aviation
Runway Overrun and Collision
Southwest Airlines Flight 1248
Boeing 737-7H4, N471WN
Chicago Midway International Airport
Chicago, Illinois
December 8, 2005
ACCIDENT REPORT
NTSB/AAR-07/06
PB2007-910407
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National
Tr ansportation
Safety Board
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
Aircraft Accident Report
Runway Overrun and Collision
Southwest Airlines Flight 1248
Boeing 737-7H4, N471WN
Chicago Midway International Airport
Chicago, Illinois
December 8, 2005
NTSB/AAR-07/06
PB2007-910407
Notation 7753F
Adopted October 2, 2007
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the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents,
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Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
National Transportation Safety Board. Year. Runway Overrun and Collision, Southwest Airlines
Flight 1248, Boeing 737-7H4, N471WN, Chicago Midway International Airport, Chicago, Illinois,
December 8, 2005. Aircraft Accident Report NTSB/AAR-07/06. Washington, DC.
Abstract: This report explains the accident involving a Boeing 737-7H4, N471WN, operated by Southwest
Airlines (SWA), which departed the end of runway 31C after landing at Chicago Midway International
Airport. The safety issues discussed in this report include the ight crew’s decisions and actions, the clarity
of assumptions used in on board performance computers, SWA policies, guidance, and training, arrival
landing distance assessments and safety margins, runway surface condition assessments and braking
action reports, airplane-based friction measurements, and runway safety areas. Safety recommendations
concerning these issues are addressed to the Federal Aviation Administration.
National Transportation Safety Board
AIRCRAFT
Accident Report
iii
Co n t e n t s
Abbreviations and Acronyms ......................................................................................vi
Executive Summary ....................................................................................................... ix
1. Factual Information.....................................................................................................1
1.1 History of Flight .............................................................................................................................. 1
1.2 Injuries to Persons ........................................................................................................................... 6
1.3 Damage to Aircraft ......................................................................................................................... 6
1.4 Other Damage ................................................................................................................................. 6
1.5 Personnel Information ................................................................................................................... 6
1.5.1 The Captain ............................................................................................................................. 6
1.5.2 The First Ofcer ...................................................................................................................... 7
1.6 Aircraft Information ....................................................................................................................... 8
1.6.1 General ..................................................................................................................................... 8
1.6.2 Southwest Airlines On Board Performance Computer ................................................... 9
1.7 Meteorological Information ......................................................................................................... 9
1.7.1 Chicago Midway International Airport Weather Information ........................................ 9
1.7.2 Flight Crew Dispatch and In-Flight Weather Information ............................................. 10
1.8 Aids to Navigation ....................................................................................................................... 11
1.9 Communications ........................................................................................................................... 11
1.10 Airport Information .................................................................................................................... 11
1.10.1 Chicago Midway International Airport Winter Operations—General ...................... 13
1.10.2 Chicago Midway International Airport Winter Operations
on the Day of the Accident ............................................................................................... 14
1.10.3 Chicago Midway International Airport Runway Safety Areas .................................. 14
1.11 Flight Recorders .......................................................................................................................... 16
1.11.1 Cockpit Voice Recorder ..................................................................................................... 16
1.11.2 Flight Data Recorder .......................................................................................................... 16
1.11.3 Flight Data Recorder Information From Other Landing Airplanes ............................ 17
1.12 Wreckage and Impact Information .......................................................................................... 18
1.13 Medical and Pathological Information .................................................................................... 18
1.14 Fire ................................................................................................................................................ 19
1.15 Survival Aspects ......................................................................................................................... 19
1.16 Tests and Research ...................................................................................................................... 19
1.16.1 Airplane Simulation and Performance Studies ............................................................. 19
1.17 Organizational and Management Information ...................................................................... 21
1.17.1 Southwest Airlines Information ....................................................................................... 21
1.17.2 Southwest Operations Guidance Information ............................................................... 21
1.17.2.1 Thrust Reverser Procedures and Information .......................................................... 21
1.17.2.2 Autobrake Procedures and Information ................................................................... 23
1.17.2.3 On Board Performance Computer-Related Guidance and Information .............. 23
1.17.2.4 Mixed Braking Action Report and Tailwind Limitation Guidance....................... 28
1.17.3 Southwest Airlines Postaccident Actions ....................................................................... 29
1.18 Additional Information .............................................................................................................. 29
1.18.1 Airplane Landing Performance Information ................................................................. 29
Contents
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Accident Report
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1.18.1.1 Previously Issued Urgent Safety Recommendation Related
to Landing Distance Assessments .............................................................................. 30
1.18.1.2 Landing Distance Assessment Technical Bulletin .................................................. 33
1.18.2 Contaminated Runway and Landing Information ....................................................... 35
1.18.2.1 Runway Surface Condition Reports .......................................................................... 35
1.18.2.2 Correlation Between Runway Surface Condition and
Airplane Braking Ability ............................................................................................. 35
1.18.2.3 Previous Contaminated Runway-Related Safety Recommendations ................... 38
1.18.3 Previous Runway Safety Area Safety Recommendations ............................................ 41
2. Analysis .......................................................................................................................43
2.1 General ........................................................................................................................................... 43
2.2 Pilots’ Decision to Land, Knowledge, and Actions ................................................................. 44
2.2.1 Interpretation and Use of Mixed Braking Action Reports ............................................ 44
2.2.2 On Board Performance Computer Displays and Underlying Assumptions ............... 46
2.2.3 Thrust Reverser Usage and Autobrakes .......................................................................... 49
2.3 Landing Distance Assessments ................................................................................................. 52
2.3.1 Preight and Arrival Landing Distance Calculations/Assessments ............................ 53
2.3.2 Safety Alert for Operators Discussion and Industry Practice
Regarding Landing Distance Assessments ....................................................................... 55
2.3.3 Landing Distance Assessments Summary ....................................................................... 56
2.4 Runway Surface Condition Assessments .................................................................................. 58
2.4.1 Braking Action Reports ....................................................................................................... 58
2.4.2 Contaminant Type and Depth ........................................................................................... 59
2.4.3 Airport Runway Surface Friction Measuring Devices ................................................... 60
2.4.4 Runway Surface Condition Assessments Summary ....................................................... 60
2.4.5 Correlating Runway Surface Condition to Airplane Landing Performance ............... 61
2.5 Airplane-Based Friction Measurements .................................................................................... 62
2.6 Runway Safety Areas ................................................................................................................... 63
3. Conclusions ................................................................................................................65
3.1 Findings .......................................................................................................................................... 65
3.2 Probable Cause .............................................................................................................................. 67
4. Recommendations .....................................................................................................68
4.1 New Recommendations ............................................................................................................... 68
4.2 Previously Issued Recommendation Resulting From This Accident Investigation and
Classied in this Report ...................................................................................................................... 69
5. Appendixes .................................................................................................................70
Investigation and Public HearingA: .......................................................................................................70
Cockpit Voice RecorderB: ........................................................................................................................71
FAA Safety Alert For Operators 06012C: .............................................................................................225
National Transportation Safety Board
AIRCRAFT
Accident Report
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Fi g u r e s
1. Photograph of the accident airplane in the roadway intersection. ........................................... 4
2. Diagram showing the accident airplane where it came to rest
(on a heading of 340°) in the intersection off the end of runway 31C. ...................................... 5
3. The MDW airport layout plan with surrounding streets and properties. ............................. 12
4. OPC display showing the results of OPC calculations based on the
accident conditions with fair braking action. .............................................................................. 26
5. OPC display showing the results of OPC calculations based on the
accident conditions with poor braking action. ........................................................................... 27
6. Draft winter operations guide that was developed by an industry group. .......................... 34
7. CRFI values for various runway surface conditions. ............................................................... 37
National Transportation Safety Board
AIRCRAFT
Accident Report
vi
Ab b r e v i A t i o n s A n d AC r o n y m s
AC
advisory circular
ACM
airport certication manual
agl
above ground level
ARFF
aircraft rescue and reghting
ASOS
automated surface observing system
ASRS
aviation safety reporting system
ATC
air trafc control
ATCT
air trafc control tower
ATIS
automatic terminal information service
ATP
airline transport pilot
BWI
Baltimore/Washington Thurgood Marshall International Airport
C
Celsius
CFME
continuous friction measurement equipment
CFR
Code of Federal Regulations
CRFI
Canadian Runway Friction Index
CVR
cockpit voice recorder
DEC
decelerometer
DOA
Department of Aviation
DOT
Department of Transportation
EASA
European Aviation Safety Agency
Abbreviations and Acronyms
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AIRCRAFT
Accident Report
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EFB
electronic ight bag
EMAS
engineering materials arresting system
F
Fahrenheit
FAA
Federal Aviation Administration
FAR
Federal Aviation Regulations
FDR
ight data recorder
FOM
ight operations manual
FRM
ight reference manual
Hg
inch of Mercury
ICAO
International Civil Aviation Organization
ILS
instrument landing system
IRFI
International Runway Friction Index
JAA
Joint Aviation Authorities
JWRFMP
Joint Winter Runway Friction Measurement Program
MDW
Chicago Midway Airport
mm
millimeter
msl
mean sea level
MU
coefcient of friction
N1
engine fan speed
NASA
National Aeronautics and Space Administration
NWS
National Weather Service
OPC
on board performance computer
Abbreviations and Acronyms
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AIRCRAFT
Accident Report
viii
OpSpec
operations specication
POI
principal operations inspector
psi
pounds per square inch
RBF
read-before-ight
RSA
runway safety area
RVR
runway visual range
S/N
serial number
SAFO
safety alert for operators
sm
statute mile
SWA
Southwest Airlines
SWAPA
Southwest Airlines Pilots Association
National Transportation Safety Board
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Accident Report
ix
ex e C u t i v e su m m A r y
On December 8, 2005, about 1914 central standard time, Southwest Airlines (SWA)
ight 1248, a Boeing 737-7H4, N471WN, ran off the departure end of runway 31C after
landing at Chicago Midway International Airport, Chicago, Illinois. The airplane rolled
through a blast fence, an airport perimeter fence, and onto an adjacent roadway, where
it struck an automobile before coming to a stop. A child in the automobile was killed,
one automobile occupant received serious injuries, and three other automobile occupants
received minor injuries. Eighteen of the 103 airplane occupants (98 passengers, 3 ight
attendants, and 2 pilots) received minor injuries, and the airplane was substantially
damaged. The airplane was being operated under the provisions of 14 Code of Federal
Regulations Part 121 and had departed from Baltimore/Washington International
Thurgood Marshall Airport, Baltimore, Maryland, about 1758 eastern standard time.
Instrument meteorological conditions prevailed at the time of the accident ight, which
operated on an instrument ight rules ight plan.
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’ rst experience and lack of familiarity with
the airplane’s 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 inherent assumptions in the
program critical to pilot decision-making; 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. Also contributing to the accident was
the pilots’ failure to divert to another airport given reports that included poor braking
action and a tailwind component greater than 5 knots. 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.
The safety issues discussed in this report include the ight crew’s decisions
and actions, the clarity of assumptions used in on board performance computers, SWA
policies, guidance, and training, arrival landing distance assessments and safety margins,
runway surface condition assessments and braking action reports, airplane-based friction
measurements, and runway safety areas.
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Accident Report
1
FA C t u A l in F o r m A t i o n1.
History of Flight1.1
On December 8, 2005, about 1914 central standard time,
1
Southwest Airlines (SWA)
ight 1248, a Boeing 737-7H4, N471WN, ran off the departure end of runway 31 center
(31C) after landing at Chicago Midway International Airport (MDW), Chicago, Illinois.
The airplane rolled through a blast fence, an airport perimeter fence, and onto an adjacent
roadway, where it struck an automobile before coming to a stop. A child in the automobile
was killed, one automobile occupant received serious injuries, and three other automobile
occupants received minor injuries. Eighteen of the 103 airplane occupants (98 passengers,
3 ight attendants, and 2 pilots) received minor injuries, and the airplane was substantially
damaged. The airplane was being operated under the provisions of 14 Code of Federal
Regulations (CFR) Part 121 and had departed from Baltimore/Washington International
Thurgood Marshall Airport (BWI), Baltimore, Maryland, about 1758 eastern standard
time. Instrument meteorological conditions prevailed at the time of the accident ight,
which operated on an instrument ight rules ight plan.
The accident occurred on the rst ight of the rst day of a scheduled 3-day trip.
The ight departed BWI about 2 hours late because of deteriorated weather conditions
in the Chicago area. The captain was the ying pilot for the accident ight, and the rst
ofcer performed the duties of the monitoring pilot.
The pilots reported that they had thoroughly reviewed the two weather
information and dispatch documents they received from dispatch before they left BWI.
A third document authorizing the release of the accident ight was prepared but was
not delivered to the pilots before departure. This document revised the expected landing
winds (from “calm” to “090° at 11 knots”), runway braking action (from “wet-good” to
“wet-fair”), and landing runway (from 04R to 31C) based on the changing weather. The
pilots stated that they subsequently received updated MDW weather information and
runway condition/braking action reports
2
for runway 31C, which was the runway in use
at MDW at the time. Postaccident interviews with the pilots and evidence from cockpit
voice recorder (CVR)
3
data and air trafc control (ATC) communications indicated that the
runway 31C braking action reports were mixed, reporting good or fair braking action for
the rst half of the runway and poor braking action for the second half.
1
Unless otherwise indicated, all times are central standard time, based on a 24-hour clock.
2
Braking action reports are generated by pilots who have used the runway and provided to other arriving
pilots by air trafc control. According to Federal Aviation Administration Order 7110.65, “Air Trafc Control,”
braking action reports provided by controllers are to include a description of the braking action, using the terms
“good,” “fair,” “poor,” or “nil,” and the type of airplane or vehicle from which the report was received.
3
For a complete transcript of the CVR recording, see appendix B.
Factual Information
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AIRCRAFT
Accident Report
2
The pilots also stated (and CVR evidence conrmed) that they reviewed and
discussed the company’s new autobrake system procedures while en route from BWI to
MDW; the accident landing was the rst time either pilot landed using autobrakes.
4
About 1833:17, as the airplane was nearing MDW at an assigned altitude of
10,000 feet,
5
ATC issued the pilots instructions to enter a holding pattern. (ATC indicated
that the hold was because of runway-clearing snowplow operations at MDW.) About
1844:04, the pilots advised ATC that they were entering the holding pattern at 10,000 feet.
The rst ofcer stated that, while in the holding pattern, he entered the updated
weather and runway conditions and wind information (090° at 11 knots) in the on board
performance computer (OPC)
6
to determine the landing distance required for runway 31C.
The reported wind conditions resulted in a computed tailwind component of 8 knots.
7
All SWA 737s are limited to landing with a 10-knot or less tailwind component under
all runway surface conditions. Additionally, SWA policies and ight operations manuals
indicate that the company does not authorize landings on runways with more than a
5-knot tailwind component with poor braking action. Postaccident statements and CVR
evidence indicated that the accident pilots were aware of these limitations and believed
that they would be unable to land at MDW if the braking action was reported poor for the
full length of the runway.
The rst ofcer entered multiple scenarios into the OPC, entering fair and poor
pilot braking action reports separately because the OPC was not designed to accept mixed
braking action report inputs. Based on the rst ofcer’s inputs, the OPC estimated that
the airplane would stop about 560 feet before the departure end of the runway with
fair braking action and about 40 feet before the departure end of the runway with poor
braking action.
8
The pilots stated that they decided that, consistent with SWA policies, they
4
According to an SWA bulletin issued the day of the accident, pilots were to begin using the company’s
autobrake system procedures beginning December 12, 2005. During postaccident interviews, the pilots told
investigators that they believed the autobrake policy was implemented the day of the accident. A review of recent
SWA bulletins revealed that the autobrake implementation date had changed several times. For additional
information regarding the 737 autobrake system and SWA’s autobrake procedures and implementation details,
see section 1.17.2.2.
5
Unless otherwise indicated, all altitudes in this report are reported as height above mean sea level.
6
The OPC is a laptop computer with which every SWA airplane cockpit is equipped and that SWA pilots
use in performing takeoff and landing performance calculations. For additional information, see sections 1.6.2
and 1.17.2.3.
7
According to ight data recorder information, the actual crosswind component at touchdown was
between 8 and 9 knots.
8
During postaccident interviews (and consistent with CVR evidence), the pilots recalled a 30-foot
stopping margin for calculations with poor braking action. They noted that they were allowed to land with any
positive margin; however, CVR evidence and postaccident interviews indicated that the pilots were concerned
about the small stopping margin shown for poor runway braking action. The captain stated that he was glad
the 5-knot tailwind component limit for poor runway conditions would prevent them from making the landing
under those conditions.
Factual Information
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AIRCRAFT
Accident Report
3
would divert to one of their alternate destinations (Kansas City or St. Louis, Missouri)
9
if the tailwind component increased to above 10 knots or if pilot braking action reports
indicated poor braking action for the full length of the runway. The automatic terminal
information service (ATIS) reported a runway visual range (RVR)
10
for runway 31C of
about 5,000 feet.
About 1854:10, ATC began providing the pilots with radar vectors and descent
instructions as they departed the holding pattern for the nal approach course for the
instrument landing system (ILS) approach to runway 31C. At that time, the RVR was
reported as 4,500 feet variable to 5,000 feet,
11
and the ATIS was reporting winds from 100°
at 11 knots. About 1903:44, ATC cleared the pilots to intercept the runway 31C localizer.
Less than a minute later, ATC cleared them for the approach and advised that the braking
action reported for runway 31C was “fair except at the end [it’s]…poor.”
According to the CVR transcript, when the pilots contacted the MDW Air Trafc
Control Tower (ATCT) at 1909:53.7, controllers advised them to “continue for [runway] 31C
the winds zero nine zero at nine, brakin’ action reported good for the rst half, poor for
the second half.” About 1912:28, the rst ofcer received a landing clearance from the
ATCT. Flight data recorder (FDR) data indicated that the airplane was aligned on the
runway centerline as it touched down at an airspeed of about 124 knots. The speed brakes
deployed and brake pressure increased within about 1 second. Both pilots described the
touchdown as “rm.”
The captain stated that he tried to deploy the thrust reversers immediately after
touchdown but had difculty moving the thrust reverser levers to the reverse thrust
position. He further stated that he felt the antiskid system cycle after the airplane touched
down but then felt it stop cycling and that the airplane seemed to accelerate. He said that
he subsequently applied the wheel brakes manually but made no further effort to activate
the thrust reversers. He told investigators that he believed that the use of the autobrake
system distracted his attention from the thrust reversers after his initial attempt to deploy
them.
The rst ofcer said that, when he sensed a decrease in the airplane’s deceleration
during the landing sequence, he exclaimed, “brakes, brakes, brakes,” and manually applied
the brakes. He stated that he then looked at the throttle console and saw that the thrust
reverser levers were still in the stowed position. The rst ofcer moved the captain’s hand
away from the thrust reverser levers and, about 15 seconds after touchdown, initiated
deployment of the thrust reversers to the maximum reverse setting. FDR evidence
9
Both pilots indicated that SWA fosters an environment in which pilots can make decisions about whether
they should divert to an alternate airport without pressure or concern for repercussions. This is consistent with
statements made by all other SWA pilots interviewed. Also, another SWA ight, arriving at MDW minutes
before the accident ight, diverted to St. Louis because of landing weight considerations. The captain of that
ight stated that he had “diverted several times as a captain for SWA and has never gotten any grief” from the
company.
10
RVR is an instrumentally derived value that represents the horizontal distance a pilot will see down the
runway from the approach end by observing runway lights or markings.
11
During postaccident interviews, both pilots stated that the airplane was clear of the clouds from about
1,400 feet to touchdown and that they estimated that the landing RVR was about 5,000 feet.
Factual Information
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AIRCRAFT
Accident Report
4
conrmed the systems functions described by the pilots and indicated that full thrust
reverser deployment occurred about 18 seconds after touchdown.
However, the airplane ran off the departure end of runway 31C and continued
through the runway safety area (RSA),
12
a blast fence, a navigational aid antenna, across
an airport road, through an airport perimeter fence, and onto an adjacent public roadway.
The airplane struck a northbound automobile on that roadway before it came to rest near
an intersection located on the northwest corner of the airport. (Figures 1 and 2 show the
airplane’s position off the end of runway 31C.)
The rst ofcer stated that, after the airplane came to a rest, he performed the
emergency evacuation checklist while the captain checked on the passengers in the cabin.
The passengers evacuated through the forward left and the right rear cabin doors.
Photograph of the accident airplane in the roadway intersection. (Looking southeast, Figure 1.
towards the departure end of runway 31C.)
12
An RSA is a designated area abutting the edge of runways that is intended to reduce the risk of
damage to an airplane that runs off those surfaces. For additional information regarding MDW RSAs, see
section 1.10.3.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
5
Diagram showing the accident airplane where it came to rest (on a heading of 340°) in Figure 2.
the intersection off the end of runway 31C.
55TH STREET
CHIP AND SCAR LOCATIONS
N
S
EW
Factual Information
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AIRCRAFT
Accident Report
6
Injuries to Persons1.2
Injury chart.Table 1.
Injuries Flight Crew Cabin Crew Passengers Other Total
Fatal
0 0 0 1 1
Serious
0 0 0 1 1
Minor
0 1 17 3 21
None
2 2 81 5 90
Total
2 3 98 10 113
Note: Title 14 CFR 830.2 denes a serious injury as any injury that (1) requires hospitalization for more than 48 hours,
starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures
of ngers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal
organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. A minor
injury is any injury that does not qualify as a fatal or serious injury.
Damage to Aircraft1.3
The airplane had substantial, repairable damage.
Other Damage1.4
The airplane rolled through an airport blast fence, an ILS array, a frangible airport
perimeter fence, and onto a roadway, where it struck an automobile and a re hydrant.
Damage to the wing leading edges and engine nacelles of the airplane aligned with vertical
posts from the airport perimeter fence; there was no damage observed in the airplane
cockpit or cabin.
Personnel Information1.5
The Captain1.5.1
The captain, age 59, was a pilot in the U.S. Air Force for 26 years before he was hired
by SWA on August 3, 1995. He was hired as a rst ofcer and was upgraded to captain in
July 2000. The captain held a multiengine airline transport pilot (ATP) certicate with a
type rating in the Boeing 737. The captain held a rst-class Federal Aviation Administration
(FAA) airman medical certicate, dated September 21, 2005, with the limitation that he
“must wear corrective lenses.”
13
According to the captain’s SWA employment and ight records, he had own
about 15,000 hours total ight time, including 9,500 hours as pilot-in-command, about
13
During postaccident interviews, the captain stated that he was wearing glasses at the time of the
accident.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
7
4,500 hours of which were in 737 airplanes. He had own about 198, 137, 58, 14, and 2 hours
in the 90, 60, 30, and 7 days and 24 hours, respectively, before the accident. Company
records showed that the captain obtained his initial 737 type rating in May 1995 and that
his most recent line check, prociency check, and recurrent training occurred in June and
July 2005. A search of FAA records revealed no accident or incident history, enforcement
action, or pilot certicates and ratings failure or retest history. A search of the National
Driver Register found no record of driver’s license suspension or revocation.
The captain had not own for the 4 days before the accident ight. He told
investigators that he slept well the night before the accident and commuted to BWI from
his home in Buffalo, New York, arriving at BWI about 1235. The accident airplane was
pushed back from the gate about 1650 for its departure to MDW.
During postaccident interviews, the captain stated that the weather on the accident
night was the worst he had experienced but that he expected to be able to land safely and
uneventfully. He estimated that he had landed when the runway conditions were poor
because of winter weather about 12 to 15 times during his tenure with SWA. However, he
indicated that there was never a time previously when he thought he would not be able to
stop before the end of the runway. The captain further told investigators that he had not
previously used the autobrake system during a simulator or airplane landing.
The First Ofcer1.5.2
The rst ofcer, age 34, was a Saab 340 pilot for Mesaba Airlines for 6 years (2 years
as rst ofcer, 4 years as captain) before he was hired by SWA as a 737 rst ofcer on
February 17, 2003. He held a multiengine ATP certicate with a type rating in the 737. The
rst ofcer held a rst-class FAA airman medical certicate, dated October 18, 2005, with
the limitation that he “must wear corrective lenses.”
14
According to the rst ofcer’s SWA employment and ight records, he had own
about 8,500 hours total ight time, including 4,000 hours as pilot-in-command and about
2,000 hours as second-in-command in 737 airplanes. He had own about 243, 151, 83, 8,
and 2 hours in the 90, 60, 30, and 7 days and 24 hours, respectively, before the accident.
Company records showed that the rst ofcer obtained his initial 737 type rating in
November 2001 and his most recent 737 prociency check and recurrent training occurred
in February 2005. A search of FAA records revealed no accident or incident history,
enforcement action, or pilot certicate or rating failure or retest history. A search of the
National Driver Register found no record of driver’s license suspension or revocation.
The rst ofcer was assigned to a reserve line of ying at the time of the accident,
and checked in for reserve duty at BWI about 1040 on December 8. He told investigators
that he had about 8 hours of sleep the night before and took a nap the day of the accident
ight.
14
During postaccident interviews, the rst ofcer stated that he was wearing glasses at the time of the
accident.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
8
During postaccident interviews, the rst ofcer stated that he had extensive
experience with weather conditions similar to those they encountered on the night of the
accident, although most of that experience was before he was hired by SWA. He stated
that he had only landed in snow a few times since he was hired by SWA, and, in those
instances, “nothing unusual occurred.” The rst ofcer further told investigators that he
had not previously used the autobrake system during a simulator or airplane landing.
Aircraft Information1.6
General1.6.1
The accident airplane, serial number 32471, was manufactured by Boeing and
received its FAA airworthiness certicate on July 13, 2004. At the time of the accident, the
airplane had accumulated about 5,273 total ight hours and 2,901 cycles.
15
The airplane
was equipped with two CFM International
16
CFM56-7B24 turbofan engines, both of which
were new when the airplane was delivered to SWA.
According to ight dispatch information, the airplane’s actual takeoff weight for
the accident ight was 129,000 pounds; the FDR recorded an actual MDW landing weight
of 118,280 pounds. (The pilots used an estimated landing weight of 119,700 pounds in their
OPC stopping margin calculations.) Airplane documentation indicates that the maximum
structural takeoff and landing weights are 154,500 and 128,000 pounds, respectively.
Each of the airplane engines is equipped with a hydraulically actuated thrust
reverser system, which is used to slow the airplane after landing. When the thrust reversers
are deployed, blocker doors change the direction of the engine fan air exhaust, moving it
outward and forward to create reverse thrust. The thrust reversers are operated by levers
located on the forward side of the thrust levers on the throttle quadrant. Postaccident
examination of the thrust reverser components from the accident airplane revealed no
evidence of preimpact anomaly.
The 737-700 autobrake system is designed to automatically apply brakes upon
main landing gear strut compression and wheel spinup after touchdown. The system
senses deceleration during the landing roll and automatically modulates brake pressure
accordingly. Postaccident examination of the autobrake system components from the
accident airplane revealed no evidence of preimpact anomaly.
15
An airplane cycle is one complete takeoff and landing sequence.
16
CFM International is jointly owned by General Electric Aircraft Engines of the United States and Societe
Nationale d’Etude et de Construction de Moteurs d’Aviation of France.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
9
Southwest Airlines On Board Performance Computer 1.6.2
SWA equips each airplane cockpit in its eet with an OPC,
17
which is stowed
behind the captain’s seat and is accessible by either pilot. The OPC is used by ight
crews for numerous performance calculations, including weight and balance, takeoff
performance, en route performance, and expected landing performance and stopping
margins. With regard to landing performance and stopping margins, SWA pilots enter
current data regarding the landing runway, wind speed and direction, airplane gross
weight at touchdown, temperature, altimeter setting, and reported runway braking
action into the OPC, and the OPC calculates the airplane’s landing performance. The OPC
alerts pilots if it calculates that the airplane will not stop on the available runway length
under the conditions entered by displaying negative stopping margin numbers in white
digits inside of a bracketed red block instead of the standard black digits against a white
background.
18
SWA policies do not authorize landings on runways with good or fair braking
action with more than a 10-knot tailwind component or with more than a 5-knot tailwind
component on runways with poor braking action. If the computed tailwind component
exceeds these tailwind component limits, the OPC displays the stopping margin
associated with the maximum tailwind limit rather than the actual tailwind component
because of the OPC calculation assumptions that were established by SWA. The reported
wind conditions for the accident landing resulted in a tailwind component of 8 knots,
which was presented on the OPC display for calculations with both fair and poor runway
braking action conditions. However, when the pilots input poor braking action, the
stopping margins that were displayed by the OPC were based on the unit’s maximum
5-knot tailwind limit. (For additional OPC-related information, see section 1.17.2.3.)
Meteorological Information 1.7
Chicago Midway International Airport Weather Information1.7.1
About 0620 on the day of the accident, the National Weather Service (NWS)
Chicago Regional Forecast Ofce began issuing snow advisories for northern Illinois.
The advisories indicated that snow would begin in northeastern Illinois and the Chicago
metropolitan area by mid-morning and continue into the evening hours, with snowfall
rates increasing by mid-afternoon. About 1819 (less than 1 hour before the accident), the
NWS forecast ofce issued a winter weather advisory that indicated that a heavy snow
warning was in affect for the Chicago area until midnight and estimated a total snow
accumulation of between 6 and 9 inches. Snow was reported at MDW beginning about
17
Although OPCs are generally assigned to a specic airplane, each OPC database contains information
for all airplanes in the SWA eet; thus, OPCs can be exchanged between airplanes. If an OPC is unavailable,
pilots may obtain required performance parameters from dispatch personnel.
18
In addition, when the wind limits are exceeded, the OPC displays a description of the limits on the
bottom of the screen in white letters with black background. For an example, see the OPC display in gure 5
in section 1.17.2.3 (“Wind limits: 5T/10X”).
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
10
1347 on December 8 and ending about 0126 on December 9, 2005, with about 10 inches of
total snow accumulation.
An ofcial weather observation recorded at MDW about 1853 indicated winds
from 100° at 11 knots; visibility 1/2 statute mile (sm) in moderate snow and freezing
fog; ceiling broken at 400 feet above ground level (agl) and overcast at 1,400 feet agl;
temperature minus 3° Celsius (C) (28° Fahrenheit [F]); dew point temperature minus 4° C
(23° F); altimeter setting 30.06 inches of Mercury (Hg). Remarks: automated observation
system, runway 31C 10-minute-averaged RVR 4,500 feet, snow increment 1 inch new
snow last hour, 10 inches total, hourly liquid precipitation less than 0.01 inch (trace). As
previously noted, according to postaccident interviews with ATC personnel, the ILS to
runway 31C was the only approach available to commercial ights landing at MDW on
the night of the accident because of approach visibility requirements.
A special weather observation recorded at MDW after the accident (at 1937)
indicated winds from 160° at 5 knots; visibility 1/4 sm in heavy snow and freezing fog; sky
condition obscured vertical visibility 200 feet; temperature minus 3° C (28° F); dew point
temperature minus 4° C (23° F); altimeter setting 30.05 inches Hg. Remarks: automated
observ[ing] system, runway 31C 10-minute-averaged RVR 3,000 feet.
Weather observations at MDW are made by an automated surface observing
system (ASOS). The 5-minute observations surrounding the time of the accident indicated
the following conditions:
19
Weather observation at 1910: winds from 110º at 8 knots, visibility 1/2 mile •
in moderate snow and freezing fog, ceiling broken at 400 feet agl, overcast
at 1,400 feet agl, temperature minus 4° C, dew point temperature minus
5° C, altimeter 30.06 inches Hg. Remarks: runway 31C visual range 4,500 feet
variable 5,000 feet, hourly precipitation less than 0.01 inches.
