Such accidents will continue to happen unless we can think beyond the Pilots. 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. One fan cowl fragment impacted the left-side fuselage near a cabin window, and the window departed the airplane, which resulted in a rapid depressurization. Chairman: Christopher Babcock Aerospace Engineer National Transportation Safety Board Member: Captain Jeff Hamlett Director of Flight Safety Southwest Airlines Member: Dave Keenan Your email address will not be published. stream @ Jxeujavxku +,3R$mwgok5wZ Q WbII|yDtha%Izun7IxC`pr;Ht{-1+. hb```f``2b`a`` BL@QAAo;l7ud^; zj*fF a\((88@`,MBZ,xu ]@l1=` 2 The airplane was powered by two General Electric/SNECMA CFM-56-3B1 engines. Sunday. The airline also announced that it was requiring Flight 345's first officer to undergo additional training. You should question them on their own pilots behavior and policies, not ALPA. who these people are!, These avoidance bid things, they are a clear indication of [11] At the time of the accident, she had a total of 12,000 hours of flight time, including 2,600 flight hours as captain of a Boeing 737. 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. The . /Filter /FlateDecode Keith Holloway 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. 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. Most reports focus on a single accident, though the NTSB also produces reports addressing issues common to a set of similar accidents. Thank you (again) for drawing a distinction between blame and contributing factor. /StructParents 1 Generally, The airplane was substantially damaged. but there was no leadership to support the change. The NTSB also discovered that the flight's captain had been the . for dates before 1993, cases under revision, or where NTSB did not have primary Three passengers and five crew members were injured during Southwest Airlines Flight 345's landing when the plane's front landing gear appeared to collapse, sending its nose into the runway. 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. And will happen. 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. 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. Follow-up / safety actions. CRM failures, my friend at Southwest told me of Flight 345, which cost the pilot her job, destroyed the 13-year old airplane, injured nine, but took no lives. Brandy King, a spokeswoman for the airline explained as part of its labor contract with pilots, first officers can express a preference not to fly 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. 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. Unless we correct those, there is no way to stop these events from occuring. endstream endobj 78 0 obj <> endobj 79 0 obj <> endobj 80 0 obj <>stream In fact, I think it was labor, not management, that bargained for the bid avoidance provision that dispensed with the need to give an explanation for an expressed preference. The aircraft entered service in October 1999. << /Widths [750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 278 333 474 556 556 889 722 238 333 333 389 584 278 333 278 278 556 556 556 556 556 556 556 556 556 556 333 333 584 584 584 611 975 722 722 722 722 667 611 778 722 278 556 722 611 833 722 778 667 778 722 667 611 722 667 944 667 667 611 333 278 333 584 556 333 556 611 556 611 556 333 611 611 278 278 556 278 889 611 611 611 611 389 556 333 611 556 778 556 556 500 389 280 389 584 350 556 350 278 556 500 1000 556 556 333 1000 667 333 1000 350 611 350 350 278 278 500 500 350 556 1000 333 1000 556 333 944 350 500 667 278 333 556 556 556 556 280 556 333 737 370 556 584 333 737 552 400 549 333 333 333 576 556 333 333 333 365 556 834 834 834 611 722 722 722 722 722 722 1000 722 667 667 667 667 278 278 278 278 722 722 778 778 778 778 778 584 778 722 722 722 722 667 667 611 556 556 556 556 556 556 889 556 556 556 556 556 278 278 278 278 611 611 611 611 611 611 611 549 611 611 611 611 611 556 611 556] [5], This article incorporates public domain material from websites or documents of the National Transportation Safety Board..mw-parser-output .reflist{font-size:90%;margin-bottom:0.5em;list-style-type:decimal}.mw-parser-output .reflist .references{font-size:100%;margin-bottom:0;list-style-type:inherit}.mw-parser-output .reflist-columns-2{column-width:30em}.mw-parser-output .reflist-columns-3{column-width:25em}.mw-parser-output .reflist-columns{margin-top:0.3em}.mw-parser-output .reflist-columns ol{margin-top:0}.mw-parser-output .reflist-columns li{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .reflist-upper-alpha{list-style-type:upper-alpha}.mw-parser-output .reflist-upper-roman{list-style-type:upper-roman}.mw-parser-output .reflist-lower-alpha{list-style-type:lower-alpha}.mw-parser-output .reflist-lower-greek{list-style-type:lower-greek}.mw-parser-output .reflist-lower-roman{list-style-type:lower-roman}. endobj endstream endobj startxref The separated fan blade impacted the engine fan case and fractured into multiple fragments. /Type /Pages Southwest Airlines Flight 345 was a scheduled flight from Nashville International Airport, Tennessee, to New York City's LaGuardia Airport. /Widths [750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 750 278 278 355 556 556 889 667 191 333 333 389 584 278 333 278 278 556 556 556 556 556 556 556 556 556 556 278 278 584 584 584 556 1015 667 667 722 