SWA MDW crash

[jbguppy]

I seem to remember a certain United Captain making a light-hearted comment or two before his DC-10 touched down in Sioux City, IA. If that wasn't a time when the chips were down, I don't know what is.

I guess some would say he needed "a little work on SOP", but most would undoubtedly say he (and his crew) did a superlative job in a nightmarish situation.

Jim

After first reading your post above, I was very upset that you would compare the two, after counting to ten I am OK.

I think after rereading the 232 transcript, and meeting all the cockpit crew members of 232 and seeing Al Haynes speak on several occasions - that mentioning the two events in the same post is your choice - but in my opinion a great disservice to the brave folks on that DC-10.

JBG

 

[KCFlyer]

After first reading your post above, I was very upset that you would compare the two, after counting to ten I am OK.

I think after rereading the 232 transcript, and meeting all the cockpit crew members of 232 and seeing Al Haynes speak on several occasions - that mentioning the two events in the same post is your choice - but in my opinion a great disservice to the brave folks on that DC-10.

JBG

JB...I didn't see it as a disservice when taken in the context of "my s*** don't stink" comments from another poster who was claiming that the "sterile cockpit" rule is NEVER violated in UAL aircraft.

 

[WNrforlife]

"That's what she said...."

 

[magsau]

JB...I didn't see it as a disservice when taken in the context of "my s*** don't stink" comments from another poster who was claiming that the "sterile cockpit" rule is NEVER violated in UAL aircraft.

KC,

I would encourage you to reread what I posted. I did not say NEVER. What I said was I don't tend to hear alot of chatter outside of the job at hand. Not to say I have not heard others say something but it is not like the EAL accident in CLT that created the sterile cockpit rule in the first place. What you have in this accident and the commuter crashes that have brought sterile cockpit to the forefront again is a lack of respect and professionalism in a daily operation. Al Haynes was in a very unique situation with his and everyone elses life in the balance. Levity at that moment versus jack jawing before a cold weather ops landing is very different situation. Sure flying the airplane to a landing on a slippery runway is a difficult task that requires all your attention. However, having full authority over the controls and engines is 180 degrees different than what Capt Haynes and his crew faced.

If you as a passenger are comfortable knowing that the cockpit crews flying you and your family do not feel the FAR's or safety is the number one concern for your flight then you are taking a calculated risk. If you like the odds in that risk then by all means you have bargained your safety. Hopefully you will never have to rethink the odds you placed.

 

[KCFlyer]

mags..suffice it to say that I feel very safe on every SWA flight I have been on.

 

[BoeingBoy]

I think after rereading the 232 transcript, and meeting all the cockpit crew members of 232 and seeing Al Haynes speak on several occasions - that mentioning the two events in the same post is your choice - but in my opinion a great disservice to the brave folks on that DC-10.

JBG

Actually, I thought long and hard about just this before making the post. In the end, these two remarks swayed me:

On an approach in conditions that existed, I would think joking would be the last thing these guys were doing.

I've been on many jump seats (UAL, DAL, CAL, NWA, even FEDEX & UPS) ALL apply strict sterile flight deck procedures every time. However, Every pilot knows that when the chips are down, it's time to cut out the bs.

The first implies, and the second states, that not absolutely observing the sterile cockpit when the chips are down is tantamount to being unsafe.

I would put forth the idea that the situation that Capt Haynes and crew faced that day makes just about anything faced by any other crew look like a walk in the park - if the chips weren't down that day they very rarely are.

While I've never had the good fortune to meet Capt. Haynes (or any of that crew), I would be surprised if he or any of them would subscribe to the idea that their light-hearted remarks in any way constituted a lack of professionalism or a distraction from their efforts to successfully land their airplane. As I said in my original post, it is my deeply held belief that those 4 men did a superlative job in a literally impossible situation. My post was not in any way meant to detract from them, their professionalism, or their accomplishments.

In the end, I decided it would be useful to point out that life is not black and white. Dotting every "I" and crossing every "T" in the regulations does not necessarily a professional make, just like missing an "I" or "T" here or there does not a "cowboy" make. Capt Haynes and crew provided the best example that I could think of to illustrate a crew that was intensely focused on the task at hand under extremely adverse circumstances, performing almost literally miracles of airmanship, yet didn't slavishly adhere to the sterile cockpit rule. I figured it would be impossible for anyone to label their "lapses" in SOP and FAR adherence as somehow "unsafe" - especially those who seem to take such perverse glee in doing exactly that when it has anything to do with WN.

