southwest 345 ntsb report

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. 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. /FirstChar 0 Refer 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. >> 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. Nose Down Landing, Southwest Airlines Flight 345 Investigation Details Completed Investigation Aviation Investigation No DCA13FA131 Event Date 7/22/2013 Location New York, NY Family Assistance Contact assistance@ntsb.gov Media Relations Contact NTSB Media Relations Keith Holloway (202) 314-6100 Docket DCA13FA131 Following the Southwest Airlines (SWA) flight 2294 event, on September 3, 2009, Boeing issued Service . .'JNKfc_/*wFnM@1w6A,:yGqSr 5rx&P23G!&t8`4 Sb EUx_`HC7[A. On July 22, . That threat would be in her mind until she. Congressional and Regulatory Correspondence. They reamin WaitingTo Happen! analysis of the factual data, conclusions and the probable cause of the accident, and the related safety recommendations. Get Alerts. Flight 345 on the runway NTSB photo 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. with up to three captains without the necessity of providing any reason for [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. Location information available for most cases in the United States since 2002. Three Customers and five Crew Members were transported to local hospitalsall have been treated and released. Boeing says it's working on fix. Author of The New York Times bestseller, The Crash Detectives, I am also a journalist, public speaker and broadcaster specializing in aviation and travel. The . Should Epsteins Pilots Have Foiled His Child Sex Trafficking Ring. These loads caused cracks to form in the fan cowl skin and frames near the radial restraint fitting. issue was the culture. The NTSB aviation accident database contains information from 1962 and later about The report said that flight crew's performance was indicative of poor crew resource management. 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. 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. An ECI has a higher sensitivity than an FPI and can detect cracks at or near the surface (unlike an FPI, which can only detect surface cracks). Some of the fan blade fragments traveled forward of the engine and into the inlet.2 In addition, the fan blades impact with the fan case caused the fan case to deform locally over a short period of time. Generally, a preliminary report is available online within a few days of an accident. << 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. Indeed, Southwest Airlines suffered a strikingly similar fan blade failure in 2016 - Southwest Airlines Flight 3472. If you've already registered, sign in. /Subtype /TrueType Welcome to the Community! >> Southwest Airlines flight 345 landed at New York's LaGuardia at 5:40 PM Eastern Monday evening from Nashville. the accident and its probable cause. 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. States, its territories and possessions, and in international waters. yI:'wRAA_JUiVXI_T1S_Jv|S;*fmJrMl@xkdBL8j&"\-{NtZb]S`J97BWaqdAFM1.%?JVbm9io~YL|_Z|qFRt9( Unless we correct those, there is no way to stop these events from occuring. Follow-up / safety actions. The aircraft entered service in October 1999. 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. On July 22, 2013, A Boeing 737, Operated As Southwest Airlines Flight 345, Landed Hard, Nose-First, On Runway 4 At LGA The NTSB found the captain's attempt to recover from an unstabilized. The NTSB update on Flight 345 was consistent with earlier . Sources: NTSB Soutwest Airlines. Delta Air Lines, United and others also give their pilots a way to opt out of sharing the cockpit with captains they find difficult to work with. According to FDR data, after the captain took control, the control column was relaxed to a neutral position and the throttles were not advanced until about 1 second before touchdown. The airport cleared and inspected the affected runway, and removed the aircraft in time for the earliest next day departures. endstream endobj startxref 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. [1][2] The aircraft, which was worth an estimated $15.5 million at the time, was written off and scrapped as a result of the accident. 104 0 obj <>stream if the FO was going to turn her in to her chief pilot. The process, called a bid avoidance, is not unique to Southwest. /Filter /FlateDecode 06:06AM EDT Tampa Intl - TPA. 90 0 obj <>/Filter/FlateDecode/ID[<43CB3E40847BE8341A94951CCEEEE12C><416ED205FCF4324CA9AE5415A5136669>]/Index[77 28]/Info 76 0 R/Length 76/Prev 533817/Root 78 0 R/Size 105/Type/XRef/W[1 2 1]>>stream 1h 55m. ]kGkDjr7 wT^$ J/|V+1=uAo|r{o;dSa)7i{sqpl Q If this crash was indeed caused or exacerbated by a Captain who was known by the company to have deficiencies in command skills, that is NOT a CRM issue, it's a MANAGEMENT issue. I'm in no position to know for sure but I'd bet dollars to doughnuts that it was the pilots' union that made it impossible for Southwest to get rid of this problem captain until she actually trashed a valuable asset. It won't be flying again", "NTSB Issues Investigative Update into Southwest Flight 345 Accident at LaGuardia Airport in New York", "Accident description (Type: Boeing 737-7H4 (WL), Operator: Southwest Airlines, Registration: N753SW)", "Accident: Southwest B737 at New York on Jul 22nd 2013, nose gear collapse on landing", "Landing gear punched into Southwest 737 jet on landing, NTSB says", "Flight's nose gear collapses as it lands at New York's LaGuardia", "Southwest jet's landing gear collapses on landing, injuring 10", "N753SW Southwest Airlines Boeing 737-700", "Pilots Didn't Want to Fly With Capt. 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 . 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. About 3 seconds from touchdown when the airplane was about 27 ft altitude, the captain announced "I got it," indicating that she was taking control of the airplane, and the first officer replied, "ok, you got it." >> 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. 