffic controllers as they approached land. While they were over the Atlantic, they were not tracked by radar.
The-safety board also expressed concern that deviations from flight paths occur frequently enough to pose "a clear and direct threat to flight safety."
Verify path three times
The board urged the Federal Aviation Administration (FAA) to require pilots flying across oceans to use at least two initial route-verification techniques and to verify the path three times en route. The board also recommended that the FAA send to all airlines with oceanic flights a bulletin describing the details of the Delta incident and emphasizing transoceanic rules of operation.
Bob Buckhorn, a spokesman for the FAA, said the agency plans to issue the bulletin promptly. He said the FAA is revising navigational procedures used in oceanic flights.
Currently, the FAA recommends, but does not require, that flight crews verify their location during oceanic crossings when their planes are not covered by radar.
A team of FAA inspectors is investigating Delta's pilot training program, and the Atlanta-based carrier has revised some procedures used in oceanic navigation.
The NTSB investigation found that the Delta crew in July did not plot its position or predicted position as the jet crossed way-points, nor did the crew (Please see SAFETY, Page A-4:) perform other verification procedures.
The Delta jet was in the third hour of flight when the incident occurred. It is widely believed that the crew entered a wrong digit into the plane's computerized navigational system before taking off from London. Consequently, the plane strayed 60 miles from its track and flew directly into the path of the Continental jet.
George A. Makrauer, 43, of Wyoming who was aboard the London-Cincinnati flight with his wife, Taaron, said Thursday, "We feel exceptionally lucky to have avoided an accident."
"There was only one hint of something out of the ordinary. About midpoint in the flight, there was a sudden·sharp shudder through the plane. The next morning we heard the (CBS morning radio) news and read newspaper articles about it, and that was the first we heard of the near-miss."
Makrauer, president of Amko Plastics, Cincinnati, said, "Both my wife and I are Delta frequent fliers and continue to be."
Many airlines routinely use computerized navigational systems to direct jets on oceanic flights. Crews flying American Airlines and Pan American World Airlines jetliners observed the near-collision of the Delta and Continental jets and took part in a four-way conversation about the incident immediately afterward. Investigators said it was suggested in that conversation that the incident go unreported.
The NTSB said the fact that the near-collision was not immediately reported further·demonstrates the need for airlines to reemphasize to their flight crews instrument flight rule procedures."
The NTSB report said the board's probe focused on "errors in navigational procedures,” but did not elaborate on how the plane strayed 60 miles off course. The board noted that the Delta crew followed a procedure calling for one crew member to enter the coordinates while another verified them. but did not elaborate on how the plane strayed 60 miles off course. The board noted that the Delta crew followed a procedure calling for one crew member to enter the coordinates while another verified them.
Another article reported these two "heavies" missed each other by only "30 feet":
Near-Collision Leads to FAA Changes : Transoceanic Flight Rules Being Altered After Delta Incident
September 04, 1987
Associated Press WASHINGTON — The Federal Aviation Administration said today that it is working on new navigation procedures for ocean flights in the wake of a July incident in which a Delta Air Lines jetliner came within 30 feet of colliding with another jet.
Investigators say the Delta airliner, flying 60 miles off course, came much closer to colliding with another jet than was previously thought. The Delta plane was within Canadian air traffic control when the near-collision occurred, and the Canadian Aviation Safety Board said Thursday that it wants immediate changes in that nation's airline safety rules to reduce the chance of additional incidents.
However, the FAA said today that it already has a program under way to improve navigation procedures used by American aircraft on transatlantic and transpacific routes. It also plans to "promptly implement" the safety board's recommendation to issue an air carrier bulletin re-emphasizing the rules that apply to transoceanic flights in areas not under radar control, the agency said in a statement.
A special FAA team has nearly completed a comprehensive review of navigation procedures and training used by Delta, the agency said. As a result of that review, Delta already has initiated changes in flight procedures for transoceanic navigation, it said.
