Narrative:Southwest Flight 1248 was scheduled for a 14:55 departure out of Baltimore/Washington International Airport, but the aircraft's departure was delayed until 16:50 because of weather. After circling for over 30 minutes the crew were cleared for landing at Midway's runway 31C (6522 feet long). The crew choose to use the auto-braking system at "max". The approach speed was 120 kts and 132 kts by the time it landed. The aircraft touched down with about 4,500 feet of remaining runway. The flying pilot (captain) stated that he could not get the reverse thrust levers out of the stowed position. The first officer, after several seconds, noticed that the thrust reversers were not deployed and activated the reversers without a problem. The reversers were activated 18 seconds after touchdown. Noticed that the airplane was not decelerating normally, both crew members applied maximum braking manually. The airplane departed the end of the runway, rolled through a blast fence, a perimeter fence, and onto a roadway. The 737 collided with some vehicles and came to rest on the corner of S Central Avenue and W 55th Street. A six-year-old boy in one of the vehicles has died as a result of injuries sustained in the accident.
Probable Cause:
PROBABLE CAUSE: "The National Transportation Safety Board determined that the probable cause of this accident was the pilots failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing, which resulted in a runway overrun. This failure occurred because the pilots first experience and lack of familiarity with the airplanes autobrake system distracted them from thrust reverser usage during the challenging landing.
Contributing to the accident were Southwest Airlines 1) failure to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to arrival landing distance calculations; 2) programming and design of its on board performance computer, which did not present critical assumption information despite inconsistent tailwind and reverse thrust assessment methods; 3) plan to implement new autobrake procedures without a familiarization period; and 4) failure to include a margin of safety in the arrival assessment to account for operational uncertainties. Contributing to the severity of the accident was the absence of an engineering materials arresting system, which was needed because of the limited runway safety area beyond the departure end of runway 31C."
Accident investigation:
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Investigating agency: | NTSB |
Status: | Investigation completed |
Duration: | 1 year and 10 months | Accident number: | NTSB AAR-07-06 | Download report: | Final report
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Classification:
Distraction in cockpit
Runway excursion
Sources:
»
SKYbrary » NTSB
METAR Weather report:
00:53 UTC / 18:53 local time:
KMDW 090053Z 10011KT 1/2SM SN FZFG BKN004 OVC014 M03/M05 A3006 RMK AO2 SLP196 R31C/4500FT SNINCR 1/10 P0000 T10331050 01:53 UTC / 19:53 local time:
KMDW 090153Z 23003KT 1/2SM SN FZFG VV002 M04/M05 A3004 RMK AO2 SLP191 R31C/4000V4500FT SNINCR 1/10 P0000 T10391050
Follow-up / safety actions
After the accident the FAA formed the Takeoff and Landing Performance Assessment (TALPA) Aviation Rulemaking Committee (ARC). The ARC provided a forum for the aviation community to discuss landing performance assessment methods.
As a result of the committees work, the FAA developed a new method for airports and air traffic controllers to communicate actual runway conditions to the pilots in terms that directly relate to the way a particular aircraft is expected to perform. TALPA improves the way the aviation community assesses runway conditions, based on contaminant type and depth, which provides an aircraft operator with the effective information to anticipate airplane braking performance. These standards were adopted on October 1, 2016.
NTSB issued 9 Safety Recommendations
Issued: 27-JAN-2006 | To: FAA | A-06-16 |
Immediately prohibit all 14 Code of Federal Regulations Part 121 operators from using the reverse thrust credit in landing performance calculations. (Urgent) (Superseded by A-07-57) (Closed - Unacceptable Action/Superseded) |
Issued: 04-OCT-2007 | To: FAA | A-07-57 |
Immediately require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to conduct arrival landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent. (Urgent) (Closed - Unacceptable Action) |
Issued: 16-OCT-2007 | To: FAA | A-07-58 |
Require all 14 Code of Federal Regulations Part 121 and 135 operators to ensure that all on board electronic computing devices they use automatically and clearly display critical performance calculation assumptions. (Open - Acceptable Response) |
Issued: 16-OCT-2007 | To: FAA | A-07-59 |
Require all 14 Code of Federal Regulations Part 121 and 135 operators to provide clear guidance and training to pilots and dispatchers regarding company policy on surface condition and braking action reports and the assumptions affecting landing distance/stopping margin calculations, to include use of airplane ground deceleration devices, wind conditions and limits, air distance, and safety margins. (Open - Acceptable Response) |
Issued: 16-OCT-2007 | To: FAA | A-07-60 |
Require all 14 Code of Federal Regulations Part 121 and 135 operators of thrust reverser-equipped airplanes to incorporate a procedure requiring the non-flying (monitoring) pilot to check and confirm the thrust reverser status immediately after touchdown on all landings. (Open - Acceptable Response) |
Issued: 16-OCT-2007 | To: FAA | A-07-61 |
Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplanes braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. (Open - Unacceptable Response) |
Issued: 16-OCT-2007 | To: FAA | A-07-62 |
Develop and issue formal guidance regarding standards and guidelines for the development, delivery, and interpretation of runway surface condition reports. (Open - Acceptable Response) |
Issued: 16-OCT-2007 | To: FAA | A-07-63 |
Establish a minimum standard for 14 Code of Federal Regulations Part 121 and 135 operators to use in correlating an airplanes braking ability to braking action reports and runway contaminant type and depth reports for runway surface conditions worse than bare and dry. (Open - Acceptable Response) |
Issued: 16-OCT-2007 | To: FAA | A-07-64 |
Demonstrate the technical and operational feasibility of outfitting transport-category airplanes with equipment and procedures required to routinely calculate, record, and convey the airplane braking ability required and/or available to slow or stop the airplane during the landing roll. If feasible, require operators of transport-category airplanes to incorporate use of such equipment and related procedures into their operations. (Open - Acceptable Response) |
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Photos
accident date:
08-12-2005type: Boeing 737-7H4
registration: N471WN
accident date:
08-12-2005type: Boeing 737-7H4
registration: N471WN
accident date:
08-12-2005type: Boeing 737-7H4
registration: N471WN
accident date:
08-12-2005type: Boeing 737-7H4
registration: N471WN
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Baltimore/Washington International Airport, MD to Chicago-Midway Airport, IL as the crow flies is 974 km (609 miles).
Accident location: Exact; deduced from official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.