southwest 345 ntsb report

Indeed, Southwest Airlines suffered a strikingly similar fan blade failure in 2016 - Southwest Airlines Flight 3472. yI:'wRAA_JUiVXI_T1S_Jv|S;*fmJrMl@xkdBL8j&"\-{NtZb]S`J97BWaqdAFM1.%?JVbm9io~YL|_Z|qFRt9( [12] The plane was descending at 960ft/min (4.9m/s) in a nose-down position when its nose wheel struck the runway. Edit: additional info, they stated that there was a flap adjustment from 30 to 40 degrees 56 seconds out. [1][2] The aircraft, which was worth an estimated $15.5 million at the time, was written off and scrapped as a result of the accident. On July 22, 2013, the Boeing 737 operating the route suffered a front landing gear collapse while landing at LaGuardia Airport, injuring 9 people on board. This page was last edited on 5 March 2023, at 06:45. That threat would be in her mind until she. << The NTSB determined the probable cause of this accident was the flight crewmembers' . [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. such preference. She told me, the program is not intended to address safety concerns.. Also, the inlet damage caused by the forward-traveling fan blade fragments was greater than that observed during the engine FBO containment certification tests and accounted for in Boeings 737-700 certification analyses (which used the state-of-the-art analytical modeling tools that were available at the time). For the full report, use the link listed below. << 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. The NTSB found the captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around was the primary cause of this accident. Theyre qualified but not adaptable, to create and execute a shared view of a successful flight. Generally, >> Southwest Airlines records indicate that the accident 1Unless otherwise indicated, all times in this report are PST, based on a 24-hour clock, and are taken from the cockpit voice recorder (CVR) transcript. /Filter /FlateDecode Sources: NTSB Soutwest Airlines. :Q*P+Z.CiiC~BP%3YlD7q'9"D}og76{grJ4WJlg0NvXTL`|1sb#-`i%]g5&b"e'`n4h{7. Southwest One Report ; Responsibility. All human performance happens inside the framework of an organizations Policies and Procedures. There is lots of stuff here that no one wants to talk about, an airline captain recently told me. /ColorSpace This deformation traveled both around and forward/aft of the fan case. Southwest Airlines flight 345 landed at New Yorks LaGuardia at 5:40 PM Eastern Monday evening from Nashville. Were the airline managers sleeping before the accident? The report said that flight crew's performance was indicative of poor crew resource management. % . Flight 345 from Nashville, Tenn., skidded off the runway Monday and came to rest on its nose after the front landing gear crumpled. hb```f``2b`a`` BL@QAAo;l7ud^; zj*fF a\((88@`,MBZ,xu ]@l1=` 2 The crack on the fan blade involved in the PHL accident was also not detected during the on-wing fan blade visual inspections (subsequent to the overhaul) that were conducted as part of fan blade relubrications, which CFM recommended to maintain the fan blade loads within the predicted range and prevent wear on the fan disk and the fan blade dovetail coating. Of the 144 passengers and 5 crewmembers on board, 8 sustained minor injuries, and the airplane was substantially damaged. 06:06AM EDT Tampa Intl - TPA. Trajectory of the inboard aft latch keeper during the accident sequence., We determinedthat the probable cause of this accident was a low-cycle fatigue crack in the dovetail of fan blade No. 0 GROUP A group was convened on July 26, 2013. About 3 seconds from touchdown when the airplane was about 27 ft altitude, the captain announced "I got it," indicating that she was taking control of the airplane, and the first officer replied, "ok, you got it." The aircraft, a Boeing 737-700, was last inspected July 18 . 4 0 obj recalcitrant pilots are not remediated by management. [9], The aircraft (built in October 1999) was a 13-year-old Boeing 737-700, registration number N753SW, owned and operated by Southwest Airlines. stream We made recommendations to the Federal Aviation Administration, Southwest Airlines and the European Aviation Safety Agency. Factual information is added when available, and when the investigation is SWAPA is the southwest pilots own union. Your email address will not be published. ($1&r/helkpfxi}HV5~aatiWl|6K;T;yn` *d@p~Y i[EWU7X](vwvO/Tl'Bde>(?>dDt -{A\ R!Ude~.O9WcGr b=Jd! :iU=dfb$aN((Z3d([^9uBf75]F~;L}G$@. C'S?Cn$i8[Ma=[D7X:_Y0q lJCF5U:!Rg'-q;JQ|k]1Ps w j>sxf_-&m8.1(C|jk2a)%(duIqaS# investigative responsibility. who these people are!, These avoidance bid things, they are a clear indication of 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. Contributing to the accident was the captain's failure to comply with standard operating procedures. Ive harangued before on the fallacy of using pilot error as a probable cause in accidents but that doesnt mean sometimes the pilots arent a contributing factor. Join FlightAware View more flight history Purchase entire flight history for SWA3345. 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 flights assigned cruise altitude. @ << NTSB has stated that he was 2 degrees nose up 4 seconds to impact, but 3 degrees nose down on first touch, so he actually came in on the nose gear first, which resulted in collapse. There were 150 people on board including Customers and Crew. You should question them on their own pilots behavior and policies, not ALPA. 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. with up to three captains without the necessity of providing any reason for The left side of the fuselage near the location of the missing cabin window (row 14) had impact damage and witness marks that were consistent with the size and shape of the inboard fan cowl aft latch keeper and surrounding structure. On Sept. 18, 2002, data from 1962-1982 were added to the aviation accident information. 