Weather observation at 1915: winds from 110º at 7 knots, visibility 1/2 mile •
in moderate snow and freezing fog, sky obscured vertical visibility 300 feet,
temperature minus 4° C, dewpoint temperature minus 5° C, altimeter
30.06 inches Hg. Remarks: runway 31C visual range 4,500 feet variable
5,000 feet, hourly precipitation less than 0.01 inches.
Flight Crew Dispatch and In-Flight Weather Information1.7.2
SWA records indicated that the airplane’s original dispatch release was revised
three times before the accident ight. Examination of these documents indicated that the
revisions resulted from changes in alternate airport destinations, the contingency fuel load,
and the planned landing runway at MDW. The accident ight’s release calculations were
based on the use of runway 31C. The release included two alternate airport destinations
and enough fuel for the most distant alternate plus 90 minutes of contingency fuel.
19
The ASOS equipment is located at the center of the airport with additional sensors at the approach
end of runway 31C. The ASOS system is augmented as needed by FAA-contracted, NWS-certied weather
observers located in the ATCT.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
11
The MDW forecast information in the dispatch paperwork was issued by the
NWS about 1515 on December 8 and was considered valid from 1500 that day to 1200
on December 9. This forecast indicated the following conditions after 1500: winds from
080° at 11 knots, visibility 1/2 sm in moderate snow and freezing fog, overcast ceiling
at 400 feet agl; temporarily between 1500 and 1600, visibility 1/4 sm in moderate snow
and freezing fog, sky obscured vertical visibility 200 feet. After 1600, winds from 070° at
8 knots, visibility 1 sm in light snow and mist, ceiling overcast at 500 feet agl; temporarily
between 1600 and 1900 visibility 1/2 sm in moderate snow and freezing fog, sky obscured
vertical visibility 400 feet. After 1900, winds from 050° at 7 knots, visibility 2 sm in light
snow, ceiling overcast at 700 feet agl. After 2100, winds from 340° at 12 knots, visibility
better than 6 sm in light snow, ceiling overcast at 2,500 feet agl, temporarily between
2100 and 0000, visibility 3 sm in light snow showers. Related NWS forecast information
indicated that the arrival of the snow system could be slightly delayed but predicted a
signicant snow event for the area the afternoon and evening of the accident.
A subsequent terminal forecast issued about 1738 predicted the snow ending and
higher ceilings and improved visibilities in the early morning of December 9, as the system
moved out of the area.
Aids to Navigation1.8
No problems with any navigational aids were reported.
Communications1.9
No communications problems between the pilots and any of the air trafc
controllers who handled the accident ight were reported.
Airport Information1.10
MDW is located about 10 miles southwest of downtown Chicago at an elevation
of about 620 feet in an area that includes residential, commercial, and industrial land uses.
(Figure 3 shows the MDW airport layout plan with surrounding streets and properties.
Runway 31C is highlighted in yellow.)
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
12
The MDW airport layout plan with surrounding streets and properties. Runway 31C is Figure 3.
highlighted in yellow.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
13
The airport is owned by the City of Chicago and operated by the Chicago
Department of Aviation (DOA). MDW has ve runways, including one set of two parallel
runways (4R/22L and 4L/22R) and one set of three parallel runways (13L/31R, 13C/31C,
and 13R/31L). Runway 31C is 6,522 feet long by 150 feet wide and is made of grooved
concrete. The usable landing distance for runway 31C is 5,826 feet.
20
Runway 31C is
equipped with an ILS approach, a visual approach slope indicator system, and runway end
identier lights.
According to postaccident interviews with ATC personnel, the ILS approach to
runway 31C was the only approach available to commercial ights landing at MDW on
the night of the accident because of approach visibility requirements. When the accident
pilots departed the holding pattern for the nal approach to runway 31C, the RVR was
reported as 4,500 variable to 5,000 feet. The approach visibility requirement for runway
13C was 1 sm, whereas the requirement for the ILS approach to runway 31C was 5/8 sm
visibility or 3,000 feet RVR.
The FAA certicated MDW as a 14 CFR Part 139 airport with Index D aircraft
rescue and reghting (ARFF) capabilities. Examination of FAA Airport Certication/
Safety Inspection records for MDW from the years 2003, 2004, and 2005 revealed no
deciencies.
Chicago Midway International Airport Winter Operations—1.10.1
General
The MDW 2005-2006 Snow Removal Manual provides an overview of the
procedures used by the Chicago DOA for snow removal operations at MDW. According to
this manual and MDW personnel, snow removal and anti-icing operations are conducted
from runway end to runway end. During snow removal operations, an MDW airport
operations supervisor is positioned in the ATCT to act as a liaison between air trafc
controllers in the tower and snow removal teams on the eld. This coordination effort is
intended to optimize use of the runways and minimize delays. The operations supervisor
receives pilot reports regarding eld conditions and/or runway braking action from
ATC and relays them to snow removal teams as necessary. The operations supervisor
also maintains a handwritten “snow log” that documents the snow removal and runway
friction test activities.
The FAA-approved Airport Certication Manual (ACM) for MDW states that the
airport is responsible, in part, for monitoring runway conditions and pilot reports, snow
and ice removal as necessary, and coordination with ATC, air carriers, and other airport
users during snow and ice events. The ACM also species that the airport will conduct
20
Displaced thresholds located at each end of runway 31C reduced the usable landing distance from
6,522 to 5,826 feet. A displaced threshold is a runway threshold located at a point other than the physical
beginning or end of the runway. The portion of the runway so displaced may be used for takeoff but not for
landing. Landing airplanes may use the displaced area on the opposite end for rollout. Most often the offset
threshold is in place to give arriving aircraft clearance over an obstruction while still allowing departing aircraft
the maximum amount of runway available.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
14
friction tests on the active runway, or any other runway available for aircraft use, on a
“frequent” basis during events involving freezing precipitation or snow.
Chicago Midway International Airport Winter Operations 1.10.2
on the Day of the Accident
According to MDW ofcials, early on the day of the accident, the Chicago DOA
had received adverse weather reports and initiated the notication and mobilization
phases of the snow operations plan. Snow began falling at the airport about 1347, at which
time snow removal operations commenced. Snow removal operations involved the use of
runway brooms, snow plows, a snow blower, deice machines, and runway friction testing
equipment.
According to postaccident interviews and documentation, runway 13C/31C had
been cleared ve times during the 5 1/2 hours of snowfall before the accident, most recently
about 1845. Friction test logs indicated that runway 31C was friction-tested before this
clearing about 1839, with resultant coefcient of friction (MU) readings
21
of .59/.45/.37
(average .47).
22
A friction test conducted about 1847 produced results of .72/.59/.68
(average .67). The most recent eld conditions reported on the MDW Web site (which
were updated about 1850) indicated that runway 31C had a trace to 1/16 inch of wet snow
over 90 percent of its surface, with 10 percent of its surface clear and wet. A friction test
conducted after the accident (about 1922) produced results of .41/.40/.38 (average .40).
Chicago Midway International Airport Runway Safety Areas 1.10.3
According to Advisory Circular (AC) 150/5300-13, change 7, “Airport Design,”
the RSA for runway 13C/31C at MDW should have extended 1,000 feet beyond the
runway ends and been 500 feet wide.
23
FAA documentation indicates that, at the time of
the accident, the runway 31C RSA extended 82 feet beyond the end of the runway and
was 500 feet wide. The FAA’s RSA determination for this runway, dated September 20,
2000, stated, “it does not appear practicable to achieve the RSA standards” because the
runway could not be realigned on site, and the acquisition of land for an RSA would
require relocation of Central Avenue, 55th Street, and many businesses and homes in the
area. However, the FAA instructed the Chicago DOA to “explore all options to bring the
RSAs into full conformance with FAA standards.”
21
For additional information regarding evaluation of contaminated runways and friction measurements,
see section 1.18.2.
22
MU friction values range from 0.0 to 1.0, where 0.0 is the lowest friction value, and 1.0 is the theoretical
best friction value available. Friction testing devices provide MU values for the rst, second, and third sections
of the runway length. These values are then averaged for an overall friction value representing the entire
runway surface.
23
According to the National Transportation Safety Board’s postaccident simulation study, using routine
procedures under the accident conditions, the accident airplane would have required an additional 750 feet of
runway to come to a complete, unobstructed stop.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
15
In 2003, the FAA asked the Chicago DOA to assess enhancement measures for
improving the RSAs at MDW. In May 2004, the city stated in a response letter that there
were no alternatives for achieving a standard RSA at MDW. The letter also stated the
following:
The runway could not be shortened and still meet the aircraft operational •
requirements.
Extending the RSA would require acquisition and major impact to surrounding •
commercial properties and residential neighborhoods, public roadways, and
public utility infrastructure.
[The use of an] EMAS [engineering materials arresting system] was assessed, •
but insufcient spacing existed for installation of EMAS without shortening
the runway, thus reducing the operational capacity of the airport.
The letter concluded that RSA enhancement at MDW could be obtained
incrementally by improvements such as relocation of light poles and service road signs
within the RSA. According to MDW ofcials, the FAA made no further requests to the
city for improvements to MDW RSAs, including the installation of shorter, nonstandard
EMAS beds,
24
before the accident.
After the accident, in April 2006, the Chicago DOA sent a letter and an EMAS
study to the FAA. The letter summarized options for improving the MDW RSAs and
concluded that a nonstandard EMAS bed with a 35-foot setback could be installed at the
end of runway 31C. Engineering calculations showed that the nonstandard arrestor bed
would be capable of stopping a Boeing 737-700 weighing 102,400 pounds and rolling at a
ground speed of up to 57 knots on a wet runway without the use of thrust reversers.
After the accident, the National Transportation Safety Board asked the EMAS
system manufacturer to model the accident scenario
25
and estimate the effect a nonstandard
EMAS installation off the end of runway 31C would have had on the accident sequence. The
EMAS manufacturer estimated that an arrestor bed 229 feet long would t in the overrun
area off the end of runway 31C. The manufacturer’s simulations predicted that, based
on the accident airplane’s estimated runway exit speed of 53 knots, a 737 landing under
conditions similar to the accident airplane would continue 206 feet into the EMAS bed
before stopping. The simulations indicated that the airplane could have been traveling as
fast as 58 knots when it ran off the end of the runway and still stop within a 229-foot-long
EMAS bed. The simulations indicated that a nonstandard EMAS installation would have
stopped the accident airplane before it departed airport property.
24
Although the FAA was aware of the feasibility of nonstandard EMAS installations and had approved
such installations at several airports (for example: John F. Kennedy International Airport, New York, New
York; Bob Hope Airport, Burbank, California; Baton Rouge Metropolitan Airport, Ryan Field, Baton Rouge,
Louisiana; and Barnstable Municipal Airport-Boardman/Polando Field, Hyannis, Massachusetts), it did not
publish guidance related to this option until 2005. In September 2005, the FAA issued AC 150/5220-22A,
“Engineered Materials Arresting Systems (EMAS) for Aircraft Overruns.”
25
Safety Board investigators provided the manufacturer with data regarding the accident scenario,
including airplane weight, airport and weather conditions, and likely runway exit speed for the modeling
simulations.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
16
After the accident, the FAA approved the installation of nonstandard EMAS beds
at MDW, and MDW and City of Chicago ofcials began to work toward installation
of nonstandard EMAS beds at the ends of runways 31C, 13C, 4R, and 22L. By early
December 2006, the rst portion (170 feet long and 170 feet wide) of an EMAS bed had
been installed off the departure end of runway 31C, with an additional 40-foot-long
portion planned. Airport and city ofcials indicated that the installation of EMAS beds
at the ends of affected MDW runways would be completed before winter 2007, pending
relocation of localizer antennas at the ends of runways 13C, 4R, and 22L.
Flight Recorders1.11
Cockpit Voice Recorder1.11.1
The accident airplane was equipped with a Honeywell model 6022 CVR, serial
number (S/N) CVR120-05823. The CVR showed no signs of damage and was sent to the
Safety Board’s laboratory in Washington, DC, for readout and evaluation. The CVR was
played back normally and without difculty and contained six separate channels of good
quality
26
audio information. The recording started at 1712:58.2 and continued uninterrupted
until 1914:01.3. A transcript was prepared of the entire 2-hour, 44.7-second recording (see
appendix B).
Flight Data Recorder1.11.2
The accident airplane was equipped with a Honeywell model solid state FDR,
S/N 10452, that recorded airplane ight information (including altitude, airspeed, heading,
wind direction and speed, control wheel and column position, elevator/aileron/rudder
position, engine fan speed, thrust reverser status and position, thrust reverser interlock,
brake pressure, and autobrake status) in a digital format using solid-state memory devices.
The FDR showed no evidence of damage or excessive wear and was sent to the Safety
Board’s laboratory for readout and evaluation. The following information was obtained
from the accident airplane’s FDR data and physical evidence:
The main landing gear touched down about 1,250 feet beyond the runway’s •
approach threshold.
27
At the time, the airplane’s ground speed was about
131 knots, its airspeed was 124 knots, its heading was 316°, and its vertical
acceleration reached about 1.4 Gs.
26
The Safety Board uses the following categories to classify the levels of CVR recording quality: excellent,
good, fair, poor, and unusable. A good quality recording is one in which most of the ight crew conversations
could be accurately and easily understood.
27
The airplane touched down within the Boeing-recommended touchdown zone of 1,000 to 2,000 feet
beyond the runway threshold. The OPC calculated the landing/stopping distance based on a touchdown point
of 1,500 feet beyond the runway threshold.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
17
The ground spoilers were fully deployed, autobrakes were applied, and vertical •
acceleration increased to a peak value of about 1.7 Gs within about 1.2 seconds
of touchdown.
About 10 seconds after touchdown, engine fan speed (N•
1
) decreased from
about 32 percent at touchdown to about 20 percent, where it remained for
about 8 seconds.
Autobrakes were deactivated about 12 seconds after touchdown, and •
pilot-commanded brake pressure increased to 3,000 pounds per square inch
(psi).
The rst indication of thrust reverser activity was recorded about 15 seconds •
after touchdown, with full deployment about 18 seconds after touchdown. N
1
reached 80 percent about 9 seconds later (about 27 seconds after touchdown)
at a ground speed of about 62 knots.
The thrust reversers were fully deployed and the brake pressure was 3,000 psi •
when the nose landing gear departed the runway overrun at a speed of about
53 knots.
The airplane came to a stop about 500 feet beyond the end of the runway on a •
heading of about 340° with a collapsed nose landing gear about 8 seconds after
it departed the runway overrun.
Flight Data Recorder Information From Other Landing 1.11.3
Airplanes
FDRs from ve air carrier airplanes that landed in the 25 minutes before the
accident were evaluated. Table 2 provides a comparison of selected parametric data for
those ve air carrier airplanes and the accident ight.
Comparison of selected parametric data for ve air carrier airplanes and the accident Table 2.
ight.
Airline
and ight
number
Airplane
type
Time
Touchdown
ground
speed in
knots
Vertical
load
(G)
Gross
weight
(lbs)
Seconds
to brake
use
Seconds to
full thrust
reverser
deployment
Seconds
to 40
knots
United
Airlines 1446
A320 1849 128 1.33 113,830 3.5* 6 18
SWA 2920 737 1852 140 N/A** 114,560 0.5 4 21
SWA 321 737 1901 121 1.5 103,320 6.0 4 25
SWA 2947 737 1902 132 1.95 110,320 8.0 4 26
SWA 1830 737 1904 126 1.35 105,520 2.0 4 24
Accident
ight
737 1913 131 1.41 118,280 3.3* 18 33
*Note: The autobrake system initially applied the brakes for United Airlines ight 1446 and the accident ight.
**N/A in this table indicates not available.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
18
Wreckage and Impact Information1.12
The airplane came to rest on a magnetic heading of about 340° at the south side of
an intersection located on the northwest corner of MDW. The airplane was resting on the
engines, both main landing gear, and the nose of the fuselage, with the nose landing gear
collapsed and folded aft. The damage to the airplane was largely limited to the forward
lower fuselage, engine cowlings and components, forward portions of the wings, and other
wing components,
28
with limited damage farther aft. The rear part of an automobile was
found damaged beneath the forward portion of the airplane’s left fuselage. Postaccident
interviews and physical evidence indicate that the automobile was northbound on the
roadway and was struck from behind by the airplane.
Postaccident examination and testing of components in the airplane’s throttle,
antiskid,
29
ground spoiler, and wheel brake systems revealed no evidence of preimpact
anomalies. In addition, investigators examined the engine controls and the throttle
quadrant (including the thrust levers) in the ight deck area and associated linkages
below the cockpit oor level; no evidence of preimpact anomalies was found.
Medical and Pathological Information1.13
In accordance with Federal regulations, postaccident drug testing was conducted
on urine specimens obtained from the captain and rst ofcer;
30
test results were negative.
In addition, both pilots volunteered blood samples for analysis within 24 hours of the
accident. These test results were negative for alcohol and a wide range of drugs, including
drugs of abuse.
31
The Cook County Medical Examiner’s Ofce reported the cause of death of
the automobile passenger as “compressional asphyxia.” Other postaccident medical
information indicated that another automobile occupant received serious injuries,
including multiple fractures, head injuries, and right shoulder pain, and 21 people
(1 ight attendant, 17 airplane passengers, and 3 automobile occupants/pedestrians)
received minor injuries, including multiple aches and pains, sprains/strains, contusions
and abrasions, and a whiplash-type injury, as a result of the accident.
28
Damage along the wings aligned with observed damage to the airport blast fence and perimeter
fence.
29
The accident airplane’s antiskid system is designed to modulate wheel brake pressure to ensure a
xed slip ratio between the tire and ground during braking.
30
These tests were to include alcohol, amphetamines, cocaine, marijuana, opiates, and phencyclidine.
31
The drugs tested in the postaccident analysis include (but are not limited to) marijuana, cocaine,
opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines,
meprobamate, and methaqualone.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
19
Fire1.14
No evidence of an in-ight or a postcrash re was found.
Survival Aspects1.15
According to postaccident interviews and airport documentation, the rst ARFF
units arrived at the airplane about 2 minutes after the accident and assisted with the
evacuation. The captain instructed a ight attendant to open the left front door and told
the rst ofcer to help passengers at the bottom of that door’s evacuation slide.
32
He used
a megaphone to advise passengers that they should evacuate through the front of the
airplane. According to City of Chicago records, about 14 minutes after the accident, ARFF
personnel positioned mobile stairs at the right rear door and assisted passengers in exiting
through that door as well.
The rst ofcer and about half of the airplane passengers evacuated through the
left front cabin door. The captain, three ight attendants, and about half of the passengers
evacuated through the right rear door using the mobile stairs provided by ARFF personnel.
During postaccident interviews, ight attendants described the evacuation as “orderly”
and stated that passengers deplaned calmly. The right front, left rear, and right and left
overwing exits were not opened during the evacuation.
Tests and Research1.16
Airplane Simulation and Performance Studies 1.16.1
A postaccident engineering study was conducted to examine the deceleration times
and distances required for the accident ight and the four other SWA 737-700 airplanes
that landed before it. The Safety Board’s airplane performance study identied an airplane
braking ability (braking coefcient)
33
that would replicate the accident airplane’s ground
speed and runway deceleration performance and quantied the effects that different winds,
ground spoiler deployment schedules, and reverse thrust throttle settings and stowage
schedules would have had on the airplane’s stopping performance.
32
The captain chose to initiate the evacuation through the front of the airplane because the nose of the
airplane was closer to the ground after the nosewheel collapsed. The rst ofcer described the evacuation
slide at the left front exit as “almost at to the ground.”
33
Airplane braking coefcient is dened as the ratio of the retarding force due to braking relative to
the normal force (that is, weight minus lift) acting on the airplane. The estimated airplane braking coefcient
incorporates effects due to the runway surface, contaminants, and airplane braking system (antiskid efciency,
tire pressure, brake wear, etc.).
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
20
Simulations that replicated the accident airplane conguration, use of deceleration
devices, and weather
34
and runway conditions (see case #31 in table 3) showed that, under
these conditions, the airplane would have required about another 753 feet beyond the end
of the runway to come to a stop. A simulation case performed under the same conditions
but with an equivalent headwind instead of tailwind component (see case #33 in table 3)
showed that the airplane could have stopped about 584 feet before the departure end of
the runway. A simulation case performed under identical airplane conguration, weather,
and runway conditions, but using SWA routine/planned deceleration procedures to
decelerate,
35
showed that the airplane would likely have stopped about 1,351 feet beyond
the end of the runway (see case #53 in table 3). Under the same conditions and if the
pilots had used Boeing’s reverse thrust procedures
36
(see case #54 in table 3), simulations
showed that the airplane would likely have stopped about 531 feet beyond the end of the
runway. However, simulations in which maximum reverse thrust was selected 2 seconds
after touchdown and maintained until the airplane came to a complete stop (see case
#60 in table 3) showed that the airplane could have stopped about 271 feet before the
departure end of the runway.
Stopping distances and runway exit speeds for various deceleration scenarios Table 3.
calculated during postaccident airplane performance simulations.
Simulation Case # Simulation ground speed at
runway exit
Calculated runway 31C
distance remaining
#31 (accident event conditions) 50 knots -753 feet
#33 (accident event conditions,
but with a headwind)
not applicable 584 feet
#53 (SWA reverse thrust) 46 knots -1,351 feet
#54 (Boeing reverse thrust) 30 knots -531 feet
#60 (Maximum reverse thrust
stop)
not applicable 271 feet
The previous four SWA 737-700 airplanes landed on runway 31C about 1853, 1901,
1902, and 1904; one of these airplanes exited the runway at taxiway B (the last taxiway
before the runway end), the other three airplanes exited at the runway-end taxiway. FDR
data indicated that the ight crews on these four airplanes deployed reverse thrust (three
out of the four ight crews commanded maximum reverse thrust) early in the landing
roll. The Safety Board’s study showed that timely and sustained application of reverse
34
FDR data indicated that the actual tailwind component at touchdown was between 8 and 9 knots. The
Safety Board’s simulations were based on a 9-knot tailwind component.
35
SWA planned deceleration procedures specied that reverse thrust be selected within 2 seconds
of touchdown and maintained until the airplane decelerated through 80 knots, followed by smooth throttle
movement to forward idle thrust as the airplane decelerated from 80 to 60 knots.
36
Boeing’s published reverse thrust procedures were similar to SWA’s except that thrust reversers were
to be maintained until the airplane decelerated through 60 knots, followed by smooth throttle movement to
reverse idle thrust as the airplane decelerated from 60 to 30 knots.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
21
thrust (including maximum reverse thrust as needed)
37
could have been used to stop the
accident airplane on the runway.
The study showed that the accident airplane landed in generally deteriorating
runway surface conditions; the ight’s braking ability was about ve times worse than
would be expected on a bare and dry runway. The study also stated that the calculated
ground roll distances were most sensitive to the airplane braking coefcient magnitude,
winds, and time delay to commanded reverse thrust under the landing conditions.
However, the study noted that the landing distances would have been less sensitive to
similar wind and time delay variations if the landings were conducted on a dry or wet
runway.
Organizational and Management Information1.17
Southwest Airlines Information1.17.1
SWA began service on June 18, 1971, and is based in Dallas, Texas. At the time
of the accident, SWA operated about 3,000 scheduled daily domestic departures to
62 destinations and had more than 31,000 employees. The company’s all-737 eet consisted
of 194 737-300s, 25 737-500s, and 222 737-700s.
Five other runway-related accidents or incidents involving SWA have occurred
since 1983,
38
including three lateral runway excursions and two runway overruns, one of
which involved a contaminated runway surface (heavy rain).
Southwest Operations Guidance Information1.17.2
Thrust Reverser Procedures and Information1.17.2.1
SWA policies and procedures specied the use of thrust reversers for all landings,
regardless of runway length or condition. At the time of the accident, SWA’s FAA-
approved ight operations manual (FOM) stated, in part, that after the airplane touches
down on the runway, the pilots should do the following:
Initiate reverse thrust: Raise the reverse thrust levers to the reverse idle
interlocks. After the interlocks release, modulate reverse thrust, as required.
Avoid exceeding engine limits. Minimum reverse thrust is 65 percent N
1
[engine fan speed]. When required, reverse thrust to engine limits may
be used. Initiating reverse thrust at touchdown is an important factor in
37
SWA procedures indicate that maximum reverse thrust is available for routine use at the pilots’
discretion, and, as noted, was also used by three of the four SWA 737s that landed at MDW before the
accident airplane. See section 1.17.2.1 for related SWA ight operations manual text.
38
More information on these ve events, FTW03MA160, LAX01IA109, DCA00MA030, FTW96IA210,
and FTW85FA202, is available on the Safety Board’s Web site at <http://www.ntsb.gov/ntsb/query.asp>.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
22
minimizing brake temperatures, minimizing brake and tire wear, and
reducing stopping distances.
The SWA FOM also stated the following:
Under braking advisories less than ‘GOOD’ use Normal Landing
Procedures except for the following:
[Manual] Brakes and thrust reversers should be applied together.
[
39]
Use thrust reversers as soon as possible during landing roll.
In addition, the SWA FOM stated the following:
Both pilots will monitor systems for warning ags, lights, or out of tolerance
conditions.
The [rst ofcer] will advise the captain of deviations from established
policies, procedures, and/or regulations.
SWA pilots are trained to move the thrust reverser levers aft smoothly and
promptly after touchdown and to keep their forearms on the throttle knobs to keep the
throttles at idle during thrust reverser deployment. If the throttle levers are forward
of the idle detent by about 1/4 inch,
40
the reverse thrust levers cannot be operated. A
postaccident survey of SWA personnel and pilots, a review of SWA maintenance records,
and a review of aviation safety reporting system (ASRS) data revealed no evidence of
systemic thrust reverser difculties. Several SWA pilots did report difculties deploying
the thrust reversers when they tried to move the reverse thrust levers past the interlock
position too rapidly; those pilots reported that the levers moved readily when they tried
to deploy the thrust reversers again after the interlocks released. Postaccident interviews
with the previous 10 ight crews for the accident airplane revealed that they reported no
difculty deploying the thrust reversers.
According to SWA personnel, there was no policy allowing pilots to apply a credit
for the use of reverse thrust during their landing distance assessments (which would
increase the calculated stopping margin for a landing) until 1998, when a reverse thrust
credit was incorporated into landing distance calculations for the 737-700 model only.
SWA pilots received instruction regarding the reverse thrust credit during differences
training when qualifying for the 737-700 model. However, until 1 week before the
accident, the information in two out of three FOM locations incorrectly indicated that
reverse thrust was not included in 737-700 OPC landing distance calculations. At the time
of the accident, the information was correct in two of the three FOM locations. Most SWA
39
For additional information regarding activities that have been grouped together in an automatic task
sequence, such as manual brakes and thrust reversers, see section 2.2.3.
40
The thrust lever interlock latch prevents movement of the reverse thrust levers (and thus prevents
thrust reverser actuation) when the forward thrust lever is forward of the idle stop.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
23
pilots interviewed after the accident were aware of the OPC reverse thrust credit for the
737-700; however, some were not.
Autobrake Procedures and Information1.17.2.2
At the time of the accident, SWA planned to implement a policy requiring the
use of autobrakes under certain landing conditions on December 12, 2005 (4 days after
the accident). Previously, SWA’s policy did not permit the use of autobrakes because
the company’s eet was not then fully equipped with autobrakes. As the eet became
fully equipped, the company took steps to implement autobrake use. In preparation,
SWA provided its pilots with a self-study training module on the autobrake system and
related SWA procedures (which both accident pilots had completed). SWA pilots were
also provided with a series of bulletins regarding the repeatedly delayed start-date for
autobrake usage. The most recent of these bulletins was issued December 8, 2005, and
noted that the company’s autobrake procedures and policies were to be used by SWA
pilots beginning December 12, 2005, and therefore were not in effect (or authorized) on
the day of the accident.
41
During postaccident interviews, the pilots told Safety Board investigators that they
had read the daily read-before-ight (RBF) letters before the accident ight but that they
failed to notice the new delay in autobrake procedure implementation.
42
CVR evidence and
postaccident statements indicated that they both believed that the autobrake policy was
in effect for the accident ight. A previous autobrake-related RBF letter indicated that the
autobrake policy would be in effect as soon as materials were available in the cockpit. On
the day of the accident, “ow” cards and checklists with information regarding autobrake
procedures had been placed in SWA airplanes.
When using autobrakes, pilots can select from several autobrake system settings,
including the following:
Maximum (MAX): Should be used when minimum stopping distance is •
required.
43
Medium (MED): Should be used for wet or slippery runways or when landing •
rollout distance is limited.
Minimum (MIN): These settings provide a moderate deceleration effect suitable •
for all routine operations.
On Board Performance Computer-Related Guidance and Information 1.17.2.3
Pilots may use a variety of aids when performing airplane performance and landing
distance calculations. Options include tabular performance charts and on board electronic
41
For additional information regarding the increased effort and cognitive resource-use required by new
procedures, see section 2.2.3.
42
The Safety Board’s review of SWA RBF letters revealed that there had been several delays in the
autobrake implementation dates associated with the autobrake procedure implementation.
43
The accident ight crew selected MAX autobrakes for the landing and transitioned to maximum manual
braking about 12 seconds after touchdown.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
24
computing devices (also known as OPCs at SWA). The FAA evaluates and approves
operators’ procedures for the use of electronic computing devices with an interactive
interface, and advisory guidance regarding the certication and operational approval
process for these devices is provided in AC 120-76A.
44
AC 120-76A addresses human
factors design issues and contains references to other sources for detailed human factors
guidance, including a series of reports developed by the Department of Transportation
(DOT) in conjunction with the FAA regarding human factors in the design and evaluation
of OPC-type devices.
45
The advisory material states that the results of calculations should
be displayed in a manner that is understood easily and accurately and that users should
be aware of any assumptions upon which the ight performance calculations are based.
Tabular charts preceded on board electronic computing devices and are still used
by many airlines today. These charts present critical information and assumptions through
notations directly on the applicable chart or on an introductory performance page. To
calculate landing distance using a chart, pilots survey rows and columns of values, select
the most appropriate value for conditions, and adjust for inputs accordingly. Use of charts
sometimes requires mathematical adjustments or interpolations to account for values that
are not exactly listed. OPC-like devices help reduce the pilots’ workload by eliminating the
need for pilot adjustments and interpolations; however, research shows that it is important
for pilots to be aware of the critical underlying performance calculation assumptions.
46
As previously stated, SWA provides its pilots with an OPC, and the company’s
FOM provides guidance regarding the use of that OPC. The SWA FOM identies, in part,
the following runway conditions with regard to OPC use:
WET-FAIR—to be used when braking action is reported as fair; and
WET-POOR—to be used when braking action is reported as poor.
The SWA FOM further states the following:
The [OPC-calculated] landing distance information is provided to give
an indication of the braking effort necessary to stop the airplane within
the available landing length….Individual pilot braking technique and
44
Although there is no requirement for the manufacturers of Class 1, Type B electronic computing
devices (like SWA’s OPCs) and/or operators using such to adhere to the guidance contained in AC 120-76A,
FAA evaluators and principal operations inspectors are encouraged to reference the advisory materials during
the approval process.
