The question we need to ask is, "Does the society and the traveling public need protection from the erring human, or does it need protection from a system that allowed the human to be in the position she was in despite having many indications that she was an under-performer and lacked CRM/team skills? The process, called a bid avoidance, is not unique to Southwest. There are certain people who should not be flying Theyre qualified but not adaptable, to create and execute a shared view of a successful flight. A management issue? Congressional and Regulatory Correspondence. Flight 345 from Nashville, Tenn., skidded off the runway Monday and came to rest on its nose after the front landing gear crumpled. >> Reports provide details about the accident, analysis of the factual data, conclusions and the probable cause of the accident, and the related safety recommendations. The NTSB's initial findings confirmed earlier reports that it was the FedEx pilot, not air traffic controllers, who detected the problem and told the Southwest plane to abort its takeoff. 0 [4] The aircraft's nose gear collapsed upward into the body of the aircraft, causing substantial damage to the avionics electronics bay in the fuselage. Pilot change in Southwest 345 landing is unusual, aviation - CNN PDF A Aircraft Accident Brief - NTSB The left side of the fuselage near the location of the missing cabin window (row 14) had impact damage and witness marks that were consistent with the size and shape of the inboard fan cowl aft latch keeper and surrounding structure. Nice article. Contributing to the accident was the captain's failure to comply with standard operating procedures. The aircraft, a Boeing 737-700, was last inspected July 18, 2013. Southwest Airlines Flight 1380: What Went Wrong and Was It Preventable? The forward-traveling fan blade fragments and the deformation compromised the structural integrity of the inlet, causing portions of the inlet to depart the airplane. SWAPA is the southwest pilots own union. endstream endobj 78 0 obj <> endobj 79 0 obj <> endobj 80 0 obj <>stream This crash reminds me of the crash in San Francisco where no one questioned captain "Way too Low", I am sorry, but I can not agree with views expressed. PDF Aviation Accident Final Report National Transportation Safety Board WN3345 (SWA3345) Southwest Flight Tracking and History - FlightAware Your email address will not be published. During the accident sequence, the fan blade fragments traveling forward of the fan case had a trajectory angle that was greater than that observed during the CFM56-7B engine FBO containment certification tests. We made recommendations to the Federal Aviation Administration, Southwest Airlines and the European Aviation Safety Agency. The NTSB tonight released the details of the last few seconds of Southwest flight 345, confirming that the Boeing 737 did indeed land nosegear first. %PDF-1.5 Southwest accident: NTSB recommends changes; Boeing says fix coming 5 0 obj Pino's North American F-51D, N551JP, sustained. f)zL9q/+E.'6'p*zbA# R205R={"VBWAEt~si[\=D M?Xfz%0Af[Yaw,KH)QLjL@+ %`ZUjNY ^;W6 2PFCf% 7UM,C2p mhOr)d)j-&pa5xDWxPoTEJkkB`;%I jaC`FlBEJ /eQDvB9jl]g:Nb^ynNOU@jmSc2x: zyse+ [11] Southwest's flight operations manual requires its pilots to abort a landing if the plane is not properly configured by the time it descends to 1,000ft (300m). Corporate Citizenship . Southwest Airlines Flight 345 Captain Interview - Hangar Chat - The Southwest345.aspx - NTSB If they are dead, blame them!". /CropBox [0.0 0.0 612.0 792.0] At the time of the accident, the airplane had 48,748 total hours with 39,786 total cycles. Specifically, the NTSB faulted the captain for failing to take control of the aircraft or abort the landing earlier, noting that the captain had warnings at 500ft (150m) (due to the flaps misconfiguration) and at 100200ft (3061m) (when the captain observed the plane was above the glide slope) and could have aborted the landing at that time. issue was the culture. One who filed two bids to avoid other captains over the years described something close to a dysfunctional atmosphere when flying with them. It is not intended to make up for known deficiencies. Required fields are marked *. Ive harangued before on the fallacy of using pilot error as a probable cause in accidents but that doesnt mean sometimes the pilots