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 >> The nose gear of Southwest Airlines Flight 345 arriving from Nashville, Tenn., collapsed Monday right after the plane touched down on the runway. After reaching the airplane structure (the inlet attach ring, which was secured to the engine fan case A1 flange), the deformation generated large loads that resulted in local damage to the inlet. Published on July 28, 2013. Delta Air Lines, United and others also give their pilots a way to opt out of sharing the cockpit with captains they find difficult to work with. endobj A summary of her three-hour interview with the NTSB investigators says, the captain considered doing a go-around and that by the book, it would have been. States, its territories and possessions, and in international waters. Location information available for most cases in the United States since 2002. The separated fan blade impacted the engine fan case and fractured into multiple fragments. "When we got ready to land, we nosedived," said a . 1 0 obj National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594. /Kids [12 0 R 1 0 R 13 0 R 14 0 R 15 0 R] Southwest has resumed full operations at LaGuardia. The NTSB determined that the captain's failure to take control until the plane had descended to only 27ft (8.2m) "did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway. 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. [8][9] Nine occupants were treated for minor injuries,[5] all sustained during evacuation,[6] six of whom were taken to local hospitals. /Count 5 16 7 WUj "Kgh_@7HB@YA6qNDwFGrel*,w`*@[18RUy.h+`3_5r9A.*@bDzP_'$4/(\`JW 2*\zs=k 1I~8ZU|D^j,']Z`39T2Z{ym#0xb^ Its not clear to me that all pilots understand that distinction. The aircraft came to rest 19 seconds after touchdown. /LastChar 255 The NTSB also discovered that the flight's captain had been the . The NTSB update on Flight 345 was consistent with earlier . I read somewhere that technically what we experienced isn't considered a crash landing, but in my mind when a plane hits the runway nose first, crushes the front landing gear, and skids 2,175 feet in a shower of . /CropBox [0.0 0.0 612.0 792.0] /Encoding /WinAnsiEncoding Of the 144 passengers and 5 crewmembers on board, 8 sustained minor injuries, and the airplane was substantially damaged. Placing crewmembers on the flight deck with known weaknesses in leadership and command is no different that placing substandard parts on the aircraft. The left engine failure occurred when one of the fan blades fractured at its root (referred to as a fan-blade-out [FBO] event). 08:01AM EDT Baltimore/Washington Intl - BWI. It will be examining why the crew did not initiate a go-around after the captain noticed the airspeed was for flaps 40 even though the flaps were set at 30, below 1000 feet on final approach. [3], The aircraft landed on runway 4 with its nose landing gear touching down prior to the main landing gear. Refer 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. 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. It is preliminary and is based on the facts as they are known at this time. /Rotate 0 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. Aviation Hazardous Materials Highway Marine << The airline also announced that it was requiring Flight 345's first officer to undergo additional training. Follow-up / safety actions. The aircraft entered service in October 1999. Pino's North American F-51D, N551JP, sustained. 16-Apr-2023. << These loads caused cracks to form in the fan cowl skin and frames near the radial restraint fitting. /Type /Page We are having a problem the Investigation Reports Page. The flight had departed from LaGuardia Airport, Queens, New York, about 30 minutes earlier. In some instances, the air traffic control (ATC) transcript indicates times that are different from those in the CVR transcript. You must be a registered user to add a comment. 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.". NTSB recommends changes following fatal Southwest accident. 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. The NTSB's initial findings confirmed earlier reports that it was the FedEx pilot, not air traffic controllers, who detected the problem and told the Southwest plane to abort its takeoff. /Contents 6 0 R Accident Reports are one of the main products of an NTSB investigation. 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. They reamin WaitingTo Happen! 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. management is being purposefully ignored or simply misunderstood. 104 0 obj <>stream 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. [5][6][7] The aircraft slid 2,175 feet (663m) on its nose along the runway, arresting off to the right of the runway pavement. 2 0 obj [/ICCBased 8 0 R] %%EOF Most reports focus on a single accident, though the NTSB also produces reports addressing issues common to a set of similar accidents. The following are excerpts from the report. endstream endobj 78 0 obj <> endobj 79 0 obj <> endobj 80 0 obj <>stream 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. >@Ujq7'0#MH-z]Ce~a /CS0 2 0 R Should Epsteins Pilots Have Foiled His Child Sex Trafficking Ring. According to a preliminary NTSB report, the pilots thought the lighted runway was 28L not theirs and they aimed their. All Rights Reserved. You can follow updates from the NTSB on twitter at @NTSB_Newsroom. (NTSB) revealed that the captain had changed the flap setting from 30 degrees to 40 degrees 56 seconds before landing.

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