Runway Incursion and Collision, Northwest Airlines, Inc. Flights 1482 and 299, Detroit Metropolitan

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Runway Incursion and Collision, Northwest Airlines, Inc. Flights 1482 and 299, Detroit
Metropolitan/Wayne County Airport, Romulus, Michigan, December 3, 1990
Micro-summary: A Boeing 727 on its takeoff roll collided with a Douglas DC-9 that had taxiied onto the
runway.
Event Date: 1990-12-03 at 1345 EST
Investigative Body: National Transportation Safety Board (NTSB), USA
Investigative Body's Web Site: http://www.ntsb.gov/
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The National Transportation Safety Board is an independent Federal agency
dedicated to promoting aviation, railroad, highway, marine, pipeline, and
hazardous materials safety. Established in 1967, the agency is mandated by the
Independent Safeti !l Board Act of 1974 to investigate transportation accidents,
determine the pro able cause of accidents, issue safety recommendations, study
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NATIONAL TRANSPORTATION
SAFETY BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
NORTHWEST AIRLINES, INC.
FLIGHTS 1482 AND 299
RUNWAY INCURSION AND COLLISION
DETROIT METROPOLITANtWAYN E COUNTY AIRPORT
ROMULUS, MICHIGAN
DECEMBER 3,1990
ADOPTED: June 25,1991
NOTATION 5416 B
Abstract: This report explains the runway collision of two Northwest Airlines aircraft
on a runway at the Detroit MetropolitantWayne County Airport, Romulus, Michigan,
on December 3, 1990. The safety issues discussed in the report are airport marking
and lighting, cockpit resource management, air traffic control procedures in low-
visibility conditions, flight attendant procedures during evacuations; and design of
the DC-9 tailcone emer ency release system. Safety recommendations concerning
(?
these issues were ma e to the Federal Aviation Administration, the Detroit
Metropolitan1W ayne County Airport, and Northwest Airlines, Inc..

CONTENTS
.............................................
EXECUTIVE SUMMARY vi
FACTUAL INFORMATION
........................................
History of the Flights 1
.......................................................
General 1
...............................
B-727 Taxi and Takeoff Activity 1
.......................................
DC-9 Preflight Activity 4
............................................
DC-9 Taxi Activity 5
...............
Tower Activity During Taxi and Takeoff Sequence 10
........................................
East Ground Controller 10
..............................................
Local Controller 10
...............................................
Area Supervisor 11
...........................................
Injuries to Persons 11
......................................................
The DC-9 11
.....................................................
The B-727 12
............................................
Damage to Aircraft 12
..................................................
Other Damage 12
.........................................
Personnel Information 12
...........................................
Cockpit Crewmembers 12
..............................................
The DC-9 Captain 12
........................................
The DC-9 First Officer 13
.............................................
The B-727 Captain 14
....................
The B-727 First Officer and Second Officer 14
.........................................
The Flight Attendants 15
....................................
The DC-9 Flight Attendants 15
...................................
The B-727 Flight Attendants 15
.................................
NWA Flight Attendant Training 15
...................................
The A i r Traffic Controllers 16
...........................................
The Area Supervisor 16
..........................................
The Local Controller 16
....................................
The East Ground Controller .................................... 16
The West Ground Controller 17
........................................
The Tower Cab Observer 17
..........................................
Aircraft Information 17
......................................................
The DC-9 17
.....................................
DC-9 Tailcone Maintenance 17
.....................................................
The B-727 18
....................................
Meteor01 ogi cal Information 19
.............................
National Weather Service Activity 19
.................
Automatic Termina.l .I.n.f.o.r.m.a..ti.o.n. .S.e.r.v.i.c.e. .(A..T.IS.). ................... 19
SIGMET Foxtrot 3 ......................... 20
Weather Observations i n the DTW Tower 20
............................................
Aids to Navigation 21
................................................
Communications 21
.........................................
Aerodrome Information 22
.......................................................
General 22
........................................
Runway 3C/21C Lighting ....................................... 22
Airfield Guidance Signs 24
.....................................
Airfield Surface Markings 24
..............................................
Flight Recorders 25
.........................
Digital Flight Data Recorders (DFDRs) 25
................................
Cockpit Voice Recorders (CVRs) 25
...............................
Wreckage an.d. .I.m.p.a.c.t. .I.n.f.o.r.m.a.t.i.o.n. ................................ 25
The B-727 25
......................................................
The DC-9 26
....................................
General Damage Descrip.t.i.o.n. ..................................... 26
Forward Exit Systems 28
............................................
Col 1 i si on Sequence 28
..........................
Medical and Pathological Information 29
.......................................................
General 29
............................
Postaccident Toxicological Testing 29
..............................
NWA Postaccident Testing Program 32
................
FAA-Mandated Postaccident Drug Testing Program 32
.......................
Drug Testing of Air Traffic Controllers 32
..............................
Injury and Fatality Descriptions 34
..........................................................
Fire 34
...............................................
Fire Initiation 34
............................................
Emergency Response 35
.................................................
Fire Fighting 35
..............................................
Survival Aspects 36
...............................................
B-727 Deplaning 36
...............................................