45
(a) <http://www.volpe.dot.gov/opsad/efb/vreppub.html>; (b) AS 25-11, FAA Policy Statement
ANM-99-2, FAA Policy Statement ANM-01-03, DOT-VNTSC-FAA-00-22; RTCA/DO-257; (c) U.S. Department
of Transportation, Human Factors Considerations in the Design and Evaluation of Electronic Flight Bags
(EFBs), Version 2, Report Number DOT-VNTSC-FAA-03-07 (Washington, DC: DOT, 2003); and (d) U.S.
Department of Transportation, A Tool Kit for Evaluating Electronic Flight Bags, Report Number DOT-VNTSC-
FAA-06-21 (Washington, DC: DOT, 2006).
46
(a) K. Mosier and L. Skitka, “Human Decision Makers and Automated Decision Aids: Made for Each
Other?,” Automation and Human Performance: Theory and Applications, R. Parasuraman and M. Mouloua
(Eds.), Mahwah, New Jersey: Lawrence Erlbaum Associates, 1996; and (b) U.S. Department of Transportation,
Human Factors Considerations in the Design and Evaluation of Electronic Flight Bags (EFBs), Version 1:
Basic Functions, Report Number DOT-VNTSC-FAA-00-22 (Washington, DC: DOT, 2000).
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
25
experience will provide equivalent braking efforts that can then be related
to the OPC output. The MAX distance is based on maximum manual
braking (without the use of thrust reversers) at touchdown.
The approximate stop margins calculated by the OPC are based on three
different levels of deceleration as dened by the autobrake system and are
based on touching down 1,500 feet from the [runway approach] threshold.
The MIN, MED, and MAX values are calculated using the deceleration
rates for [associated autobrake settings]. The stop margins include the
effects of reverse thrust (-300/-500: stop margins do not include the effects
of reverse thrust).
[
47]
Additionally, according to SWA’s FOM, company procedures authorize pilots to
land using a MAX autobrake setting, “provided a positive stopping margin is computed”
by the OPC.
Specic OPC-related training was provided to SWA pilots during 1 day of dispatch
training and two additional classroom training periods. During training, one scenario
addressed use of the OPC from takeoff to landing during a normal ight, whereas another
addressed use of the OPC from takeoff to landing during an abnormal ight.
48
Additionally,
upon completion of the specic OPC training, pilots spent 3 classroom days with a check
airman instructor who covered additional FOM topics, including use of the OPC.
Most SWA pilots, instructors, and check airmen who were interviewed told
investigators that the company’s pilots had adapted well to the use of the OPC and had
a good understanding of and trusted the system. There were no procedures in place for
pilots to verify or check the numbers calculated by the OPC with another independent
source.
Postaccident examination of the data stored on the accident OPC conrmed that
the pilots had entered the expected airplane touchdown weight and updated weather
data. As previously noted, evidence indicated that the pilots selected WET-FAIR and
WET-POOR as possible runway conditions and that the OPC estimated 560 and 40 feet,
respectively, of runway remaining under those conditions. (As previously noted, SWA
procedures permit company pilots to land with any positive calculated stopping margin.)
Based on its assumptions, the OPC display would reect the landing distance associated
with a maximum tailwind component of 5 knots for poor braking action even if the
47
SWA pilots were type-rated in all three 737 models owned by SWA (-300/-500/-700) and switched
between these models on a day-by-day or ight-by-ight basis. Pilots were taught that stopping margins
assumed reverse thrust credit (85 percent to MAX) for the -700 model only and not for the other two models
(-300/-500). This method of calculation resulted in a more favorable stopping margin for the -700. As noted,
until 1 week before the accident, OPC-related information in the SWA FOM stated that reverse thrust was not
included in the landing distance calculations in two of three locations; the incorrect information remained in
one location when the accident occurred but has since been corrected.
48
Beginning in July 2005, SWA recurrent training included a scenario involving a potential conict
between runway condition reports from two different sources; however, the accident pilots had completed their
2005 recurrent training before that date, and the training still did not include interpretation of mixed-condition
runway braking action reports.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
26
computed tailwind component exceeded 5 knots. Figures 4 and 5 show OPC-displayed
results of OPC calculations based on the accident conditions with fair and poor braking
action, respectively. Note that in both gures the OPC display shows the tailwind value of
8 knots even though the displayed landing distance is based on the OPC tailwind limit of
5 knots. In gure 5, the white “8T” with a red background and the “Wind limits: 5T/10X”
remark in white with a black background near the bottom of the display indicate that the
tailwind limits for poor braking action were exceeded.
OPC display showing the results of OPC calculations based on the accident conditions Figure 4.
with fair braking action.
The Safety Board’s investigation revealed that if SWA OPCs had used the actual
tailwind component of 8 knots instead of the company limit of 5 knots, the stopping
margin for poor braking action would have been -260 feet. Because of its negative value,
this number would have been presented as bracketed white digits inside of a red block
(instead of the standard black digits against white background) to alert the pilots that they
could not safely land on the runway. The Board notes that calculations performed using
Boeing’s more conservative data, an 8-knot tailwind component, and poor braking action
indicated that the airplane would have stopped 2,070 feet beyond the end of the runway.
Similar calculations performed using fair braking action indicated that the airplane would
have stopped 260 feet beyond the end of the runway. A review of SWA guidance and
MEL/CDL ReturnModule Menu
31C 5826 - DT 8T / 7X [ -810 ] 350 560
Runway Condition: WET _ FAIR
Air Conditioning: BLEEDS ON
Anti-Ice: ENGINE ON
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
27
training regarding OPC assumptions revealed one reference in the OPC section of the
ight reference manual (FRM) but none in the FOM. Further, no references were made to
this topic during initial, recurrent, or OPC-related ground training.
Note: the white “8T” with a red background and the “Wind limits: 5T/10X” remark in white with a black background near the
bottom of the display indicate that the tailwind limits for poor braking action were exceeded.
OPC display showing the results of OPC calculations based on the accident conditions Figure 5.
with poor braking action.
As a result of its investigation of the July 31, 1997, accident involving a Federal
Express McDonnell Douglas MD-11 that crashed while landing on runway 22R at
Newark International Airport, Newark, New Jersey,
49
the Safety Board determined that
some ight crewmembers may lack prociency in the operation of airplane performance
computing devices and that confusion about calculated landing distances may result in
potentially hazardous miscalculations of available runway distances after touchdown. In
August 2000, the Safety Board issued Safety Recommendation A-00-95, which asked the
FAA to require principal operations inspectors (POI) assigned to Part 121 operators that
49
National Transportation Safety Board, Crash During Landing, Federal Express, Inc., McDonnell
Douglas MD-11, N611FE, Newark International Airport, Newark, New Jersey, July 31, 1997, Aircraft Accident
Report NTSB/AAR-00/02 (Washington, DC: NTSB, 2000).
MEL/CDL ReturnModule Menu
Wind limits: 5T/10X.
31C 5826 - DT 8T / 7X [ -730 ] [ -30 ] 40
Runway Condition: WET _ POOR
Air Conditioning: BLEEDS ON
Anti-Ice: ENGINE ON
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
28
use auxiliary performance computers
50
to review and ensure the adequacy of training and
procedures regarding the use of this equipment and interpretation of the data generated,
including landing distance data.
As a result of this recommendation, in August 2002, the FAA issued Flight
Standards Information Bulletin for Air Transportation 02-03, which was intended to
1) call attention to the importance of operating procedures and pilot training related to
OPCs and 2) cause operators and POIs to review those procedures and related training to
ensure their adequacy, if OPCs are to be used by the operator. In December 2002, Safety
Recommendation A-00-95 was classied “Closed—Acceptable Action.”
Mixed Braking Action Report and Tailwind Limitation Guidance1.17.2.4
SWA guidance indicates that mixed braking action reports are not unexpected
during routine operations and company policy requires pilots to defer to the more
critical braking action assessment when mixed braking action conditions are reported.
Specically, SWA’s FAA-approved FOM, chapter 3, “Normal Operations,” pages 3.23.1
through 3.23.5, states the following:
Braking action reports less than good are classied according to the most
critical term [emphasis added] (fair, poor, nil, or combinations). Operations
are prohibited on all surfaces classied as nil.
The Safety Board’s review of SWA training materials revealed that, at the time of
the accident, the topic of mixed conditions was not routinely or explicitly introduced to
pilots during training. Further, the topic was not addressed in the FOM sections regarding
braking action and runway friction reports, entering runway conditions into the OPC,
and/or programming the OPC for landing. After the accident, SWA published a revision
to chapter 3 of the FOM, which added, “If a combination is given (e.g., fair to poor), use
the more restrictive of the two.” In addition, SWA implemented pilot training specic to
interpretation of braking action reports, including mixed conditions.
51
According to SWA’s FOM, chapter 2 (“Operational Considerations”), page 2.2.6
“landing is not authorized … when wind limitations are exceeded.” The FOM, chapter 2,
page 2.2.9, indicates that SWA’s maximum tailwind component for landing under poor
braking action conditions is 5 knots; under all other conditions, the maximum tailwind
component for landing is 10 knots. As previously noted, when the wind limits for a given
braking action are exceeded, the OPC displays a description of the limits on the bottom of
the screen in white letters with black background, but uses SWA’s programmed maximum
tailwind component (not the actual computed component) to calculate landing distance.
For an example, see the OPC display in gure 5 (“Wind limits: 5T/10X”).
50
“Auxiliary performance computer” is another term for an electronic computing device or OPC.
51
For additional information regarding postaccident SWA actions, see section 1.17.3.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
29
Southwest Airlines Postaccident Actions1.17.3
As a result of this accident, SWA revised its operational policies and procedures
and guidance as follows:
Amended sections of its FOM to reinforce the company’s policy requiring •
pilots to enter the most restrictive braking action report in the OPC for landing
distance assessments and provided additional training specic to braking
action reports, including mixed conditions.
52
Revised its OPC to standardize the use of thrust reverser credit in landing •
distance assessments for all airplane types and to modify the landing output
screens to show the amount of reverse thrust needed to obtain the calculated
distances.
Reinforced thrust reverser policies regarding the immediate deployment of •
thrust reversers after landing.
Revised the procedures for use of thrust reverse to be consistent with the Boeing •
guidance, such that pilots are to begin reducing the reverse thrust at 60 knots
instead of 80 knots.
Claried FOM guidance regarding the responsibility of the monitoring pilot •
to monitor thrust reverser deployment and to call out any specic related
deviation.
Implemented an autobrake familiarization period before autobrake use (in •
addition to the existing ight crew autobrake training and related information
package) and revised FOM to include a technical description of the autobrake
system. SWA required that pilots complete at least four familiarization landings
(two as the ying pilot and two as the monitoring pilot) on dry runways with
ample stopping margins before using the autobrake system on a routine
basis.
Added a 15 percent safety margin to its arrival landing distance calculations •
and revised its OPC to reect the additional margin.
53
Additional Information1.18
Airplane Landing Performance Information1.18.1
Two categories of airplane landing distance performance information are pertinent
to normal commercial airplane operations. The rst, preight (or dispatch) landing distance
52
Preaccident SWA guidance regarding braking action reports was consistent with the postaccident
guidance, stating, “braking action reports less than good are classied according to the most critical term (fair,
poor, nil, or combinations).”
53
The added safety margin was consistent with that recommended in the FAA’s August 31, 2006, Safety
Alert for Operators 06012. For more information, see section 1.18.2.
Factual Information
National Transportation Safety Board
AIRCRAFT
Accident Report
30
performance data, is used during ight planning to determine the maximum takeoff weight
at which the airplane can depart an airport and, after its planned fuel burn, land on the
available landing distance at the destination/alternate airport. This determination is based
on specic 14 CFR requirements for dry or wet/slippery runway conditions. Dispatch
landing distance calculations are intended to ensure that dispatched airplanes will be able
to land safely at the intended destination airport or a planned alternate and are based
on estimated landing weights and forecast conditions. According to Federal regulations,
the dry and wet/slippery landing performance data used for dispatch calculations are
obtained by multiplying the numbers demonstrated
54
during certication landings on a
level, smooth, dry, hard-surfaced runway by factors of 1.67 and 1.92, respectively.
55
The second category, arrival (or operational) landing distance information, is used
by pilots while en route and uses updated information, including runway conditions,
weather, and planned congurations, to determine the landing distance required. Airplane
landing performance data for conditions other than bare and dry are typically calculated
rather than demonstrated via a ight test. Operational landing distance assessments
are intended to ensure that the arrival weather and runway surface conditions and the
planned airplane conguration, pilot technique, and deceleration devices will result in a
safe landing distance at the arrival weight.
Dispatch planning distance calculations are required and standardized by U.S.
and international aviation authorities. However, U.S. Federal regulations do not require
or standardize arrival landing distance assessments, nor do they specify safety margins
for such assessments.
Previously Issued Urgent Safety Recommendation Related to Landing 1.18.1.1
Distance Assessments
As a result of this accident, on January 27, 2006, the Safety Board issued urgent
Safety Recommendation A-06-16, which asked the FAA to do the following:
Immediately prohibit all 14 CFR Part 121 operators from using the reverse
thrust credit in landing performance calculations.
The stated intent of this recommendation was to ensure adequate landing safety
margins for landings on contaminated runways. The FAA responded in part by conducting
an internal review of existing regulations, orders, notices, ACs, International Civil
Aviation Organization (ICAO) and foreign country requirements, airplane manufacturer-
developed material, independent source material, and the current practices of air carrier
operators.
54
For these demonstrations, the airplane is decelerated using maximum manual braking and full spoiler
deployment but no reverse thrust during the landing roll.
55
U.S.-based airplane manufacturers have not historically demonstrated landing performance on all
possible runway surface conditions, including a wet/slippery runway, largely because of the difculties involved
in attaining representative and repeatable conditions during a nite ight test program.
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31
The FAA does not require landing performance calculations at the time of arrival,
nor does it impose standards for these manufacturer-supplied or operator-packaged
landing performance data or the use of such data. Therefore, the FAA observed numerous
inconsistencies and wide variation in operators’ practices regarding airplane landing
performance calculations at the time of arrival. These inconsistencies were observed in
numerous related areas, including the circumstances under which the landing distance for
the time of arrival was calculated; the data used for such calculations, which were either
provided by the manufacturer or developed by the operator or a third-party vendor; the
currency of landing distance assessment data; application of safety margins; the existence
of landing distance performance information; and the application of credit for the use of
thrust reversers. Landing distance performance information is available in a wide variety
of informational documents and is available for a range of runway or braking action
conditions using various airplane deceleration devices and settings under a variety of
meteorological conditions, depending on the operator and the source.
During the Safety Board’s investigation of the SWA ight 1248 accident,
investigators determined that two different operators were using manufacturer-supplied
landing performance data that were not the most suitable or currently available.
Further, in some cases, the landing performance data presented by the operator and/
or third-party vendor were less conservative (provided a larger stopping margin) than
the manufacturer’s data for the same conditions (as was the case with SWA’s data in this
accident). The operational landing performance data used to dene landing limitations
may be based on a wide range of assumptions, depending on the manufacturer and
whether the data have been modied before presentation to pilots. Although operators
practices may differ, manufacturer-provided dispatch landing performance data are
typically included in an airplane ight manual, while arrival landing performance data
are included in the airplane’s quick reference handbook for accessibility in the cockpit.
(Both dispatch and arrival landing performance data are typically available to operators
using electronic ight bags [EFB].)
On June 7, 2006, the FAA published an “Announcement of Policy for Landing
Performance After Departure for All Turbojet Operators,” which stated, in part, that the
FAA considered a 15 percent margin as the minimum acceptable safety margin between
the expected actual airplane landing distance and the available runway landing distance
at the time of arrival. In a June 13, 2006, letter to the Safety Board, the FAA stated its belief
that the actions described in its June 7 notice would yield a greater safety benet than a
blanket prohibition against taking credit for use of thrust reversers. The Board supported
the FAA’s planned action and its timely implementation. As a result, the FAA planned
to issue mandatory Operations Specication (OpSpec) N 8400.C082 to all 14 CFR Part 91
subpart K, 121, 125, and 135 turbojet operators, requiring the following:
Use of an operationally representative air distance;•
Use of data at least as conservative as the manufacturer’s data;•
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Use of the worst reported braking action for the runway during landing •
distance assessments; and
Operators’ addition of an extra margin of at least 15 percent to the landing •
distance calculation.
56
Further, OpSpec N 8400.C082 would require POIs to ensure that operators’
ight crew and dispatcher training programs provide information about all aspects and
assumptions of actual landing distance performance determinations.
The FAA intended that operators comply with OpSpec N 8400.C082 by
October 2006. However, the FAA encountered considerable industry opposition to its
June 7 proposal, and, on August 31, 2006, decided not to issue the mandatory OpSpec
but, rather, to pursue formal rulemaking regarding these issues. In the interim, the FAA
published Safety Alert for Operators (SAFO) 06012, compliance with which was voluntary.
SAFO 06012 suggested that operators (1) establish procedures that require assessing the
landing distance as close as practicable to the time of arrival if conditions have adversely
changed since the preight landing distance assessments, (2) apply a safety margin of at
least 15 percent to the calculated airplane landing distance when such assessments are
required at the time of arrival, and (3) provide information regarding all aspects of actual
landing distance performance assessments in their ight crew and dispatcher training
programs, among others. FAA personnel told Safety Board staff that the FAA intended to
pursue formal rulemaking in the area of landing distance assessments and believed that
operators would voluntarily comply with SAFO 06012 in the interim.
The Safety Board is currently investigating two additional accidents involving
contaminated runway overruns by air carrier airplanes. On February 18, 2007, a Shuttle
America Embraer EMB-170 ran off the end of snow-contaminated runway 28 at Cleveland
Hopkins International Airport in Cleveland, Ohio. This ongoing investigation has revealed
that Shuttle America did not require its pilots to perform landing distance assessments
based on conditions at the time of arrival.
57
Additionally, on April 12, 2007, a Pinnacle
Airlines Bombardier Regional Jet CL600-2B19 ran off the end of snow-covered runway 28
at Cherry Capital Airport in Traverse City, Michigan. This ongoing investigation
has revealed that Pinnacle had incorporated an arrival landing distance assessment
56
The FAA-advocated minimum safety margin of 15 percent was established based on historic links to the
FAA-mandated additional 15 percent factor for wet/slippery dispatch requirements and the 15 percent factor
embedded in the European Aviation Safety Agency and the European Joint Aviation Authorities’ operational
requirements for landing on a contaminated runway.
57
More information on this accident, CHI07MA072, is available on the Safety Board’s Web site at <http://
www.ntsb.gov/ntsb/query.asp>.
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requirement consistent with SAFO 06012;
58
however, the accident ight crew in this case
did not perform an arrival landing distance assessment.
59
In a May 8, 2007, response regarding Safety Recommendation A-06-16, the Safety
Board stated, “A year after this urgent recommendation was issued, the FAA has not
yet taken any effective action in response to it.” The Board cited FAA-issued guidance
advising the use of a 15 percent safety factor in landing distance assessments but noted
that the FAA was unable to say how many Part 121 operators had adopted that guidance.
In its letter, the Board classied Safety Recommendation A-06-16, “Open—Unacceptable
Response.”
Landing Distance Assessment Technical Bulletin 1.18.1.2
In January 2007, Safety Board staff attended a meeting with FAA, Boeing, SWA,
and SWA Pilots Association (SWAPA) personnel at which the history and practices related
to landing distance assessments at the time of arrival were discussed. Figure 6 shows a
related draft winter operations guide that was developed by an industry group.
SWA is currently incorporating the information contained in this guide, which it
plans to incorporate in October 2007, and Boeing attached similar guidance to a bulletin,
dated August 23, 2007, that was issued to all operators of Boeing turbojet airplanes.
60
The
Boeing guidance recommends that operators develop arrival landing distance assessment
procedures for their ight crews to use to ensure that a full-stop landing can be made
on the arrival runway in the conditions (weather and runway) existing at the time of
arrival and with the deceleration means and airplane conguration to be used. The Boeing
guidance also recommends that the landing distance assessment use the most adverse
braking condition in the landing distance assessment and that an additional safety margin
be applied to the resultant landing distance.
58
If requested by an operator, the FAA may approve another OpSpec, which would require that operator
to conduct arrival landing distance assessments and include a minimum 15 percent safety margin for every
landing. As a result of Pinnacle’s request, the FAA issued an OpSpec. Pinnacle’s resultant documentation
states, “When landing on a contaminated runway, the landing runway must have a minimum safety margin of
15 percent available length beyond the calculated landing distance. The landing distance must take into account
the actual runway conditions existing at the time of arrival, the expected deceleration means, and aircraft
conguration to be used. If the safety margin is not available, the pilot should not land the aircraft, absent an
emergency. This will be considered the minimum acceptable safety margin. These requirements are separate
from the regulatory landing distance calculations required by FAR [Federal Aviation Regulation] 121.195 for
dispatch, and are only necessary when a contaminated landing runway is expected.”
59
More information on this accident, DCA07FA037, is available on the Safety Board’s Web site at <http://
www.ntsb.gov/ntsb/query.asp >.
60
Boeing plans to issue similar guidance to all operators of Douglas airplanes in October 2007.
Factual Information
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Draft winter operations guide that was developed by an industry group. Figure 6.
he ai
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Contaminated Runway and Landing Information 1.18.2
Runway Surface Condition Reports1.18.2.1
Three methods typically used to describe a runway’s surface condition are:
1) runway contaminant type and depth observations, 2) ground surface vehicle friction
measurements,
61
and 3) pilot braking action reports. Safety Board public hearing testimony
indicated that, regardless of the method used, the reported runway surface conditions
may differ from the actual runway surface conditions encountered by a landing ight.
In SAFO 06012, the FAA stated that joint industry and international government
tests have not established a reliable correlation between any of these runway surface
condition description methods and an airplane’s braking ability. In part, the FAA attributed
this to the fact that runway surface conditions can change signicantly in very short periods
of time, depending on precipitation, accumulation, usage, temperature, direct sunlight,
and runway maintenance/treatment. Runway contaminant type and depth reports may
also be adversely affected by the observer’s vantage point and/or a lack of uniformity of
contaminants across the runway’s surface. The FAA also stated that operators should not
base their landing distance calculations solely on ground surface vehicle runway friction
measurements because extensive testing did not indicate that “a repeatable correlation
exists through the full spectrum of runway contaminant conditions.”
62
Further, pilot braking action reports are subjective, reecting individual pilot
expectations, perceptions, and experiences, and are sensitive to airplane type and the
actual deceleration methods used to slow or stop the airplane. Mixed pilot braking action
reports (for example, fair for the rst half of the runway and poor for the second half), and
conicting braking action reports from different sources (for example, an air carrier pilot, a
general aviation pilot, or a ground vehicle) can also make the interpretation and use of such
reports more difcult. The FAA acknowledges that braking action reports are subjective
and advises pilots to consider all available information and make landing decisions based
on the most restrictive reports, the pilots’ experience, and sound judgment.
Correlation Between Runway Surface Condition and Airplane 1.18.2.2
Braking Ability
During its investigation of this accident, the Safety Board noted that different
methods and terminologies were used throughout the aviation industry to dene the
relationship between runway surface condition and an airplane’s braking ability (also
61
Runway contaminant type and depth observations and ground surface vehicle friction measurements
are provided by airport operations personnel and may be broadcast in an ATIS message. According to
AC 150/5200-30A,
“
Airport Winter Safety and Operations,” the FAA considers two types of friction testers—
the decelerometer (DEC) and the continuous friction measurement equipment (CFME)—to be “generally…
reliable” when the runway surface is contaminated by ice (or wet ice) or compacted snow. (MDW uses both
DEC and CFME friction testers.) AC 150/5200-30A also states that friction tests
“
…will be reliable as long as
the depth of dry snow does not exceed 1 inch and the depth of wet snow or slush does not exceed 1/8 inch.”
62
Variability in equipment design and calibration is also an issue with ground surface vehicle friction
measurements.
Factual Information
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termed “airplane braking coefcient” in this report). For example, the European Aviation
Safety Agency (EASA) and Joint Aviation Authorities (JAA) state that a correlation between
contaminant type and depth and the effective braking ability of an antiskid-controlled
braked wheel “may be used to [calculate airplane landing performance conservatively]
in the absence of any direct test evidence.” Both Boeing and SWA calculate operational
airplane landing performance based on correlations between airplane braking ability and
braking action reports.
63
Transport Canada provides guidance that can be used to correlate
ground surface vehicle friction survey measurements to airplane performance on certain
winter-contaminant surfaces in the form of Canadian Runway Friction Index (CRFI) tables
in its Aeronautical Information Manual.
64
Existing FAA guidance on runway surface condition reporting, contained in
AC 91-6A, “Water, Slush, and Snow on the Runway,” dated May 24, 1978, does not
correlate runway braking action and an airplane’s braking ability. In August 1989, the
FAA issued a draft AC (91-6B), “Performance Information for Operation with Water,
Slush, Snow, or Ice on the Runway,” that proposed that such a correlation be used “if the
braking performance is based on analysis rather than tests.” However, the draft AC was
never published, and the guidance contained in AC 91-6A remains in effect.
The FAA allows airplane manufacturers and operators (like Boeing and SWA)
to dene custom braking action/airplane braking ability correlations. SAFO 06012
advocates the use of a specic correlation between reported braking action and runway
contaminant type and depth to predict turbojet landing performance when manufacturer-
supplied wet or contaminated runway landing distance data are unavailable. In addition,
SAFO 06012 stated, “The FAA considers the data developed for showing compliance with
the European contaminated runway certication…to be acceptable for making landing
distance assessments for contaminated runways at the time of arrival.”
ICAO published yet another method used to dene the relationship between
runway surface condition and an airplane’s estimated braking action. This correlation of
the measured runway braking action (MU reading) to estimated braking action is shown
in table 4.
Correlation of the measured runway braking action to estimated braking action.Table 4.
Measured Runway Braking Action (MU Reading) Estimated Braking Action
0.40 and above Good
0.39 to 0.36 Medium to good
0.35 to 0.30 Medium
0.29 to 0.26 Medium to poor
0.25 and below Poor
63
Although both are based on correlations between airplane braking ability and braking action reports,
Boeing and SWA correlations differ in the numeric values and the braking action report terminology used.
64
For additional information, see section 1.18.2.2.1.
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Canadian Runway Friction Index1.18.2.2.1
A detailed method of measuring and reporting friction on contaminated runways
to determine landing distances has been in use in Canada for about 30 years. Runway
friction values obtained from decelerometers (DEC) are reported as CRFI values and are
included in surface condition reports and notices to airmen. The information contained
in the CRFI tables is based on eld test performance data of airplanes braking on
winter-contaminated surfaces and provides recommended landing distances based on
the CRFI values. Figure 7 shows the CRFI values for various runway surface conditions,
highlighting the CRFI values for loose snow 3 millimeters (mm) deep or less on pavement,
which ranged from 0.16 to 0.76.
CRFI values for various runway surface conditions. Note that the CRFI values for loose Figure 7.
snow 3 mm deep or less on pavement ranged from 0.16 to 0.76 (see the bold horizontal line).
International Runway Friction Index1.18.2.2.2
In January 1996, the Joint Winter Runway Friction Measurement Program
(JWRFMP), consisting of a group of representatives from international organizations,
65
convened to do the following:
Study methods of friction measurement and dene an International Runway •
Friction Index (IRFI) for worldwide use;
65
Thirty international organizations from 12 countries, including the United States, Canada, Japan,
Norway, France, Austria, Germany, Scotland, Sweden, and Switzerland, participated in this program.
Factual Information
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Establish an international methodology whereby a common indication of •
runway conditions could be established worldwide; and
Study the operational performance of aircraft on contaminated surfaces and •
establish a relationship with the harmonized IRFI.
In contrast to the CRFI, which used only DECs in measuring friction values, the
IRFI was designed to use readings from a variety of friction testing devices (DEC and
continuous friction measurement equipment [CFME] from multiple manufacturers). The
results of this study were incorporated into American Society for Testing and Materials
report 2100-02, “Standard Practice for Calculating the International Runway Friction
Index,” which prescribed methods for calculating the IRFI for winter surfaces and
produced a harmonized scale for expressing pavement friction characteristics, regardless
of the friction measurement equipment used. The IRFI obtained by using this practice has
not been extended to address the braking performance of an aircraft; therefore, no tables
of recommended landing distances based on the IRFI exist at this time.
Several FAA publications
66
indicate that the FAA does not believe that it is possible
to predict aircraft braking performance from MU values obtained from runway friction
surveys. Further, according to the FAA’s Aeronautical Information Manual, “no correlation
has been established between MU values and the descriptive terms ‘good,’ ‘fair,’ ‘poor,’
and ‘nil’ used in braking action reports.”
Previous Contaminated Runway-Related Safety Recommendations1.18.2.3
In 1982, the Safety Board conducted a special investigation to examine commercial
airplane operations on contaminated runways.
67
As a result of this investigation, the Board
issued several contaminated runway-related safety recommendations to the FAA. Safety
Recommendation A-82-152 asked that the FAA do the following:
Amend 14 CFR 139.31 and … 139.33 to require that airports certied under
14 CFR Part 139 and located in areas subject to snow or freezing precipitation
have an adequate snow removal plan, which includes criteria for closing,
inspecting, and clearing contaminated runways following receipt of “poor”
or “nil” braking action reports and to dene the maximum snow or slush
depth permissible for continued ight operations.
On November 18, 1987, the FAA issued Amendment 139-14 to Part 139, requiring
snow and ice control plans in ACMs at airports where snow and icing conditions regularly
occur. As a result of this action, the Safety Board classied Safety Recommendation
A-82-152 “Closed—Acceptable Action.”
66
These FAA publications include AC 150/5200-31A, CertAlert 95-06, CertAlert 05-01, and the FAA’s
Aeronautical Information Manual.
67
National Transportation Safety Board, Large Airplane Operations on Contaminated Runways, Special
Investigation Report NTSB/SIR-83/02 (Washington, DC: NTSB, 1983).
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Safety Recommendation A-82-155 asked that the FAA do the following:
Convene an industry-government group to develop standardized criteria
for pilot braking assessments and guidance for pilot braking action reports
for incorporation into pilot training programs and operations manuals.
The FAA formed the Joint Aviation/Industry Landing and Takeoff Performance
task group to review this recommendation, among others. The task group included
representatives from Aerospace Industries Association, Air Line Pilots Association, Air
Transport Association of America, Flight Safety Foundation, Inc., National Air Carrier
Association, Inc., and the Regional Airline Association. However, because the FAA
provided no evidence of progress in this area after 4 years, the Safety Board classied
Safety Recommendation A-82-155 “Closed—Unacceptable Action.”
Safety Recommendation A-82-168 asked that the FAA do the following:
In coordination with the National Aeronautics and Space Administration
[NASA], expand the current research program to evaluate runway friction
measuring devices which correlate friction measurements with airplane
stopping performance to examine the use of airplane systems such as
antiskid brake and inertial navigation systems to calculate and display in
the cockpit measurements of actual effective braking coefcients attained.
In a response letter dated April 1, 1983, the FAA indicated that it was working with
NASA to form a runway braking action test program. In a January 1984 letter, the FAA
indicated that it was involved with NASA in efforts to develop a method for obtaining
runway braking condition information with a more quantitative basis than subjective pilot
reports. However, in a May 5, 1987, letter, the FAA expressed concern that such a system
would encourage operations from a runway with a very low friction coefcient and,
further, that it would be of little value because of the differences in braking performance
between dissimilar aircraft models.