arent a contributing factor. investigative responsibility. From a United pilot comes this troubling comment, I B738. You can follow updates from the NTSB on twitter at @NTSB_Newsroom. The report said that flight crew's performance was indicative of poor crew resource management. r/aviation on Reddit: Onboard video landing of Southwest 345 The airplane landed safely at PHL about 17 minutes after the engine failure occurred. Of the 144 passengers and 5 crewmembers on board, 8 sustained minor injuries, and the airplane was substantially damaged. Since the time that the CFM56-7B engine and the Boeing 737-700 airplane were certificated (in December 1996 and December 1997, respectively), new technologies and analytical methods have been developed that will better predict the interaction of the engine and airframe during an FBO event and the response of the inlet, fan cowl, and associated airplane structures. 6 0 obj The engine cowl was broken in the failure and cowl fragments damaged the fuselage, causing explosive depressurization of the aircraft after damaging a cabin window. Edit: additional info, they stated that there was a flap adjustment from 30 to 40 degrees 56 seconds out. hmo0?n_8T!-]C Z'!>dH!AIu~>;Z^}w~|_n[Kr -IW6t2"gJDHYDjk:,v*F!aJFCzVeX.QLT}9Nu$F1U:yV.Lajo3+LH `T5? f;XEitD}a&2NpSV9Rk6N| om=jRY0/$^=EPQzY lULtnC2~'.rj r"^;9mqq:JnO('/aN,V4xYBH5K#tM!9m[!@jjC[K]yxS')pdp40iQGC*d7\4(x COGnBcBxjvZ"}C tci-z). /Parent 5 0 R After an August 2016 FBO event involving another SWA 737-700 airplane equipped with CFM56-7B engines, which landed safely at Pensacola International Airport, Pensacola, Florida, CFM developed an eddy current inspection (ECI) procedure to be performed at overhaul (in addition to the FPI that was already required). Update on Flight 3472 and working with the NTSB - The Southwest It is a symptom of a disease called "Poor Organizational Management". Both the obtained flight data and the available video record have the nose gear making contact with the ground before the main landing gear did, which is the opposite order from the normal landing sequence. Foreshadowing things to come, the shrapnel from that engine explosion hit the fuselage at high speed leaving a large gouge and came dangerously close to hitting the cabin windows. The nose gear of Southwest Airlines Flight 345 arriving from Nashville, Tenn., collapsed Monday right after the plane touched down on the runway. The crack on the fan blade involved in the PHL accident was also not detected during the on-wing fan blade visual inspections (subsequent to the overhaul) that were conducted as part of fan blade relubrications, which CFM recommended to maintain the fan blade loads within the predicted range and prevent wear on the fan disk and the fan blade dovetail coating. Three Customers and five Crew Members were transported to local hospitalsall have been treated and released. [12] At 100200ft (3061m), the captain observed that the plane was still above the glide slope, and ordered the first officer to "get down" instead of aborting the landing. with up to three captains without the necessity of providing any reason for Because poor organizational management will sooner than later defeat the human and precipitate an error. [5][6][7] The aircraft slid 2,175 feet (663m) on its nose along the runway, arresting off to the right of the runway pavement. pic.twitter.com/vSqIMBNosc, This map shows the airport of departure and the intended destination of the flight. 3 0 obj << On April 17, 2018, about 1103 eastern daylight time, Southwest Airlines (SWA) flight 1380, a Boeing 737-7H4, N772SW, experienced a left engine failure while climbing through flight level 320 en route to the flights assigned cruise altitude. The regularly scheduled domestic passenger flight was operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121 with a destination of Dallas Love Field, Dallas, Texas. Southwest Airlines Flight 345's nose gear "collapsed rearward," NTSB On July 22, 2013, the Boeing 737 operating the route suffered a front landing gear collapse while landing at LaGuardia Airport, injuring 9 people on board. Southwest Airlines flight 345 landed at New Yorks LaGuardia at 5:40 PM Eastern Monday evening from Nashville. "[12], On October 2, 2013, Southwest Airlines announced that it had fired Flight 345's captain. Metallurgical examinations