NTSB report on Southwest 737 at LGA
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NTSB report on Southwest 737 at LGA
http://www.ntsb.gov/_layouts/ntsb.av...23X13256&key=1
An interesting report and I thought I would post it. Let me know if this is the wrong place as I AM NEW!
An interesting report and I thought I would post it. Let me know if this is the wrong place as I AM NEW!
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Thanks for posting this, here is the punch line:
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
•The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.
•The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.
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More interesting though, to me at least, is this:
Accident data suggest that pilots often fail to perform a go-around or missed approach when stabilized approach criteria are not met. 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. 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 companies' standard operating procedures (SOPs).
Accident data suggest that pilots often fail to perform a go-around or missed approach when stabilized approach criteria are not met. 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. 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 companies' standard operating procedures (SOPs).
Hard to believe really. The following also interests me
He scanned the altimeter and airspeed at 27 ft?
This inclination to be inside when you should be outside is something I am seeing more and more of as the years go by. It is totally inappropriate but seems to be more and more common with people coming out of the training system. Why was the F/O high in the first place? If he had just looked out the window more he probably wouldn't have been. I quite often see people scanning their instruments very very low to the ground and it rarely ends well.
What is happening with our training systems that people who were quite competent at landing a C172 now abandon those skills and stare at their screens?
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."
This inclination to be inside when you should be outside is something I am seeing more and more of as the years go by. It is totally inappropriate but seems to be more and more common with people coming out of the training system. Why was the F/O high in the first place? If he had just looked out the window more he probably wouldn't have been. I quite often see people scanning their instruments very very low to the ground and it rarely ends well.
What is happening with our training systems that people who were quite competent at landing a C172 now abandon those skills and stare at their screens?
@Framer
The "he" refers to teh First Officer, earlier in the article the Captain is referred to as "she". This says to me that the FO scanned the instruments at 27ft NOT the Captain
Or have I misunderstood?
The "he" refers to teh First Officer, earlier in the article the Captain is referred to as "she". This says to me that the FO scanned the instruments at 27ft NOT the Captain
Or have I misunderstood?
Why was the F/O high in the first place?
He scanned the altimeter and airspeed at 27 ft?
However - with the inertia and slowish response of a medium jet, someone needs to keep an eye on airspeed, at least. (cf: Asiana/SFO) Single-pilot, you just have to be good at shifting your attention rapidly in and out. Or have a HUD. Or have another pilot monitoring the gauges for you (and communicating about them).
There may be "sky gods" who can see the difference between 138 kts and 130 kts from 100 feet up just by looking out the window. I need to spare a half-second for the gauge now and then to be certain.
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As is the modern custom, nitpicking on callouts is part of the report. Instead of saying 'I have the aircraft' she says 'I got it'. Looks like the transfer of control was unambiguous if poorly timed.
The NTSB spells 'captain' with a small 'c' and these days I have to agree.
Anyway, he transferred control immediately and acknowledged 'Okay, you got it.'
In these times of shared blame and Kumbaya CRM I'm somewhat surprised that the FO didn't also get gigged in the probable cause for not executing a go-around when they realized that the aircraft was not properly configured at 1000 feet AGL.
The CVR is in the accident docket here:
Document 2 Materials Laboratory 15 - Factual Report 13-062 (with 6 embedded images) Filing Date August 27, 2013 5 page(s) of Image (PDF or TIFF) 0 Photos
In addition, the captain did not follow SOPs at several points during the flight. As PM, she should have made the standard callout per the Southwest FOM when the airplane was above glideslope, stating "glideslope" and adding a descriptive word or words to the callout (for example, "one dot high"). Rather than make this callout, however, the captain repeatedly said "get down" to the first officer before stating "I got it." The way she handled the transfer of airplane control was also contrary to the FOM, which indicates that the PM should say "I have the aircraft." The flight crew's performance was indicative of poor crew resource management.
My guess is he was trying to figure out what had led the PIC to grab control. "What did I screw up?"
In these times of shared blame and Kumbaya CRM I'm somewhat surprised that the FO didn't also get gigged in the probable cause for not executing a go-around when they realized that the aircraft was not properly configured at 1000 feet AGL.
The CVR is in the accident docket here:
Document 2 Materials Laboratory 15 - Factual Report 13-062 (with 6 embedded images) Filing Date August 27, 2013 5 page(s) of Image (PDF or TIFF) 0 Photos
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Unless I missed them, where are the conclusions? I read nothing about the fact that the crew were kept pretty busy threading themselves through weather, or that the co-pilot seemed to be a little bit behind the airplane. The Captain remarked several times that he should be slowing up, and it seemed to me that she thought that "coaching" him on aspects of using the automatics was appropriate when considering the need to slow the airplane and get it descending at the same time.
Furthermore, looking at the FDR traces it appears that 90% of the final approach was flown pretty close to the 3 degree path and at a relatively stable speed near to the target. It was only in the very latter part of the approach, and quite a while after the flap 40 selection, that the airplane drifted slightly high. Not by much though.