722 667 611 778 722 278 500 667 556 833 722 778 667 778 722 667 611 722 667 944 667 667 611 278 278 278 469 556 333 556 556 500 556 556 278 556 556 222 222 500 222 833 556 556 556 556 333 500 278 556 500 722 500 500 500 334 260 334 584 350 556 350 222 556 333 1000 556 556 333 1000 667 333 1000 350 611 350 350 222 222 333 333 350 556 1000 333 1000 500 333 944 350 500 667 278 333 556 556 556 556 260 556 333 737 370 556 584 333 737 552 400 549 333 333 333 576 537 333 333 333 365 556 834 834 834 611 667 667 667 667 667 667 1000 722 667 667 667 667 278 278 278 278 722 722 778 778 778 778 778 584 778 722 722 722 722 667 667 611 556 556 556 556 556 556 889 500 556 556 556 556 278 278 278 278 556 556 556 556 556 556 556 549 611 556 556 556 556 500 556 500] Of the 144 passengers and 5 crewmembers on board, 8 sustained minor injuries, and the airplane was substantially damaged. 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. These loads caused cracks to form in the fan cowl skin and frames near the radial restraint fitting. /Contents 6 0 R Contributing to the accident was the captain's failure to comply with standard operating procedures. 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. A spokeswoman for Southwest told the Associated Press the landing was not "in accordance" with operating procedures for the airline. We made recommendations to the Federal Aviation Administration, Southwest Airlines and the European Aviation Safety Agency. Additionally, line operations safety audit data presented at the International Air Safety Summit in 2011 suggested that 97% of unstabilized approaches were continued to landing even though doing so was in violation of airlines' standard operating procedures. More from CNN at http://www.cnn.com/video/ /Subtype /TrueType There is lots of stuff here that no one wants to talk about, an airline captain recently told me. analysis of the factual data, conclusions and the probable cause of the accident, and the related safety recommendations. 0 The Air Canada crew was cleared to land on 28R, to the right of 28L. You can follow updates from the NTSB on twitter at @NTSB_Newsroom. 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. << a preliminary report is available online within a few days of an accident. Indeed, Southwest Airlines suffered a strikingly similar fan blade failure in 2016 - Southwest Airlines Flight 3472. A prime example of what can go wrong when a plane's nose gear touches down first is Southwest Airlines Flight 345. Southwest Airlines Flight 345 Captain Interview. Welcome to the Community! 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. ECIs at the time of overhaul or ultrasonic inspections at the time of fan blade relubrication identified 15 blade cracks on separate engines (as of August 2019)., Congressional and Regulatory Correspondence. NTSB Media Relations Reports provide details about the accident, analysis of the factual data, conclusions and the probable cause of the accident, and the related safety recommendations. Boeing says it's working on fix. [1][5][8][10], Flight 345's captain, who was 49 years old, had flown for Southwest Airlines for nearly 13 years, six years in the rank as captain. . National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594. >> %%EOF (202) 314-6100, NTSB Issues 7 Safety Recommendations Based on Findings from Southwest Airlines Flight 1380 Investigation, WASHINGTON (Nov. 19, 2019) The National Transportation Safety Board determined during a public board meeting held Tuesday that a fractured fan blade, Left Engine Failure and Subsequent Depressurization, Southwest Airlines Flight 1380, Boeing 737-7H4, N772SW, National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594. Use of the Southwest websites and our Company [3], The aircraft landed on runway 4 with its nose landing gear touching down prior to the main landing gear. The late transfer of control resulted in neither pilot being able to effectively monitor the airplane's altitude and attitude. /Font All human performance happens inside the framework of an organizations Policies and Procedures. Reports provide details about the accident, Of the 144 passengers and 5 crewmembers on board, 8 sustained minor injuries, and the airplane was substantially damaged. 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.. Call them arrogant, call them as-s as my friend did, whatever you call them, they are pilots for whom communication and collaboration better known as crew resource management, did not take root and flourish. /Count 5 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 . 104 0 obj <>stream The NTSB says the nose gear hit the ground first when a Southwest jet crash-landed at LaGuardia Airport. Operator: Southwest Airlines, Flight 345 Registration: N753SW NTSB Number: DCA13FA131 2. of similar accidents. (NTSB) revealed that the captain had changed the flap setting from 30 degrees to 40 degrees 56 seconds before landing. After an August 2016 FBO event involving another SWA 737-700 airplane equipped with CFM56-7B engines, which landed safely at Pensacola International Airport, Pensacola, Florida, CFM developed an eddy current inspection (ECI) procedure to be performed at overhaul (in addition to the FPI that was already required). The airplane landed safely at PHL about 17 minutes after the engine failure occurred. Should Epsteins Pilots Have Foiled His Child Sex Trafficking Ring. 