NTSB report on Southwest 737 at LGA

[flexstraw]

http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20130723X13256&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!

[Airbubba]

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.

[deefer dog]

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).

[framer]

Hard to believe really. The following also interests me
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."
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?

[golfbananajam]

@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?

[pattern_is_full]

Why was the F/O high in the first place?Probably the late flap deployment. The extra bump in lift slowed his descent rate and took him above the glide path. Which, of course, is why "stabilized" includes "configured" - you don't want to be changing the aerodynamics in the last 1000 feet. Unless one really enjoys the extra work load - messing with power and pitch to compensate.

He scanned the altimeter and airspeed at 27 ft?Point taken - 27 feet is a bit late. My guess is he was trying to figure out what had led the PIC to grab control. "What did I screw up?"

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.

[Airbubba]

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.

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.

The NTSB spells 'captain' with a small 'c' and these days I have to agree.

My guess is he was trying to figure out what had led the PIC to grab control. "What did I screw up?"

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 (http://dms.ntsb.gov/pubdms/search/document.cfm?docID=418228&docketID=55193&mkey=87548)

[deefer dog]

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.

[de facto]

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..

[RAT 5]

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.

[chksix]

Wasn't this the case where the captain was using the HUD to monitor the approach while the FO was on instruments and the two systems disagreed by a bit?

[deefer dog]

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.

[galaxy flyer]

interview that she had been using the HUD...even though they had planned for a visual approach, and were actually visual at the time.


You don't use the HUD on visuals? I use it all the time, visuals are one of the best uses of the HUD.

GF

[CDRW]

Deefer dog - probably best post - particularly your last paragraph - the nit picking seems to be a way to justify more pages of waffle.

Very disappointing report

[ontheklacker]

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.

[Smott999]

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?

[safetypee]

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/index.php/Portal:Go-Around_Safety)
http://www.skybrary.aero/bookshelf/books/2325.pdf
Toolkit:Stabilised Approach Awareness Toolkit for ATC - SKYbrary Aviation Safety (http://www.skybrary.aero/index.php/Toolkit:Stabilised_Approach_Awareness_Toolkit_for_ATC)
Portal:OGHFA - SKYbrary Aviation Safety (http://www.skybrary.aero/index.php/Portal:OGHFA)

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.
.

[peekay4]

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.

[Smott999]

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?

[Smott999]

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...?

[Airbubba]

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.

Feel bad for her but glad she's not flying for SWA anymore. Do we know if she got another job in aviation?

From an earlier thread here about the SWA LGA mishap:

Quick question to the pilots on here. Do you think the lady involved will ever get a job as a pilot again ?

I offered this view and cited a few previous examples:

In cases I've seen of pilots fired after an airline accident I would say quite possibly.

As mentioned earlier in this thread, at least one of the pilots in the Y2K Southwest BUR crash subsequently got his job back. Years ago a pilot who was fired by Eastern after a fatal crash later became chief pilot of a cargo non-sked out of MIA.

When diversity is considered, a checkered employment history has not prevented some folks from finding a job in night freight. Wouldbe FDX 705 hijacker Auburn Calloway was hired by FedEx after being terminated at several other employers including famously, Flying Tigers. RS (RIP) had a history of checkride failures and 609 rides at a previous employer before she was hired by FedEx. Her poor performance continued, culminating in her role as flying pilot in one of the other FedEx MEM Mad Dog mishaps.

I'm told one of the pilots in the recent BHM A300 crash was fired at a major pax carrier before coming to work at UPS.

Another pilot fired, uh, I mean allowed to retire, at this pax carrier now successfully sells interview preps and airline consulting services to prepare for 'the coming pilot shortage'.

In years past I've run into pilots who left the U.S. airlines for cause (or 'unfortunate' dates of hire) in that that infamous last refuge of scoundrels, expat flying.

http://www.pprune.org/rumours-news/519707-southwest-klga-gear-collapse-24.html#post8084023

Not sure if it is significant for CRM but both pilots involved in the accident had mostly single pilot flight time mixed with some instructor time prior to joining Southwest.

The captain flew night freight for Ameriflight and the first officer was a Zoomie with a Bandit number (an Air Force Academy graduate with F-117 time) and flew several fighter tours.

[vapilot2004]

Aside from the unsupported decision to allow the FO to proceed with an unstabilized approach, the caption appeared to lack a clear overall SA of the approach and specifically lacked awareness of the energy state of her aircraft.

One wonders how many times the FO had landed at LGA. 4/22 particularly, alongside many airport runways with water lapping at the thresholds seems to be a human factors issue for many new to those approaches in my observations over the years (tendency to be above the GS) while an airfield ringed by a ridgeline tends to focus the attention rather smartly.