Jim

 

[SegmentKing]

I've always found a lighthearted joke helps relieve tension... and that's normally when I'm prone to say them.

Same thing with these WN guys... they had close to 2 hours of discussions about the runway and oops, #### happened.

My main question is --- what if the thrust reverses functioned properly... would the plane have ended up on the street, just at the end of the runway, or parked at Gate A11 and on to LAS/SLC?

 

[N421LV]

I've always found a lighthearted joke helps relieve tension... and that's normally when I'm prone to say them.

Agreed. Realistically, was this cockpit really any less safe than one full of tension, poor CRM, and poor communications? You know, one that is created by having to fly with an uptight, domineering tool like, say, magsau?

BTW magsau, I'm disappointed to see you were aced-out of the first rock-thrower position by hp_fa on this thread. You're starting to slip, my friend.

 

[hp_fa]

BTW magsau, I'm disappointed to see you were aced-out of the first rock-thrower position by hp_fa on this thread. You're starting to slip, my friend.

I'm sorry if you thought I was throwing a rock. I wasn't. I asked a specific question after having read the entire transcript. My question had nothing to do with the quips or other conversation. It had to do with what the pilots did with information they had and whether or not they might have gotten tunnel vision at the end. To date, no one has stated an opinion to that question.

If I had wanted to imply that the pilots were acting as cowboys I would have said that. I didn't. I tried to ask an intelligent question. (End of rant.)

 

[BoeingBoy]

I asked a specific question after having read the entire transcript.

hp_fa,

Here's my take, after the transmissions it's based on (emphasis mine):

1932.6
APR - Southwest twelve forty eight braking action reported fair except at the end its ah poor.

19:07:05.1
APR - Southwest nineteen fifty two last report I had for
runway three one center on the braking was ah braking
fair except at the end it was poor.

19:07:22.3
APR - yea braking action on runway three one center is fair
and then poor at the end as reported by company seven
three.

[Note: Our (US East) ops manual states that reports from company aircraft have more relevance than those from other aircraft - Jim]

19:08:18.7
SW1952 - and ah was that braking action ah was that that poor was just or the fair was just at the end or what was the main part of the runway?

19:08:25.0
APR - okay braking action was fair except at the end it was poor.

19:08:31.8
APR - and we're just havin a Citation land now I'll get a new pilot report.

19:09:57.6
TWR - Southwest twelve forty eight Midway tower continue for three one center the winds zero nine zero at nine brakin' action reported good for the first half, poor for the second half.

[Note: It's unclear if this was the report from the Citation that the Approach Controller mentioned - Jim]

1941.2
TWR - Gulfstream three Kilo Foxtrot say brakin' action.

1946.0
G3KF - fair to poor.

1947.6
TWR - Three Kilo Foxtrot than ah thank you very much can you make a left on Alpha?

1952.8
G3KF - standby.

1954.7
TWR - if unable just let me know and go to the end.

1956.5
G3KF - yea we can make a left on Alpha.

[Note: Alpha is roughly 3/4 of the way down the runway - Jim]

19:12:28.4
TWR - Southwest twelve forty eight runway three one center cleared to land wind zero nine zero at nine brakin' action fair to poor.

19:13:07.8
CAM - [sounds similar to aircraft touchdown].

So here's what I get....

A company flight gave a report of fair braking except at the end of the runway.

Until 3 minutes 10.2 seconcs before touchdown, this was still reported to be the case.

Some aircraft (the Citation, possibly) apparently reported fair braking for the 1st half and poor for the 2nd half since that's what the tower reported when WN checked on the frequency.

A Gulfstream (presumably G-II thru G-V since few G-I's are still flying) confirmed fair for the 1st half and poor for the 2nd half - yet used only 3/4 of the runway.