DC-9 Evacuation 37
................................................
Pilot Activity 37
.....................................
Cabin Evacuation Activity 37
............................................
Tests and Research 38
...............
Tailcone Release System Examination and Testing 38
.........................................
Additional Information 40
....
FAA Surveillance of NWA DC-9 Pilot Training and Operations 40
...........................
FAA Surveillance of NWA Maintenance 40
......................
Pre- and Postaccident Corrective Actions 41
..........
Safety Board Runway Incursion Safety Recommendations 41
...............................
Tailcone Safety Recommendations 42
......................................
Douglas Aircraft Company 43
.......................................................
The FAA 44
............................
1.17.3.4.1 Tail cone Airworthiness Directives 44
.............................
1.17.3.4.2 Runway Incursion Prevention Plan 44
.....................
1.17.3.5 Detroit Metropolitan/Wayne County Airport 46
............................................
1.17.3.6 Northwest Airlines 46
..................
1.17.4 Advanced Runway Incursion Prevention Systems 46
.........
1.17.4.1 Advanced Airport Surface Detection Equipment (ASDE-3) 46
...................
1.17.4.2 Airport Movement Area Safety System (AMASS) 47
.....................
1.17.4.3 Airport Surface Traffic Automation (ASTA) 47
..................
1.17.4.4 Tower Information Presentation System (TIPS) 47
..............
1.17.4.5 Surface Movement Guidance Control System (SMGCS) 47
.......
1.17.4.6 Short-Term FAA Plans for Signs and Marking Improvements 48
............................
1.17.5 Tailcone Description and Operation 48
.
2 ANALYSIS
.......................................................
2.1 General 50
.......................
2.2 DC-9 Pilots' Preflight and Taxi Actions 52
..................................
2.2.1 Pilot Background Information 52
......................................
Role Reversal in Cockpit 53
...................................
Decisionmaking in DTW Tower 60
.......................................
Visibility Observations 60
...................................
Ground Controller's Actions 61
....................................
Local Controller's Actions 62
...............................................
Area Supervisor 63
..........................
B-727 Captain's Decision to Take Off 64
............................
DTW Signage. Lighting and Markings 65
..........................................
Survivability Issues 67
.......................................
DC-9 Crewmember Actions 67
............................
Flight Attendant Tailcone Training 68
..................
FAA Oversight of Flight Attendant Operations 68
.......................
The B-727 Captain's Decision to Deplane 69
...............................
Fire Response and Fire Fighting 69
............................................
Initiation of Fire 69
.....................
Rescue Response and Fire Fighting Tactics 70
....................
Tail cone Maintenance. Design and Operation 70
..........................................
FAA NASIP Inspection 71
..........................
Analysis of Other Corrective Actions 73
....................
The FAA's Runway Incursion Prevention Plan 73
.....................
Detroit Metropol itan/Wayne County Airport 73
.......................................
Northwest Air1 ines, Inc 74
McDonnel 1 Doug1 as Aircraft Company's Tai 1c one Service
....................................................
Bulletins 74
................................
SIGMET Foxtrot 3 Ramifications 74
.....................................
Postaccident Drug Testing 75
CONCLUSIONS
......................................................
Findings 76
................................................
Probable Cause 79
...............................................
RECOMMENDATIONS 79
APPENDIXES
.........................
Appendix A~Investigationa nd Hearing 83
.............................
Appendix B.. Personnel Information 84
..............................
Appendix CÃ Airplane Information 87
................
Appendix D-'Cockpit Voice Recorder Trans.c.r.i.p.t.s. ................. 88
Appendix E.. Airpl ane Performance Study 157
...........
Appendix ..F Runway Incursion Recommendation Summary 160
EXECUTIVE SUMMARY
On December 3, 1990, at 1345 eastern standard time, Northwest
Airl ines flight 1482, a McDonnell Douglas DC-9, and Northwest Airl ines
flight 299, a Boeing 727, collided near the intersection of runways 09/27 and
03C/21C in dense fog at Detroit Metropol itan/Wayne County Airport, Romulus,
Michigan. At the time of the collision, the B-727 was on its takeoff roll,
and the DC-9 had just taxied onto the active runway. The B-727 was
substantially damaged, and the DC-9 was destroyed. Eight of the 39
passengers and 4 crewmembers aboard the DC-9 received fatal injuries. None
of the 146 passengers and 10 crewmembers aboard the B-727 were injured.
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, inadeauate visibility
observations, failure to use progressive taxi instructions in low-visibil ity
conditions, and issuance of ina.o.o ro. ~riate and confusina 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 Airl ines, Inc., to provide adequate cockpit resource management
training to their line aircrews.
Contributing to the fatalities in the accident was the
inoperabil i ty of the DC-9 internal tailcone 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.
The safety issues raised in this report include:
Airport marking and lighting;
Cockpit resource management;
Air traffic control procedures in low-visibil ity
conditions;
Flight attendant procedures during evacuations;
Design of the DC-9 tailcone emergency release system.
Recommendations concerning these issues were addressed to the
Federal Aviation Administration, the Detroit Metropolitan/Wayne County
Airport, and Northwest Airlines, Inc.