[alf5071h]

This investigation missed the opportunity to investigate the difficulties of modern operations; the interactions between technology, ATC, and humans - work as imagined (SOPs) vs work as done.

The flaps were set to 30 (17:43:37) which is the ‘norm’ for most operations; the checklist was complete and called. Although a flap 40 landing was briefed it is a ‘non-normal’ config relating to the specific conditions; the error was detected and rectified before 500ft.
Although the choice of action just above 500ft was not ‘technically’ correct for IFR operations, there had been significant discussion about a visual approach. Also, what is the norm for this operator; are there routine late flap selections and transgressions of the rule. FDR/FOQA might not be able to differentiate between VFR and IFR; how can the operator management know what the everyday flap selection practice is?

The point about the HUD could be significant (chksix #11); not so much a systems disagreement, but different interpretations/use of the data and presentation.

How does the operator specify the HUD to be used for monitoring vs how it is actually used? Is the approach monitored with raw data (where the aircraft is/is going) or is the monitoring via the computed guidance symbol (what is required to achieve the idealised computed flight path).
In the latter case, and depending on the type of computation, reverting to the guidance at low level from an off ideal flight path might be hazardous.
During a HUD approach it is normal for the computer to fadeout the ILS GS with reducing altitude and substitute an averaged flight path or attitude, thus if the guidance is to be used for corrections at low altitude from an off-ideal flight path then a ‘maintain flightpath’ command might be expected, yet erroneously with a higher than normal descent rate.

What parameters was the Captain using as a monitor and then what for a landing reference after take over?
It is difficult to determine the descent rate from the HUD alone, particularly if the focus of attention is being transferred to the real world from the guidance symbol. Contrary to many beliefs it is difficult to comprehend both the HUD guidance and the real world simultaneously, and the changeover between the two is similar to that of head down (instruments) to head up (real world) where the time required to establish a meaningful understanding of the situation could be 2-4 secs … 20 to 40 ft.

Even if the investigation was not able to determine facts in these aspects they could have considered and reported on them, more so than the attendance on site or otherwise, or quoting ‘meaningless’ safety statistics.
A lost opportunity for safety learning.

[Airbubba]

The flaps were set to 30 (17:43:37) which is the ‘norm’ for most operations; the checklist was complete and called. Although a flap 40 landing was briefed it is a ‘non-normal’ config relating to the specific conditions; the error was detected and rectified before 500ft.
Although the choice of action just above 500ft was not ‘technically’ correct for IFR operations, there had been significant discussion about a visual approach.

At Southwest (and I believe virtually all other major U.S. carriers these days) you are supposed to be stable at 1000 feet, not 500 feet, rain or shine.

Some excerpts from Chapter 11 (a famous chapter in airline history :cool:) of the Southwest FOM:

Stabilized Approach Criteria – All Approaches

By 1,000 feet above TDZE, the aircraft must be in the planned landing configuration(landing gear down and landing flaps).

For approaches flown in Vertical Speed, the aircraft must be in the planned landing configuration by the final approach segment.

By 1,000 feet above TDZE, the aircraft must be in the VTARGET speed range.

By 1,000 feet above TDZE, the aircraft must be on appropriate glidepath with a normal descent rate.

Warnings

o If a stabilized approach is not obtained, a go-around/missed approach is
mandatory.

o It is the duty and responsibility of the PM to direct a go-around when stabilized approach criteria are not met or anytime the approach appears unsafe.

Unstabilized approaches are not acceptable.

By 1,000 ft above TDZE, the aircraft must be in the planned landing configuration (landing gear down and landing flaps).


If stabilized approach criteria is [sic] not met, execute a go-around/missed approach.

A go-around/missed approach is mandatory from any approach that fails to satisfy stabilized approach criteria.

It is the duty and responsibility of the PM to direct a go-around/missed approach when the stabilized approach conditions are not met. Additionally, anytime the approach or landing appears unsafe, direct a go-around/missed approach.

[deefer dog]

I'm flabbergasted that some here think that this incident was in any way related to or as a result of the late selection of flap 40, or the handover of control.

The FDR clearly shows that the aircraft was, and remained throughout, just about on the profile and also pretty close to the target speed - until the last 100 feet or so. It was only then, WAY after the flap 40 selection, that things started to get out of shape.

Using the logic of the author of this report, I'm surprised that he didn't look back even further and study just what SOPS the crew might have busted while flying the departure!

The fact of the matter is the FO screwed up at a very late stage in the approach. The Captain warned him that things were getting out of shape, and then she screwed up the recovery after she had taken control. It was a clusterfkuc, but of course the report can't simply state that....it MUST find a reason.