So my opinion is that this crew expected to be able to slow to taxi speed on the available runway, based on the computer and reports. Nothing they heard in the final moments of the approach changed that view. Two jet aircraft (presumably, assuming that the Citation reference wasn't a misstatement and really refered to the Gulfstream) landed and were able to slow down, with the heavier one using only 3/4 of the available runway.

For some as yet unexplained reason, the WN flight failed to decelerate as it should have.

19:13:08.5
HOT-1 - oh baby I guess it comes on. [Expecting rapid deceleration from the autobrakes as had been discussed previously?]

19:13:11.5
HOT-1 - come on baby. [Recognition of lack of deceleration or problem deploying speedbrakes?]

19:13:13.4
CAM-2 - about two thousand feet to go. [Realizing that the airplane isn't decelerating fast enough?]

At this point in the investigation, I can only fault this crew for possibly one thing - over-reliance on untrieed (by them) automation (the autobrakes). Not having experience with the autobrakes, this crew may have been slow to recognize that they weren't performing "as advertised" - whether due to a machanical fault or runway conditions. That night, on that runway, hesitation was their worst enemy - if present, it wasted valuable runway and potentially kept them from slowing the airplane in time to prevent the overrum.

Jim

 

[hp_fa]

Thanks Jim

 

[Breath_of_Fresh_USAirways]

Al Haynes and crew were dealing with a catastrophe and not one they created for themselves. They were doing everything they could to save that aircraft, the passengers, and themselves. Pretty much, they thought they were probably gonna die. I would hope my last words (or what I think are going to be my last words) are "light-hearted" at the end. Al & company really didn't have any "choices" per se and did an incredible job with what they were dealt.

The difference here is these SWA guys were joking ("not my day to stop sniffing glue") and were swaggering with an "it will never happen to us attitude" and from my perspective, looking for a way to "cheat death" rather than deal with the actual situation at hand. Not to mention they were relying on a system -- auto-brakes -- that they had no authority to use and little, or no training on how to use (and many, many other issues, like speed throughout their entire approach, if you read that transcript closely!) They had choices and because of the atmosphere and attitude in the cockpit (and maybe even corporate-wide -- rush, rush, rush), they made really bad choices. And now, like someone said, they have to live with the consequences. Frankly, they're lucky they only killed one little boy who was singing Christmas carols at the time...

Flame away. That transcript provides enough evidence for everyone to learn something from as well as reasons to criticize SWA pilots for days to come. It's a fine line. However, to comnpare these 2 accidents is absurd. Period.

 

[KCFlyer]

Al Haynes and crew were dealing with a catastrophe and not one they created for themselves. They were doing everything they could to save that aircraft, the passengers, and themselves. Pretty much, they thought they were probably gonna die. I would hope my last words (or what I think are going to be my last words) are "light-hearted" at the end. Al & company really didn't have any "choices" per se and did an incredible job with what they were dealt.

The difference here is these SWA guys were joking ("not my day to stop sniffing glue") and were swaggering with an "it will never happen to us attitude" and from my perspective, looking for a way to "cheat death" rather than deal with the actual situation at hand. Not to mention they were relying on a system -- auto-brakes -- that they had no authority to use and little, or no training on how to use (and many, many other issues, like speed throughout their entire approach, if you read that transcript closely!) They had choices and because of the atmosphere and attitude in the cockpit (and maybe even corporate-wide -- rush, rush, rush), they made really bad choices. And now, like someone said, they have to live with the consequences. Frankly, they're lucky they only killed one little boy who was singing Christmas carols at the time...

Flame away. That transcript provides enough evidence for everyone to learn something from as well as reasons to criticize SWA pilots for days to come. It's a fine line. However, to comnpare these 2 accidents is absurd. Period.

Oddly enough, a very respected USAirways pilot seems to disagree with you a bit. Read his take on the transcript, just two posts above yours.