In response, the Safety Board stated that it did not believe that the FAA and NASA
had conducted sufcient research to conclude that objective measurements taken from
dissimilar airplanes would not be meaningful and that “such reports would be very
useful to airport operators as a means of detecting the degradation of runway conditions
in winter weather and would provide a basis upon which the pilots of large airplanes
could make better decisions.” Therefore, in April 1988, the Board classied Safety
Recommendation A-82-168 “Closed—Unacceptable Action.”
As a result of the December 20, 1995, accident involving a Tower Air 747 at John F.
Kennedy International Airport,
68
the Safety Board issued Safety Recommendation A-96-164,
which asked that the FAA do the following:
68
National Transportation Safety Board, Runway Departure During Attempted Takeoff, Tower Air
Flight 41, Boeing 747-136, N605FF, JFK International Airport, December 20, 1995. Aircraft Accident Report
NTSB/AAR-96-04 (Washington, DC: NTSB, 1996).
Factual Information
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Require the appropriate Aviation Rulemaking and Advisory Committee to
establish runway friction measurements that are operationally meaningful
to pilots and air carriers for their slippery runway operations (including
a table correlating friction values measured by various types of industry
equipment), and minimum coefcient of friction levels for specic airplane
types below which airplane operations will be suspended.
In its response, the FAA stated that it did not consider it technologically feasible
to establish runway friction measurements that were operationally meaningful to pilots
and air carriers for slippery runway operations. The FAA noted its participation in the
JWRFMP, which had a goal of developing the IRFI and correlating it with airplane stopping
capability. However, the FAA maintained that there were serious shortcomings in several
operationally signicant aspects of the IRFI standard, in addition to the historical record of
failures attempting to correlate ground friction measurements with airplane performance.
The FAA did not expect any new developments related to this recommendation.
In June 2002, the Safety Board responded that, although the FAA’s effort to develop
an operationally meaningful runway friction measurement tool was unsuccessful, it did
result in the development of an international standard for determining a runway friction
index. The Board also stated that proposed testing might yield more meaningful tools and
encouraged the FAA to continue its efforts in this area. However, the Board acknowledged
that the technology to convert the runway friction index into an operational tool did not
exist at the time and, therefore, classied Safety Recommendation A-96-164 “Closed—
Reconsidered.”
As a result of the June 1, 1999, accident involving an American Airlines MD-82
at Little Rock National Airport in Little Rock, Arkansas,
69
the Safety Board issued Safety
Recommendation A-01-54, which asked that the FAA do the following:
For all 14 CFR Part 121 and 135 operators, require the use of automatic
brakes, if available and operative, for landings during wet, slippery, or
high crosswind conditions, and verify that these operators include this
procedure in their ight manuals, checklists, and training programs.
On June 21, 2004, the FAA issued a notice (N8400.68) to its POIs, recommending
the use of autobrakes for landings in adverse conditions caused by weather and directing
POIs to convey the information in N8400.68 to their respective certicate holders. Because
issuance of this notice met the intent of the recommendation, the Safety Board classied
Safety Recommendation A-01-54 “Closed—Acceptable Alternate Action.” According to
SWA representatives, the company’s efforts to equip its airplanes with autobrakes and
develop and implement related procedures stemmed, in part, from these actions.
69
National Transportation Safety Board, Runway Overrun During Landing, American Airlines Flight 1420,
McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999. Aircraft Accident Report NTSB/
AAR-01-02 (Washington, DC: NTSB, 2001).
Factual Information
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Previous Runway Safety Area Safety Recommendations1.18.3
As a result of its investigation of the May 6, 2003, accident involving a Southwest
Airlines airplane that overran the end of the runway after landing at Burbank, California,
70
the Safety Board issued Safety Recommendations A-03-11 and -12, which addressed RSAs
and asked that the FAA do the following:
Require all 14 Code of Federal Regulations Part 139 certicated airports to
upgrade all runway safety areas that could, with feasible improvements,
be made to meet the minimum standards established by Advisory
Circular 150/5300-13. These upgrades should be made proactively, not
only as part of other runway improvement projects. (A-03-11)
Require all 14 Code of Federal Regulations Part 139 certicated airports to
install engineered materials arresting systems in each runway safety area
available for air carrier use that could not, with feasible improvements,
be made to meet the minimum standards established by Advisory
Circular 150/5300-13, “Airport Design.” The systems should be installed
proactively, not only as part of other runway improvement projects.
(A-03-12)
In an August 7, 2003, letter, the FAA indicated that it agreed with the intent of these
recommendations and stated that FAA Order 5200.8, “Runway Safety Area Program,”
established a program to bring all RSAs up to current standards, whenever possible.
The letter stated that the FAA’s goal was to upgrade 456 RSAs by 2007 and that such
improvements “may be initiated at any time.” The FAA stated that its goal was to upgrade
at least 65 RSAs per year through 2007 and that 71, 68, and 74 RSAs were upgraded in
scal years 2000, 2001, and 2002, respectively. The FAA also noted that eight EMAS beds
had already been installed and that several more installations were planned. The Board
asked the FAA to provide annual updates on RSAs that could not meet the standards and
the specic alternatives that would be used to improve the safety of these RSAs.
The issue of RSA improvements was discussed at the Safety Board’s June 2006
public hearing that was held for the accident involving SWA ight 1248. In response
to questioning during this hearing, FAA personnel indicated that, under current FAA
policy, it is possible that some RSAs will not meet the dimensional standards or have
arrester beds installed even after the FAA considers its improvement projects successfully
completed. In a July 7, 2006, letter, the FAA indicated that 208 RSA upgrades and 15 EMAS
installations had been completed though scal year 2005. The letter further stated that
more than 90 percent of the RSA upgrades would be completed by 2010, and all RSA
70
For additional information, see National Transportation Safety Board, Aircraft Accident Brief NTSB/
AAB-02/04 (Washington, DC: NTSB, 2002).
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upgrades would be completed by 2015. A recent update from FAA personnel indicated that
303 RSA improvement projects were completed. The update further indicated that 37 RSA
upgrades and 5 EMAS installations were completed in scal year 2006 and that 20 RSA
upgrades and 1 EMAS installation had been accomplished to date in scal year 2007.
Safety Recommendations A-03-11 and -12 are currently classied “Open—Acceptable
Response.”
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An A l y s i s2.
General2.1
The pilots were properly certicated and qualied under Federal regulations.
No evidence indicated any medical or behavioral conditions that might have adversely
affected their performance during the accident ight. There was no evidence of ight
crew fatigue.
The accident airplane was properly certicated and was equipped, maintained,
and dispatched in accordance with industry practices.
No evidence indicated any failure of the airplane’s powerplants, structures,
or systems that would have affected the airplane’s performance during the accident
landing.
71
The pilots received thorough weather information for MDW and two alternate
airport destinations in their dispatch documents and were well aware of the winter
weather conditions in the area. They obtained numerous weather updates while en route
from BWI to MDW and discussed conditions under which they would divert to one of the
alternate destinations. Therefore, the Safety Board concludes that the pilots had adequate
initial and updated weather information throughout the ight.
About 10 inches of snow accumulated at MDW on the day of the accident, and
snow was falling at a moderate rate at the time of the accident. However, the accident
runway had been recently cleared and treated with deice uid, and four other SWA 737-
700 airplanes landed and successfully stopped on runway 31C in the 21 minutes before
the accident.
72
On the basis of this information, the Safety Board concludes that MDW
personnel monitored runway conditions and provided appropriate snow removal services
on the night of the accident.
This analysis will discuss the ight crew’s decisions and actions, the clarity of
assumptions used in OPCs, company policies and guidance, arrival landing distance
assessments and safety margins, runway surface condition assessments and braking
action reports, airplane-based friction measurements, and RSAs.
71
Section 2.2.3 discusses the thrust reverser operation.
72
The pilots of another SWA ight, which would have arrived at MDW minutes before the accident ight,
elected to divert to an alternate airport because of airplane landing weight considerations.
Analysis
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Pilots’ Decision to Land, Knowledge, and Actions2.2
During its investigation, the Safety Board evaluated the pilots’ decision to land at
MDW and their actions during the approach and landing. Section 2.2.1 details the pilots’
use of braking action reports, which included mixed braking actions, during their arrival
landing distance assessments. Section 2.2.2 discusses the information displayed by the
OPC during the arrival landing distance assessment and the pilots’ awareness of the
underlying OPC assumptions. Section 2.2.3 explains the pilots’ use of autobrakes and
reverse thrust during the accident landing. Integral to these issues is the pilots’ awareness
of SWA guidance and policies relevant to their decision and actions during the accident
landing. These issues are addressed in this and subsequent sections.
Interpretation and Use of Mixed Braking Action Reports 2.2.1
As previously noted, the accident pilots were aware of the inclement weather in the
Chicago area before they left BWI and obtained updated weather information throughout
the ight. The Safety Board’s review of recorded CVR information indicated that weather,
landing performance assessments, landing criteria (including autobrake usage), and
suitable alternates dominated the crew’s conversation during the 2-hour ight.
Although not required by FAA regulations, SWA policies required the company’s
pilots to perform a landing distance calculation before the approach, using updated weather,
airplane conguration,
73
and runway conditions. On the basis of the most current ATIS
report for MDW, the accident pilots evaluated and discussed performance calculations
for both fair and poor reported braking conditions. Although the pilots’ calculations
resulted in positive stopping margins for both fair and poor braking conditions (560 and
40 feet, respectively), and company policy indicated that landing was authorized with
any positive stopping margin, the crew was concerned about the small positive stopping
margin with poor braking action. Information from the CVR and postaccident interviews
indicates that the pilots were also aware of a company policy for a maximum 5-knot
tailwind component with a reported braking action of poor. Updated wind information
resulted in a landing tailwind component of 8 knots. The pilots verbalized the decision
not to land if the braking action was reported as poor for the full length of the runway.
As the airplane neared MDW, air trafc controllers provided the accident pilots
with mixed runway 31C braking action reports. These reports indicated that the braking
action was good or fair for the rst half of runway 31C and poor for the second half. (The
Safety Board notes that the accident ight was cleared for the approach to runway 31C
because approach visibility requirements precluded approaches to all other MDW
runways on the night of the accident.) However, the MDW controller did not routinely
follow FAA procedures requiring controllers to include the type of airplane from which
the braking action reports were made; in this case, the reports were provided by the pilots
of several arriving 737s. Further, the controller did not provide the accident pilots with a
report obtained from the pilot of a smaller airplane that described the braking action as
73
For example, although the dispatch calculations were based on 30° of aps, the actual conguration
at the time of landing was 40° of aps.
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poor, as required. Therefore, the Safety Board concludes that the MDW ATCT controller
did not follow FAA guidance when he did not provide all of the required braking action
report information.
74
All of the braking action reports provided by ATC to the accident pilots were
mixed and reported poor braking action on some portion of the runway. For example, 8 to
9 minutes before touchdown, the pilots received a braking action report of “fair…except
at the end it’s poor,” and 3 minutes before touchdown they received a braking action
report of “good for the rst half, poor for the second half.” SWA policy requires pilots
to defer to the more critical braking action assessment when they receive mixed braking
action reports. Therefore, because “poor” braking conditions were reported for a portion
of the runway and SWA guidance indicates a maximum 5-knot tailwind to land if such
conditions are reported, the pilots should not have landed at MDW. The Safety Board
concludes that because the pilots did not use the more critical braking action term (poor)
during their landing distance assessment (which, combined with the associated tailwind
limitation, would have required them to divert), they were not in compliance with SWA’s
policies.
The pilots did not discuss interpretation of mixed runway condition reports,
although their behavior and other discussion suggests that they interpreted the runway
condition as closer to fair than poor. They stated during postaccident interviews (and CVR
evidence indicates) that they were not aware of SWA’s guidance regarding mixed braking
action reports. On the day of the accident, three preceding company aircraft (same make,
model, policies, and procedures) landed with braking action reports containing the term
poor and with similar wind conditions. Based on this and information obtained from
postaccident interviews, it appears that other SWA pilots also were not aware of the mixed
braking action report guidance in the FOM or did not adhere to it. The fact that other SWA
pilots decided to land at MDW in these conditions likely inuenced the accident pilots’
decision to land; the accident pilots were less likely to consider their decision to land as
contrary to company guidance if other SWA crews landed in similar conditions.
SWA guidance regarding how to provide a braking action report includes an
example of a mixed condition report, indicating that mixed conditions were not unexpected
during routine operations. However, the Safety Board’s review of SWA training materials
revealed that the topic of mixed conditions was not routinely introduced to pilots during
training and was absent in the FOM for the topics of braking action and runway friction
reports, entering runway condition into the OPC, and programming the OPC for landing,
all of which dened the runway condition categories.
The Safety Board notes that, after this accident, SWA amended the wording in its
FOM to clarify its policy regarding mixed braking action reports and provided its pilots
with additional training specic to braking action reports, including mixed conditions.
74
The inuence this information would have had on the pilots’ decision to land is unknown, although it is
unlikely that it would have led them to divert. SWA guidance species that its pilots should use braking action
information provided by “other commercial airplanes (emphasis added).” Also, the accident pilots were aware
that several of the airplanes preceding them to MDW, and from which braking action reports were obtained,
were commercial airplanes (including several SWA 737s).
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On Board Performance Computer Displays and Underlying 2.2.2
Assumptions
The Safety Board evaluated the clarity of the information displayed to the pilots
on the SWA OPC and the underlying assumptions (including reverse thrust credit) upon
which the resultant landing distance assessments were based. Pilots use a variety of aids
to accomplish airplane performance calculations, including tabular performance charts.
The information on tabular charts is designed to be clear and readily available;
75
however,
pilots must survey rows and columns and select the most appropriate value, apply
required adjustments, and sometimes interpolate between listed values. SWA provides its
pilots with an OPC for such calculations. Using an OPC or similar electronic computing
device instead of tabular charts can decrease the pilots’ workload because the computing
device can automatically apply adjustments and interpolate based on the operator’s
programming. However, if pilots misunderstand the output because they are unaware of
critical performance calculation assumptions, use of an electronic computing device can
lead to errors in decision-making.
For example, as the accident pilots neared MDW, they used the OPC to calculate
the airplane’s landing distance multiple times, assessing updated weather conditions and
stopping margins on runway 31C under both fair and poor braking action conditions.
All of the resultant OPC calculations indicated that they could land and stop the airplane
in the available runway length. The OPC indicated a stopping margin of about 560 feet
before the end of the runway for fair braking action and about 40 feet before the end of the
runway for poor braking action. However, evidence indicates that the landing distances
displayed on the OPC could have been misleading to the crew because the pilots were
not aware of at least two underlying OPC assumptions, neither of which was displayed
on the OPC. Both of these assumptions resulted in OPC indications showing larger (more
favorable) stopping margins.
One OPC assumption that the accident pilots were not aware of was that stopping
margins displayed by the OPC for poor runway conditions were in some cases based
on a lower tailwind component than that which was presented. Typically, the stopping
margin output corresponded to the presented tailwind component. However, the tailwind
component exceeded the 5-knot limit for poor runway conditions, but the displayed
stopping margin was instead based on the tailwind limit of 5 knots, not the actual 8-knot
tailwind component, as entered by the ight crew. Although in these cases the actual
tailwind component is highlighted with white text on a red background, and the tailwind
component limits are presented at the bottom of the display in white text on a black
background, there is no indication that the stopping margin is not based on the presented
tailwind component.
75
Tabular charts present critical information and assumptions through notations either directly on the
applicable chart or on an introductory overview page.
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For the accident landing, the OPC-calculated stopping margin of 40 feet for poor
runway braking action was based on the company-programmed 5-knot tailwind component
limit, despite the fact that the display showed the actual 8-knot tailwind component
based on the winds input by the pilots. Calculations based on the 5-knot tailwind limit
resulted in more favorable displayed stopping margins. If the OPC calculations had been
based on the actual 8-knot tailwind component, the stopping margin would have been
-260 feet (or 260 feet beyond the departure end of the runway), indicating that there was
not enough runway available to land with poor braking action. This information would
have provided the pilots with a more conservative and realistic indication of the expected
landing performance. To highlight negative stopping margin values and to alert pilots
that it is not safe to land on a particular runway, SWA’s OPC uses alternate graphics and
the color red on the display.
76
CVR and postaccident interview evidence indicated that
both pilots were uncomfortable with the low positive stopping margins exhibited by the
OPC. Had a negative stopping margin been shown and highlighted on the OPC display,
the pilots would have been further alerted to the potential hazards involved in a landing
on runway 31C at MDW under the accident conditions.
The accident pilots were also not aware that the 737 stopping margins computed by
the SWA OPC were designed to incorporate the use of reverse thrust for the 737-700 model
only,
77
which resulted in more favorable stopping margins. Postaccident interviews with
SWA pilots indicated that some (including the accident crew) assumed that none of the
737 OPC landing distance calculations took into account the use of reverse thrust. Because
of this, the accident pilots believed that their intended use of reverse thrust during the
landing roll would provide them with several hundred feet more stopping margin than
the OPC estimated.
A review of SWA guidance and training regarding the OPC revealed one reference
regarding wind calculation assumptions in the FRM. However, no related information was
provided in the FOM, and no slides were devoted to this topic during initial, recurrent, or
OPC-related ground training. This review also revealed that although pilots were taught
that thrust reverser use was assumed for the -700 and not for the -300 or -500 models
during “differences” training when qualifying for the -700 model, SWA’s FOM guidance
on OPC assumptions regarding the use of reverse thrust was inconsistent and may have
been misleading to pilots. Until 1 week before the accident, information was incorrect
in two of three locations in the FOM, stating that reverse thrust was not included in the
landing distance calculations.78 Interviews with SWA pilots indicated that they were not
uniformly aware of this and other landing distance assumptions, such as air distance.
79
76
Negative values are presented in brackets as white digits inside of a red block instead of the standard
black digits against a white background.
77
SWA pilots were type-rated in one of three 737 models owned by SWA (-300/-500/-700), but were
expected to y all three 737 models. Therefore, they had to be aware of differences between the models, as
they switched between these models on a day-by-day or ight-by-ight basis.
78
At the time of the accident, the information was correct in two of the three FOM locations.
79
Air distance is the distance allowance from the threshold crossing point at 50 feet agl to the estimated
touchdown point, upon which the landing performance calculations are based.
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Therefore, the Safety Board concludes that if the pilots had been presented with
stopping margins associated with the input winds or had known that the stopping
margins calculated by the OPC for the 737-700 already assumed credit for the use of thrust
reversers, the pilots may have elected to divert.
Another OPC-programming factor observed by the Safety Board is that the
airplane performance data programmed into the OPC by SWA was less conservative than
the airplane performance data recommended by Boeing for braking action reports worse
than good; this resulted in more favorable displayed stopping margins. Calculations
performed using the Boeing-recommended data for a landing on runway 31C and the
actual tailwind component of 8 knots showed that the airplane would require a longer
landing distance than available under both fair and poor braking action conditions (an
additional 260 and 2,070 feet beyond the departure end of the runway, respectively).
80
The
Safety Board concludes that if Boeing’s recommended airplane performance data were
used in SWA’s OPC calculations, the resulting negative stopping margins for even fair
braking action conditions would have required the pilots to divert.
After this accident, SWA redesigned its arrival landing distance performance
calculations to consistently reect the assumption of two-engine reverse thrust and
revised its OPC display to show the reverse thrust level assumed based on the conditions.
Additionally, SWA modied its OPC display to consistently present output associated
with the actual tailwind component. When the tailwind component exceeds authorized
limits for landing (5 knots for poor braking action, 10 knots for good or fair braking
action) a numeric stopping margin value is not presented. Finally, SWA amended its FOM
guidance and policies regarding OPC reverse thrust assumptions to ensure consistency
and to clarify the assumption of reverse thrust use across all 737 models. In response to
this accident, the FAA issued SAFO 06012 to all turbojet operators, encouraging them to
require pilots to perform arrival landing assessments if the weather conditions, runway,
or airplane landing conguration has changed since the dispatch calculation and to train
pilots regarding all aspects and assumptions used in these assessments. However, the
Safety Board notes that operators are not required to comply with FAA guidance material
such as this SAFO.
81
FAA advisory material regarding electronic ight performance calculations
82
suggests that the output be displayed in a manner that is understood easily and accurately
and that users of such devices should be aware of any assumptions upon which the ight
performance calculations are based. There is no specic guidance suggesting that these
assumptions be as clear to pilots as similar information would be on a tabular chart,
however. Such clarity is critical because airplane performance data and related OPC
assumptions are not consistent across manufacturers, airplane models, or operators
80
As previously mentioned, SWA’s OPC display would have alerted the pilots to these negative stopping
margin values by presenting the numbers as bracketed white digits inside a red block instead of the standard
black digits against a white background.
81
Although not required by the FAA, SWA did require its pilots to conduct arrival landing distance
assessments at the time of the accident.
82
There are currently no requirements for the design and certication of airplane OPCs; all current
guidance is advisory in nature.
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and may be based on information other than what the pilots entered. In the case of the
accident ight, the SWA OPC screen did not display OPC assumptions (for example, the
thrust reverser credit assumptions) when they were applicable; this information would
have been readily available on a tabular chart. Therefore, the Safety Board concludes that
presentation of the OPC assumptions upon which landing distance calculations are based
is critical to a pilot’s decision to land. Therefore, the Safety Board believes that the FAA
should require all 14 CFR Part 121 and 135 operators to ensure that all on board electronic
computing devices they use automatically and clearly display critical performance
calculation assumptions.
As a result of its evaluation of the accident pilots’ decision to land and their actions
during the approach and landing, the Safety Board determined that if the pilots had been
aware of existing company guidance and policies in several areas, including runway
braking action reports and the underlying assumptions factored into OPC stopping
margin calculations, they would have made a better-informed landing decision. Accident
evidence indicated that other SWA pilots were similarly unaware of SWA’s guidance and
policies in these areas. Therefore, the Safety Board concludes that SWA did not provide
its pilots with clear and consistent guidance and training regarding company policies and
procedures in several areas, including interpretation of braking action reports and the
assumptions affecting landing distance assessments. Therefore, the Safety Board believes
that the FAA should require all 14 CFR 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.
Thrust Reverser Usage and Autobrakes 2.2.3
According to SWA procedures, the ying pilot was required to deploy the thrust
reversers as soon as possible after nosewheel touchdown for all landings. SWA guidance
especially emphasized immediate deployment of reverse thrust when braking actions
were reported to be less than good. The accident pilots reported that they were aware of
the company’s reverse thrust policies and routinely carried them out; however, for the
accident landing, the captain (the ying pilot) did not deploy reverse thrust immediately
after the airplane touched down. During postaccident interviews, the captain stated that he
tried to deploy the thrust reversers promptly after touchdown but was not successful. SWA
procedures also required the monitoring pilot to be attentive for procedural deviations
during all landings. The rst ofcer stated that, when he realized that the captain had
not deployed the thrust reversers, he moved the thrust levers to command reverse thrust
(thrust reverser activation was initiated about 15 seconds after touchdown according to
FDR data). FDR data indicated that the thrust reversers were eventually fully deployed
about 18 seconds after touchdown, and the pilots held maximum reverse thrust until the
airplane came to a stop off the end of the runway.
The Safety Board’s review of FDR data from four SWA 737s that landed and came
to a stop on runway 31C at MDW during the 21 minutes before the accident indicated
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that reverse thrust on these airplanes was deployed promptly after landing. Postaccident
calculations showed that, if the pilots had promptly initiated and maintained maximum
reverse thrust throughout the landing roll, the airplane would not have run off the end
of the runway. Therefore, the Safety Board concludes that the pilots would have been
able to stop the airplane on the runway if they had commanded maximum reverse thrust
promptly after touchdown and maintained maximum reverse thrust to a full stop.
Despite the captain’s reported difculties in his initial attempt to deploy the thrust
reversers, they extended normally in a coordinated manner for the rst ofcer. The captain’s
seat position was the same as he routinely used, and the CVR recorded no comments or
utterances indicating that the pilots were having difculty with the thrust reverser levers.
Further, postaccident examination of the throttle quadrant and reverse thrust systems
provided no evidence of mechanical irregularity or failure; the levers were in a position to
be deployed at any time during the landing rollout. In addition, postaccident interviews
with other SWA pilots indicated that most had not experienced any difculty deploying
the thrust reversers, nor had they heard of others doing so, aside from occasionally not
waiting long enough at the interlock position. Any difculties that were described by
SWA pilots were reportedly resolved immediately upon second attempt.
83
Finally, the
pilots who had own the accident airplane for the 10 ights before the accident reported
experiencing no difculties in deploying the thrust reversers in that airplane. Therefore, the
Safety Board concludes that the pilots’ delay in deploying the thrust reversers cannot be
attributed to mechanical or physical difculties.
SWA planned to implement a new policy the week after the accident that would
have required the use of autobrakes during landings under some conditions, including the
accident landing conditions.
84
In preparation, SWA provided its pilots with a self-study
training module on the system and related procedures. Despite having completed the
training module, neither of the accident pilots had previous operational experience with
autobrakes. Information from the CVR indicates that although both pilots expressed
concern, the captain, in particular, was hesitant to use the autobrakes for the rst time in the
weather and runway conditions that existed for the accident landing. The pilots discussed
possible contingencies (for example, autobrake failure, loss of directional control, and
reversion to manual braking). They ultimately agreed that use of the autobrakes would
allow them to stop in the shortest distance and used the autobrakes on maximum setting
during the accident landing.
Use of autobrakes when landing on short or slippery runways required a change
in the sequence of landing tasks for both the ying pilot and the monitoring pilot. Before
83
A review of ASRS data revealed no history of difculty in deploying the thrust reversers for the
Boeing 737 series airplanes.
84
In part, SWA developed this new policy because of FAA guidance resulting from a Safety Board
recommendation (A-01-54). The company issued a series of autobrake-related bulletins, some of which
estimated policy implementation dates. The most recent bulletin, issued by SWA the morning before the
accident, indicated that required autobrake usage would begin 4 days later (on December 12); however, the
accident pilots mistakenly believed that the company’s autobrakes policy was already effective the day of the
accident. At the time of the accident, the cockpit checklists and the pilots’ FOM guidance had already been
updated to reect the new autobrake procedures. Had this new policy been in effect at the time of the accident,
the pilots would have been required to use the maximum autobrake setting for that landing.
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SWA’s new autobrakes procedures took effect, procedures required the ying pilot to
manually apply wheel brakes and deploy the thrust reversers simultaneously as soon as
possible after touchdown. However, with the use of autobrakes, only one of these two
tasks was required at touchdown; the prompt manual application of wheel brakes was
no longer necessary. Research indicates that carrying out new procedures requires more
effort and cognitive resources than does carrying out routine procedures and limits the
number of tasks that can be carried out simultaneously.
85
Because of the pilots’ concerns
regarding the autobrakes and their unfamiliarity with the system’s operation, it would
have been natural for them to focus on the autobrake system’s performance after the
airplane touched down.
During postaccident interviews, both pilots reported that they were preoccupied
by the autobrake system during the accident landing. The captain reported that his focus
on the autobrake system performance distracted him from trying to deploy the thrust
reversers again after his rst attempt was unsuccessful. The rst ofcer had the additional
task of monitoring the autobrakes light on the front instrument panel during the landing
rollout, although he reported that he maintained his focus outside of the cockpit and on
their stopping performance. Research also indicates that activities that have been grouped
together in an automatic task sequence require substantial effort to separate.
86
In this case,
applying the wheel brakes would normally be accomplished with deployment of the
thrust reversers, and omitting one of these linked activities (wheel brakes) could help
explain omission of the other (thrust reversers). The pilots stated that, as the landing roll
continued, they were not satised with the airplane’s deceleration, and FDR data indicated
that, about 12 seconds after touchdown, they transitioned from autobrakes to maximum
manual wheel braking. FDR data indicated that the thrust reversers deployment was
initiated 15 seconds after touchdown, with full thrust reverser deployment occurring
18 seconds after touchdown.
According to postaccident interviews with SWA personnel, similar distractions
were observed in SWA pilots during the development of the company’s autobrake program.
SWA check airmen and their rst ofcers reported concern prior to use and difculty with
the transition from using autobrakes to manual braking after touchdown; some were so
distracted that they delayed reverse thrust application. Pilots also indicated that these
challenges persisted for the rst few landings only, until they had the chance to acclimate
to the new procedures. At the time of the accident, SWA’s planned implementation of
its autobrakes procedures did not include a familiarization period with the use of the
85
See (a) S. Shiffrin and W. Schneider, “Controlled and Automatic Human Information Processing: II.
Perceptual Learning, Automatic Attending and a General Theory,” Psychological Review, vol. 84, no. 2,
pages 127-190, 1977; (b) G. Logan, “Toward an Instance Theory of Automatization,” Psychological Review,
vol. 95, no. 4, pages 492-527, 1988; and (c) G. Logan and W.B. Cowan, “On the Ability to Inhibit Thought and
Action: A Theory of an Act of Control,” Psychological Review, vol. 91, no. 3, pages 295-327, 1984.
86
See G. Logan, “On the Ability to Inhibit Complex Movements: A Stop-Signal Study of Typewriting,”
Journal of Experimental Psychology: Human Perception and Performance, vol. 8, no. 6, pages 778-792,
1982.
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autobrakes,
87
nor was one required by regulations.
88
However, feedback from other SWA
pilots should have alerted SWA management and the company’s FAA POI to the need for
a familiarization or transition period.
The Safety Board concludes that the pilots’ rst use of the airplane’s autobrake
system during a challenging landing situation led to the pilots’ distraction from the
otherwise routine task of deploying the thrust reversers promptly after touchdown. Had
SWA implemented an autobrake familiarization period in advance, such a period would
have allowed pilots to become comfortable with the changed sequence of landing tasks.
The Safety Board further concludes that the implementation of procedures requiring
thrust reverser status conrmation immediately after touchdown may prevent pilots
from inadvertent failure to deploy the thrust reversers after touchdown. Therefore, the
Safety Board believes that the FAA should require all Part 121 and 135 operators of
thrust reverser-equipped airplanes to incorporate a procedure requiring the non-ying
(monitoring) pilot to check and conrm the thrust reverser status immediately after
touchdown on all landings.
The Safety Board notes that the timing and nature of this autobrake policy change
was specic to SWA, based on its operation of a eet of only one model airplane (the 737)
and the company’s desire to implement the policy simultaneously throughout that eet.
After this accident, the company voluntarily amended its autobrake policy and training
program, delaying the implementation date and requiring a familiarization period,
which allowed SWA pilots to rst use the autobrakes in good conditions and with large
stopping margins.
89
In addition, SWA provided its pilots with specic instructions that the
monitoring pilot was to monitor the reverse thrust levers during the landing sequence and
to make a specic callout in the event of deviation from SWA reverse thrust procedures.
Landing Distance Assessments 2.3
Preight landing distance calculations (assessments) are required by Federal
regulation while arrival landing distance calculations (assessments) are not. This section
discusses the differences between preight and arrival landing distance calculations
and evaluates the need for both. This section also discusses related content in the FAA’s
proposed OpSpec, recent SAFO, and observed industry landing distance practices.
87
SWA had not initially planned to implement the new autobrake policy during the winter; however,
delays associated with other procedures implemented simultaneously delayed the autobrake implementation
date.
88
The FAA POI approved the SWA autobrakes policy in accordance with Federal regulations and
guidelines. Guidance for POIs when reviewing these types of changes is general but requires the POI to
consider the impact of such changes and the best training method suitable to the change.
89
Pilots were required to use autobrakes under certain conditions only after they completed at least four
familiarization landings on dry runways with ample safety margins. Even under these circumstances, there
were reported instances of pilot failure to immediately deploy the thrust reverse during initial landings with use
of autobrakes.
