NTSB report on Southwest 737 at LGA
Join Date: Jun 2001
Location: Rockytop, Tennessee, USA
Posts: 5,898
Likes: 0
Received 1 Like
on
1 Post
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?
Quick question to the pilots on here. Do you think the lady involved will ever get a job as a pilot again ?
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.
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.
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.
Join Date: Aug 2005
Location: fairly close to the colonial capitol
Age: 55
Posts: 1,693
Likes: 0
Received 0 Likes
on
0 Posts
Stating the obvious?
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.
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.
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.
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.
Join Date: Jun 2001
Location: Rockytop, Tennessee, USA
Posts: 5,898
Likes: 0
Received 1 Like
on
1 Post
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.
Although the choice of action just above 500ft was not ‘technically’ correct for IFR operations, there had been significant discussion about a visual approach.
Some excerpts from Chapter 11 (a famous chapter in airline history
) 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.
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.
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.
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.
Join Date: May 2010
Location: europe
Age: 67
Posts: 645
Likes: 0
Received 0 Likes
on
0 Posts
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.
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.
Join Date: Jul 2000
Location: London
Posts: 1,256
Likes: 0
Received 0 Likes
on
0 Posts
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.
Its one of the best safety tools and confidential so that trends can be examined not individuals.
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?
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.
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.
I'm late to the party on this thread
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
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
Join Date: Aug 2005
Location: fairly close to the colonial capitol
Age: 55
Posts: 1,693
Likes: 0
Received 0 Likes
on
0 Posts
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.
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.
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
Join Date: Apr 2008
Location: nowhere
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
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.
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.
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.
Join Date: Jan 2006
Location: US
Posts: 2,205
Likes: 0
Received 0 Likes
on
0 Posts
FDR readout - http://dms.ntsb.gov/public/55000-55499/55193/561678.pdf
Boeing summary -
http://dms.ntsb.gov/public/55000-55499/55193/561677.pdf
Boeing summary -
http://dms.ntsb.gov/public/55000-55499/55193/561677.pdf
Join Date: May 2010
Location: europe
Age: 67
Posts: 645
Likes: 0
Received 0 Likes
on
0 Posts
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.
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.
Join Date: Oct 2013
Location: Sweden
Age: 47
Posts: 443
Likes: 0
Received 0 Likes
on
0 Posts
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...)
(I'm on your side guys, trying to blame something when there is nothing to blame doesn't make anyone's life better...)
Join Date: Aug 2005
Location: fairly close to the colonial capitol
Age: 55
Posts: 1,693
Likes: 0
Received 0 Likes
on
0 Posts
No worries OBD and LW.
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.
Wasn't there quite a bit of discussion on a previous thread about the difference between the HUD depiction and the PAPI visual depiction?
Join Date: Aug 2005
Location: fairly close to the colonial capitol
Age: 55
Posts: 1,693
Likes: 0
Received 0 Likes
on
0 Posts
This was simply a botched landing after a mishandled take over by the Captain who had been PM.
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.
Join Date: Jan 2006
Location: US
Posts: 2,205
Likes: 0
Received 0 Likes
on
0 Posts
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.
Crosswind was under 10 kts the entire way. No factor.
@ vapilot2004
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.
......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.
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.