Sunday, April 9, 2017

Airbus A320-200, Delta Air Lines, N333NW: Incident occurred July 07, 2016 in Rapid City, South Dakota

Warnings went unheeded in wrong-airport landing at Ellsworth



As Delta Flight 2845 soared west above eastern South Dakota at 7:50 p.m. on July 7, the pilot forewarned the co-pilot about mistaking Ellsworth Air Force Base for their intended destination, Rapid City Regional Airport.

“You do have to be careful with, ah, Eielson — not Eielson, Ellsworth,” said Capt. James Evans, “because their runways kind of align.”

The comment, revealed in public documents that are part of an ongoing investigation by the National Transportation Safety Board, did not prevent the pilots from landing at Ellsworth by mistake.

Nor did their review of a document in the cockpit that explained the close proximity of the base runway and the intended runway at the airport.

Nor did a routine verbal warning from an Ellsworth approach controller who told the pilots, “Use caution for Ellsworth Air Force Base located six miles northwest of Rapid City Regional.”

Nor did an expensive air-traffic control computer system at Ellsworth that failed to issue the warning it should have.

In hindsight, the fate of the flight was sealed at 8:39 p.m., while the plane was dropping altitude northeast of Rapid City and the pilots began a left turn. They caught sight of what they thought was Rapid City Regional Airport in the twilight below and took the plane down to it.

Both pilots had inklings of their mistake as they descended, they later told investigators.

At about 500 feet from the ground, they did not see the type of runway lights they expected.

At about 20 feet from the ground, the co-pilot, First Officer Matthew Moeller, noticed the number 13 on the runway instead of the expected 14.

As the unlucky number passed beneath the plane, Moeller realized what was happening.



“OK," he said, "we’re on Ellsworth.”

“Oh #,” Evans replied. (The numerous expletives in the transcript of the cockpit voice recording are replaced by “#” signs.)

Evans considered pulling up, he later said to investigators, but his mind flashed to his training and he decided it was safer to land. The tires hit the runway at 8:42 p.m. and both pilots uttered more expletives before Evans said, “All right, tell ’em. Talk.”

Moeller went on the radio and broke the news to an air-traffic controller at Rapid City Regional Airport, who had noticed the plane drop off a radar screen moments earlier.

Evans addressed the plane’s four flight attendants and 123 passengers.

“Well, ladies and gentlemen, you’re not gonna believe this,” he said over the passenger address system. “It was my leg and Ellsworth and Rapid City are directly in line. And I just landed at Ellsworth. So we’re gonna have to get off the runway, come back around and take off and go over to Rapid City. First time in my career to do that.”

Two hours and 21 minutes of waiting ensued for the plane's crew and passengers while airmen at Ellsworth followed their protocol, which is well established from at least six wrong-airport landings at the base during the past 20 years.

Airmen secured the plane and collected information from the pilots while talks began among Ellsworth, Rapid City Regional Airport and Delta Air Lines. Arrangements were made for a short flight to Rapid City Regional.

Amid the bustle, Col. John Martin of Ellsworth spoke about the pilot, Capt. Evans, to Ellsworth’s tower watch supervisor.

“He might be hanging it up after this,” Martin said of Evans, according to a transcript of radio communications.

Delta reported the next day that Evans and Moeller were grounded as pilots. More recently, a Delta spokesman declined to tell the Journal anything about the pilots’ current status, but the investigative documents made public by the NTSB include extensive biographical information about both men.

Evans, the captain of the flight, was 60 years old at the time and resided in Alaska. He had been flying since he was 16 and flew Army helicopters before becoming a commercial pilot. He had flown into and out of Rapid City Regional Airport once before, in 2014.

The July 7 trip from Minneapolis to Rapid City was among the first flights Evans had piloted since returning from a monthlong break, during which he used all his vacation time before his planned retirement on Aug. 31, 2016.

A transcript of the cockpit voice recording includes colorful language that Evans used throughout the flight. Among the 72 expletives replaced by “#” signs in the transcript, 62 are attributed to Evans, including many before the landing.

The Journal asked NTSB spokesman Peter Knudson why the NTSB scrubs the expletives from transcripts, and whether the scrubbing masks unprofessional conduct in the cockpit.

“Including the actual expletives spoken by crew members would not add any investigative value to the product,” Knudson wrote in an email reply. “All of the information relevant to understanding the communications about the accident or incident being investigated is included in the transcript.”

Moeller, the co-pilot, was 51 years old at the time and resided in Utah. He formerly flew for the Air Force, but he had never flown into or out of Ellsworth or Rapid City Regional Airport.

Neither pilot had any record of prior accidents, incidents or enforcement actions, and both tested negative for drugs the day after the Ellsworth incident. No one was injured in the mistaken landing.