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Preight and Arrival Landing Distance Calculations/2.3.1
Assessments
The FAA requires Part 121 operators to perform preight landing distance
calculations before they depart on a ight, in part, to determine the maximum takeoff
weight at which the airplane can depart, travel to the destination, and safely land on the
available landing distance at the destination and/or alternate airport. Although preight
landing distance assessments are standardized by Federal regulations, the assessments
do not attempt to comprehensively account for the actual conditions, conguration, and
pilot techniques that exist and/or occur at the time of arrival.
90
The manufacturer’s ight
test data upon which these calculations are based are primarily accumulated during
demonstrated landings on a dry, smooth, hard-surfaced runway without the effects of
reverse thrust. To account for variations in landing conditions, pilot techniques, and other
operational uncertainties, the FAA requires operators to factor in a signicant safety
margin in excess of the demonstrated landing distance during their preight landing
distance assessments.
91
The Safety Board’s review of SWA dispatch documents for the
accident ight indicated that, based on preight calculations, the accident airplane was
legal to depart BWI intending to land at MDW.
Arrival landing distance assessments assist pilots in ensuring that they will
be able to land the airplane and safely stop on the intended runway given the arrival
weather and runway surface conditions and the planned airplane conguration, landing
technique, and use of deceleration devices. Like preight landing distance calculations,
arrival landing distance calculations/assessments are typically developed by an operator
or contractor based on data provided by the manufacturer. However, unlike the preight
data, specic FAA approval is not required for the data used by operators in their arrival
landing distance assessments because those assessments are not required.
Although the FAA does not require operators to perform arrival landing distance
assessments, many Part 121 operators (including SWA) do require their pilots to perform
landing distance assessments before every landing. However, because the FAA does not
require or standardize arrival assessments as it does preight assessments, operators are
allowed to set their own policies and use data from various sources (for example, the
manufacturer, in-house personnel, an outside contractor, etc.). Depending on the source,
the data used may be less conservative than the manufacturer’s data and may contain
embedded assumptions related to landing and deceleration techniques, the airplane’s
braking ability for a given runway surface condition report, and/or the application of
additional safety margins. If pilots are unaware of these embedded assumptions, they
might believe that they need less landing distance than they actually do or have an
inaccurate perception of how much braking effort will be needed on landing. Depending on
an operator’s policies, pilots may not be required to conduct arrival landing assessments;
may conduct such assessments based on variable landing performance data sources,
90
Preight landing distance calculations are based on conditions that are forecast for the destination at
time of landing.
91
The FAA requires operators to factor safety margins of 67 and 92 percent (for dry and wet/slippery
runways, respectively) into their preight landing distance calculations.
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assumptions, and calculation methods; or may conduct such assessments based on data
that include no additional safety margin.
SWA required its pilots to perform arrival landing distance assessments for each
landing and developed a system, primarily based on Boeing’s performance data, to account
for actual conditions and planned procedures/techniques. However, FAA personnel did
not approve the data or calculation methods developed by SWA. The resultant system
used data that were less conservative than Boeing recommended for braking reports worse
than good. Although SWA and FAA personnel were aware that actual arrival conditions
cannot be perfectly dened, planned procedures cannot always be accomplished, and
the resultant variations will not always yield a conservative safety margin, the data
programmed into SWA’s OPC did not account for reasonable operational variations. This
is of particular concern because SWA’s policies at the time of the accident and its new
autobrake policy authorize landing with even the smallest of positive calculated stopping
margins.
The Safety Board notes that, although not required by the FAA, SWA’s arrival
landing distance assessment practices exceeded those of many other operators; yet,
the safety margin was inadequate to prevent this accident. The Safety Board notes that
preight safety margins alone may not be sufcient to ensure adequate stopping margins
at arrival. This investigation has shown that an arrival landing distance assessment should
be conducted before arrival and should incorporate the following six basic components:
Approved aerodynamic performance data obtained from demonstrated ight •
test landings;
A set of dened operational procedures and assumptions (for example, •
touchdown at 1,500 feet, reverse thrust deployment promptly after touchdown,
etc.);
Actual arrival condition data (weather, airplane conguration, runway surface •
condition, etc.);
A physics-based method for calculating airplane performance;•
A minimum acceptable standard for correlating the airplane’s braking ability •
to the runway surface condition; and
A minimum acceptable safety margin/factor that accounts for reasonable •
operational variations and uncertainties.
At the time of the accident, SWA had incorporated the rst four components into
their arrival landing distance assessments and prescribed the fth component. After the
accident, SWA incorporated the sixth component by adding an additional 15 percent
safety margin to account for operational variations and uncertainties into its arrival
landing distance assessments.
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Safety Alert for Operators Discussion and Industry Practice 2.3.2
Regarding Landing Distance Assessments
As previously noted, although the FAA is on record as advocating arrival landing
distance assessments, there is currently no requirement, FAA-approved data, minimum
correlation standards, or minimum safety margin for such assessments. As a result,
operators remain free to choose whether and how they perform such assessments.
As a result of the SWA ight 1248 accident, the Safety Board issued urgent
Safety Recommendation A-06-16, which asked the FAA to prohibit all 14 CFR Part 121
operators from using reverse thrust credit in landing performance calculations. The
stated intent of this recommendation was to ensure adequate landing safety margins on
contaminated runways. In response, in June 2006, the FAA issued an advance notice of its
intent to issue mandatory OpSpec N 8400.C082, which would have required all Part 121,
135, and 91 subpart K turbojet operators to conduct landing performance assessments
(not necessarily a specic calculation) before every arrival based, in part, on planned
touchdown point, procedures and data at least as conservative as the manufacturer’s,
updated wind and runway conditions, and an additional 15 percent safety margin.
However, the FAA subsequently decided not to issue the mandatory OpSpec at that time
and, in August 2006, published SAFO 06012 as an interim guidance measure. SAFO 06012
addressed similar issues to the mandatory OpSpec, but operator compliance with the
SAFO is, by denition, voluntary. Although the FAA published SAFO 06012 with the
intent of pursuing rulemaking in the area of landing distance assessments, in the interim,
operators are still not required to comply with its recommendations and, currently, many
operators do not.
For example, on February 18, 2007, a Shuttle America Embraer ERJ-170 ran off
the end of snow-contaminated runway 28 at Cleveland Hopkins International Airport,
Cleveland, Ohio.
92
The investigation to date has revealed that Shuttle America did not
require its pilots to perform (and therefore did not incorporate landing distance safety
margins into) arrival landing distance assessments. About 2 months later, a Pinnacle
Airlines Bombardier Regional Jet CL600-2B19 ran off the end of snow-covered runway 28
at Cherry Capital Airport in Traverse City, Michigan.
93
By contrast, the investigation into
this accident showed that Pinnacle’s OpSpecs required its pilots to perform arrival landing
distance assessments (including a minimum 15 percent safety margin) per SAFO 06012;
94
however, the pilots did not perform the required assessment before the accident landing. If
an arrival landing distance assessment had been performed, given the existing conditions,
Pinnacle’s OpSpecs would have dictated that a diversion was required.
92
This accident investigation is ongoing at the time of this writing. Additional information about this
accident, CHI07MA072, is available on the Safety Board’s Web site at <http://www.ntsb.gov/ntsb/query.asp>.
93
More information on this accident, DCA07FA037, is available on the Safety Board’s Web site at <http://
www.ntsb.gov/ntsb/query.asp>.
94
The OpSpec developed by Pinnacle and approved by the FAA required pilots to perform arrival
landing distance calculations taking into account actual runway conditions, expected deceleration means, and
airplane conguration, and including a minimum safety margin of 15 percent when landing on a contaminated
runway.
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The Safety Board is concerned that, because of operational and conditional
variations, it is possible for an airplane to use more of the landing runway than preight
(dispatch) calculations predicted and for pilots to continue to run off the end of contaminated
runways. During a January 2007 meeting, Safety Board, FAA, Boeing, SWA, and SWAPA
personnel discussed landing distance assessment and runway surface condition issues.
A subsequent Boeing document recommended that operators develop arrival landing
distance assessment procedures for their ight crews to use to better ensure that a full-stop
landing can be made on the arrival runway in the conditions existing at the time of arrival
(weather and runway) and with the deceleration means and airplane conguration to be
used, consistent with SAFO 06012. The circumstances of the ight 1248 accident (among
others) demonstrate that conditions
95
can change between dispatch and arrival and that
there is a safety benet to landing distance assessments at both times.
The Safety Board notes that the FAA concluded in SAFO 06012 that operator
compliance with preight landing distance planning requirements alone “does not
ensure that the airplane can safely land within the distance available on the runway in
the conditions that exist at the time of arrival, particularly if the runway, runway surface
condition, meteorological conditions, airplane conguration, airplane weight, or use of
airplane ground deceleration devices is different than that used in the preight calculation.”
In addition, the FAA stated that “a landing distance assessment should be made under the
conditions existing at the time of arrival in order to support a determination of whether
conditions exist that may affect the safety of the ight and whether operations should be
restricted or suspended.”
Landing Distance Assessments Summary 2.3.3
Existing FAA regulations do not specify either the type of arrival landing distance
assessment that should be performed or specify a safety margin that should be applied.
The FAA-advocated minimum safety margin of 15 percent for arrival landing distance
assessments published in SAFO 06012 is based on historic links to the FAA-mandated
additional 15 percent factor for wet/slippery preight planning requirements and
the 15 percent factor embedded in the EASA and JAA operational requirements for
contaminated runway landing performance. Although during public hearing testimony
the FAA stated that the 15 percent landing safety margin has not been substantiated by a
specic data collection and evaluation effort, the Safety Board is convinced that a dened
landing safety margin is necessary for air carrier operations on contaminated runways.
The Board was encouraged when the FAA proposed OpSpec N 8400.C082, which would
have required operators of transport-category airplanes to incorporate a 15 percent
safety margin in arrival landing distance calculations. The proposed 15 percent safety
margin identied in FAA OpSpec N 8400.C082 would have satised the intent of Safety
Recommendation A-06-16. However, the FAA subsequently sought voluntary operator
implementation of such actions through SAFO 06012; although SAFO 06012 contains
95
For example, between SWA ight 1248’s dispatch from BWI and its arrival at MDW, the airplane’s
landing conditions were affected by many factors, including continuing snowfall, the timing of runway clearing
operations, and an updated landing weight.
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similar information to OpSpec N 8400.C082, compliance with the SAFO is not required by
the FAA.
96
Because the FAA has not required actions to address the Board’s urgent safety
recommendation, ight crews of transport-category airplanes may still be permitted to
land in wet, slippery, or contaminated runway conditions, without performing arrival
landing distance assessments that incorporate adequate safety margins. As another winter
season approaches, the urgent need for such margins becomes more critical. The Safety
Board concludes that because landing conditions may change during a ight, preight
landing assessments alone may not be sufcient to ensure safe stopping margins at the
time of arrival; arrival landing distance assessments would provide pilots with more
accurate information regarding the safety of landings under arrival conditions. Further,
the Safety Board concludes that although landing distance assessments incorporating a
landing distance safety margin are not required by regulation, they are critical to safe
operation of transport-category airplanes on contaminated runways. Therefore, the Safety
Board believes that the FAA should require all 14 CFR 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 airplane’s braking ability with runway
surface conditions using the most conservative interpretation available, and including
a minimum safety margin of 15 percent. The Board recognizes that development of such
a standardized methodology will take time. Therefore, the Safety Board further believes
that, until a standardized methodology as described in the previous recommendation
can be developed, the FAA should immediately require all 14 CFR 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. Because the objectives of this recommendation and Safety
Recommendation A-06-16 are identical, the Safety Board classies A-06-16 “Closed—
Unacceptable Action/Superceded.” Because the FAA has had adequate time to require
landing distance assessments and implement a landing distance safety margin, but has not,
A-06-16 was classied “Open—Unacceptable Response” on May 8, 2007. The superceding
safety recommendation will maintain the status of “Open—Unacceptable Response.”
96
The Safety Board is currently investigating two more recent runway overruns involving air carrier
operators landing on snow-contaminated runways; landing distance calculations were not conducted in either
of these cases.
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Runway Surface Condition Assessments2.4
The Safety Board has long been concerned about runway surface condition
assessment issues.
97
During this investigation, the Safety Board reevaluated the three
methods currently used to assess a runway’s surface condition before landing: 1) pilot
braking action reports, 2) runway contaminant type and depth observations, and
3) ground surface vehicle friction measurements. The Board notes that all three methods
have limitations and that, regardless of the method used, runway surface conditions may
vary over time because of changes in precipitation, accumulation, trafc, direct sunlight,
temperature, or as a result of runway maintenance/treatment. The Board further notes
that no standardized and universally accepted correlation exists to dene the relationship
between the runway surface condition (using any of the three runway surface assessment
methods) and an airplane’s braking ability.
This section discusses the accuracy and limitations associated with each method
of runway surface condition assessment. Pilot braking action reports, contaminant type
and depth reports, and airport runway surface friction measuring devices are discussed
in sections 2.4.1, 2.4.2, and 2.4.3, respectively. Runway surface condition assessments are
summarized in section 2.4.4, and correlating runway surface condition to airplane landing
performance/braking ability is discussed in section 2.4.5.
Braking Action Reports2.4.1
Pilot braking action reports are commonly used by arriving pilots to predict landing
runway conditions. However, Safety Board safety recommendation communications,
public hearing testimony, and ight 1248 accident evidence indicate that pilot braking
action reports are subjective and can vary signicantly depending on the reporting pilot’s
experience level and the type of airplane in use.
The FAA has frequently acknowledged (most recently in SAFO 06012) that pilot
braking action reports are subjective and reect individual pilot expectations, perceptions,
and experiences. Further, braking action reports are sensitive to airplane type and the
actual deceleration methods used to slow or stop the airplane. In addition, an arriving
pilot may have to interpret mixed pilot braking action reports (for example, fair-to-
poor braking action reported on a landing runway) or conicting runway condition
97
In 1983, the Safety Board issued a special investigation report titled, Large Airplane Operations on
Contaminated Runways, which recommended that research be conducted to identify reliable and consistent
methods for determining runway conditions. Although several industry working groups have convened to
address this issue, no consensus has been reached to date regarding the preferred method for doing so, and
no signicant advances have been developed to eliminate the subjectivity or minimize the variances between
reports. In addition, there is no standardized correlation between pilot braking action reports and runway
contaminant type and depth, nor is there an internationally recognized and standardized terminology for braking
action reports or contaminant type and depth reports. The Board classied Safety Recommendation A-82-155,
“Closed—Unacceptable Action.”
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reports (for example, a pilot braking action report that conicts with a runway friction
measurement).
98
In SAFO 06012, the FAA dened a reliable braking action report as a braking action
report submitted from a turbojet airplane with landing performance capabilities similar
to those of the airplane being operated. The FAA recommends in the SAFO that pilots
should use all available information and make decisions based on experience and sound
judgment; however, the FAA has not yet provided standardized procedures or specic
criteria for pilots to use in the development and delivery of braking action reports.
99
Since this accident, the FAA has hosted an industry workshop that attempted to
address this issue. A mid-2006 industry working group produced guidance regarding
runway surface condition assessments that has since been disseminated to all operators of
Boeing turbojet airplanes in an August 2007 bulletin. SWA is incorporating the working
group guidance into its materials and training and plans to publish related revisions in
October 2007 (see gure 6).
100
Contaminant Type and Depth 2.4.2
A eld report or observation of the type and depth of contaminant on the runway,
typically conducted by airport personnel, may also be used to assess the runway surface
condition. However, these observations may also be subjective and dependent on the
observer’s experience and vantage point, the timing of the observation, and rapidly
changing conditions. The FAA has not established and dened a standard correlation
between an airplane’s braking ability and reports of contaminant type and depth.
The Safety Board notes, however, that many airplane manufacturers worldwide
(for example, Airbus and Embraer) provide their operators with contaminant type and
depth options for landing distance calculations. Further, European agencies (EASA and
JAA) require operators to account for contaminated runway conditions and dene a
minimally acceptable standard that manufacturers can use to correlate contaminant type
and depth to airplane landing performance. In practice (and as stated in SAFO 06012),
the FAA considers the data developed for showing compliance with EASA and JAA
contaminated runway certication or operating requirements acceptable for U.S. arrival
landing distance assessments.
98
A postaccident Safety Board survey of seven operators (not including SWA) indicated that none of
them provided their pilots with guidance regarding mixed and/or conicting braking action or runway condition
reports. However, most of the operators surveyed based landing distances on runway contaminant type and
depth, not braking action reports.
99
The FAA does have standards and requirements for ATC’s delivery of a pilot’s braking action report to
other pilots.
100
The draft industry product addressing landing distance assessments (see gure 6) contained
winter operational guidance that was developed by a team of aviation industry representatives and included
proposed braking action and contaminant type and depth terminology, denitions, and estimated correlations.
The Safety Board’s review of this document indicated that it represents a good initial effort in the development
of standardized guidelines for runway surface condition assessments.
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Airport Runway Surface Friction Measuring Devices 2.4.3
Runway friction measuring devices were originally developed for use by airports
for runway maintenance purposes and were not intended for use in assessing airplane
landing performance. Although the FAA funds purchase of these devices for airports and
believes that measurements are useful in identifying trends in runway surface condition,
FAA representatives have stated that these devices cannot be reliably correlated with
airplane performance or pilot braking action reports. Specically, FAA statements and
testimony at the Safety Board’s public hearing on this accident indicate that ground
surface vehicle friction measurements should not be used to predict airplane stopping
performance, in part, because of 1) unresolved variability in equipment design and
calibration; 2) changes over time in temperature, sunlight, precipitation, accumulation,
and operating trafc; and 3) the results of maintenance and/or treatment of a runway.
MDW friction readings were less conservative than the available braking action
reports and the postaccident calculated runway 31C surface condition. The runway 31C
friction measurement taken at MDW 30 minutes before the accident landing (immediately
after the most recent runway cleaning) was 0.67, which a Transport Canada public hearing
witness correlated with expected “bare and dry” runway surface condition performance.
A measurement taken just after the accident was 0.40, which was considered fairly good
according to a public hearing witness from NASA. According to CRFI data for various
runway surface conditions, both measurements (0.67 and 0.40) were within the range of
normal values observed with 3 mm or less of loose snow on the runway. Measurements
for this surface condition ranged from 0.16 to 0.76 (see gure 7 in section 1.18.2.2.1). The
broad range of measurements possible with a single contaminant demonstrates that this
type of runway friction measurement device cannot reliably be used to predict airplane
stopping performance under these contaminant conditions (3 mm or less of loose snow).
The Safety Board has previously issued safety recommendations supporting
efforts to correlate friction measurement device readings to airplane performance. Boeing
does not attempt to correlate runway friction measurements to airplane performance;
however, many operators (including SWA) have developed tables that correlate friction
measurements to braking action reports. Internationally, Transport Canada provides
CRFI tables that correlate ground surface vehicle friction survey measurements to airplane
performance for certain contamination conditions; however, use of the CRFI is optional.
The Canadian academic community and members of the international research community
also support the use of the IRFI, which is not fully operational or widely supported by
the aviation industry. For both the CRFI and the IRFI, runway friction measurements are
subject to contaminant type and depth constraints.
Runway Surface Condition Assessments Summary2.4.4
The Safety Board concludes guidance on braking action and contaminant type and
depth reports would assist pilots, ATC, operator dispatch, and airport operations personnel
in minimizing the subjectivity and standardization shortcomings of such reports. Further,
the Safety Board concludes that using the most conservative interpretation of runway
Analysis
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braking action or surface condition reports from mixed or conicting reports (for example,
a fair-to-poor braking action report or a pilot braking action report that conicts with a
runway friction measurement) would increase the landing safety margin. Therefore, the
Safety Board believes that the FAA should develop and issue formal guidance regarding
standards and guidelines for the development, delivery, and interpretation of runway
surface condition reports.
Correlating Runway Surface Condition to Airplane Landing 2.4.5
Performance
The Safety Board is concerned that the FAA currently provides no minimally
acceptable standard for U.S. operators to use to correlate runway surface condition
reports to airplane braking ability.
101
Although a draft AC, dated August 1989, proposed a
correlation between runway condition (braking action) and an airplane’s braking ability,
the FAA never published it. SAFO 06012, issued by the FAA in 2006, also advocated the use
of a specic correlation between reported braking action and runway contaminant type
and depth to predict turbojet landing/stopping performance but only if the manufacturer-
supplied wet or contaminated runway data were unavailable.
Operators need a method to relate any of the three runway surface condition reports
and airplane braking ability to determine an airplane’s landing performance. However,
because the FAA has dened no acceptable correlation standards, manufacturers,
operators, and/or third-party suppliers develop their own standards to fulll their needs.
102
This practice results in variable estimates of an airplane’s actual landing performance
capability and different landing safety margins being used across even operators of the
same make and model airplane. The Safety Board notes that ight crews preparing to land
similar airplanes on similar runways, under similar actual conditions should not obtain
arrival landing distance results that permit one ight crew to land while the other ight
crew cannot, based solely on the operator’s choice of how to correlate a runway surface
condition report to the airplane’s braking ability.
Further, required arrival landing distance assessments should include an
additional safety margin to account for variations in actual landing conditions and
operational techniques. The current lack of standards in manufacturer-supplied and
operator-packaged arrival landing data complicates the validation of both the airplane’s
basic landing performance capability and adequate safety margins. The Safety Board’s
investigation of this accident revealed arrival landing distance implementation errors
that resulted in latent safety risks at two air carriers. The Safety Board concludes that an
101
In Europe, EASA and JAA provide a default relationship between an airplane’s braking ability and
contaminant type and depth.
102
The Safety Board notes that operators and third-party suppliers do not generally possess the expertise
needed and should not be given license to dene (or redene) basic airplane performance capability. During
its investigation of the SWA ight 1248 accident, the Safety Board noted several instances of manufacturer-
supplied errors and operator use of outdated or otherwise inaccurate data for their landing performance
calculations. Although manufacturers and operators should be allowed to base arrival landing distance
assessments on more conservative airplane braking ability correlations, the use of less conservative data
should be prohibited.
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adequate safety margin would account for operational variations and uncertainties when
factored into arrival landing distance assessments. Further, the Safety Board concludes
that establishment of a means of correlating the airplane’s braking ability with the runway
surface condition would provide a more accurate assessment of the airplane’s basic
landing performance capability. Therefore, the Safety Board believes that the FAA should
establish a minimum standard for 14 CFR Part 121 and 135 operators to use in correlating
an airplane’s braking ability to braking action reports and runway contaminant type and
depth reports for runway surface conditions worse than bare and dry.
Airplane-Based Friction Measurements2.5
The circumstances of this accident demonstrate the need for a method of
quantifying the runway surface condition in a more meaningful way to support
airplane landing performance calculations.
103
The Safety Board and industry practice
of analyzing an airplane’s actual landing performance in the aftermath of an accident
based on airplane-recorded data demonstrates that runway surface condition and braking
effectiveness information can be extracted from recorded data.
104
These practices have
shown that if the necessary parameters are recorded, specic calculations and operational
procedures performed at lower rollout speeds (for example, wheel brake application for
several seconds below 60 knots) can be used to quantify the runway surface condition
and estimate the airplane’s potential braking ability.
105
Thus, airplane braking coefcient/
runway surface condition data derived from one type of landing airplane could be used to
estimate another type of airplane’s braking ability and landing distance.
106
During a postaccident meeting in January 2007, Boeing, FAA, SWA, and SWAPA
personnel agreed that this approach to obtain runway surface condition and braking
effectiveness data has technical merit. However, the technical and operational feasibility
issues associated with an airplane-based friction measurement system have not been
evaluated on a test bed or an in-service air carrier airplane to date. A measurement
103
The Safety Board has previously issued a safety recommendation on this subject (A-82-168), urging
the FAA to conduct research to determine whether the characteristic variables of aircraft systems could be
correlated to an airplane’s stopping ability and related information displayed to pilots for objective braking
action reports. The Board did not believe that the FAA’s resultant actions were sufcient and subsequently
classied Safety Recommendation A-82-168 “Closed—Unacceptable Action.”
104
Specically, the Safety Board’s airplane performance study for this accident demonstrated the
technical feasibility of calculating an airplane’s braking ability during the landing roll based on recorded FDR
data (including accelerometer, attitude, speed, control input, control surface position, deceleration device
usage, and air/ground logic parameters), the airplane conguration, and existing airplane simulation models.
Conceptually, the calculation determines how much of the energy (initial energy and any added forward thrust)
is dissipated by aerodynamic drag and reverse thrust forces acting during the landing rollout. The remaining
energy is used together with airplane weight, aerodynamic lift, and any applicable thrust force data to derive
the airplane braking coefcient. If wheel brakes are not applied, the calculated result should correspond to the
rolling coefcient of friction, assuming no contaminant drag exists.
105
Operational procedures at lower rollout speeds could be used to estimate the maximum or bound the
minimum airplane braking coefcient available.
106
The airplane braking coefcient report from the preceding airplane would be used to perform a rational
arrival assessment for the trailing airplane, after correcting for known airplane type, loading, conguration,
braked wheel conguration, and antiskid efciency differences.
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system installed on in-service airplanes could provide runway surface condition data
that would surpass information produced by methods currently in use (including ground
friction surveys, pilot braking action reports, and type and depth reports), without
interfering with trafc ow. Such a system could provide unparalleled runway surface
condition quantication and trend information of direct use to pilots, ATC, and airport
maintenance.
The Safety Board concludes that development and implementation of an
operationally feasible, airplane-based, airplane braking ability/runway surface condition
measurement and communication system would provide high value information to
subsequent landing airplanes; the benets of such a system during inclement weather
would likely meet or exceed all existing runway surface condition reporting systems, with
no resultant interruption to trafc operations. Therefore, the Safety Board believes that the
FAA should demonstrate the technical and operational feasibility of outtting 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
an airplane during the landing roll. If feasible, the FAA should also require operators of
transport-category airplanes to incorporate use of such equipment and related procedures
into their operations.
Runway Safety Areas2.6
The Safety Board’s investigation of this accident revealed that FAA and MDW
airport personnel had been discussing RSA improvements off the ends of MDW runways
for about 5 years before the accident; however, no such improvements had been made
when the accident occurred. Correspondence between the FAA and MDW personnel
indicated that the option of acquiring land to develop dimensionally standard RSAs
(which would extend 1,000 feet beyond the ends of the MDW runways) was determined to
be both undesirable
107
and economically infeasible. Further, realigning the runways on the
available airport property was not possible, and shortening the runways to improve RSAs
was not practical given the operational requirements of the airplanes operating at MDW.
A practicability study contracted by MDW concluded that insufcient space
existed for standard EMAS installations off the ends of MDW runways. The study did
not address nonstandard EMAS installations, and, throughout most of the FAA/MDW
correspondence, the FAA did not reference the installation of nonstandard EMAS beds
off the end of MDW runways. However, although the FAA had no ofcial guidance
regarding nonstandard EMAS installations until 2005, agency personnel were aware of
the feasibility of such installations and had approved nonstandard EMAS installations at
several other airports at the time of the accident. The Board’s postaccident calculations
indicated that even a nonstandard EMAS installation off the end of runway 31C at MDW
would have stopped the accident airplane before it left airport property and thus would
have prevented the collision with the automobile.
107
Acquisition of the required land would result in the forced relocation of businesses, residences, and
roadways in the surrounding area.
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Therefore, the Safety Board concludes that the absence of an EMAS installation in
the limited overrun area for runway 31C contributed to the severity of the accident; even a
nonstandard EMAS installation would have safely stopped the airplane before it left airport
property. After the accident, the FAA approved the installation of nonstandard EMAS
beds at the ends of runways 31C, 13C, 4R, and 22L at MDW. By early December 2006, the
rst portion (170 feet long and 170 feet wide) of an EMAS bed had been installed off the
departure end of runway 31C, with an additional, 40-foot long portion planned. Airport
and City ofcials indicated that the installation of EMAS beds at the ends of affected MDW
runways would be completed by winter 2007, pending relocation of localizer antennas at
the ends of runways 13C, 4R, and 22L.
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Co n C l u s i o n s3.
Findings3.1
The pilots were properly certicated and qualied under Federal regulations. No 1.
evidence indicated any medical or behavioral conditions that might have adversely
affected their performance during the accident ight. There was no evidence of ight
crew fatigue.
The accident airplane was properly certicated and was equipped, maintained, and 2.
dispatched in accordance with industry practices.
No evidence indicated any failure of the airplane’s powerplants, structures, or systems 3.
that would have affected the airplane’s performance during the accident landing.
The pilots had adequate initial and updated meteorological information throughout 4.
the ight.
Chicago Midway International Airport personnel monitored runway conditions and 5.
provided appropriate snow removal service on the night of the accident.
The Chicago Midway International Airport air trafc control tower controller did not 6.
follow Federal Aviation Administration guidance when he did not provide all of the
required braking action report information.
Because the pilots did not use the more critical braking action term (poor) during their 7.
arrival landing distance assessment (which, combined with the associated tailwind
limitation, would have required them to divert), they were not in compliance with
Southwest Airlines’ policies.
If the pilots had been presented with stopping margins associated with the input winds 8.
or had known that the stopping margins calculated by the on board performance
computer for the 737-700 already assumed credit for the use of thrust reversers, the
pilots may have elected to divert.
If Boeing’s recommended airplane performance data were used in Southwest Airlines’ 9.
on board performance computer calculations, the resulting negative stopping margins
for even fair braking action conditions would have required the pilots to divert.
Presentation of the on board performance computer assumptions upon which landing 10.
distance calculations are based is critical to a pilot’s decision to land.
Southwest Airlines did not provide its pilots with clear and consistent guidance 11.
and training regarding company policies and procedures in several areas, including
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interpretation of braking action reports and the assumptions affecting landing distance
assessments.
The pilots would have been able to stop the airplane on the runway if they had 12.
commanded maximum reverse thrust promptly after touchdown and maintained
maximum reverse thrust to a full stop.
The pilots’ delay in deploying the thrust reversers cannot be attributed to mechanical 13.
or physical difculties.
The pilots’ rst use of the airplane’s autobrake system during a challenging landing 14.
situation led to the pilots’ distraction from the otherwise routine task of deploying the
thrust reversers promptly after touchdown. Had Southwest Airlines implemented an
autobrake familiarization period in advance, such a period would have allowed pilots
to become comfortable with the changed sequence of landing tasks.
The implementation of procedures requiring thrust reverser status conrmation 15.
immediately after touchdown may prevent pilots from inadvertent failure to deploy
the thrust reversers after touchdown.
Because landing conditions may change during a ight, preight landing assessments 16.
alone may not be sufcient to ensure safe stopping margins at the time of arrival; arrival
landing distance assessments would provide pilots with more accurate information
regarding the safety of landings under arrival conditions.
Although landing distance assessments incorporating a landing distance safety margin 17.
are not required by regulation, they are critical to safe operation of transport-category
airplanes on contaminated runways.
Guidance on braking action and contaminant type and depth reports would assist 18.
pilots, air trafc control, operator dispatch, and airport operations personnel in
minimizing the subjectivity and standardization shortcomings of such reports.
Using the most conservative interpretation of runway braking action or surface 19.
condition reports from mixed or conicting reports (for example, a fair-to-poor
braking action report or a pilot braking action report that conicts with a runway
friction measurement) would increase the landing safety margin.
An adequate safety margin would account for operational variations and uncertainties 20.
when factored into arrival landing distance assessments.