All of us make a bad landing from time to time...and many times we can't explain why. Often times there is no explainable reason, but of course the NTSB have to find some tosh to write....and that is exactly what they did this time.

[4Greens]

Dodgy approaches can be analysed if your airline has Flight Data Analysis. Training etc can then be adusted to cover these problems.

Its one of the best safety tools and confidential so that trends can be examined not individuals.

[Lonewolf_50]

I don't get the part about why the landing attitude of nose down: as I've never flown a 737, what explains landing nose low .. regardless of how good or bad the approach is?

[alf5071h]

Airbubba, thanks for the SOP info. However, this would not remove the potential for a false mind-set where the normal config was set before 1000ft, and then setting a non-normal config at 500ft which might not be associated with an unstable approach because the SOP was previously checked as satisfactorily. It’s easy to assume with hindsight that the flap aspect of the SOP should apply throughout the approach, but with habit where the focus is on speed, GS, etc, humans forget.

deefer, most accidents have contributory factors way back in time; investigators might not appreciate their significance or even fail to look for them as indicated here.
“All of us make a bad landing from time to time...and many times we can't explain why”, but at least the factors which could have affected the landing should be considered and questioned “what if the circumstances were slightly different”.
There are always reasons, not all discoverable, some constructed to fit the situation (which are hazardous because you believe that ‘it’ won’t happen to you), but none can be found without looking and thinking about them, a failure which appears to be the case in this investigation.

The crew probably believed that they were acting normally, the decisions valid for the situation that they perceived; they were doing a good job. Only hindsight judges differently, WHY?
Why did the crew have such beliefs or come to the decisions that they did; ‘Often times there is no explainable reason, but of course the NTSB have to find some tosh to write....and that is exactly what they did this time’, exactly, but this does not excuse the lack of questions and considerations in this investigation.

Instead of the NTSB quoting safety statistics why not review the operator’s violation / GA data and compare; assuming that this operator does collect and review the data.

Lonewolf, “what explains landing nose low ..”, good question.
What about the HUD use, can anyone describe what the guidance system would display during a late off-course take-over at low altitude.

[Old Boeing Driver]

I haven't read all the comments on this thread, so if this has already been discussed here, I apologize.

Wasn't there quite a bit of discussion on a previous thread about the difference between the HUD depiction and the PAPI visual depiction?

As I recall she was using the HUD (for ILS info) and he was using the PAPI's, and the difference made it look to her that they were high.

They weren't out of whack on anything until the last 100 feet, it looks to me.

Regards,

OBD

[vapilot2004]

Due respect to OBD (and a few others), while the approach may have looked standard going on altitude loss alone, the DFDR data shows that for much of the way down from 1000 RA, the energy state of the aircraft was in constant flux.

From the data, it appears the FO seemed to be on GS safari. He began low, passing the target and ended up high for the remainder of time he had the aircraft.

On another note, the late flap change, while not critical, despite being contrary to SWA SOP (and most sane operators I would imagine), was part of the ever changing milieu of parameters and targets that never seemed to settle in.

I don't get the part about why the landing attitude of nose down: as I've never flown a 737, what explains landing nose low

The aircraft was not really nose low until just before touchdown and that was caused by a lack of back pressure during what little flare there was.

[Lonewolf_50]

The aircraft was not really nose low until just before touchdown and that was caused by a lack of back pressure during what little flare there was. Thank you.

[Old Boeing Driver]

Thanks for the info vapilot.

Regards

[JammedStab]

The fact of the matter is the FO screwed up at a very late stage in the approach. The Captain warned him that things were getting out of shape, and then she screwed up the recovery after she had taken control. It was a clusterfkuc, but of course the report can't simply state that....it MUST find a reason.

All of us make a bad landing from time to time...and many times we can't explain why. Often times there is no explainable reason, but of course the NTSB have to find some tosh to write....and that is exactly what they did this time.

I am disappointed by the quality of some of the accident reports I have read lately from more than one agency. The investigators seem to sometimes get hung up on minutiae that really had nothing to do with the accident but was a technical violation of an SOP and focus on that instead of the real cause.

In other accident reports where it is known that there was a weak captain based on multiple previous failures(circumstances known to me), this information has been completely ignored but the reality was that any competent captain would have avoided the accident. Focus was also on the makeup of the checklist. I recently saw another accident where the screw ups were so bad that incompetency was the only explanation(at least for a significant portion of final cause) yet no mention of this.

I think the paragraph that I have quotes from the previous poster is what really matters as an explanation for this accident. These things happen on approaches where SOPs were exactly followed as well. The question is...what was done about it. To suggest that a late flap setting is part of the cause will make some people think that if only an exact meeting the stable approach requirements would have prevented this accident, which is not the case at all.