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. Two hours later, the airport's other runway reopened for traffic. Most reports focus on a single accident, though the NTSB also produces reports addressing issues common to a set 2013 aviation incident in New York City, US, "National Transportation Safety Board Aviation Accident Final Report", "Remember that Southwest Airlines jet that slid down the runway? 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. The following are excerpts from the report. 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. The National Transportation Safety Board says Boeing needs to make the engine covers on its 737 NGs . We express our utmost gratitude to emergency responders and Southwest Employees who assisted us last night. One who filed two bids to avoid other captains over the years described something close to a dysfunctional atmosphere when flying with them. The Crash Landing of Southwest 345. After the August 2016 FBO event, CFM developed an on-wing ultrasonic inspection technique that could be performed at the time of fan blade relubrication. Southwest Airlines Co. All Rights Reserved. /Encoding /WinAnsiEncoding This damage then propagated forward and aft, severing the three latch assemblies that joined the inboard and outboard halves of the fan cowl, which caused large portions of both fan cowl halves to separate and depart the airplane. Edit: additional info, they stated that there was a flap adjustment from 30 to 40 degrees 56 seconds out. Southwest Airlines says giving first officers the ability to decline to fly with captains does not require them to declare the reason, which is a shame since Southwest and every other airline doing this could be sitting on a Published on July 28, 2013. The flight had departed from LaGuardia Airport, Queens, New York, about 30 minutes earlier. [6] The plane came to a stop halfway down the runway[8] after skidding on its nose in a sea of sparks. It doesnt get handed to you on a silver platter better than this.. 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. [15], The Boeing 737 involved in the accident, worth an estimated $15.5 million at the time, was found to be too extensively damaged to be repaired and was written off as a total loss. A management issue? have always thought that this was a fundamental threat to safe operations when The NTSB has released its preliminary report from that accident, which occurred on February 5, 2016, at about 1157 mountain standard time. [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). She did not think the line pilots were against having the culture changed. Access Now, Inc. v. Southwest Airlines Co. https://en.wikipedia.org/w/index.php?title=Southwest_Airlines_Flight_345&oldid=1142966688, Accidents and incidents involving the Boeing 737 Next Generation, Airliner accidents and incidents in New York City, Southwest Airlines accidents and incidents, Airliner accidents and incidents caused by pilot error, Short description is different from Wikidata, Wikipedia articles incorporating text from the National Transportation Safety Board, Creative Commons Attribution-ShareAlike License 3.0, Landing gear collapse on landing due to pilot error. The opt-out practice at Southwest is part of the pilot labor agreement. Location information available for most cases in the United States since 2002. About 150 people were aboard the Boeing 737, and 16 passengers . Every airline has the kind of pilot, best described in Skygods, Robert Gandts book on the collapse of aviation giant, Pan Am. The NTSB provided an update on what investigators know about the hard landing of Southwest Flight 345. With the NTSB involved, does the plane need to stay at the airport for a certain time for investigation? [12] The plane was descending at 960ft/min (4.9m/s) in a nose-down position when its nose wheel struck the runway. [12] Analyzing flight recorder data, the NTSB determined that the captain had changed the airplane's flaps from 30 degrees to 40 degrees at an altitude of only 500ft (150m). Pino's North American F-51D, N551JP, sustained. Southwest One Report ; Responsibility. << civil aviation accidents and selected incidents within the United Southwest Airlines flight 345 landed at New York's LaGuardia at 5:40 PM Eastern Monday evening from Nashville. 2019 Southwest is working with both the NTSB and Boeing in a preliminary investigation of this event. It is a symptom of a disease called "Poor Organizational Management". Will Jeff Epsteins Popular Global Girl Face Sex Crime Charges Too? Accident data suggest that pilots often fail to perform a go-around or missed approach when stabilized approach criteria are not met. GROUP A group was convened on July 26, 2013. The fan blade fractured due to a low-cycle fatigue crack that initiated in the dovetail (part of the blade root), which remained within a slot of the fan disk. In addition, FBO-generated loads were transmitted to the fan cowl through the radial restraint fitting, which was not accounted for in the fan cowls design, and the stresses in the fan cowl were greater than those calculated in the certification analyses. 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. Placing crewmembers on the flight deck with known weaknesses in leadership and command is no different that placing substandard parts on the aircraft. Southwest Airlines flight 345 landed at New Yorks LaGuardia at 5:40 PM Eastern Monday evening from Nashville. .'JNKfc_/*wFnM@1w6A,:yGqSr 5rx&P23G!