 

[BoeingBoy]

After a little digging, here's some more factual info from the NTSB:

Braking action reports:

At 1811 UA flt 1446 reported "Fair"

At 18:53:10 WN flt 2920 reported "Fair and it’s poor at the end here" [This is apparently the report that approach control was passing along as from a "company flt" - Jim]

At 19:01:33 WN flt 321 reported "Good first half of 31 Center, poor the second half" [Apparently the report that the tower controller passed along without reference to it being a "company flt" - Jim]

At 19:09:08 a C500 (Citation) reported "It’s poor right now (crew indicated they were passed taxiway A) [The Citation that the approach controller mentioned, but this apparently wasn't passed on to WN 1248 - Jim]

At 1004 a G-IV reported "Fair to poor" [WN 1248 was on the frequency when this report was given - Jim]

Five FDR equipped transport aircraft landed in the 25 minutes prior to flt 1248. In order of their arrival, their brake use was:

UA 1446 used the Medium setting on autobrakes, which reached a maximum brake pressure of 448 psi 3.5 seconds after touchdown. Autobrakes were disengaged 11 seconds after touchdown when manual braking increased brake pressure.

The following aircraft were all WN flights and used manual braking:

WN 2920 reached full 3000 psi brake pressure within 6 seconds after touchdown.

WN 321 did not exceed 700 psi brake pressure until 20 seconds after touchdown when differential braking was used.

WN 2947 did not exceed 700 psi brake pressure until 14 seconds after touchdown when differential braking was used.

WN 1830 also used maximum brake pressure, but not until 19 seconds after touchdown as reverse thrust was decreasing.

The accident aircraft:

WN 1248 - the autobrakes activated 3.3 seconds after touchdown and reached maximum pressure of approximately 2500 psi (2400 for the left brake & 2600 for the right) approximately 8.3 seconds after touchdown. Autobrakes were disengaged 12 seconds after touchdown and brake pressure increased to 3000 psi. The aircraft left the runway 33.8 seconds after touchdown, at a speed of 39.5 kts, with T/R deployed and brake pressure at 3000 psi.

The FDR traces show that all these other aircraft achieved deceleration rates of approximately 0.3 gee, regardless of brake usage. Flight 1248 achieved a maximum of 0.24 gee.

Simulator recreations:

Approach 1: Full manual braking and reverse thrust at touchdown, WET-FAIR2 runway conditions, and touchdown at 1,500 feet.

Result: Able to come to a complete stop about 700 feet from end of runway. The on board performance computer (OPC) on the accident airplane calculated 560 feet of runway remaining after stop for this approach and these parameters.

Approach 2: Full manual braking and reverse thrust at touchdown, WET-POOR runway conditions, and touchdown at 1,500 feet.

Result: Able to come to a complete stop about 100 feet from end of runway. The OPC on the accident airplane calculated 50 feet of runway remaining after stop for this approach and these parameters.

Approach 3: Full manual braking and reverse thrust delayed 15 seconds after touchdown, WET-FAIR conditions, and touchdown at 1,800 feet.

Result: Able to stop about 100 feet from end of runway.

Approach 4: Full manual braking and reverse thrust delayed 15 seconds after touchdown, WET-POOR conditions, and touchdown at 1,800 feet.

Result: Airplane ran off the end of the runway.

Jim

 

[magsau]

UA 1446 used the Medium setting on autobrakes, which reached a maximum brake pressure of 448 psi 3.5 seconds after touchdown. Autobrakes were disengaged 11 seconds after touchdown when manual braking increased brake pressure.

IIRC from when I was on the bus (UA1446 was an A320 in TED config) the highest setting for landing was MED. The A320 has three settings LOW MED and MAX. MAX is the boeing equivilant of RTO and MED is the landing maximum setting equal to the Boeing setting of MAX for landing. The inference of the post that MED was used as a less than best setting is incorrect. While labled MED it is the HIGHEST Airbus landing setting and was being utilized correctly for the conditions.

By the way 11 seconds of deceleration is a significant timeframe. Would you happen to have the groundspeed from which the brakes were deactivated on UA 1446?

Close scrutiny is being paid at some techniques used by the SWA crews . One involves the slamming of the throttles to idle. In this instance there is a chance the throttles bounced off the stops due to the techniques used by the SWA pilots. This small bounce may have played a role in the Capt not being able to pull the reverser levers up. It may very well have been the F/O that finally pulled the to the aft point allowing for selection of reverse thrust.

Also the SWA non-use of Autothrottles, LNAV/VNAV is a workload issue that could come under review. SWA is setting up crews with long duty days to not have available safety elements to protect the passengers. By not using automation installed on the aircraft the safety chain is being stretched on a daily basis.