The National Transportation Safety Board said Thursday that the three-member Delta crew did not have the oceanic charts needed to verify that the plane's computerized navigation system was in fact directing the aircraft on course.
Many investigators believe that Delta Flight 37, a Lockheed L-1011, flew so far off course because a wrong coordinate was punched into the plane's computerized system before the plane left London on a flight to Cincinnati.
The safety board, in a letter to the FAA, urged that the agency require pilots on transoceanic flights to verify their location, independent of the automated system, at least three times during a flight.
In its letter to the FAA, the safety board disclosed that the Delta plane and a Continental Airlines Boeing 747 bound from London to Newark, N.J., came closer to colliding than previously thought. Witness reports had indicated previously that the two planes came within about 100 feet of each other 31,000 feet over the North Atlantic. But the safety board said a Canadian inquiry into the incident established that the separation was actually about 30 feet. The two planes carried nearly 600 people.
The "inside" story...
Clear, calm, beautiful day... flying home from London to Cincinnati, two weeks after Delta commenced direct, non-stop service between CVG and Gatwick airports. Gone, the hassle (and risks) of flying Cincinnati to La Guardia; car (or helicopter) shuttle to JFK; JFK to LGW. And the return.
Our close friends (Jim and Deb) and we wanted to give it a shot, enjoy some days and theater nights in London, visit the countryside for antiquing, and do it with the most expeditious flight schedule. How unpleasant (or risky) could that be?
On prior travels forced to take extra planes and shuttle time to get to London, the new direct, non-stop was a fun prospect. The Delta "welcome aboard" chart for Flight #37 (click it for an enlargement; crew names hidden) taped on the jet door bulkhead looked great... ONE straight line, LGW/CVG:
To have a flight memento, I regularly asked the cabin service chief to give me the chart after the plane lifted-off, and I was never declined the request.
Our L-1011 (remember those?) lifted off LGW at 2:33 PM, London-time:
Smooth flight... all pleasantness. A couple of hours into the flight, Taaron left her seat and stepped into the front lavatory. 30 seconds later, VERBOOM-JOLT! -- a HUGE shudder rocked the plane. Instantly, Debbie, from her seat in the row behind us shouted out in high pitch -- and LOUID -- "WHAT THE F--- WAS THAT?1?!" Everyone in the nearby seats laughed out with surprise at the VERBOOM-JOLT and the loud candid question.
I turned 'round to Debbie. "That's the kind of jolt you get in a plane following too close to a plane ahead... it's called 'clear-air turbulence.' But, Debbie, we're at forty-thousand feet; it doesn't make any sense up here." (I walked up to the lavatory door, talked through it to my wife, learned all was okay with her, and I returned to my seat.)
About five minutes later, I pulled out my memento chart. A flight attendant walked by and I asked her, pointing to the track on the chart, "Could you tell me where we are on this route?"
Answer, "I don't know, but I'll ask the captain." (Days of no-locked cockpit doors et al pre-9/11.)
She opened the cockpit door, and the interior looked unusual. The entire 3-man (they were all men) crew were not in their normal positions. Instead of the captain and first-officer seated facing forward and the navigator/engineer facing his control/gauge panel, ALL THREE WERE TURNED INWARD FACING ONE ANOTHER. In the middle of their triangle seating arrangement was a collection of official charts and navigation books.
The flight attendant entered the cockpit, pulled the door closed... and never returned to me.
A few hours later, 5:24 PM Eastern Time, our DL #37 landed. No unusual activity; we deplaned, cleared immigration and customs, drove home, went to bed at the proper jet-lag time-adjusted time.
Next morning, 6:00 AM, the CBS Morning News radio alarm clock sounded off:
"Last night on a flight from London, England to Cincinnati, Ohio, a Delta jumbo jet experienced a near-miss with a Continental jumbo jet over the Atlantic Ocean."
Local, national and cable news inquiries and interviews followed for several days.
Many government investigative reports, including this from the Canadian Aviation Safety Board.
End of story...