3 0 obj The following are excerpts from the report. << The NTSB determined the probable cause of this accident was the flight crewmembers' . ", The basic issue is, why is this being talked about AFTER an accident? /Subtype /TrueType Human error is a symptom, not a disease. recalcitrant pilots are not remediated by management. civil aviation accidents and selected incidents within the United 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. The CFM56-7B engine has 24 fan blades installed in the fan disk. [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). NTSB : Status: Investigation completed: Duration: 1 year and 1 months: Accident number: DCA09FA065: Download report: Summary report: Classification: Forced landing on runway. National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594, Congressional and Regulatory Correspondence. On July 26, 2013, the National Transportation Safety Board (NTSB) issued a press release disclosing its initial findings, which included: No mechanical malfunctions were found, but the nose landing gear collapsed due to stress overload. One who filed two bids to avoid other captains over the years described something close to a dysfunctional atmosphere when flying with them. 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. %PDF-1.5 % treasure trove of information about whether crew resource >> We are having a problem the Investigation Reports Page. << We made recommendations to the Federal Aviation Administration, Southwest Airlines and the European Aviation Safety Agency. CRM is a threat identification and management strategy that is only as good as the people using it. The aircraft, a Boeing 737-3T5, registration N668SW, [2] came to rest on a city street adjacent to a gas station. airplanes, an airline pilot told me. GROUP A group was convened on July 26, 2013. Otherwise, register and sign in. Keith Holloway Generally, After reaching the airplane structure (the inlet attach ring, which was secured to the engine fan case A1 flange), the deformation generated large loads that resulted in local damage to the inlet. Two hours later, the airport's other runway reopened for traffic. (NTSB) revealed that the captain had changed the flap setting from 30 degrees to 40 degrees 56 seconds before landing. /Annots 7 0 R /FirstChar 0 ", Nashville International Airport, TN (BNA/KBNA), New York-La Guardia Airport, NY (LGA/KLGA), Jet bound for scrap (Times Union, 29-1-2014), Accident investigation report completed and information captured. Southwest One Report ; Responsibility. The nose gear of Southwest Airlines Flight 345 arriving from Nashville, Tenn., collapsed Monday right after the plane touched down on the runway. Reports provide details about the accident, Even more reason then that when an airline has information about difficult captains it should use it to provide said captains with more training, counseling or if necessary, to show them the door, before a difficult situation becomes a catastrophe. NTSB recommends changes following fatal Southwest accident. [3] The aircraft was ultimately removed from LaGuardia Airport via barge to the Port of Albany (New York) in November 2013, where the airframe was broken up by a salvage dealer at the Port of Albany in March 2014, with some parts trucked to Owego for final destruction. Southwest Airlines flight 345, a Boeing 737-700, suffered a nose gear collapse during a hard landing on runway 4 at New York-LaGuardia Airport (LGA), USA. Also, the inlet damage caused by the forward-traveling fan blade fragments was greater than that observed during the engine FBO containment certification tests and accounted for in Boeings 737-700 certification analyses (which used the state-of-the-art analytical modeling tools that were available at the time). HISTORY OF FLIGHT On July 22, 2013, about 1744 eastern daylight time (EDT), a Boeing 737-700, N753SW, operated as Southwest Airlines (SWA) flight 345, had a nose gear collapse during a hard landing on runway 4 at LaGuardia Airport (LGA), Flushing, Queens, New York. Contributing to the accident was the captain's failure to comply with standard operating procedures. endobj [11][12] The NTSB discovered that Flight 345's captain had been the subject of multiple complaints by first officers who had flown with her. /Resources 13, which resulted in the fan blade separating in flight and impacting the engine fan case at a location that was critical to the structural integrity and performance of the fan cowl structure. This information is not presented as the Flight Safety Foundation or the Aviation Safety Networks opinion as to the cause of the accident. The NTSB has released the following details: "Flaps on SWA 737-700 were set from 30 to 40 degrees about 56 seconds prior to touchdown at LGA. /Kids [12 0 R 1 0 R 13 0 R 14 0 R 15 0 R] There are certain people who should not be flying pic.twitter.com/vSqIMBNosc, This map shows the airport of departure and the intended destination of the flight. The flight had departed from LaGuardia Airport, Queens, New York, about 30 minutes earlier. The airplane was powered by two General Electric/SNECMA CFM-56-3B1 engines. Your email address will not be published. Theyre qualified but not adaptable, to create and execute a shared view of a successful flight. For the full report, use the link listed below. /ColorSpace 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. It doesnt get handed to you on a silver platter better than this.. 1 0 obj Metallurgical examinations of the fractured fan blade found that the crack had likely initiated before the fan blade sets last overhaul in October 2012. :Q*P+Z.CiiC~BP%3YlD7q'9"D}og76{grJ4WJlg0NvXTL`|1sb#-`i%]g5&b"e'`n4h{7. Because poor organizational management will sooner than later defeat the human and precipitate an error. Get started here. to query help for limitations of location information. %PDF-1.5 You can follow updates from the NTSB on twitter at @NTSB_Newsroom. All Rights Reserved. % Agree wholeheartedly with Jim B. CRM requires a buy-in