Establishment of a means of correlating the airplane’s braking ability with the runway 21.
surface condition would provide a more accurate assessment of the airplane’s basic
landing performance capability.
Development of an operationally feasible, airplane-based, airplane braking ability/22.
runway surface condition measurement and communication system would provide
Conclusions
National Transportation Safety Board
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Accident Report
67
high value information to subsequent landing airplanes; the benets of such a system
during inclement weather would likely meet or exceed all existing runway surface
condition reporting systems, with no resultant interruption to trafc operations.
The absence of an engineering materials arresting system (EMAS) installation in the 23.
limited overrun area for runway 31C contributed to the severity of the accident; even
a nonstandard EMAS installation would have safely stopped the airplane before it left
airport property.
Probable Cause3.2
The National Transportation Safety Board determines 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’ rst experience and lack of familiarity with
the airplane’s 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 inherent assumptions in the
program critical to pilot decision-making; 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. Also contributing to the accident was
the pilots’ failure to divert to another airport given reports that included poor braking
actions and a tailwind component greater than 5 knots. 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.
National Transportation Safety Board
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re C o m m e n d A t i o n s4.
New Recommendations4.1
As a result of this investigation, the National Transportation Safety Board makes
the following recommendations to the Federal Aviation Administration:
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.
(A-07-57) Urgent (Supercedes Safety Recommendation A-06-16 and
classied “Open—Unacceptable Response.”)
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. (A-07-58)
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. (A-07-59)
Require all 14 Code of Federal Regulations Part 121 and 135 operators
of thrust reverser-equipped airplanes to incorporate a procedure
requiring the non-ying (monitoring) pilot to check and conrm the
thrust reverser status immediately after touchdown on all landings.
(A-07-60)
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
airplane’s braking ability with runway surface conditions using the
most conservative interpretation available, and including a minimum
safety margin of 15 percent. (A-07-61)
Develop and issue formal guidance regarding standards and guidelines
for the development, delivery, and interpretation of runway surface
condition reports. (A-07-62)
Recommendations
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Establish a minimum standard for 14 Code of Federal Regulations Part 121
and 135 operators to use in correlating an airplane’s braking ability to
braking action reports and runway contaminant type and depth reports
for runway surface conditions worse than bare and dry. (A-07-63)
Demonstrate the technical and operational feasibility of outtting
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. (A-07-64)
Previously Issued Recommendation Resulting From 4.2
This Accident Investigation and Classied in this Report
As a result of the SWA ight 1248 accident investigation, the Safety Board issued
the following urgent safety recommendation to the FAA on January 27, 2006:
Immediately prohibit all 14 Code of Federal Regulations Part 121 operators
from using reverse thrust credit in landing performance calculations.
(A-06-16)
This recommendation (previously classied “Open—Unacceptable Response”
on May 8, 2007) is classied “Closed—Unacceptable Action/Superceded” by Safety
Recommendation A-07-57 in section 2.3 of this report.
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
Mark V. Rosenker Deborah A. P. Hersman
Chairman Member
Robert L. Sumwalt Kathryn O’Leary Higgins
Vice Chairman Member
Steven R. Chealander
Member
Adopted: October 2, 2007
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Ap p e n d i x e s5.
Ap p e n d i x A
in v e s t i g A t i o n A n d pu b l i C He A r i n g
Investigation
The National Transportation Safety Board was notied about the accident on
December 8, 2005, shortly after it occurred. A full go-team arrived at the accident scene
early the next morning. The go-team was accompanied by representatives from the Safety
Board’s Ofce of Transportation Disaster Assistance and Public Affairs and by then
Chairman-designee Ellen Engleman Conners.
The following investigative groups were formed during the course of this
investigation: Structures, Systems, Powerplants, Air Trafc Control, Meteorology,
Operations, Human Performance, Airport/Survival Factors, Airplane Performance, Flight
Data Recorder, and Cockpit Voice Recorder.
Parties to the investigation were the Federal Aviation Administration (FAA); Boeing
Commercial Airplane Company; Southwest Airlines, Inc. (SWA); Southwest Airlines Pilots
Association (SWAPA); National Air Trafc Controllers Association (NATCA); the City of
Chicago; CFM International; SWA Employee Association Dispatch; Transport Workers
Union #556; and SWA AMFA. The Safety Board received submissions on this accident
from SWA, SWAPA, Boeing, and the City of Chicago.
Public Hearing
A public hearing was held on June 21 and 22, 2006, in Washington, D.C. Then-
Acting Chairman Mark V. Rosenker presided over the hearing.
The issues discussed at the public hearing were the accuracy and dissemination
of runway friction measurements, the adequacy of runway safety areas on the ends of
runways, and aircraft landing performance. Parties to the public hearing were the FAA,
SWA, SWAPA, Boeing Commercial Airplane Company, and the City of Chicago.
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Ap p e n d i x b
Co C k p i t vo i C e re C o r d e r
The following is a transcript of the Honeywell model 6022 cockpit voice recorder
installed on Southwest Airlines ight 1248, a Boeing 737-74H, N471WN, which ran off
the departure end of runway 31C after landing at Chicago Midway International Airport,
Chicago, Illinois, on December 8, 2005.
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Attachment II – Transcript - Page 1
Start of Transcript
17:12:58.2
[start of recording]
17:13:15.9
CAM-2
I thought it said that read before fly said actually it
was in the weather packet. (the) front page said don't
do the new procedures until you post the change and
then then have at it.
17:13:26.5
CAM-1 oh really?
17:13:28.2
CAM-2
there was a big long thing on it and it's not on there
any more.
17:13:32.8
CAM-2 have to read that that little blurb again.
17:15:37.2
CTR
Southwest twelve forty eight climb maintain flight level
three three zero.
17:15:41.0
RDO-2 flight level three three zero Southwest twelve forty.
17:15:43.5
CAM-1 well?
17:15:43.6
CTR
Southwest twelve forty eight contact Washington one
one eight point zero two she'll have higher.
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Attachment II – Transcript - Page 2
17:15:48.2
RDO-2
eighteen oh two have a great night Southwest twelve
forty eight.
17:15:50.7
CTR goodnight.
17:15:54.3
RDO-2
center Southwest twelve forty eight leavin' thirty for
flight level three three zero.
17:15:57.6
CTR
Southwest twelve forty eight Washington center roger
climb maintain flight level three niner zero.
17:16:04.1
HOT-1 three nine zero now.
17:16:05.2
HOT-2 thirty nine.
17:16:13.6
CAM-1 (see) anything exciting in there?
17:16:16.2
CAM-2 if I knew how to read it would be a lot easier.
17:16:17.9
CAM-1 ahuh.
17:16:18.5
CAM-2 [sound similar to laughter].
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Attachment II – Transcript - Page 3
17:16:21.6
CAM-2
you know we're gonna get rid of all the two, two
hundred (stuff). that should make it (a) little bit
skinnier.
17:17:53.3
HOT-1
talkin' to a buddy a mine $. said yesterday the winds,
most they got were the winds hundred and eighty
eight knots dead on their nose.
17:18:02.4
HOT-2 man.
17:18:03.0
HOT-1 yea.
17:18:03.7
HOT-2
the highest I ever saw and it made me wonder what
the plane what the computer went up to we're over
Atlanta like couple months ago and it was two seven
zero at one ninety nine. we were goin' north to
Baltimore but...
17:18:15.1
HOT-1 yeah yeah.
17:18:16.3
CAM-2
...(that) made me wonder if it didn't go any higher,
sure it does but.
17:18:27.2
HOT-2
its a lot a wind, that blows [sound similar to
laughter].
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17:18:29.7
HOT-1 yup.
17:19:58.5
CAM-1 gonna do it huh?
17:19:59.7
CAM-2 I don't want to but.
17:20:03.2
HOT-1 kinda light drinkin' the spittoon.
17:20:04.6
HOT-2 [sound similar to laughter].
17:20:11.2
CAM [sound similar to altitude alert warning tone].
17:20:12.7
HOT-1 (thirty) eight one fer thirty nine.
17:20:14.6
CAM-2 eight one thirty five.
17:20:39.9
HOT-1 same all the way up.
17:20:41.2
CAM-2 yea (looks), no penalty.
17:20:43.0
CAM-1 unchanged two sixty five oh one fifty.
17:20:48.8
HOT-1 for the last nine thousand feet.
17:20:50.8
HOT-2 man, well.
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17:20:59.5
CAM-2 * * * *.
17:21:01.6
CAM-1 yea.
17:21:02.7
CAM-1 (think) we have a ninety eight on board wow.
17:21:04.9
CAM-2
(that's good) we're supposed to only have fifty one
right when we started?
17:21:07.6
CAM-1 yea it kept on gettin' more and more.
17:21:17.1
HOT-1
I’ll put three nine zero in there I don't know if we're
goin' up or not but.
17:21:19.6
CAM-2 'kay.
17:21:23.5
HOT-1 yeah.
17:21:55.0
CAM-1 okay.
17:22:01.6
CAM-2 okay now or you want me to wait till we get (up)?
17:22:04.1
CAM-1 you can let 'em up.
17:22:04.6
CAM-2 okay cool I'll be right back.
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Attachment II – Transcript - Page 6
17:22:07.8
PA-2
and folks good evenin' ah again from the guys up front thank
you so much for your patience this evenin' ah with our troubles
with mother nature we sure do appreciate your understanding *
* * are at thirty nine thousand feet we're gonna make a slow
climb to forty thousand feet here in just a couple minutes our
friends at air traffic controller (tell) us its gonna be a pretty
smooth flight this evenin' [sound similar to seatbelt warning
tone] the seatbelt signs comin' off so folks if you wanna get up
and stretch your legs or move about you sure can do so well
please folks while you're in your seats always stay buckled up
just in case we do find a few unexpected bumps along the way.
ah folks as long as the flight attendants are busy trying to get
their service out you sure can do them a big favor by trying to
keep those aisles clear they really do appreciate it and so do we
* * * no lines up by the forward lavatory and you can't stand up
in the forward galley area ah these are FAA security regulations
and each of us want to thank you here in advance for complyin'.
ahhh pretty strong headwinds right now folks are out of the
West at about a hundred and fifty knots 'bout a hundred seventy
five mile an hour right on the nose ah normal a normally our
speed across the ground is close to about five hundred miles an
hour right now it's only about three hundred and fifty or so so
it's not gonna help us make up any time at all right now about
four hundred and fifty miles to go. showin' us ah - touchin'
down in Chicago at about and hour twenty minutes or so 'bout
an hour twenty five minutes we should have you safely at the
gate. folks as we get closer * we'll keep you posted get you up
to date on the latest for the Chicago weather. for now folks
again ah thanks so much for your patience and understanding
this evening we really do appreciate it and finally folks one
extra note ah we have three great flight attendants and I promise
ya they didn't have a single thing to do with us gettin' off to the
late start this evenin' so folks please be kind to them 'cause
they’re gonna take excellent care of you thanks so much folks
again and good evenin'.
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Attachment II – Transcript - Page 7
17:23:51.7
CAM-1 wow whaddya say?
17:23:53.8
CAM-2
yadda yadda yadda. yadda yadda yadda. good flight
attendants yadda yadda. we like visitors yadda yadda.
17:24:01.6
CAM-1 wow.
17:24:03.7
CAM-2
I always give 'em the be good to our flight attendants
'cause it's not their fault we're late. they're they
always say ohh that's so nice thank you.
17:24:13.9
HOT-1 huh.
17:24:14.2
HOT-2 it's all lies and garbage.
17:24:15.5
HOT-1 yeap.
17:24:17.0
HOT-2 windy windy windy.
17:25:01.0
HOT-1 big three hundred and thirteen knots a groundspeed.
17:25:04.2
HOT-2 man oh man.
17:25:11.6
HOT-1 hope this stays with us for the last day.
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Attachment II – Transcript - Page 8
17:25:14.0
CAM-2 yea no kidding.
17:25:14.9
CAM-1 although it doesn't matter.
17:25:16.3
CAM-2 that's true.
17:25:17.0
CAM-1 ain't no flights I can make.
17:25:18.6
CAM-2 yea me neither.
17:25:22.0
HOT-1 see.
17:25:23.4
HOT-2 it's not even close for me.
17:25:28.1
HOT-1 Albany?
17:25:29.2
HOT-2
I think it's like eight, actually Saturday it's earlier it's
seven somethin'.
17:25:33.6
HOT-1 (no) it's five somethin' on Saturday.
17:25:35.5
HOT-2 five.
17:25:36.0
HOT-1 yeah.
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Attachment II – Transcript - Page 9
17:25:36.6
HOT-2 man.
17:25:37.3
HOT-1 (see) I better turn this off I guess (huh)?
17:25:38.8
HOT-2 [sound similar to laughter].
17:25:40.4
HOT-1 (ah) it is off how 'bout that it's smarter than I think.
17:25:42.6
HOT-2 my battery's probably dead already.
17:26:32.5
CAM-1 wow wow wow.
17:26:35.2
CAM-2 big stuff right here.
17:26:36.4
CAM-1 yeah.
17:26:37.2
CAM-2 be sleep *.
17:26:37.9
CAM-1 be the next leg for me.
17:26:39.0
CAM-2 [sound similar to laughter].
17:27:10.7
CAM-2
you know this is some heavy stuff. (think I'm) gonna
be sorry I (got into this).
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Attachment II – Transcript - Page 10
17:27:14.8
CAM-1 yup.
17:29:56.8
CTR
Southwest twelve forty eight contact Indianapolis center
one two zero point two seven.
17:30:01.4
RDO-2
twenty twenty seven have a great night Southwest
twelve forty eight.
17:30:04.0
CTR 'kay.
17:30:21.4
RDO-2
and center Southwest twelve forty eight flight level
three nine zero.
17:30:24.6
CTR Southwest twelve forty eight Indy center roger.
17:31:12.0
CAM [sound similar to ACARS chime].
17:31:22.6
HOT-1 landin' north Salt Lake ten miles fifteen thousand.
17:31:28.3
HOT-2 alright nice from Vegas.
17:31:32.5
HOT-2
alright here's the autobrakes. autobrakes if
operational will be used when min two stopping
margin is less than five hundred feet and the reported
or anticipated runway condition is not dry.
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Attachment II – Transcript - Page 11
17:31:49.1
CAM-1 alright.
17:31:50.8
CAM-2
use the lowest autobrake setting resulting in a
stopping margin of five hundred feet or more.
17:31:56.7
CAM-2
if stopping margin of at least five hundred feet cannot
be achieved with autobrake setting landing is still
authorized using MAX provided a positive stopping
margin is computed.
17:32:08.6
CAM-1 alright what does that mean? I cause I can't...
17:32:12.4
CAM-2 I have no idea. [sound similar to laughter].
17:32:14.1
CAM-1 I gotta read it.
17:32:15.2
CAM-2
it (has it) in here I'll show you. (you) get a good idea
now.
17:32:20.1
HOT-1 yeah.
17:32:22.0
CAM-2
I guess if you use MAX my buddy flew whales for
Atlas and he said when you land at max it'll get your
freakin' attention.
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17:32:30.3
HOT-2
I mean it's a mega-stop. it like throws ya for you
know he said I when they used max he used to do the
- he never did the crotchstrap till he did his first
MAX.
17:32:36.1
HOT-1 yeah.
17:32:40.9
HOT-1 really?
17:32:41.4
HOT-2 yeah.
17:32:42.6
HOT-2 he said after that I use it every time.
17:32:53.7
HOT-2 let's see.
17:32:54.8
HOT-1 crossfeedin' the centers.
17:32:55.9
HOT-2 alright.
17:33:11.3
CAM [sound similar to ACARS chime].
17:33:13.3
CAM-1 Romeo. Romeo Romeo where art thou?
17:33:17.7
HOT-2 half a mile snow freezing fog two hundred who hoo.
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17:33:22.3
CAM-2 you wanted to go first.
17:33:24.1
HOT-1 half a mile we can't do it can we?
17:33:26.6
HOT-2
three one center we can if they're using three one
center.
17:33:32.3
CAM-2 you need three thousand RVR.
17:33:35.2
CAM-2 you prob - you probably won't get in but.
17:33:35.3
CAM-1 * *.
17:33:37.5
CAM-1
you got a different one? it says four thousand or three
quarters unless you got a...
17:33:40.5
CAM-2 you can do that ILS-Z.
17:33:42.6
HOT-1 I haven't got that one.
17:33:43.8
HOT-2 you don't?
17:33:46.6
CAM-2 pretty sure it's a (V).
17:33:47.7
CAM-1 okay. it's a HUD one?
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17:33:51.2
CAM-2 it's the same approach but.
17:33:53.2
CAM-1 yeah get a little lower.
17:33:55.4
CAM-1 no where it went.
17:33:55.8
CAM-2 I I don't know if we'll see it.
17:33:57.2
HOT-2 'cause there's no approach lights.
17:34:00.6
CAM-2 (see).
17:34:03.9
CAM-1 (two hundred broken).
17:34:04.4
CAM-2 there's a lead in that's it three one center.
17:34:07.7
CTR Southwest twelve forty eight cleared direct Fort Wayne.
17:34:10.5
RDO-2
wow direct Fort Wayne thanks Southwest twelve forty
eight.
17:34:12.9
CTR you're welcome.
17:34:13.3
CAM-1 direct Fort Wayne.
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Attachment II – Transcript - Page 15
17:34:15.4
CAM-2 you had the the Zee.
17:34:17.8
CAM-1
well let me take a peak then how's that look direct
Fort Wayne.
17:34:20.5
CAM-2 good to me.
17:34:22.6
CAM-2 here we go three thousand or five (E).
17:34:27.5
CAM-1 yeah.
17:34:31.5
HOT-2 (well) there's.
17:34:32.9
HOT-1 okay.
17:34:33.8
HOT-2 probably a two -- what's the --
17:34:39.0
HOT-2 the so what's to altitude on it though a * two hundred.
17:34:41.7
HOT-1 eight seventeen.
17:34:42.7
HOT-2 two hundred and fifty.
17:34:43.6
HOT-1 two hundred and four.
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Attachment II – Transcript - Page 16
17:34:44.5
HOT-2 oh two oh four so we'll probably see it.
17:34:47.2
HOT-1 neh heh.
17:34:50.1
CAM-2 temperature.
17:34:52.3
CAM-1 but five eighths is not a half a mile.
17:34:54.9
CAM-2 no I know (the).
17:34:55.8
CAM-1 gotta have three thousand.
17:34:57.1
HOT-2 he sent me a a dispatch message.
17:35:00.3
HOT-1 okay.
17:35:00.8
HOT-2 and he said fair and three thousand RVR.
17:35:03.4
HOT-1 alright it's three thousand RVR we can do it.
17:35:09.5
CAM-2
I can type him a little message and see what he's got
now.
17:35:11.3
CAM-1 nah 'at's all right.
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Attachment II – Transcript - Page 17
17:35:14.9
CAM-2 * * *.
17:35:18.9
CAM-2 so I'll do I'll do wet fair just for # and giggles.
17:35:29.5
CAM-? I'm with you.
17:35:34.9
HOT-2 four point five.
17:35:58.6
HOT-2
so the - the way I get it since this is the one that has
five hundred.
17:36:03.9
HOT-1 yeah.
17:36:07.2
HOT-2 and you can't use one.
17:36:10.0
HOT-2 two is - min so you'd have to use ah three.
17:36:13.1
HOT-1 three.
17:36:14.7
HOT-2 that's the way I get it but.
17:36:15.9
HOT-1 okay.
17:36:19.1
HOT-2 if its ah.
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Attachment II – Transcript - Page 18
17:36:20.2
HOT-1 Hmmm.
17:36:21.0
HOT-2 use those.
17:36:21.2
HOT-1 I would I would agree with that.
17:36:22.4
HOT-2 yeah yeah I think that's what I get.
17:36:24.2
HOT-2 you can't use one so it starts at two.
17:36:26.5
HOT-2 like two three from MAX.
17:36:28.3
HOT-1 you got wet fair.
17:36:29.8
HOT-2 and then ah ice on.
17:36:32.0
HOT-1 okay.
17:36:34.0
HOT-1 'kay.
17:36:34.6
HOT-2 no clutter we'll see.
17:36:36.4
HOT-1 didn't say any clutter add some clutter if they got any.
17:36:37.7
HOT-2 yeah.
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Attachment II – Transcript - Page 19
17:36:38.7
HOT-2 yeah.
17:36:39.5
HOT-1 add some clutter see what it says.
17:36:40.8
HOT-2 okay ah.
17:36:44.1
HOT-1 please.
17:36:44.7
HOT-2 sure.
17:36:47.6
HOT-2 well lemee see.
17:36:49.7
HOT-2 do ya just do clutter fer ahhh.
17:36:53.9
HOT-1 (ten).
17:36:54.3
HOT-2
maybe you just do clutter for takeoff I think you just
do...
17:36:56.2
HOT-1 yeah.
17:36:56.5
HOT-2 ...clutter.
17:36:57.4
HOT-2 but if it was wet poor we'll do wet poor and see.
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Attachment II – Transcript - Page 20
17:36:59.8
HOT-1 yeah we can.
17:37:05.3
HOT-1 hmm ha.
17:37:07.4
HOT-2 wow. wooo. if it's poor it's scary.
17:37:12.0
HOT-1 I ain't doin' it.
17:37:12.8
HOT-2 max is thirty that's really scary.
17:37:15.2
HOT-1 yeah.
17:37:16.5
HOT-1 naw that's no good.
17:37:21.1
CAM-2 six knot tailwind.
17:37:23.4
HOT-1 did ya put in ah go back to wet fair did ya put in a.
17:37:29.0
HOT-2 HGS?
17:37:29.9
HOT-1 yeah.
17:37:30.8
HOT-2 well do we?
17:37:32.9
HOT-1 says it's a requirement.
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Attachment II – Transcript - Page 21
17:37:34.1
HOT-2 it is?
17:37:36.7
HOT-2 I did less than four thousand.
17:37:39.7
HOT-2 *.
17:37:39.7
HOT-1 ah you did less than four okay. ah that's good enough.
17:37:41.7
CAM-2
when when you put in the HGS I've never seen that
before.
17:37:45.6
CAM-1 runway limited.
17:37:47.2
CAM-2 maybe it maybe it 'cause I don't think we're...
17:37:50.4
HOT-1
yeah just do wet poor ah ah poor and then ah below
four yeah not HGS though.
17:37:56.4
HOT-1 you just have to be HGS cert- certified.
17:37:57.3
HOT-2
...maybe 'cause they don't have... we'll do it we'll see
as we get the next one but. (oh).
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Attachment II – Transcript - Page 22
17:38:02.2
HOT-1
alright it's gotta have the lead in gotta have the REIL
gotta have the VASI gotta have the HIRL and RVR
for three one center must be operating. and DME is
required.
17:38:11.2
HOT-2
let's see if they got a the fi- there's a field condition
one in here.
17:38:14.9
HOT-1 yeah.
17:38:16.7
HOT-2 it didn't have the RVR in there before but.
17:38:21.7
HOT-2 field METAR.
17:38:26.4
HOT-2 that's really the only reason I wanna look.
17:38:29.3
CAM-2 hate to have somethin' happen when ya got the.
17:38:38.1
HOT-2 then the only other stuffs that really is gonna (bra-).
17:38:40.7
HOT okay? [sound similar to ACARS chime]
17:38:41.1
HOT-2 yeah.
17:38:43.8
HOT-1 there's field conditions and the METAR too.
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Attachment II – Transcript - Page 23
17:38:47.0
HOT-2 field condition.
17:38:49.1
HOT-1 wet poor.
17:38:50.0
HOT-2 wow.
17:38:51.0
HOT-1 can't do it.
17:38:52.3
HOT-2 I (I oh).
17:38:53.1
HOT-1 wait a minute that was ah.
17:38:55.9
HOT-2
it says ya can but I don't wanna. [sound similar to
laughter]
17:38:58.2
HOT-1
what's ah thirty one center though? wet snow no
clutter wet poor.
17:39:04.3
HOT-2
so that I mean it the books says you can as long it's
positive but man that's whoo.
17:39:09.6
HOT-1 yeah.
17:39:15.6
HOT-2
I mean it's (what is it) thirty feet at max
b
raking whao
#.
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Attachment II – Transcript - Page 24
17:39:20.1
HOT-1 I know.
17:39:20.2
HOT-2 know you're good but.
17:39:25.3
HOT-2 I mean that's really tight.
17:39:29.3
HOT-1 nope
17:39:30.8
HOT-2
and then you know what's funny like if if you know
we got we got that thirty feet of stopping MAX.
17:39:36.1
HOT-1 ah ha.
17:39:36.5
CAM-2
no procedure if that sucker fails when you touch
down? we just go through the fence? we never talk
about any of that stuff ya know?
17:39:45.1
HOT-2 er if it fails on * on landing?
17:39:47.3
HOT-1 yeah.
17:39:47.7
HOT-2
you do I tell you to go around? what you know what
what if it doesn't there's no guidance on it.
17:39:53.7
HOT-1 yeah I don't know stand on the brakes?
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Attachment II – Transcript - Page 25
17:39:55.9
HOT-2
maybe there is once we get in here there might be
something further down the road that.
17:40:01.3
HOT-2 that tells us what to do but.
17:40:24.1
HOT-1 what's the date on this thing?
17:40:29.7
HOT-2 it's August ah.
17:40:34.9
HOT-1 what's it say ah hey where's the date?
17:40:36.3
HOT-1 November ninth oh five.
17:40:38.8
HOT-1 what is it?
17:40:39.5
CAM-2 November ninth.
17:40:41.9
CAM-1 on these revisions?
17:40:43.4
CAM-2 yeah.
17:40:43.7
CAM-1 oh yea there it is down there.
17:40:45.4
HOT-1 #.
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Attachment II – Transcript - Page 26
17:40:48.6
CAM-1 we haven't had it that long.
17:40:49.9
CAM-2 no.
17:41:06.9
HOT-1 where's that sucker * *.
17:41:11.5
HOT-2 I'm hoping that in the like the normal.
17:41:14.5
CAM-2 or in the approach it might have some guidance on it.
17:41:21.9
HOT-1 zero eight zero at ten. huh.
17:41:26.8
HOT-2 yeah it's a eight knot tailwind.
17:41:28.3
HOT-1 #.
17:41:33.4
HOT-1 let's go ah.
17:41:38.1
HOT-1 one three zero at ten.
17:41:38.3
HOT-2 I put in fair.
17:41:43.4
HOT-1 wet fair landing *.
17:41:53.0
HOT-1 close to ten knots can't do it.
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Attachment II – Transcript - Page 27
17:41:55.2
HOT-2 ahmm did you check in HGS?
17:42:00.4
HOT-1 no.
17:42:01.3
HOT-2 did I not take it out?
17:42:02.9
HOT-1 RVR four thousand.
17:42:06.3
HOT-1 with one three zero at ah ten.
17:42:08.4
HOT-2 oh yeah.
17:42:08.8
HOT-2 yeah with a ten knot tailwind you can't do it.
17:42:10.6
HOT-1 yeah.
17:42:11.5
HOT-2
well (do I) eh ah that's a less than four thousand
thing.
17:42:15.1
HOT-2
it's like a five with anything less than with wet poor I
think it's a five knot tailwind.
17:42:15.1
HOT-1 okay.
17:42:20.0
HOT-2 if it's poor you can only have a five - oh.
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Attachment II – Transcript - Page 28
17:42:22.0
HOT-1 that would make sense.
17:42:22.7
HOT-2 yeah. I think.
17:42:23.1
HOT-1 (they).
17:42:24.6
HOT-2 I think it is.
17:42:24.7
HOT-1 how 'bout one three zero at nine?
17:42:28.4
HOT-2 peak gust tailwind brakin' poor five knots.
17:42:33.9
HOT-1 can't do it there either.
17:42:37.2
HOT-1 so what is our?
17:42:39.9
HOT-1 you had a zero eight zero at ah.
17:42:43.8
HOT-2 eh I can throw it back up quick.
17:42:48.8
HOT-2 the I think it was. ahhh. oh.
17:42:56.1
HOT-1 Romeo wasn't it?
17:42:57.1
HOT-2 (L M) P Q R I think it was Romeo.
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Attachment II – Transcript - Page 29
17:43:00.4
HOT-2 zero eight zero at ten, must be right on the limit.
17:43:17.4
HOT-1 that gives us six knots a tailwind.
17:43:20.5
CAM-2 and it still says it's legal?
17:43:20.6
CTR
Southwest twelve forty eight contact Indy center one
tree tree point seven seven.
17:43:25.8
RDO-2
thirty three seventy seven have a great night Southwest
twelve forty eight.
17:43:28.7
CTR see ya.
17:43:29.6
HOT-2 *.
17:43:34.2
CAM-1 (but) like you say.
17:43:36.6
CAM-2 that thing says five knot tailwind.
17:43:38.2
CAM-1 yeah. so really.
17:43:39.6
RDO-2
howdy center Southwest twelve forty at flight level
three nine zero.
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Attachment II – Transcript - Page 30
17:43:42.3
HOT-2
well that's kinda scary that that doesn't save your #
you know?
17:43:46.7
CTR who's that checkin' in?
17:43:47.8
HOT-1 peak gust.
17:43:48.4
RDO-2
Southwest twelve forty eight at flight level three nine
zero good evening.
17:43:51.1
CTR Southwest twelve forty eight ** rog.
17:43:57.2
HOT-1 that's braking poor.
17:43:59.7
CAM-1 braking fair is ten knots.
17:44:01.9
CAM-2 yeah but the field conditions was poor.
17:44:04.4
CAM-1 yeah.
17:44:04.8
HOT-2 which means we couldn't do it anyway.
17:44:06.3
HOT-1 right.
17:44:06.5
HOT-2 well * we could but -
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Attachment II – Transcript - Page 31
17:44:08.2
CAM-2
I'm my butt's gonna be squeezed so tight * you never
seen a butt squeezed tighter.
17:44:11.4
HOT-1 no.
17:44:12.1
HOT-2 [sound similar to laughter].
17:44:14.0
HOT-1 we got too much tailwind we can't do it.
17:44:15.6
HOT-2 yea with six.
17:44:16.2
HOT-1 that's our savior.
17:44:17.4
HOT-2 yup.
17:44:17.6
HOT-1 [sound similar to laughter].
17:44:18.1
HOT-2 get another one in a few.
17:44:19.7
HOT-1 ah huh.
17:44:21.0
HOT-2 let's see.
17:44:34.9
HOT-1 well you want your own copy?
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Attachment II – Transcript - Page 32
17:44:36.8
HOT-2 yeah that'd be great.
17:44:45.5
HOT-2 ah I don't feel like doin' the rest of this.
17:44:47.9
HOT-2 we got the meat 'n potatoes.
17:44:50.3
HOT-2 let's see.
17:45:13.7
HOT-2
oh there is some more stuff in here. three nine one
(that's).
17:45:20.4
CAM-2 kinda gives ya the --
17:45:21.7
CAM-1 [sound similar to violent sneeze]. * *.
17:45:22.7
CAM-2 bless ya.
17:45:40.6
HOT-1 alright let me look in there.
17:46:00.4
HOT-1
alright. I said I sent ah. okay what is it? (Maryland’s)
I'm Midway status for zero zero five zero ETA.
17:46:07.5
HOT-2 cool.
17:46:09.0
HOT-1 sent.
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Attachment II – Transcript - Page 33
17:46:42.1
HOT-2
ah it says you can put clutter in but if there is clutter
you can only have a twenty knot crosswind limit.
which that won't be a big deal.