of the fractured fan blade found that the crack had likely initiated before the fan blade sets last overhaul in October 2012. << The NTSB found the captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around was the primary cause of this accident. The NTSB aviation accident database contains information from 1962 and later about 06:06AM EDT Tampa Intl - TPA. /Type /Page July 26, 2013 -- The Southwest plane that landed hard at LaGuardia Airport earlier this week touch downed on its front nose wheel before the main landing gear, causing the jet to skid more than . Indeed, Southwest Airlines suffered a strikingly similar fan blade failure in 2016 - Southwest Airlines Flight 3472. Southwest Airlines flight 345 landed at New York's LaGuardia at 5:40 PM Eastern Monday evening from Nashville. CRM failures, my friend at Southwest told me of Flight 345, which cost the pilot her job, destroyed the 13-year old airplane, injured nine, but took no lives. . [12] Analyzing flight recorder data, the NTSB determined that the captain had changed the airplane's flaps from 30 degrees to 40 degrees at an altitude of only 500ft (150m). 16 7 WUj "Kgh_@7HB@YA6qNDwFGrel*,w`*@[18RUy.h+`3_5r9A.*@bDzP_'$4/(\`JW 2*\zs=k 1I~8ZU|D^j,']Z`39T2Z{ym#0xb^ The Southwest Airlines captain who flew a Boeing 737 into the runway nose first at LaGuardia Airport last summer had been on the receiving end of multiple complaints by first officers at the airline who did not want to fly with her, according to an employee at the airline who asked not to be identified. Accident Reports are one of the main products of an NTSB investigation. Access Now, Inc. v. Southwest Airlines Co. https://en.wikipedia.org/w/index.php?title=Southwest_Airlines_Flight_345&oldid=1142966688, Accidents and incidents involving the Boeing 737 Next Generation, Airliner accidents and incidents in New York City, Southwest Airlines accidents and incidents, Airliner accidents and incidents caused by pilot error, Short description is different from Wikidata, Wikipedia articles incorporating text from the National Transportation Safety Board, Creative Commons Attribution-ShareAlike License 3.0, Landing gear collapse on landing due to pilot error. Of the 144 passengers and 5 crewmembers on board, 8 sustained minor injuries, and the airplane was substantially damaged. Southwest flight landed nose first at LaGuardia, NTSB says Chairman: Christopher Babcock Aerospace Engineer National Transportation Safety Board Member: Captain Jeff Hamlett Director of Flight Safety Southwest Airlines Member: Dave Keenan One fan cowl part that was recovered after the accident was the inboard fan cowl aft latch keeper. /Encoding /WinAnsiEncoding The impact of the separated fan blade with the fan case also imparted significant loads into the fan cowl (also part of the nacelle) through the radial restraint fitting, which was located at the bottom of the inboard fan cowl. How about a union issue? Its not clear to me that all pilots understand that distinction. I read somewhere that technically what we experienced isn't considered a crash landing, but in my mind when a plane hits the runway nose first, crushes the front landing gear, and skids 2,175 feet in a shower of . Keith Holloway On Oct. 2, 2001, minor cases which do not fall under the definition of "accident" or "incident" were removed from the database; these entries were previously identified with "SA" in the accident number. This information is not presented as the Flight Safety Foundation or the Aviation Safety Networks opinion as to the cause of the accident. In some instances, the air traffic control (ATC) transcript indicates times that are different from those in the CVR transcript. 