by all crewmembers. Southwest Airlines Flight 1455 was a scheduled passenger flight from McCarran International Airport, Las Vegas, Nevada, to Burbank-Glendale-Pasadena Airport, Burbank, California, that overran the runway during landing on March 5, 2000. endobj Its not clear to me that all pilots understand that distinction. This impact led to the in-flight separation of fan cowl components, including the inboard fan cowl aft latch keeper, which struck the fuselage near a cabin window and caused the window to depart from the airplane, the cabin to rapidly depressurize, and the passenger fatality.. >> One fan cowl part that was recovered after the accident was the inboard fan cowl aft latch keeper. endobj 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? And trust me, they know The flight landed safely without incident at Pensacola International Airport at 9:40 a.m. central time . Southwest Airlines flight 345 landed at New York's LaGuardia at 5:40 PM Eastern Monday evening from Nashville. We express our utmost gratitude to emergency responders and Southwest Employees who assisted us last night. While the NTSB has already called for action following the engine on this 737 Next Generation, its final report closes the investigation and emphasizes how it was a piece of the cowling, and . /Rotate 0 /Contents 6 0 R She did not think the line pilots were against having the culture changed. Aviation Hazardous Materials Highway Marine /Encoding /WinAnsiEncoding NTSB Media Relations This is exactly what I also tried to explain in my book "WaitingTo Happen!". The airplane was equipped with two CFM International CFM56-7B24 turbofan engines. The Aviation Safety Network is an exclusive service provided by: Southwest Airlines flight 345, a Boeing 737-700, suffered a nose gear collapse during a hard landing on runway 4 at New York-LaGuardia Airport (LGA), USA. 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. [9], The aircraft (built in October 1999) was a 13-year-old Boeing 737-700, registration number N753SW, owned and operated by Southwest Airlines. The format and type of data contained in the earlier briefs may differ from later reports. 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. 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. 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. 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. /Parent 5 0 R 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 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. When the airplane was between 100 to 200 ft altitude, it was above the glideslope. 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. (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. have always thought that this was a fundamental threat to safe operations when . >> A prime example of what can go wrong when a plane's nose gear touches down first is Southwest Airlines Flight 345. 16 Innominate11 10 yr. ago investigative responsibility. Southwest is working with both the NTSB and Boeing in a preliminary investigation of this event. The accident airplane, a Boeing 737-3H4, N632SW (serial number 27707 and line number 2799), was manufactured on May 22, 1996, and delivered new to Southwest Airlines on June 13, 1996. The National Transportation Safety Board is still investigating what happened on Flight 345 to make the plane go crashing nose wheel landing gear-first, onto runway 4 on a grey day in July 2013. The airplane touched down at a descent rate of 960 ft per minute and a nose-down pitch attitude of -3.1 degrees, resulting in the nose gear contacting the runway first and a hard landing. The first officer reported that, after the captain took control of the airplane, he scanned the altimeter and airspeed to gain situational awareness but that he became distracted by the runway "rushing" up to them and "there was no time to say anything.". Delta Retaliated Against Pilot By Sending Her to Shrink Judge Rules, Irony of Pilot Laying Blame On Pilots in Boeing 737 Max Disasters. 4 0 obj The late transfer of control resulted in neither pilot being able to effectively monitor the airplane's altitude and attitude. With the NTSB involved, does the plane need to stay at the airport for a certain time for investigation? for dates before 1993, cases under revision, or where NTSB did not have primary It is preliminary and is based on the facts as they are known at this time. "When we got ready to land, we nosedived," said a . /Type /Page I would think space would be a problem. Southwest Airlines Co. All Rights Reserved. management is being purposefully ignored or simply misunderstood. 0 According to a preliminary NTSB report, the pilots thought the lighted runway was 28L not theirs and they aimed their. In some instances, the air traffic control (ATC) transcript indicates times that are different from those in the CVR transcript. /Type /Font The aircraft entered service in October 1999. 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. Want to receive some free swag from Christine? 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 NTSB has published the final report on Southwest Flight 1380, whose left-side CMF56 engine suffered a failure that led to one fatality in April 2018. You should question them on their own pilots behavior and policies, not ALPA. The National Transportation Safety Board says Boeing needs to make the engine covers on its 737 NGs . 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+ The NTSB says the nose gear hit the ground first when a Southwest jet crash-landed at LaGuardia Airport. %%EOF Southwest Airlines Flight 1380 was a Boeing 737-700 that experienced a contained engine failure in the left CFM56-7B engine after departing from New York-LaGuardia Airport en route to Dallas Love Field on April 17, 2018. 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). The left engine failure occurred when one of the fan blades fractured at its root (referred to as a fan-blade-out [FBO] event). endobj /CropBox [0.0 0.0 612.0 792.0]
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