Sure the report has to look into every possible non-compliance of SOPS, but does it not appear to anyone else here that this accident was not caused by non-compliance with SOPS, but more it was a case of a late, (and maybe unnecessary?) take over of the controls - and one that was unfortunately mis-handled?
Would a go-around have saved the day? Maybe yes, but as has already been noted by the FAA 97% of the time we do not go-around when SOPS call for it. This is surely the elephant in the room, and one that the Human Performance guys need to accept and find a work around. My (simplistic) guess is that pilots are generally "mission orientated" rather than being robots which blindly follow instructions day in and day out. Take cross wind landings for example, and the hundreds of very hairy ones that have been captured on video. Of these do you recall many that didn't actually land, but instead went around well before the point of touch down? Not many is my guess, and of the few that did go around I would bet that it was only due to the airplane being completely out of shape in the last few seconds.
As for "I got it" instead of "I have control" this is certainly nitpicking. The instruction was given in the heat of the moment and was clearly understood and acknowledged. If taking control of an aircraft was a common occurrence perhaps crews would have the presence of mind to recall and use verbatum the standard phraseology, but when faced with the rare requirement to avoid imminent danger stating what is obvious using a more common and appropriate phrase (considering the time constraint) is only normal and expected human behaviour.
I was disappointed with the report.
Furthermore, looking at the FDR traces it appears that 90% of the final approach was flown pretty close to the 3 degree path and at a relatively stable speed near to the target. It was only in the very latter part of the approach, and quite a while after the flap 40 selection, that the airplane drifted slightly high. Not by much though.
Sure the report has to look into every possible non-compliance of SOPS, but does it not appear to anyone else here that this accident was not caused by non-compliance with SOPS, but more it was a case of a late, (and maybe unnecessary?) take over of the controls - and one that was unfortunately mis-handled?
Would a go-around have saved the day? Maybe yes, but as has already been noted by the FAA 97% of the time we do not go-around when SOPS call for it. This is surely the elephant in the room, and one that the Human Performance guys need to accept and find a work around. My (simplistic) guess is that pilots are generally "mission orientated" rather than being robots which blindly follow instructions day in and day out. Take cross wind landings for example, and the hundreds of very hairy ones that have been captured on video. Of these do you recall many that didn't actually land, but instead went around well before the point of touch down? Not many is my guess, and of the few that did go around I would bet that it was only due to the airplane being completely out of shape in the last few seconds.
As for "I got it" instead of "I have control" this is certainly nitpicking. The instruction was given in the heat of the moment and was clearly understood and acknowledged. If taking control of an aircraft was a common occurrence perhaps crews would have the presence of mind to recall and use verbatum the standard phraseology, but when faced with the rare requirement to avoid imminent danger stating what is obvious using a more common and appropriate phrase (considering the time constraint) is only normal and expected human behaviour.
I was disappointed with the report.
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Unstabilised approaches that are continued to a landing are very seriously looked at in my last 2 airlines and in case of a recurrence happening, a clear sanction.
I find odd that an experienced fo gets unstabilised because of selecting flaps 40....unless they selected flaps at max speed and used them as speed brakes.
Taking controls at low levels is possible(in case of pilot struggling with the flare..) but if the aircraft is outside or very close to be outside of stabilised criteria then a go around is the safest action...if obviously those pilots are confident/trained well in conducting balked landings...
On that note,such maneuvers are rarely trained in the sim and every day goes by another incident is waiting to happen where people feel "safer" on the ground than going around..
I find odd that an experienced fo gets unstabilised because of selecting flaps 40....unless they selected flaps at max speed and used them as speed brakes.
Taking controls at low levels is possible(in case of pilot struggling with the flare..) but if the aircraft is outside or very close to be outside of stabilised criteria then a go around is the safest action...if obviously those pilots are confident/trained well in conducting balked landings...
On that note,such maneuvers are rarely trained in the sim and every day goes by another incident is waiting to happen where people feel "safer" on the ground than going around..
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I've flown for airlines with a zero tolerance for continuing past 500' unstabilised. Fine. In the TQ, because it is mandatory exercise, there is a low level - 50'agl - waveoff/ Go round. In 10 years of recurrency training we were subjected to a 'windshear on approach' manoeuvre tick in the box. NEVER did we experienced a sudden shift in wind to a tail wind at 200' to cause a sudden destabilisation and a PILOT called G/A at low level. We were told that we should not be afraid of going round if ever there is a problem, BUT it was never given to us to experience. I've been there done that in real life; no fears or worries, but today there are modern captains with just >3000hrs and little experience of weather, plus these new cadet apprentice F/O's; they need all the confidence building they can get and as much exposure to fear quenching exercises as possible. Low level windshear exposure, before the bells & whistles have chance to tell you, is of more recurrency value than a 'source off' or a windshear occurrence at 800', or even an engine failure. It's only the latest a/c models that have this warning anyway. Experiences of real life scenarios that require a human decision and response are invaluable training moments.