17:46:51.5
HOT-1 'kay.
17:46:58.7
HOT-2 I got a PC next month ha ha this is good ha ha.
17:47:00.9
HOT-1 yah hah.
17:47:02.5
CAM-1 I gotta PT.
17:47:05.8
CAM-2
select autobrakes as required here's the operational
part of it.
17:47:11.7
HOT-1 'kay.
17:47:14.8
HOT-2 if it's operational it must be used. use the lowest...
17:47:19.1
CAM [sound similar to ACARS chime].
17:47:20.0
HOT-2 ...brake level that gets you five hundred feet.
17:47:24.6
CAM-2
if neither setting results in a stopping margin of five
hundred feet or more *
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Attachment II – Transcript - Page 34
17:47:29.3
HOT-1 huh oh.
17:47:30.8
CAM-1 not good back to you in a minute.
17:47:32.2
CAM-2 [sound similar to laughter].
17:47:32.5
CAM-1 [sound similar to laughter].
17:47:39.4
HOT-2
wow it says if neither setting results in a stopping
margin of five hundred feet or more landing is still
authorized using MAX provided a positive (starch)
stopping margin is computed.
17:48:02.4
HOT-1
what are we hurryin' to get there for then? [sound
similar to laughter].
17:48:04.9
HOT-2 yeah really.
17:48:08.7
HOT-2 uh well that I see that's in here really.
17:48:28.2
CAM-1 I'm gettin' ri- rid of all these (received messages).
17:48:30.9
HOT-2 that's cool delete delete delete.
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Attachment II – Transcript - Page 35
17:48:51.4
CAM-1
well let's see here our alternate happens to be Kansas
City or St. Louis.
17:48:57.0
CAM-2 think ah Kansas City was a little better weather.
17:49:02.3
CAM-1 let's look. **
17:49:04.0
HOT-2
think a St. Louis was snowin' a little bit (I mean)
either way.
17:49:13.3
HOT-1 let's look a St. Louie first that's the closest.
17:49:18.8
HOT-2
oh I can show you somethin' cool in here too you
probably seen it before.
17:49:28.1
CAM [sound similar to ACARS chime].
17:49:30.2
HOT-1
alright there's St Louis. alright five miles light snow
mist twenty three hundred broken forty five hundred
broken. twenty five thousand broken. 'kay.
17:49:55.7
HOT-2
okay if we touch down and we get this -- where's the
auto --
17:50:02.3
HOT-1
hang on hang on a second lets ah let's sit the
passengers down a little bit here.
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Attachment II – Transcript - Page 36
17:50:07.1
HOT-2 okay.
17:50:07.9
HOT-1 since we're gettin' in that area.
17:50:10.6
PA-2
and folks from the guys up front a few bumps [sound
of single chime] seatbelts signs comin' back on so
please folks if you're up (and about) head on back to
your seats and buckle up thanks so much.
17:50:15.9
HOT-1 **.
17:50:20.2
HOT-1 okay.
17:50:24.8
CAM [sound similar to ACARS chime].
17:50:26.5
HOT-1 I'm gonna sit the flight attendants down too.
17:50:27.9
HOT-2 okay.
17:50:28.7
PA-1
ah flight attendants go ahead and take your seats for a
few minutes as well. folks I've asked the flight
attendants to take their seats so ah make sure that
you're in your seats as well seatbelts fastened thank
you.
17:50:39.4
CAM-2 (yeah).
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Attachment II – Transcript - Page 37
17:50:40.8
HOT-1 Kansas City is - clear I like that. cold but clear.
17:50:44.6
HOT-2 clear. woo hoo.
17:50:47.9
HOT-2
that's alright aw I wanted to do this thirty eleven fer
Midway.
17:50:51.3
HOT-1 alright.
17:51:07.4
HOT-2 this one.
17:51:08.9
HOT-1 okay get that on?
17:51:09.9
HOT-2
if that pops on it says you can achieve the OPC
stopping distance by applying brakes as it would do
so if it comes on you just jam 'em baby and.
17:51:21.3
HOT-1 hmm kay.
17:51:22.2
HOT-2 hold on.
17:51:26.4
HOT-1 sounds good I can do that except where it says a -
17:51:27.6
HOT-2 et cetera da da tada.
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Attachment II – Transcript - Page 38
17:51:32.3
CAM-1 maximum thirty feet.
17:51:34.0
CAM-2 yeah that's.
17:51:34.8
CAM-1 that's outside my limits.
17:51:36.2
CAM-2 yeah.
17:51:38.1
HOT-1 that plus the tailwind.
17:51:41.4
HOT-1 wet poor tailwind.
17:51:46.6
HOT-2
eh and it says like if you want it to disarm - wow that
was a nice shooting star.
17:51:50.4
HOT-1 what was it?
17:51:50.9
HOT-2 once you land.
17:51:51.8
HOT-1 yeah.
17:51:52.2
HOT-2
if you want it to disarm ah if you start pushing on the
b
rakes and it's not letting go it says you might have to
go a little further to get it to to pop off.
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Attachment II – Transcript - Page 39
17:52:01.4
HOT-1 okay.
17:52:01.9
HOT-2
that's about the only thing that I see in here that's
different.
17:52:20.0
CAM-2
it's in my flow now so if we use it hit me or remind
me to turn that stupid thing off after we land.
17:52:37.1
HOT-1 okay I'm turnin' this off.
17:52:39.0
HOT-2 alright.
17:53:01.6
CAM-1 oh boy ah uh oh oh huh.
17:53:12.9
CAM-1 let's see here checking the just for the # of it here.
17:53:18.8
HOT-2 hey know we can do?
17:53:21.5
CAM-1 last I heard that was even worse.
17:53:24.1
HOT-2
yeah I heard 'em sayin' ah. ah they asked if there was
a ground...
17:53:29.0
CAM-2 ...groundhold but it wasn't a groundhold.
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Attachment II – Transcript - Page 40
17:53:30.8
HOT-1 just delayed.
17:53:31.0
HOT-2 they had a little bit of a delay though.
17:53:33.0
CAM [sound similar to ACARS chime].
17:53:37.9
CAM-1 quarter mile snow freezing fog.
17:53:40.2
CAM-2 wo hoo.
17:53:40.7
CAM-1 * *.
17:53:47.8
HOT-1 ILS five right approach in use.
17:53:52.1
HOT-2 I got mine out if you don't wanna dig.
17:53:53.7
HOT-1 Indy?
17:53:55.6
CAM-1
ah take a look and see what they got there they got a
HGS I think.
17:53:58.9
CAM-2 yeah I think so.
17:54:00.3
HOT-2 five five *.
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Attachment II – Transcript - Page 41
17:54:02.5
CAM-1 five right.
17:54:03.7
CAM-2 *.
17:54:10.8
HOT-2
ah brakin' action advisories I'll pull in the field
conditions for them too and see what the the brakin'
action is.
17:54:19.3
HOT-1 'kay.
17:54:22.5
HOT-2
five right CAT two and CAT three eight forty one
fifty foot seven hundred RVR.
17:54:30.4
HOT-1 okay yeah.
17:54:31.8
HOT-2 we'll see what this is.
17:54:35.1
HOT-2 ahhh.
17:54:35.7
HOT-1 one forty at ten there too.
17:54:37.5
HOT-2 yeah let's do this (field)
17:54:42.2
HOT-1 crosswind.
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Attachment II – Transcript - Page 42
17:54:43.1
HOT-2
here's some completely useless knowledge for ya.
this is great when you have two alternates.
17:54:50.9
HOT-1 one right.
17:54:55.1
HOT [sound similar to ACARS chime].
17:54:58.0
HOT-2
I didn't mean to have it on my side (but). this thing
kicks # [sound similar to laughter] it'll give ya ETA
and fuel from your present position.
17:55:07.7
HOT-1 alright. how about that how'd ya do that?
17:55:11.7
HOT-2
$ showed me that a long time ago he's a great guy
outta Chicago.
17:55:14.1
HOT-1 huh.
17:55:15.7
HOT-1 huh.
17:55:16.2
HOT-2
I said how the # did you learn that he said I don't
know somebody else showed me.
17:55:18.7
HOT-1 ahah.
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Attachment II – Transcript - Page 43
17:55:22.1
HOT-1 Indy field.
17:55:24.5
HOT-1 wet good.
17:55:25.0
HOT-2 wet good see that's not a bad alter-
17:55:27.4
CAM-1 no.
17:55:27.8
CAM-2 what was the ceiling?
17:55:29.4
HOT-2 do you remember?
17:55:29.9
HOT-1 four hundred.
17:55:30.7
HOT-2 now see that's not bad.
17:55:37.4
HOT-1 and that'll keep changin huh?
17:55:40.2
HOT-2 yeah.
17:55:40.5
HOT-2 I.
17:55:41.5
CAM-2 oh let's see thought it did.
17:55:49.0
CAM-2 is it clicking down?
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Attachment II – Transcript - Page 44
17:55:50.1
HOT-1 (I don't).
17:55:50.6
HOT-2 yeah it is clicking down.
17:55:50.6
HOT-1 no.
17:55:52.2
CAM-2 St. Louis just *.
17:55:58.5
HOT-1 sixty seven five fifty seven.
17:56:00.7
CAM-2 takin' an awful long time.
17:56:03.9
CAM-2 (see if we) go out (then go) back.
17:56:09.0
HOT-1 sixty six.
17:56:12.8
HOT-2 guess maybe ya go back and forth.
17:56:14.5
CAM-2 but if you go between 'em
17:56:16.4
CAM-1 the (S) changed a minute earlier.
17:56:18.3
HOT-2 it also gives you ah like the closest airports.
17:56:21.7
HOT-1 'kay.
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Attachment II – Transcript - Page 45
17:56:22.6
HOT-2 it's kinda cool.
17:56:23.1
HOT-1 closest one is Columbus.
17:56:25.6
CAM-1 how did ya get to that point.
17:56:27.5
CAM-2 this.
17:56:28.2
CAM-1 say I'm right here.
17:56:29.4
CAM-2 yeah.
17:56:30.1
HOT-1 you have to do it on (both)?
17:56:30.1
HOT-2 ya have to.
17:56:31.2
CAM-2 yeah.
17:56:32.3
HOT-2
* I guess you can pay fer the software but we didn't
pay for it so you gotta do like jump through a bunch
of hoops.
17:56:37.6
HOT-2 hit that INIT reference page.
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Attachment II – Transcript - Page 46
17:56:38.4
CTR
Southwest twel- twelve forty eight descend maintain
flight level three eight zero.
17:56:42.7
PA-2 flight level three eight zero Southwest.
17:56:45.4
RDO-2
flight level three eight zero Southwest twelve forty
eight.
17:56:47.3
HOT-2 hate when I do that.
17:56:47.3
HOT-1 (three) eight zero.
17:56:48.7
CAM-2
people in the back know we're goin' to three eight
zero.
17:56:50.2
HOT-1 ha ha.
17:56:51.9
HOT-2 if ya hit ya hit this button.
17:56:56.1
CAM-2 ya get to the index wa --
17:56:58.5
HOT [sound similar to single chime].
17:56:59.7
HOT-1 I'm sorry say eh which one?
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Attachment II – Transcript - Page 47
17:57:01.0
HOT-2 hit the INIT REF.
17:57:01.6
HOT-1 initial reference at same time
17:57:03.3
CAM-2
* you don't have to a -- [sound similar to single
chime] the only thing you have to do at the same time
is.
17:57:06.6
CAM-1 delete 'em.
17:57:07.4
CAM-2
so you can just go. go to the main index page. and go
to the offset mode.
17:57:13.4
CAM-1 alright.
17:57:14.0
CAM-2
and then you can you can have this guy do it er have
me do it or you can do it. and then go to offset.
17:57:17.6
CAM-1 go to offset alright and then what?
17:57:19.3
HOT-2
either side you just put in any offset. (just) one right
er one left er.
17:57:21.3
HOT-1 okay.
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Attachment II – Transcript - Page 48
17:57:23.2
HOT-1 'kay.
17:57:24.6
HOT-2 and eh ya only have to do it in one.
17:57:26.3
HOT-2
the only thing you have to do at the same time is you
have to hit erase right at the same time.
17:57:30.1
HOT-1 alright.
17:57:30.8
HOT-2
eh I think if you do yours a little bit quicker it'll put
'em on yer side if you do mine like a split second
quicker. I'll try to do it on-.
17:57:36.0
HOT-1 alright.
17:57:39.5
CAM-2
see now I'll put it on your side. now you can kinda
play back and forth.
17:57:43.1
CAM-1 alright.
17:57:43.9
CAM-2 there'll be a test later. [sound similar to chuckle].
17:57:49.9
HOT-1 zero zero two one huh? to Columbus.
17:57:54.5
HOT-1 it's close.
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Attachment II – Transcript - Page 49
17:57:56.3
HOT-2 yeah.
17:57:58.5
CAM-2 we should be able to get the new weather now.
17:58:00.3
CAM-1 just passed over.
17:58:01.3
CAM-2 the bummer is like.
17:58:02.8
HOT-2
if you click out of that 'cause you wanna see a
progress page you gotta do the whole thing again to
get back to it.
17:58:08.0
HOT-1 yeah.
17:58:26.1
CAM [sound similar to ACARS chime].
17:58:27.8
HOT-1 Sierra.
17:58:30.7
HOT-2 quarter mile. can't do that.
17:58:32.5
HOT-1 can't do it.
17:58:35.6
HOT-2 see. oh.
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Attachment II – Transcript - Page 50
17:58:40.6
HOT-1
well if they call that quarter mile and three thousand
we can do it.
17:58:44.5
HOT-2
four left two two right three one only runway open's
three one center.
17:58:47.6
HOT-1 yeah.
17:59:09.1
CAM [sound similar to ACARS chime].
17:59:10.5
HOT-2 see what that has to say.
17:59:14.5
HOT-2 wet poor wet poor no clutter wet poor.
17:59:17.4
HOT-1 yeah but its what they tell us.
17:59:19.0
HOT-2 yeah.
17:59:21.5
HOT-1 verbally that counts.
17:59:22.8
HOT-2 yup.
17:59:27.0
CAM-2 well the weather outside. [in a sing song voice].
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Attachment II – Transcript - Page 51
17:59:28.1
CTR
Southwest twelve forty eight contact Indy center one
two eight point seven seven.
17:59:32.0
RDO-2
two eight seven seven you have a great night Southwest
twelve forty eight.
17:59:35.1
CTR you too.
17:59:37.8
RDO-2
howdy center Southwest twelve forty eight at flight
level three eight zero.
17:59:40.6
CTR Southwest twenty forty eight Indy center roger.
17:59:45.4
HOT-1 [unintelligible vocalizations].
17:59:49.3
HOT-2 * * *.
18:00:23.3
HOT-2 the weather outside is frightful [in a sing song voice].
18:00:27.2
HOT-1 the weather outside is rosey.
18:00:29.4
HOT-2 [sound similar laughter].
18:00:30.8
HOT-1 [sound similar to humming].
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Attachment II – Transcript - Page 52
18:00:31.2
HOT-2 and I -- ten thousand at AWSUM.
18:00:40.0
HOT-2 oh'right.
18:00:50.1
CAM [sound similar to ACARS chime].
18:00:51.4
CAM-2 uh oh there he is it's your friend dispatch.
18:01:02.2
CAM-1 well alright aloha. [sound similar to laughter] alright.
18:01:05.8
CAM-2 I'll ask him how's the RVR.
18:01:53.3
HOT-1 $.
18:01:54.9
HOT-2 [sound similar to laughter].
18:01:57.5
CAM-1 * and $. [in a sing song voice]
18:02:09.2
CAM-2 the weather outside is. [in a sing song voice]
18:02:12.7
CAM [sound similar to ACARS chime].
18:02:14.2
CAM-2 oh oh oh oh oh oh. [in a sing song voice]
18:02:23.9
HOT-2 right now it's at fifty five hundred.
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Attachment II – Transcript - Page 53
18:02:27.1
CAM-2 whoo.
18:02:28.5
CAM-1 alright that's good.
18:02:30.2
CAM-2 that's is das'n zere gud.
18:03:17.3
CAM-1 da da da da da. [in a sing song voice].
18:03:22.3
HOT-2 you working Christmas $?
18:03:23.9
HOT-1 say again?
18:03:24.5
HOT-2 you working Christmas?
18:03:25.5
HOT-1 I am working Christmas.
18:03:26.8
HOT-1 be where ya gotta be.
18:03:28.5
CAM-1
I picked it up for a guy so he could be home with his
three year old and ah six year old.
18:03:33.3
CAM-2 aren't you a nice guy.
18:03:35.9
CAM-2 where ya gonna be.
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Attachment II – Transcript - Page 54
18:03:37.5
CAM-1 ah I just do a turn.
18:03:39.0
CAM-2 oh cool.
18:03:39.9
CAM-1 back through Baltimore unfortunately.
18:03:42.4
CAM-1 there's nothin' there.
18:03:43.4
CAM-2 yeah.
18:03:45.9
CAM-2 you're a good man.
18:03:50.8
HOT-1 hmmm.
18:04:13.8
HOT-2 do you wanna let the girls up again.
18:04:15.4
HOT-1 oh yeah.
18:04:18.0
HOT-1 yeah go ahead.
18:04:18.6
HOT-2 I'll be right back.
18:04:20.7
HOT-2 let everybody up?
18:04:21.8
HOT-1 sure.
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Attachment II – Transcript - Page 55
18:04:23.2
HOT [sound similar to double chime].
18:04:28.3
INT
[non-pertinent conversation between pilots and flight
attendants not transcribed].
18:05:00.7
PA-2
hey folks and from the guys up front you have a few
minutes if you need to get up again ah you sure can
do so * * * * * into Chicago in ah about another
thirteen minutes and that's when I'll turn the seatbelt
sign back on thanks so much folks a total distance
two hundred twelve miles looks good to be in the
gate ah touchin' down at fifty after in the gate about
fifty five past. thanks so much folks.
18:05:26.3
CAM-2 alright.
18:05:28.3
CAM-1 yeah.
18:05:37.5
CAM-2 one hundred at (nine). * *.
18:05:45.9
CAM-2 * *.
18:05:48.3
CAM-2 vertical visibility a hundred feet. woo hoo.
18:05:52.1
CAM-1 huh.
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Attachment II – Transcript - Page 56
18:05:53.6
CAM-2
*. go around thrust TOGA. [sound similar to
laughter]
18:05:57.6
CAM-1 yeah.
18:05:59.6
CAM-2 ah they got four right open.
18:06:05.7
CAM-2
I'll put in ah well he said it was good I'll put in fair
just for # and giggles.
18:06:10.5
HOT-1 okay.
18:06:11.6
HOT-1 yeah.
18:06:13.4
CAM-1 still snowin' isn't it?
18:06:14.5
CAM-2 yeah freezin' fog.
18:06:16.8
HOT-2 which means type four on the way out.
18:06:20.2
HOT-1 yup.
18:06:23.1
HOT-2 gonna be an expensive night tonight.
18:06:24.8
HOT-1 yeah that is.
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Attachment II – Transcript - Page 57
18:07:35.6
HOT-1
you I don't know if I'm comfortable usin' the
autobrakes * in --
18:07:39.2
HOT-2 yeah.
18:07:39.5
HOT-1 in ah in this ah situation.
18:07:43.4
HOT-2 first time.
18:07:44.3
CAM-1
you know havin' not even seen 'em operate before
and then all of a sudden go in with a.
18:07:47.9
CAM-2 yeah.
18:07:50.7
CAM-2 it's MAX now.
18:07:51.3
CAM-1 number three.
18:07:52.8
CAM-2 yeah you gotta use MAX now.
18:07:55.6
CAM-2 to get five sixty it's a eight knot tailwind.
18:08:00.9
CAM-1 #.
18:08:02.9
CAM-2 we gotta check if it's fair.
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Attachment II – Transcript - Page 58
18:08:06.2
CAM-1 yeah.
18:08:07.1
CTR
ah Southwest twelve forty eight descend and maintain
flight level three six zero.
18:08:10.7
RDO-2
flight level three six zero Southwest twelve forty eight
you have any complaints about the rides in the descent?
18:08:14.9
CTR
I think what's - in this area anyway its ah twenty and
below are the only bad rides.
18:08:21.1
RDO-2 okay thanks alot.
18:08:23.4
CAM-2 alright.
18:08:24.5
CAM-1 three six zero down.
18:08:31.2
CAM-2 this is wet fair.
18:08:35.1
CAM-1 wet good we don't need it right?
18:08:43.1
CAM-2 there's ten.
18:08:46.2
CAM-2 can't do poor.
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Attachment II – Transcript - Page 59
18:08:49.3
CAM [sound similar to metallic clank].
18:09:03.7
CAM-2 (let me make) sure nothing's broke.
18:09:05.7
CTR
*** if able cross three five ah thirty miles south of Fort
Wayne at maintain flight level three zero zero.
18:09:13.1
CAM-2 * (percent) *.
18:09:13.2
RDO-2 thirty this side of (Fort Wayne).
18:09:17.1
CAM-1 (stay) this side at three zero zero.
18:09:18.9
CAM-2 should be able to do that.
18:09:20.4
CAM-1
so let me put ah I've already got twenty so another
ten huh?
18:09:24.5
CAM-2 thirty this side of Fort Wayne not *.
18:09:26.2
CAM-1 oh Fort Wayne.
18:09:27.2
CAM-2 yeah.
18:09:27.4
CAM-1 oh yeah that's thirty nine miles.
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18:09:29.4
CAM-1 there ya go.
18:09:30.5
CAM-2 'at's.
18:09:33.9
CAM-1 three zero zero.
18:09:35.0
CAM-2 (got it).
18:09:39.1
HOT-1 (it's) *.
18:09:40.6
CAM-2 (operative).
18:09:50.9
HOT-2 why does it do that?
18:09:52.6
HOT-1 hm hm.
18:09:55.0
HOT-2 sometimes they.
18:09:55.8
CAM-1
well I got sixteen miles to get down I'll just get on
(down).
18:09:58.5
CAM-2 it's really crazy sometimes I don't know why (yeah).
18:10:05.7
HOT-1 I can do it.
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Attachment II – Transcript - Page 61
18:10:07.7
CAM-2 (maybe it) won't let you the next one *.
18:10:10.5
HOT-2 yeah I don't know why ah.
18:10:15.7
CAM-1
oh well we're gonna make it. got fourteen miles to do
it.
18:10:17.8
CAM-2 yeah.
18:10:19.0
CAM-2 yup.
18:10:20.1
CAM-1 (my side) ten fifteen (we're good).
18:10:23.0
HOT-1 not a problem.
18:10:23.8
HOT-2 nope.
18:10:25.0
HOT-2 it's sure not.
18:10:27.9
HOT-2 and he said below twenty it's kinda yucky.
18:10:30.2
HOT-1 yeah that's what I heard yeah. 'kay.
18:10:33.8
HOT-1
well. why don't ya hand me the doodly bopper there
for a ILS zay Z.
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Attachment II – Transcript - Page 62
18:10:40.8
HOT-2 Zee.
18:10:41.2
HOT-1 and ah or should say. not much difference really.
18:10:46.6
HOT-2 nah.
18:10:49.2
CAM-1 twenty May oh five eleven seven.
18:10:55.3
HOT-1 ten miles.
18:10:55.9
CAM-? * one thousand (three).
18:11:02.4
CAM-1
one oh nine nine three fifteen inbound seventeen
hundred at HOBEL that's (ten ten) eighty seven.
18:11:07.9
HOT-1
eight seventeen the decision height two hundred we'll
keep in the radar altimeter.
18:11:12.2
CAM-1 six thirteen is touchdown.
18:11:26.7
CTR
Southwest twelve forty eight * * * speed your
discretion (expect) vectors * * * comin' out.
18:11:34.7
HOT-1 'kay.
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Attachment II – Transcript - Page 63
18:11:35.3
RDO-2 okay where's everybody holdin'?
18:11:39.3
CAM-1 (alright) we'll slow 'er down.
18:11:43.4
HOT-1
so anyway six thirteen touchdown ah we got the
minsafes there they're at twenty eight and thirty four
north.
18:11:50.0
HOT-1 ahmm.
18:11:53.0
HOT-1
we got all those special aircrew certification required
we got that ah lead in REILs VASIs HIRLs RVR
three one center must be operating and DME
required. ahmm need three thousand RVR three
degree glideslope. if we have to go missed approach
it's climb to eleven hundred feet then ah climbing left
turn to twenty one via heading one five zero * the
PEON VOR zero zero one until crossing the IGECY.
18:11:56.6
HOT [sound similar to ACARS chime].
18:12:00.4
CAM [sound similar to altitude warning horn].
18:12:31.2
HOT-2 you're at thirty.
18:12:31.9
HOT-1 - intersection then climb to twenty six. fracken a.
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Attachment II – Transcript - Page 64
18:12:35.8
HOT-2 (I know).
18:12:36.1
HOT-1 what a #.
18:12:38.0
HOT-1
so anyway what we'll do we'll (hook) it up. if we
have to go around it's ah go around thrust TOGA
flaps fifteen landing gear up.
18:12:48.9
CAM-2 L-NAV [sound similar to laughter].
18:12:50.2
CAM-1 L-NAV [sound similar to laughter].
18:12:52.7
CAM-2 yeah # it.
18:12:53.6
CAM-1
L-NAV # it and then we'll clean it up as required
okay.
18:12:56.5
HOT-2 okay.
18:12:56.9
HOT-1 you double check that get a good IDENT.
18:12:59.3
HOT-2 I'll just write it down.
18:13:00.3
HOT-1 yeah.
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Attachment II – Transcript - Page 65
18:13:01.1
CAM-2 and you - since you're gonna be flying it.
18:13:04.7
CAM-2 eight seventeen.
18:13:09.1
CAM-1 and.
18:13:14.0
CAM-1
we'll probably take her down the end turn off see
what the weather's like. [sound similar to chuckle]
18:13:20.5
HOT-1 flaps forty.
18:13:23.0
HOT-2 MAX brakin'.
18:13:28.5
CAM-1 ('kay) hold airspeed.
18:13:36.2
HOT-2 * *.
18:13:46.0
CTR
Southwest twelve forty eight * *direct GOSHN descend
and maintain flight level two eight zero.
18:13:51.5
RDO-2 direct GOSHN flight level two eight zero Southwest.
18:13:53.7
CAM-1 direct GOSHN how's that look?
18:13:55.1
CAM-2 yeah GOSHN (you can) * *.
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Attachment II – Transcript - Page 66
18:13:56.6
CAM-1 two eight zero.
18:13:57.7
CAM-2 okay.
18:13:58.0
CAM-1 here we go.
18:14:11.2
CAM-2
ah we have this missed in here? ah three one center
eleven hundred one fifty IGECY * .
18:14:19.7
HOT-1 and all the altitudes in there good.
18:14:21.5
HOT-2
ahhh what's the eight seventeen. we need three
thousand. or five (eighths). okay. that's good enough
for me.
18:14:40.5
HOT-1
I'll hold around two twenty does that sound good to
you?
18:14:42.8
HOT-2 sure.
18:14:43.1
HOT-1 you know actually I don't need this anymore.
18:14:44.9
HOT-2 you don't need it?
18:14:46.1
HOT-1 I don't believe so.
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Attachment II – Transcript - Page 67
18:14:47.2
HOT-2 okay.
18:14:49.5
CAM-1 see.
18:14:52.9
CAM-2
I looked in the NOTAMS on the on the ATIS and it
didn't say anything was out.
18:14:56.5
CAM-1 okay good.
18:14:57.1
CAM-2 it looks like all that stuff * *.
18:14:59.2
CAM-1 'kay.
18:14:59.5
CAM-2
if you want it 'cause you're flyin' it's cool I wrote it
down.
18:15:01.6
HOT-1 no you need you need it. yeah you need it there.
18:15:03.9
HOT-2 okay.
18:15:04.2
HOT-1 I'm good with it.
18:15:05.1
HOT-2 okay.
18:15:05.5
HOT-1 I trust ya.
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Attachment II – Transcript - Page 68
18:15:06.3
HOT-2
whatever makes you happy I don't care. twenty nine
twenty eight.
18:15:10.6
HOT-1 twenty nine twenty eight.
18:15:12.1
HOT-2 how we doin' here?
18:15:13.1
CAM [sound similar to altitude warning horn].
18:15:14.9
CAM-? * * .
18:15:47.2
CAM-1 and I think as far as the autobrakes go.
18:15:49.6
HOT-1 I think I will use ah manual braking.
18:15:53.8
CAM-? *.
18:15:54.7
HOT-1 yeah.
18:15:55.3
HOT-2 (okay).
18:15:55.3
HOT-1 we'll try 'em into Vegas. if that's alright with you.
18:15:59.7
HOT-2 do you really wanna?
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Attachment II – Transcript - Page 69
18:16:01.0
HOT-1 huh?
18:16:01.5
HOT-2 you really wanna?
18:16:03.0
CAM-1 you want to try 'em into Midway?
18:16:04.9
CAM-2
I know they work better than we do at least that's
what my buddy told me. he said they kick ass. like
you'll be when you land in MAX you it it is gonna
get maximum braking out of the aircraft.
18:16:14.8
CAM-1 yeah.
18:16:17.5
CAM-1
I you know I just I don't know I don't know what to
do. like if it starts to and it starts.
18:16:18.8
CAM-2 [sound similar to laughter].
18:16:25.4
CAM-2 yeah.
18:16:25.9
CAM-1 takin' us off course ya know?
18:16:27.7
CAM-2 yeah.
18:16:28.1
CAM-1 then I gotta come in ah brake it.
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Attachment II – Transcript - Page 70
18:16:31.1
CAM-1 I guess.
18:16:31.9
CAM-2 I *.
18:16:32.1
CAM-1 let me think about maybe we can do it.
18:16:34.1
CAM-2 eh I would be cool with whatever your decision is.
18:16:36.7
CAM-1 okay.
18:16:37.9
CAM-2 fine.
18:16:39.4
CAM-1 it's the old guys fear of.
18:16:41.3
CAM-2 [sound similar to laughter].
18:16:42.1
CAM-1 [sound similar to laughter].
18:16:42.5
CAM-2 they say it's better it's better than we could ever be.
18:16:45.4
CAM-1 yeah okay.
18:16:46.1
CAM-2
but that's cool I will you know what I'll be happy
with whatever you decide.
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Attachment II – Transcript - Page 71
18:16:49.4
HOT-1
well keep talkin' I I I guess we could do it let's let's
see what the conditions are up there. we'll do it.
18:16:58.7
HOT-1 if you're comfortable with that I am too.
18:17:00.8
CAM-2 I will be happy with whatever you decide.
18:17:08.3
CAM-1 if it goes to ah autobrake.
18:17:10.8
CAM [sound similar to ACARS chime].
18:17:11.3
CAM-1 eh uh oh.
18:17:14.9
CAM-2 then you just jump on it as hard as you can.
18:17:17.0
HOT-1 yup.
18:17:19.5
CAM-2
if I'm not already there for ya. [sound similar to
laughter]
18:17:21.2
HOT-1 yeah.
18:17:23.3
HOT-2 hey it's bumpy.
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Attachment II – Transcript - Page 72
18:17:24.5
CAM-2
Pennsylvania New Jersey Ohio Indiana Wisconsin
my # Detroit. eastern Kentucky western Kentucky
West Virginia Virginia.
18:17:34.3
HOT-2 code three one eight oh to three two oh.
18:17:37.8
HOT-1 'kay.
18:17:38.2
HOT-2 mostly below thirty.