In an interview with investigators and in a written statement, Moeller was apologetic. While noting that others involved in the landing, including air-traffic controllers, could have done more to help him and Evans avoid their mistake, Moeller blamed himself and Evans and listed several things they should have done differently.

In a written statement for Delta, Moeller said, “I apologize for any problems or inconvenience our error may have caused our passengers and Delta Air Lines.”

Evans did not apologize in his written statement. In a phone interview with investigators, he resisted blame.

“When asked if there was anything he could have done differently to avoid this incident, he stated he has spent a lot of time thinking about the event but could not think of anything he could have done differently,” said a written summary of the interview. “He felt that the event itself was 'the perfect storm' and that it was a big embarrassment for him.”

It could also prove embarrassing for Raytheon Co., maker of the air-traffic control system known as STARS, for Standard Terminal Automation Replacement System. The system is included in a $10 million air-traffic control facility that opened at Ellsworth in 2008.

An NTSB investigator’s written report about the July 7 Delta landing at Ellsworth concluded with a finding about STARS.

“In ‘wrong airport’ landings, STARS and similar systems should detect that the aircraft is unexpectedly descending to the ground away from the destination airport and generate a minimum safe altitude alert,” the investigator wrote, but in this case, “no alert was generated.”

Similar STARS failures have been noted in other wrong-airport landings. The NTSB issued a safety recommendation in 2015 asking the Federal Aviation Administration to fix the problem. But, wrote the NTSB investigator assigned to the Ellsworth incident, a fix will require Raytheon Co. to modify the STARS software. Recent Journal phone and email messages to Raytheon spokespeople were not returned.

The failure to issue alerts during wrong-airport landings is one of many problems the FAA and Raytheon have faced while trying to implement STARS in air-traffic control facilities across the nation. The FAA began upgrading to STARS in 1996 with a goal of replacing 172 systems for $940 million by 2005. Cost increases and delays added $1.3 billion to the effort in 2004, and the project is still underway with completion now expected in 2020.

Whether or not the STARS problem gets fixed, other changes have already been made at Ellsworth and Rapid City Regional Airport to decrease the likelihood of future wrong-airport landings. At Ellsworth, according to NTSB documents, air-traffic controllers have been directed to ensure that pilots arriving from north of the base on a visual approach to Rapid City Regional Airport have both airports in sight, except for pilots who report being familiar with the local area. Additionally, Rapid City Regional Airport has directed its controllers to refrain from issuing landing clearances to aircraft arriving from the vicinity of Ellsworth until those aircraft have passed the base.

Meanwhile, the investigation into the July 7 mistaken landing at Ellsworth is wrapping up, an NTSB spokesman told the Journal recently. A final written report could be released within a few months.

The events of July 7 ended with Evans and Moeller taking off from Ellsworth shortly after 11 p.m. — with all passengers still aboard — and flying east past Rapid City Regional Airport before swinging around for an approach from the southeast. They landed at 11:31 p.m., four hours and six minutes after taking off from Minneapolis and nearly three hours past their expected arrival at Rapid City Regional.

Though Evans later resisted blame while talking with investigators, he was apologetic to the passengers during several addresses he made while waiting on the runway at Ellsworth.

“I can’t believe this,” Evans said in one of those addresses. “In over 30 years I’ve never done anything like this."

Then he added: "Nice landing. Just at the wrong airport.”

Original article can be found here: http://rapidcityjournal.com



The National Transportation Safety Board did not travel to the scene of this incident. 


Docket And Docket Items - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 

Delta Air Lines Inc:  http://registry.faa.gov/N333NW

Aviation Incident Preliminary Report  -  National Transportation Safety Board:   https://app.ntsb.gov/pdf

NTSB Identification: DCA16IA200
Scheduled 14 CFR Part 121: Air Carrier operation of DELTA AIR LINES INC (D.B.A. Delta Airlines)
Incident occurred Thursday, July 07, 2016 in Rapid City, SD
Aircraft: AIRBUS INDUSTRIE A320 211, registration: N333NW
Injuries: 129 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.


On July 7, 2016, at 8:42pm central daylight time, Delta flight 2845, an Airbus A320, N333NW, landed on runway 13 at the Ellsworth Air Force Base (RCA), Rapid City, South Dakota. The flights intended destination was Rapid City Regional Airport (RAP), Rapid City, South Dakota. The airplane was not damaged and none of the six crew members or123 passengers were injured. The flight was operating under 14 Code of Federal Regulation Part 121 as a regularly scheduled passenger flight originating from Minneapolis–Saint Paul International Airport (MSP), Minneapolis, Minnesota. Visual weather conditions prevailed at the time of the incident.

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