16 Innominate11 10 yr. ago Learn more. >> Reports provide details about the accident, The following are excerpts from the report. PDF National Transportation Safety Board As the airplane was on final approach, the captain, who was the pilot monitoring, realized that the flaps were not configured as had been briefed, with a setting of 40 degrees for the landing. % /Resources [12], The NTSB ultimately concluded that the crash was due to pilot error. Investigation Details What Happened On April 17, 2018, about 1103 eastern daylight time, Southwest Airlines (SWA) flight 1380, a Boeing 737-7H4, N772SW, experienced a left engine failure while climbing through flight level 320 en route to the flight's assigned cruise altitude. Southwest Airlines Flight 345 was a scheduled flight from Nashville International Airport, Tennessee, to New York City 's LaGuardia Airport. They reamin WaitingTo Happen! A review of NTSB-investigated accidents by human factors researchers found that about 75% of accidents were the result of plan continuation errors in which the crew continued an approach despite cues that suggested it should not be continued. Sunday. DCA18MA142.aspx - NTSB The airplane was equipped with two CFM International CFM56-7B24 turbofan engines. << /Font NTSB : Status: Investigation completed: Duration: 1 year and 1 months: Accident number: DCA09FA065: Download report: Summary report: Classification: Forced landing on runway. Generally, a preliminary report is available online within a few days of an accident. The captain of Southwest Flight 345, whose nose gear was broken while landing at LaGuardia Airport in New York last month, took control of the aircraft from his co-pilot when the plane was. ** - Do not use these fields as selection parameters if your date range includes pre-1982 dates, as they did not exist prior to 1982 and their use may falsely limit the data returned. This accident along with so many other approach and landing accidents is much more a function of leadership, command and judgement than it is airmanship. Indicates external site which may or may not meet accessibility guidelines. Sources: NTSB Soutwest Airlines. Sign up for the mailing list! NTSB: Southwest 345 Hit Ground Nose First (202) 314-6100, NTSB Issues 7 Safety Recommendations Based on Findings from Southwest Airlines Flight 1380 Investigation, WASHINGTON (Nov. 19, 2019) The National Transportation Safety Board determined during a public board meeting held Tuesday that a fractured fan blade, Left Engine Failure and Subsequent Depressurization, Southwest Airlines Flight 1380, Boeing 737-7H4, N772SW, National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594. The NTSB says the nose gear hit the ground first when a Southwest jet crash-landed at LaGuardia Airport. Published on July 28, 2013. Contributing to the accident were Southwest Airlines' 1) failure to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to arrival /Filter /FlateDecode Additionally, line operations safety audit data presented at the International Air Safety Summit in 2011 suggested that 97% of unstabilized approaches were continued to landing even though doing so was in violation of airlines' standard operating procedures. 4 0 obj National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594, Congressional and Regulatory Correspondence. Safety is the business of the Accountable Manager and the Accountable manager needed to speak, think and act BEFORE the accident, not now, when it has already occured. /Annots 7 0 R for dates before 1993, cases under revision, or where NTSB did not have primary The NTSB aviation accident database contains information from 1962 and later about civil aviation accidents and selected incidents within the United States, its territories and possessions, and in international waters. Were the airline managers sleeping before the accident? In fact, I think it was labor, not management, that bargained for the bid avoidance provision that dispensed with the need to give an explanation for an expressed preference. [5], This article incorporates public domain material from websites or documents of the National Transportation Safety Board..mw-parser-output .reflist{font-size:90%;margin-bottom:0.5em;list-style-type:decimal}.mw-parser-output .reflist .references{font-size:100%;margin-bottom:0;list-style-type:inherit}.mw-parser-output .reflist-columns-2{column-width:30em}.mw-parser-output .reflist-columns-3{column-width:25em}.mw-parser-output .reflist-columns{margin-top:0.3em}.mw-parser-output .reflist-columns ol{margin-top:0}.mw-parser-output .reflist-columns li{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .reflist-upper-alpha{list-style-type:upper-alpha}.mw-parser-output .reflist-upper-roman{list-style-type:upper-roman}.mw-parser-output .reflist-lower-alpha{list-style-type:lower-alpha}.mw-parser-output .reflist-lower-greek{list-style-type:lower-greek}.mw-parser-output .reflist-lower-roman{list-style-type:lower-roman}. endobj Southwest One Report ; Responsibility. /Contents 6 0 R [12], The first officer, who was 44 years old, had 20 years of prior experience in the United States Air Force and had been hired by Southwest Airlines a year and a half before the accident.