Look at the big picture investigators.

[misd-agin]

FDR readout - http://dms.ntsb.gov/public/55000-55499/55193/561678.pdf






Boeing summary -
http://dms.ntsb.gov/public/55000-55499/55193/561677.pdf

[deefer dog]

Thank you JammedStab, and misd-agin!

This was simply a botched landing after a mishandled take over by the Captain who had been PM.

The traces posted by misd-agin clearly show that nothing untoward happened even remotely after the (albeit late) flap 40 selection, and that things only started to get out of shape at 100 feet. Also the glide slope trace, although not perfect, looked acceptable to me and pretty well matched the varying headwind component until 100 feet PA. Prior to the 100 ft point I would not have considered any deviations worthy of comment.

I defy anyone to identify the cause of this incident as being due to the late flap selection, or even the Captain's use of the phrase "I got it" instead of "I have control." Personally I think it is ridiculous to suggest that either of these were contributory factors.

If the real cause of an accident cannot be determined by the investigators they are doing us all a great dis-service by citing breaches of SOPS that bear no resemblance to the event, and took place at a time that did not even relate to the lead up to event. As for "I got it" versus "I have control," it only serves to highlight the fact that these investigators were struggling to find a cause.

[MrSnuggles]

Just a tiny chime in... Apparently Sully said "My airplane" - would that have been SOP at the time?

(I'm on your side guys, trying to blame something when there is nothing to blame doesn't make anyone's life better...)

[vapilot2004]

No worries OBD and LW.

Wasn't there quite a bit of discussion on a previous thread about the difference between the HUD depiction and the PAPI visual depiction?


I was unaware of this OBD. If true, the ILS (facility & aircraft) should have been checked after the accident. I wouldn't mind reading more on that.

[vapilot2004]

This was simply a botched landing after a mishandled take over by the Captain who had been PM.

Deefer:
They landed long and touched down hard thanks in part to an off-profile approach and mishandled energy state. The V/S at touchdown was reported to be -960 fpm. If our Captain took over at 27 feet, it was too little too late at that point, correct?

Disregarding stabilized approach SOP, a missed approach should have been called at least at 200 feet. This was the cause of the accident. Reasonable?

Do you find the DFDR data to be odd for a stabilized approach? I do. The traces suggest fairly moderate gusting winds, contrary to the met reports.

[misd-agin]

Two dots high, at 115' into a 7000' runway, with a flat approach attitude, would have had the velocity vector way down the runway. Ergo the Captain's comments about getting it down. Several FDR hits of a sink rate below 500 FPM, even while high on the glide slope. That's just gettting uglier. The only reason the airplane didn't land longer was because they 'spiked the deck'.

Crosswind was under 10 kts the entire way. No factor.

[pattern_is_full]

@ vapilot2004

......the difference between the HUD depiction and the PAPI visual depiction?......If true, the ILS (facility & aircraft) should have been checked after the accident. I wouldn't mind reading more on that.

Depends on which part of the HUD display the captain was focusing on, the ILS loc/gs bars, or the velocity vector (aka "bird"). Although they are in close proximity (one hopes).

The LGA RWY4 ILS approach plate has a note saying "VGSI and ILS glidepath not coincident". Following the VGSI, the TCH is 22 feet higher than the TCH for the ILS. (76 feet vs. 54 feet).

If the captain was watching the HUD's ILS crosshairs, and the FO was flying the PAPI, the captain would indeed have seen the aircraft high on GS - even if it was correctly tracking the VGSI glide path. Not something that needs to be "checked" - it already has been checked and documented - a "normal" and known discrepancy for this approach.

(As to why the discrepancy is allowed, you'd have to take that up with the FAA or PANYNJ).

If, as misd-agin mentions, she was watching the HUD "bird", that might have been giving yet a different picture, since it pays no attention to ILS or VGSI, and simply calculates where (at current descent rate, drift and speed) you WILL meet the runway.

[misd-agin]

Light winds, VFR, and kept on the a/p until 500'? I'm never impressed by guys that do that. It's like a 'tell' in gambling. From about 200' AGL on down the a/c trended higher and higher on both the PAPI and GS. FD commanding more nose down. Captain mentioned concern on flight path. The a/c never achieved a normal descent path even if it was already on a 'high' wire. At least that would have maintained the deviation from the desired path. Instead the trend was divergent, ergo the Captain's spoken commands.




It would be very interesting if the NTSB/Boeing had produced an animation of what the HUD and instruments had looked like on the approach. Instead of trying to flip back and forth between graphs we could have it presented in a visual format that would tell the story much better.

[flexstraw]

We know the right way to fly a jet. Stable, on speed, aiming point fixed in windscreen.