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I don't recall reading that, but the Captain did indicate in her interview that she had been using the HUD...even though they had planned for a visual approach, and were actually visual at the time.
Last edited by deefer dog; 25th Jul 2015 at 23:23. Reason: spelling
interview that she had been using the HUD...even though they had planned for a visual approach, and were actually visual at the time.
GF
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You all missed why the plane crashed...
"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 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..."
You can not pull the throttles to idle and relax the control column at 27' and expect to land normally. No one was flying the plane even though she said she was. FO was a passenger.
"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 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..."
You can not pull the throttles to idle and relax the control column at 27' and expect to land normally. No one was flying the plane even though she said she was. FO was a passenger.
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Yes if I am reading correctly
AFTER she assumed "control" the Captain gave no input to the yoke, but did I also see that the throttle was then pushed on the Left engine only?
WTH?
WTH?
A disappointing report!?? It’s more an appalling example of an investigation without consideration of human performance.
There is little or no safety value, lessons to be learnt, improvements, etc. For all of the limited field efforts of the investigators they might as well have remained in their offices and still have been able to blame the human.
And if they need to quote others’ views and statistics on approach stability, GA, or human factors, then perhaps a wider view was warranted:-
Portal:Go-Around Safety - SKYbrary Aviation Safety
http://www.skybrary.aero/bookshelf/books/2325.pdf
Toolkit:Stabilised Approach Awareness Toolkit for ATC - SKYbrary Aviation Safety
Portal
GHFA - SKYbrary Aviation Safety
This report might even reflect weaknesses in the overall investigation and reporting process, its management, vetting and approval; perhaps not particularly good value for the US tax payer.
.
There is little or no safety value, lessons to be learnt, improvements, etc. For all of the limited field efforts of the investigators they might as well have remained in their offices and still have been able to blame the human.
And if they need to quote others’ views and statistics on approach stability, GA, or human factors, then perhaps a wider view was warranted:-
Portal:Go-Around Safety - SKYbrary Aviation Safety
http://www.skybrary.aero/bookshelf/books/2325.pdf
Toolkit:Stabilised Approach Awareness Toolkit for ATC - SKYbrary Aviation Safety
Portal
GHFA - SKYbrary Aviation SafetyThis report might even reflect weaknesses in the overall investigation and reporting process, its management, vetting and approval; perhaps not particularly good value for the US tax payer.
.
Last edited by safetypee; 26th Jul 2015 at 16:05.
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Transfer of control --
If I recall, the full report stated that the Captain initiated transfer of control not by saying "I got it" or "I have control" -- but by chopping off the throttles at low altitude. Only after she chopped the throttles did she inform the PF that she was taking control.
Then apparently the Captain realized her mistake and started to apply full throttle a couple of seconds before impact.
Then she changed her mind, and chopped the throttles for a second time. Oops!
But she made another mistake -- she didn't pull the left throttle all the way back, leaving the aircraft with asymmetric thrust just prior the crash.
Meanwhile no one was actually flying the plane as the control column was left at neutral, all the way until the nose-down impact.
Not the finest day for the co-pilot for sure, but it's also hard to defend / excuse the Captain's actions. Unfortunately for her this was a career-ending accident.
If I recall, the full report stated that the Captain initiated transfer of control not by saying "I got it" or "I have control" -- but by chopping off the throttles at low altitude. Only after she chopped the throttles did she inform the PF that she was taking control.
Then apparently the Captain realized her mistake and started to apply full throttle a couple of seconds before impact.
Then she changed her mind, and chopped the throttles for a second time. Oops!
But she made another mistake -- she didn't pull the left throttle all the way back, leaving the aircraft with asymmetric thrust just prior the crash.
Meanwhile no one was actually flying the plane as the control column was left at neutral, all the way until the nose-down impact.
Not the finest day for the co-pilot for sure, but it's also hard to defend / excuse the Captain's actions. Unfortunately for her this was a career-ending accident.
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Read all of it
I read all of it...
Strange story for the Captain....thought of herself as a stickler for procedure, in fact seemed to feel persecuted for it (correcting FOs and so on) yet busted SOPs several times on this flight and in critical ways, not the least of which was not ordering the GA after forgetting flaps 40 til 650 feet, then cutting power without telling the PF....wow. Feel bad for her but glad she's not flying for SWA anymore. Do we know if she got another job in aviation?
Strange story for the Captain....thought of herself as a stickler for procedure, in fact seemed to feel persecuted for it (correcting FOs and so on) yet busted SOPs several times on this flight and in critical ways, not the least of which was not ordering the GA after forgetting flaps 40 til 650 feet, then cutting power without telling the PF....wow. Feel bad for her but glad she's not flying for SWA anymore. Do we know if she got another job in aviation?
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Are you certain re throttles?
http://dms.ntsb.gov/public/55000-55499/55193/561678.pdf
This looks like they were idled just before touchdown, then only the left was pushed up, them idled again...?
This looks like they were idled just before touchdown, then only the left was pushed up, them idled again...?