[12]. ($1&r/helkpfxi}HV5~aatiWl|6K;T;yn` *d@p~Y i[EWU7X](vwvO/Tl'Bde>(?>dDt -{A\ R!Ude~.O9WcGr b=Jd! :iU=dfb$aN((Z3d([^9uBf75]F~;L}G$@. 2019 ]kGkDjr7 wT^$ J/|V+1=uAo|r{o;dSa)7i{sqpl Q Portions of the left engine inlet and fan cowl separated from the airplane, and fragments from the inlet and fan cowl struck the left wing, the left-side fuselage, and the left horizontal stabilizer. This damage then propagated forward and aft, severing the three latch assemblies that joined the inboard and outboard halves of the fan cowl, which caused large portions of both fan cowl halves to separate and depart the airplane. >@Ujq7'0#MH-z]Ce~a PDF National Transportation Safety Board - NTSB Overnight, the aircraft was removed from the runway. I would think space would be a problem. The fan blade fractured due to a low-cycle fatigue crack that initiated in the dovetail (part of the blade root), which remained within a slot of the fan disk. (function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[3]='MMERGE3';ftypes[3]='text';fnames[1]='SOURCE';ftypes[1]='text';}(jQuery));var $mcj = jQuery.noConflict(true); Your email address will not be published. The opt-out practice at Southwest is part of the pilot labor agreement. NTSB: Southwest jet landed nose first at LaGuardia - YouTube the accident and its probable cause. Most reports focus on a single accident, though the NTSB also produces reports addressing issues common to a set endobj Information constitutes acceptance of our Terms and Conditions. If you've already registered, sign in. PROBABLE CAUSE: "The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. >> /FirstChar 0 WestJet Denies Close Call Caught on Camera at St. Maarten. recalcitrant pilots are not remediated by management. At that time, the overhaul process included a fluorescent penetrant inspection (FPI) to detect cracks; however, the crack was not detected for unknown reasons. >> have always thought that this was a fundamental threat to safe operations when Generally, Trajectory of the inboard aft latch keeper during the accident sequence., We determinedthat the probable cause of this accident was a low-cycle fatigue crack in the dovetail of fan blade No. The NTSB determined that the captain's failure to take control until the plane had descended to only 27ft (8.2m) "did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway. Three Customers and five Crew Members were transported to local hospitalsall have been treated and released. For the full report, use the link listed below. [16][17] The accident represents the third hull loss of a Boeing 737-700. One captain, actively degraded you personally throughout the entire flight, second guessing every decision you did. In the second instance, the senior pilot was intentionally non compliant. The NTSB has released its preliminary report from that accident, which occurred on February 5, 2016, at about 1157 mountain standard time. Privacy Policy. /Count 5 >> Delta Retaliated Against Pilot By Sending Her to Shrink Judge Rules, Irony of Pilot Laying Blame On Pilots in Boeing 737 Max Disasters. >> After the August 2016 FBO event, CFM developed an on-wing ultrasonic inspection technique that could be performed at the time of fan blade relubrication. 1 0 obj 90 0 obj <>/Filter/FlateDecode/ID[<43CB3E40847BE8341A94951CCEEEE12C><416ED205FCF4324CA9AE5415A5136669>]/Index[77 28]/Info 76 0 R/Length 76/Prev 533817/Root 78 0 R/Size 105/Type/XRef/W[1 2 1]>>stream One fan cowl fragment impacted the left-side fuselage near a cabin window, and the window departed the airplane, which resulted in a rapid depressurization. [6] The plane came to a stop halfway down the runway[8] after skidding on its nose in a sea of sparks. It will be examining why the crew did not initiate a go-around after the captain noticed the airspeed was for flaps 40 even though the flaps were set at 30, below 1000 feet on final approach. The Southwest FOM also states that the captain can take control of the airplane for safety reasons; however, the captain's decision to take control of the airplane at 27 ft above the ground did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway.