&t8`4 Sb EUx_`HC7[A. On Jan. 8, 2001, dynamic access to the accident data repository was implemented. Get started here. Nice article. As the airplane was on final approach, the captain, who was the pilot monitoring, realized that the flaps were not configured as had been briefed, with a setting of 40 degrees for the landing. There were 150 people on board including Customers and Crew. This deformation traveled both around and forward/aft of the fan case. 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. 1h 55m. If you've already registered, sign in. Metallurgical examinations of the fractured fan blade found that the crack had likely initiated before the fan blade sets last overhaul in October 2012. The airplane came to a stop on the right side of the runway centerline about 2,500 ft from its initial touchdown. 2023 Christine Negroni. << The captain of Southwest Flight 345, whose nose gear was broken while landing at LaGuardia Airport in New York last month, took control of the aircraft from his co-pilot when the plane was. such preference. She told me, the program is not intended to address safety concerns.. Agree wholeheartedly with Jim B. CRM requires a buy-in by all crewmembers. [12], The first officer, who was 44 years old, had 20 years of prior experience in the United States Air Force and had been hired by Southwest Airlines a year and a half before the accident.[12]. "[12], On October 2, 2013, Southwest Airlines announced that it had fired Flight 345's captain. [14][15] Neither pilot was publicly identified by the airline. /LastChar 255 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? NTSB . Delta Retaliated Against Pilot By Sending Her to Shrink Judge Rules, Irony of Pilot Laying Blame On Pilots in Boeing 737 Max Disasters. The aircraft entered service in October 1999. The NTSB determined the probable cause of this accident was the flight crewmembers' . Refer They reamin WaitingTo Happen! [13] The NTSB's investigation became focused on the behavior of the flight crew during Flight 345's approach into LaGuardia Airport. Information constitutes acceptance of our Terms and Conditions. /TT1 3 0 R 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 /Type /Font On July 22, . Full narrative descriptions may not be available 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/$^=EPQzY lULtnC2~'.rj r"^;9mqq:JnO('/aN,V4xYBH5K#tM!9m[!@jjC[K]yxS')pdp40iQGC*d7\4(x COGnBcBxjvZ"}C tci-z). States, its territories and possessions, and in international waters. Of the 144 passengers and 5 crewmembers aboard the airplane, 1 passenger received fatal injuries, and 8 passengers received minor injuries. ** - Do not use these fields as selection parameters if your date range includes pre-1982 dates, as they did not exist prior to 1982 and their use may falsely limit the data returned. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Investigating the Worlds Most Mysterious Air Disasters, Why the Experts Failed to Prevent the TWA Flight 800 Disaster and How It Could Happen Again, I am a journalist, a published author, speaker and broadcaster specializing in aviation and travel. That threat would be in her mind until she. (function($) {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 $mcj = jQuery.noConflict(true); Your email address will not be published. It is not hard to imagine this accident being tagged with the dreaded pilot error, but the way this particular captain presumably made other subordinate pilots feel on the flight deck, should not be discounted as unique. C'S?Cn$i8[Ma=[D7X:_Y0q lJCF5U:!Rg'-q;JQ|k]1Ps w j>sxf_-&m8.1(C|jk2a)%(duIqaS# The line between the airports does. [12] At an altitude of only 27ft (8.2m) and 3 seconds from touching down, the captain took control of the aircraft from the first officer. 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 NTSB recommends changes following fatal Southwest accident. << The flight landed safely without incident at Pensacola International Airport at 9:40 a.m. central time . Page 1 of 5 National Transportation Safety Board Aviation Accident Final Report Location: SAN LUIS OBISPO, CA Accident Number: DCA88MA008 Date & Time: 12/07/1987, 1616 PST Registration: N350PS Aircraft: BRITISH AEROSPACE BAE-146-200 Aircraft Damage: Destroyed Defining Event: Injuries: 43 Fatal Flight Conducted Under: Part 121: Air Carrier - Scheduled Analysis NTSB investigating accident involving nose-gear collapse of SWA 737 at LGA. 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. Southwest is working with both the NTSB and Boeing in a preliminary . /FontDescriptor 9 0 R Following the Southwest Airlines (SWA) flight 2294 event, on September 3, 2009, Boeing issued Service . CRM is a threat identification and management strategy that is only as good as the people using it. the accident and its probable cause. Want to receive some free swag from Christine? 16-Apr-2023. How about a union issue? 08:01AM EDT Baltimore/Washington Intl - BWI. This is exactly what I also tried to explain in my book "WaitingTo Happen!". yI:'wRAA_JUiVXI_T1S_Jv|S;*fmJrMl@xkdBL8j&"\-{NtZb]S`J97BWaqdAFM1.%?JVbm9io~YL|_Z|qFRt9( The aircraft came to rest 19 seconds after touchdown. 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.