18:17:45.7
HOT-2 well the weather -- [in a sing song voice]
18:17:46.6
HOT-1 the other part of my briefing is.
18:17:49.0
HOT-2 *.
18:17:49.4
HOT-1
on this day If we're all together here. if. sometimes
when we do a descent checklist you know we're so
far out that ya switch things around a little bit.
18:17:57.6
HOT-2 oh.
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Attachment II – Transcript - Page 73
18:17:58.0
HOT-1
so if I'm ever in a position down there and I'll do the
same for you. on approach or whathaveyou and you
would normally have the localizer course in or the
frequency in and and I don't have it in there say
sumpin'.
18:18:07.4
HOT-2 okay.
18:18:11.1
HOT-2
and ah you can't hurt my feelings you can try if I'm
not doin' what - .
18:18:12.9
HOT-1 [sound similar to laughter].
18:18:14.2
CTR
Southwest twelve forty eight turn right heading three
five zero for sequence maintain, two hundred and fifty
knots. well what are you doing right now actually for
knots?
18:18:23.2
HOT-1 two ten.
18:18:23.8
RDO-2
we're slowed to two ten we're heading right to three
fifty for Southwest twelve forty eight.
18:18:27.6
CTR
and Southwest twelve forty eight you can keep your
current airspeed fly heading three five zero they're out
of the hold they gotta sequence you now.
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Attachment II – Transcript - Page 74
18:18:33.0
RDO-2
okay great three fifty heading and two ten Southwest
twelve forty eight.
18:18:38.4
CAM-1 two fifty heading.
18:18:39.3
CAM-2
if I'm not doin' what you asked me to do it's not
because I'm disobeying you it's 'cause I'm stupid and
so sometimes this this is the most effective thing that
ya ha ha.
18:18:49.7
CAM-1 well sometimes I might not hear ya.
18:18:51.6
CAM-2 [sound similar to laughter].
18:18:54.5
HOT-1 ya can't hurt my feelings by yelling.
18:18:56.1
HOT-2
you can feel free to smash me right over the head
with that thing.
18:18:58.5
HOT-1 yeah.
18:19:02.0
CAM-1 now we're gonna pick up some speed.
18:19:03.7
CAM-2 yeah.
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Attachment II – Transcript - Page 75
18:19:05.9
CAM-2 I told you two ten not three ten.
18:19:08.0
CAM-1 uhuh.
18:19:08.4
CAM-2 [sound similar to laughter].
18:19:10.8
CAM-1
alright three five zero come on baby. what's the story
here?
18:19:14.3
CTR
Northwest twelve forty correction Southwest twelve
forty eight descend and maintain flight level * five zero.
18:19:19.7
RDO-2 * level two five zero Southwest twelve forty eight.
18:19:22.1
HOT-1 alright two five zero there we go.
18:19:23.6
CAM-1 go ahead and * * * *.
18:19:25.0
CAM-2 yeah.
18:19:27.7
HOT-1 five zero.
18:19:28.4
HOT-2 (three) fifty (now).
18:19:29.3
CAM-1 down to a two five.
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Attachment II – Transcript - Page 76
18:19:30.4
CAM-2 alright.
18:19:31.3
CAM-2 I'm gonna sit 'em down. * *.
18:19:32.9
CAM-1 okay yeah yeah. sounds good.
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Attachment II – Transcript - Page 77
18:19:36.4
PA-2
* * * * startin' our very gradual descent into Chicago
Midway airport [sound similar to single chime] ah
seatbelt signs comin' back on so folks please if you're
up and about head on back to your seats * * * for the
duration. there's only a hundred and twenty three
miles between us and the airport. ah that's the good
news * * * get our sequence into arrival * * * * into
Chicago * * * * ah out of the east a ten miles an hour
ah low visibility due to on and off light snow and it's
very chilly it's only twenty five degrees. folks again
ah * * * * * this evenin' ah we sure do appreciate all
your patience and understanding and all and we
welcome you to Chicago folks if you're continuing ah
da ah Las Vegas and then ah finally to Salt Lake City
with us we're gonna be on the ground in Chicago
hopefully for only about twenty five minutes and
we're gonna get you (safely on your way) yeah folks
thanks so much for your patience and understanding
tonight (and we hope) everybody has a wonderful
night on your way home buckle up drive safely and
next time you're gonna go flying we'd sure love for
you to come back and see us again here at Southwest
thanks so much folks good night.
18:20:23.8
CTR
Southwest twelve forty eight turn left heading three one
zero.
18:20:27.6
RDO-1 three one zero Southwest ah twelve forty (eight).
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Attachment II – Transcript - Page 78
18:20:48.7
HOT-1 down ta two four zero now.
18:20:50.3
HOT-2 twenty four I am back.
18:20:52.5
HOT-? 'kay.
18:21:04.2
CAM-2 try try to grab a gate.
18:21:06.4
CAM-1 okay.
18:21:06.6
CAM-2 I'll be right back.
18:21:07.8
CAM-1 we won't have one.
18:21:08.9
CAM-2 yeah.
18:21:09.6
CAM-1 [sound similar to laughter].
18:21:09.6
RDO-2 hey Midway Twelve forty eight.
18:21:13.8
OPS twelve forty eight go ahead.
18:21:16.2
RDO-2
we're not on time I guess you probably knew that by
now though we're gonna be there around fifty with
thirteen eight.
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Attachment II – Transcript - Page 79
18:21:23.8
OPS
okay your gate is Alpha eleven A eleven with gate
services.
18:21:28.2
RDO-2
A eleven with the service ah you think it's gonna be
open?
18:21:31.7
OPS
ah yeah I mean the visibility is better ah the last one we
had ah the braking action was was fair snow covered
taxiways that's the last report I have.
18:21:40.7
RDO-2 it was fair you said?
18:21:42.1
OPS
ah that's the last flight that came into Chicago that's
how he reported it.
18:21:46.3
OPS
okay thanks eh and I I meant d-do you know if eleven
gonna be open?
18:21:46.7
CAM-1 she doesn't know, she doesn't know.
18:21:50.7
OPS ah yes it will.
18:21:52.0
RDO-2 great.
18:21:52.2
HOT-2 thanks.
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Attachment II – Transcript - Page 80
18:21:53.1
RDO-2 thank you.
18:21:54.4
CAM-2
yeah [sound of chuckle] we oughta get a little better
report than hers.
18:21:58.0
CAM-1 well our.
18:22:00.5
HOT-2
she made it sound like there hasn't been anybody that
landed for a while.
18:22:02.8
HOT-1
yeah our twenty one year old at at a a operations said
it was poi fair.
18:22:07.9
CAM-2 [sound similar to laughter].
18:22:08.5
CAM [sound similar to altitude warning horn].
18:22:09.0
CAM-2 whaddya mean we did sumpin' wrong?
18:22:10.1
CAM-1 twenty four nine twenty four.
18:22:14.8
CAM-2 twenty four nine is twenty four.
18:22:23.7
CAM-1 Alpha eleven.
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Attachment II – Transcript - Page 81
18:22:25.2
CAM-2 yeah.
18:22:25.5
CAM-1 that's right way the # over there.
18:22:26.2
CAM-2 * *.
18:22:27.1
CAM-2 horrible Potbellies * *.
18:22:29.6
CAM-2 ah it's not so bad.
18:22:30.4
CAM-1 it's not so bad.
18:22:32.0
CAM-1 somebody had the number.
18:22:34.7
CAM-1 let me (ask 'em) * there.
18:22:40.1
CAM-1 what are you going to have?
18:22:41.7
CAM-2 ahhh.
18:22:44.9
INT-1 hello.
18:22:45.9
INT-1 hey you guys got the number to Potbellies?
18:22:48.2
FA no.
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Attachment II – Transcript - Page 82
18:22:49.7
INT-1 why not?
18:22:50.6
FA I don't know.
18:22:51.6
FA do you have the number to Potbellies?
18:22:53.5
FA
(bummer) (good job) * * * (I don't know how) * * (I
can't believe it). [sound similar to laughter]
18:22:53.9
CTR
Southwest twelve forty eight cleared direct GOSHN * *
* * at two hundred and ten knots.
18:22:59.5
RDO-2
kay two hundred ten knots direct GOSHN * *
Southwest *.
18:23:02.8
INT-1 ya don't have it.
18:23:03.8
FA nooo.
18:23:04.7
INT-1 okay well we'll just have ta we're goin' to A eleven.
18:23:12.0
CAM-1 direct GOSHN.
18:23:12.8
CAM-2 direct GOSHN two ten she said still * *.
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Attachment II – Transcript - Page 83
18:23:16.3
INT-1 oh well all right we'll see ya later. bye.
18:23:17.3
FA *.
18:23:28.5
CAM-1 two ten.
18:23:33.6
RDO-2 * * Southwest twelve forty eight.
18:23:40.4
RDO-2 ...two hundred and ten knots.
18:23:41.9
CTR
* twelve forty eight * confirmed good evening descend
and maintain one six thousand and * altimeter * three
zero one three.
18:23:49.3
RDO-2 Southwest twelve forty eight do you still * * *.
18:23:52.1
CTR ah now ah what do you wanna do? * * *.
18:23:55.3
CAM-1 (I don't know).
18:23:58.7
CTR ...how 'bout two fifty or less (from now)?
18:24:00.2
CAM-2 okay.
18:24:02.6
CAM-1 two fifty or less.
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Attachment II – Transcript - Page 84
18:24:06.9
CAM-1 okay sir we're goin' down to one six thousand.
18:24:09.8
CAM-2 (sixteen).
18:24:13.8
CAM-1 * slowly picked up speed.
18:24:15.4
CAM-2 ohhhh.
18:24:19.4
HOT-2 nice night up here.
18:24:41.9
HOT [sound similar to ACARS chime].
18:24:43.6
HOT-2 Tango.
18:24:43.9
HOT-1 Tango another new one huh?
18:24:45.8
HOT-2 quarter snow freezin' fog hundred feet.
18:24:48.2
HOT-1 oh well.
18:24:51.8
HOT-1 # man.
18:24:53.1
HOT-2 three thousand feet what's * * * .
18:24:57.1
HOT-1 [sound similar to laughter].
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Attachment II – Transcript - Page 85
18:24:58.4
HOT-2 snow (inch) three ninths?
18:25:01.0
HOT-1 I don't know.
18:25:03.3
HOT-1 snow NCR?
18:25:04.6
HOT-2 [sound similar to laughter].
18:25:07.9
HOT-1 what's that mean?
18:25:08.7
HOT-2 [sound similar to laughter] # if I know.
18:25:10.3
HOT-1 snow increasing.
18:25:12.2
HOT-2 snow increasing.
18:25:16.1
HOT-1 three to nine four to nine.
18:25:18.8
HOT-2 [sound similar to laughter].
18:25:28.7
CAM-1 one hundred at nine?
18:25:30.7
CAM-2 # I don't know.
18:25:31.4
CAM-1 alright anti-ice comin' on.
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Attachment II – Transcript - Page 86
18:25:40.1
CAM-2 * three thousand RVR * * *.
18:25:42.5
CAM-1 that what it says?
18:25:43.6
CAM-2 three thousand feet ah yeah.
18:25:44.9
CAM-1 oh three thousand feet.
18:25:46.7
CAM-2 snow increasing.
18:25:56.7
HOT-2 uh. hey now.
18:25:58.6
CTR
Southwest twelve forty eight you can resume normal
airspeed and cross AWSUM at and maintain one zero
(ten) thousand.
18:26:04.2
RDO-2
Normal speed AWSUM at ten Southwest twelve forty
eight.
18:26:07.5
HOT-2 AWSUM at ten.
18:26:08.5
CAM-1 'kay. got it AWSUM at ten.
18:26:13.3
HOT-1 well lets see. we aren't there yet. at eighteen but.
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Attachment II – Transcript - Page 87
18:26:33.9
CAM-1 nice.
18:26:46.4
CAM-2 * * * * * (it) up here *.
18:26:48.4
CAM-1 yeah.
18:26:49.9
CAM-1
ahhh (pickin') some out there. don't ya get the lights
on there for a second.
18:26:54.4
HOT-2 you got it.
18:26:56.2
CAM-2 little bit.
18:26:56.9
CAM-1 eh let's put it on.
18:26:58.0
CAM-2 alright.
18:26:58.8
HOT-1 there we go.
18:27:11.7
HOT-2
one hundred and nine is a eight knot tailwind so if
anybody says poor. we can't do it.
18:27:18.1
HOT-1 yeah.
18:27:22.9
HOT-1 it's comin' off it's comin' on.
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Attachment II – Transcript - Page 88
18:27:27.5
HOT-1
haven't gotten any on the outside on the very eh outer
edge do we?
18:27:31.4
HOT-2 ah vee looks like ah on top --
18:27:33.9
HOT-1
I mean we have it there but we don't have any anti-
ice on there.
18:27:36.0
HOT-2 (anti-) no no.
18:27:38.8
HOT-2 not there the tail. bummer.
18:27:40.3
HOT-1 eh.
18:27:45.8
CTR
* three Kilo Fox * * * * forty eight they are plowing the
runway at Midway now so the next sector is in the hold
you can expect to hold on the next frequency reaching
one zero thousand slow to two hundred and fifty knots.
18:27:50.8
CAM-2 uh oh.
18:28:09.1
CAM-1 hmm.
18:28:09.2
CTR
Southwest twelve forty eight reaching one zero
thousand maintain a speed of two five zero.
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Attachment II – Transcript - Page 89
18:28:10.3
CAM-2 * *.
18:28:13.9
RDO-2
'kay two fifty knots at ten thousand Southwest twelve
forty eight.
18:28:18.1
HOT-1 two fifty at ten.
18:28:21.6
HOT-1 'kay.
18:28:23.4
HOT-2
what do we say thirty thirty oh nine when we get
there.
18:28:24.0
HOT-1 we can do that.
18:28:27.5
HOT-1 alright lets do it thirty oh nine
18:28:35.2
HOT-1 wow.
18:28:42.3
CAM-1
well let's see what kinda lights we got here and a
descent check please.
18:28:46.8
CAM-2 altimeters and bugs.
18:28:48.8
HOT-1
well eight seventeen and ah altimeters and bugs set
and crosschecked.
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Attachment II – Transcript - Page 90
18:28:54.6
HOT-2 Vref and target.
18:28:56.4
HOT-1 whadda we got here?
18:28:58.1
HOT-2 twenty.
18:28:59.3
HOT-1 we have --
18:29:00.0
CTR
Southwest twelve forty eight expedite your descent to
one zero ten thousand please.
18:29:04.0
RDO-2
'kay we'll hurry down to ten Southwest twelve forty
eight.
18:29:08.2
CAM-1
hurryin' down. alright let me see ah one twenty five
one thirty?
18:29:13.0
CAM-2 yeah.
18:29:23.6
CAM-1 alright.
18:29:25.7
HOT-1 twenty five thirty set.
18:29:27.1
HOT-2 autobrake. [sound similar to laughter]
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Attachment II – Transcript - Page 91
18:29:29.3
HOT-1 alright four ah three four?
18:29:31.3
HOT-2 four.
18:29:31.9
HOT-1 four.
18:29:32.4
HOT-2 the big boy.
18:29:33.3
HOT-1 four for now.
18:29:34.6
HOT-1 set #.
18:29:36.5
HOT-2
[sound similar to chuckle] hey to get there you have
to pull it out.
18:29:39.0
HOT-1 alright.
18:29:40.3
HOT-1 that's what she said.
18:29:41.2
HOT-2 [sound similar to laughter] *.
18:29:43.8
HOT-1 are auto.
18:29:45.7
HOT-2 start switches.
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Attachment II – Transcript - Page 92
18:29:46.5
CAM-1 are continuous.
18:29:48.2
CAM-2 and a recall.
18:29:50.3
HOT-1 clear.
18:29:51.3
HOT-2 Alpha eleven.
18:29:53.0
CAM-1 alright.
18:29:55.6
HOT-2 descent check is complete.
18:30:02.1
HOT-1 oh no.
18:30:02.1
HOT-2 * * Elmo.
18:30:03.4
HOT-1 uh oh.
18:30:08.3
HOT-1 hm hm I don't like Elmo.
18:30:10.9
CAM-2
(usually) what follows Elmo. [sound similar to
chuckle].
18:30:10.9
CAM-1 Elmo's good.
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Attachment II – Transcript - Page 93
18:30:14.6
CAM-2 is a da da da da I got a four year old I love Elmo.
18:30:19.8
CAM-1 yeah Elmo's good. that respect.
18:30:22.5
HOT-2 how many kids did you have.
18:30:23.7
CAM-1 I have three ah --.
18:30:25.6
CTR -- two five zero.
18:30:27.0
HOT-1 two five zero.
18:30:27.2
RDO-2 heading two five zero Southwest twelve forty eight.
18:30:29.6
HOT-1 I have uhm.
18:30:33.2
CAM-1 yeah three children and two grandchildren.
18:30:37.5
HOT-2 two grandkids any more grandkids on the horizon?
18:30:39.9
HOT-1 nah not yet.
18:30:41.0
HOT-2 yeah.
18:30:41.8
CAM-1 although my oldest son got just got married so.
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Attachment II – Transcript - Page 94
18:30:44.9
HOT-2 ah that's cool.
18:30:45.4
HOT-1
and ah he (he) been married a little over a year so
they're thinkin' about it. (they) weren't thinkin' about
it before but they are now.
18:30:49.6
HOT-2 I.
18:30:51.0
HOT-2 yeah.
18:30:52.1
CAM-2 I never told the girls to sit either.
18:30:54.6
CAM-1 well * I know I haven't told 'em to clean up yet.
18:30:57.8
CAM-2 yeah. * too.
18:31:01.7
HOT-? *.
18:31:03.4
PA-1
ah flight attendants take your seat if you haven't
already just keep your seats 'till we let ya up thanks.
18:31:19.8
HOT-1 well we're hurryin' down.
18:31:21.0
CAM-2 yeah.
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Attachment II – Transcript - Page 95
18:31:23.0
CAM-1 on the heading now.
18:31:29.4
HOT-1 (looks) good out there.
18:31:33.3
HOT-1
well let's see let's try it we'll turn it off turn the wing
off for a minute.
18:31:37.6
HOT-2 looks pretty clean to me.
18:31:39.0
HOT-1 alright and then we'll look back a little bit later.
18:31:41.9
HOT-2 (go).
18:31:47.9
HOT-1 I don't want the people back there seein' it.
18:31:49.8
HOT-2 ah don't blame ya.
18:32:06.5
HOT-1 (that's) a little better.
18:32:07.8
HOT-2 yeah not too bad.
18:32:15.8
HOT-1 little bit of stuff out there uh?
18:32:17.5
HOT-2 yeah.
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Attachment II – Transcript - Page 96
18:32:28.2
HOT-1 let's see.
18:32:31.1
HOT-1 eh its stayin' off.
18:32:32.1
HOT-2 yeah much better than before.
18:32:35.6
HOT-2 eleven for ten.
18:32:37.4
HOT-1 eleven for ten.
18:32:40.7
HOT-1 huh huh huh.
18:32:43.1
HOT-2 zero three two.
18:32:59.0
CTR
Southwest twelve forty eight maintain a speed of two
five zero knots and contact Chicago center one three
two point niner five goodnight.
18:33:05.1
RDO-2
two fifty and thirty two ninety five you have a good
night too Southwest twelve forty eight.
18:33:11.2
RDO-2
hello Chicago Southwest twelve forty eight just levelin'
a * * fifty * * * *.
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Attachment II – Transcript - Page 97
18:33:17.1
CTR
* Midway altimeter (three) zero zero * and I have
holding instructions advise when you're able to copy.
18:33:22.7
RDO-2 thirty oh seven go ahead.
18:33:24.6
CTR
Southwest twelve forty eight you're cleared to the
LUCIT intersection via direct hold southeast as
published expect further clearance zero zero five five
and now maintain one zero thousand.
18:33:37.8
RDO-2
okay LUCIT hold southeast as published zero zero five
five can you spell the fix for us?
18:33:38.3
CAM-1 spell it.
18:33:43.1
CTR
and ah Southwest twelve forty eight LUCIT intersection
is Lima Uniform Charlie India Tango ah and ah one
zero mile DME (right) there * *.
18:33:52.3
RDO-2 * * * * * * * *.
18:33:58.2
CAM-2 (LUCIT).
18:33:59.8
CAM-1 LUCIT huh? one zero miles.
18:34:02.3
CAM-2 L-U-C.
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18:34:03.3
CAM-1 how ya spell it L?
18:34:05.3
CAM-2 L-U-C-I-T.
18:34:09.6
CAM-1 C-I-T.
18:34:14.0
CAM-2 * (to go).
18:34:14.2
CAM-1 forty three miles away.
18:34:15.5
CAM-2 (we're) okay.
18:34:16.9
HOT-2 so we can go direct to there.
18:34:18.3
HOT-1
alright and then we can hold there if you would set
that I'm gonna put us LNAV into LUCIT.
18:34:41.6
CAM-2 so here's the * * Boiler Two.
18:35:08.7
CAM-1 alright can you (hit) that?
18:35:10.4
CAM-2 yeah.
18:35:11.4
CAM-1 I got LUCIT down here.
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18:35:13.9
CAM-2 hold. LUCIT
18:35:15.5
CAM-1 there ya are grab it.
18:35:16.9
CAM-2 southeast one fifty six outbound.
18:35:22.1
CAM-1 'kay.
18:35:22.6
CAM-2 right turns. ten DME legs.
18:35:23.8
CAM-1 * * okay.
18:35:28.3
CAM-2 zero zero five five.
18:35:42.2
HOT-1 'kay there it is then.
18:35:43.4
RDO-2 (Indy) Center Southwest twelve forty eight.
18:35:47.6
CTR ah Southwest twelve forty eight go ahead --
18:35:49.2
RDO-2
* * * as well LUCIT you want us to hold as published
on the Boiler Two arrival?
18:35:54.2
CTR ah yes sir that is correct * * *...
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Attachment II – Transcript - Page 100
18:35:56.8
RDO-2 ... * * * west twelve forty eight.
18:35:59.6
CAM-1 yup.
18:36:00.8
CAM-2
* we weren't on that arrival I mean you they kinda
give ya.
18:36:03.9
CAM-1 right turn is that the arrival LUCIT there?
18:36:06.6
CAM-2 yeah yeah.
18:36:07.3
CAM-1 okay.
18:36:07.8
HOT-2
I I'll back it up too for ya inbound the Chicago
Heights fourteen two. and it is three thirty six
inbound.
18:36:14.9
HOT-1
uhmm best speed is two oh seven but he gave us he
gave two fifty didn't he?
18:36:18.8
HOT-2 yeah I'll ask him too.
18:36:20.3
RDO-2 hey center Southwest twelve forty eight.
18:36:22.1
CTR Southwest twelve forty eight go ahead.
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Attachment II – Transcript - Page 101
18:36:23.6
RDO-2 can we slow down as well?
18:36:25.0
CTR ah yes sir airspeed at your discretion sir.
18:36:27.5
RDO-2 okay thanks a lot.
18:36:28.9
RDO-2 you think the fifty five will be hard time?
18:36:32.6
CTR
ah right now my understanding is ah they're just clearin'
the runway and ah I should get an update here shortly it
looks like I've got ah three jets from the west ah just
starting to go in at this time.
18:36:45.4
RDO-2
okay thanks a lot and after we exit the hold do you want
us to set the box up for the Boiler Two?
18:36:52.1
CTR
ah yes sir that would be correct ahm ah it'll be right
around * * (Midway).
18:36:56.2
CAM-1 okay good.
18:36:56.9
CAM-2 ** (thank you much).
18:36:59.0
CAM-1 alright very good.
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Attachment II – Transcript - Page 102
18:37:00.3
CAM-2
that's cool. I'll save that one * ah *ah little holding
action.
18:37:02.0
CAM-1 alright.
18:37:11.1
HOT-2 L-U.
18:37:14.0
CAM-1 alright.
18:37:15.2
HOT-1
(can you) monitor the -- I'm gonna I'll talk to the
folks real quick.
18:37:21.2
HOT-2 okay *.
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Attachment II – Transcript - Page 103
18:37:24.0
PA-1
well folks you've probably felt that ah we've slowed
here ahm we're gonna have to hold here for about ah
twenty minutes it looks like ah 'till they clear the
runway off they've been off and on doing that ah as
we've been flying into Chicago to get the braking
action ah such that we can land. so ah it's still
snowing so ah the plows are workin' on the runway
we're gonna hold and let 'em do their job and then ah
and then ah once they ah get * * * * then we'll be
heading into Chicago so they gave us a fifty five after
the hour expected approach clearance time and ah
that's when we expect to ah leave the holding pattern
and head to (Chicago) * * * * * * *.
18:38:12.3
FA
ladies and gentlemen we are ah (about to make our)
final approach into Chicago * * * make sure your
seatbelts are fastened * * lean forward and press the
silver button * * * ...
18:38:14.1
HOT-2
fer ah alternate forty seven. seventy seven. like eight
thousand would be as low as you we could go that's
probably what he's figuring out. maybe eight five
hundred be extra *.
18:38:28.9
HOT-1
* ETA zero zero four three eh? alright then we'll have
about ah twelve minutes in the fix eleven twelve. ten
thousand feet.
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Attachment II – Transcript - Page 104
18:38:42.0
HOT-2 we got a lot a extra gas so that's not.
18:38:43.6
HOT-1
got enough gas ah holding (avail) at one plus fifteen
*.
18:38:46.8
CAM-1 before we go to.
18:38:56.6
CAM-2 (where we goin') to Kansas City?
18:38:59.5
CAM-1 (let's see our worst run) Kansas City.
18:39:02.0
CAM-2 we need ah * * * *.
18:39:08.6
CAM-2 just (checking) *.
18:39:17.6
CAM-1 * (thrown it away).
18:39:19.3
CAM-2 huh.
18:39:48.1
HOT-2 yeah.
18:40:15.9
CAM-1 well let's take a peek here.
18:40:17.3
CAM-2 yeah I (knew) while you were talkin'.
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Attachment II – Transcript - Page 105
18:40:18.4
CAM-1 eh it's still good.
18:40:19.7
CAM-2 yeah.
18:40:32.9
CAM-1 got us holdin' all over the place.
18:40:34.5
CAM-2 yeah.
18:40:42.3
HOT-1
alright what so us comin' in this way whaddya think
it's gonna do?
18:40:46.7
CAM-1 left turn isn't it?
18:40:47.0
CAM-2 well let's see.
18:40:49.5
CAM-1 parallel?
18:40:50.1
CAM-2
outbound. (it is) one fifty six so it should be. right
turn. parallel.
18:41:01.7
HOT-1 so right turn you think? then the seventy?
18:41:03.8
HOT-2 yeah should turn.
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Attachment II – Transcript - Page 106
18:41:04.6
CTR
Southwest twelve forty eight expect further clearance
zero one one five.
18:41:08.5
RDO-2 zero one one five thank you.
18:41:10.7
HOT-1 alright zero one one five now. #. 'kay.
18:41:17.9
CAM-2 I think it's gonna go.
18:41:20.1
CAM-1 right?
18:41:20.7
HOT-2
right turn so right now left should be a parallel it's
gonna turn left there.
18:41:22.2
HOT-1
whadda we got here oh he's telling' us what we're
gonna do.
18:41:27.0
CAM-1 yeah that’s gonna be my guess.
18:41:27.1
CAM-2 (should) should turn left to one fifty six.
18:41:30.2
CAM-1 there ya go look at it.
18:41:31.5
CAM-2 do another lap.
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Attachment II – Transcript - Page 107
18:41:32.3
CAM-1 ha ha ha.
18:41:33.8
CAM-1 I love it.
18:41:34.6
CAM-2 that’s cool.
18:41:38.1
CAM-2 the map this is this is such a great deal. man
18:41:40.1
CAM-1 yeah aw yeah.
18:41:44.4
HOT-2
such a great great great aw hey (let's see) ATIS Golf
quarter mile and snow Indy is not a good idea.
18:41:45.1
HOT-1 I'm slowin' her down a little here.
18:41:51.7
HOT-1 naw Indy's not good.
18:41:53.4
CAM-2 so MCI? MCI was better right?
18:41:56.7
CAM-1 STL?
18:41:58.4
CAM-2 MCI?
18:41:59.0
CAM-1 yes MCI was great but that's a ways away.
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Attachment II – Transcript - Page 108
18:42:01.7
CAM-2 how much further though?
18:42:17.1
HOT-1 there he is.
18:42:17.6
HOT-2 (they're at nine).
18:42:22.0
CAM-2 (they're not).
18:42:33.8
HOT-2 nine miles at St Louis.
18:42:36.3
HOT-1 ah that's good.
18:42:37.2
HOT-2 yeah.
18:42:38.6
HOT-2 thirty right.
18:42:40.5
HOT-1 yeah we can do a St Louis that'd be best.
18:42:40.7
HOT-2 let's do this S-T-L.
18:42:44.9
HOT-1 two hundred five miles.
18:42:45.3
HOT-2 two oh five.
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Attachment II – Transcript - Page 109
18:42:47.0
HOT-2
well let's do this wa how many we don't really have
two much time forty three.
18:42:49.9
HOT-1 ah let's just enter here.
18:42:51.1
HOT-2
I was gonna put in the # again but. two oh five so
really. really this is even extra cautious 'cause I'm
sure the alternate gas is all the way to Kansas City.
18:43:02.2
HOT
[transients and sounds similar to telephone keypad
touchtone].
18:43:03.8
HOT-? *.
18:43:04.7
HOT-2
so if we did like eight or eighty five hundred we'd
still have plenty ah gas to go.
18:43:09.3
HOT-1 yeah what does it say we're gonna go over there at?
18:43:12.1
HOT-2
forty seven and thirty two, seventy nine. plus
whatever your fudge factor is.
18:43:21.3
CAM-1 'kay.
18:43:22.8
CAM-2 forty seven and then ah reserve.
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Attachment II – Transcript - Page 110
18:43:24.5
CAM-1 oh yeah yeah.
18:43:31.4
CAM-2 seems like they're startin' to get 'em goin'.
18:43:33.2
HOT-1 yeah.
18:43:38.5
HOT-2 you're gonna make some extra money tonight.
18:43:40.6
HOT-1 yeah.
18:44:03.2
HOT-1 here we go.
18:44:04.1
RDO-2
Southwest twelve forty eight's enterin' the hold at
LUCIT ten thousand.
18:44:08.8
CTR Southwest twelve forty eight ah roger thanks.
18:44:12.8
HOT-2 my pleasure.
18:44:35.0
HOT-2 it shoulda showed right turn.
18:45:13.6
CAM-2 diversion plan uplink. wow.
18:45:18.5
CAM-2
eight point * point five so that's pretty about what we
figured.
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18:45:23.0
CAM-1 that's to go where St. Louis?
18:45:24.6
CAM-2 yea that's pretty cool.
18:45:25.7
HOT-1 alright.
18:45:26.5
HOT-1 where did you get that?
18:45:27.7
CAM-2 it just said it on the bottom its.
18:45:29.1
HOT-1 huh.
18:45:30.7
CAM-2 'kay.
18:45:31.1
HOT-2 so I guess we accept.
18:45:36.0
HOT-1 hmm.
18:45:36.8
CAM-2 Detroit must be # too.
18:45:44.3
HOT-2 that'd be a lot closer too.
18:45:46.6
HOT-1 hmm oh yea some weather out here.
18:45:52.3
HOT-2 how we doing.
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Attachment II – Transcript - Page 112
18:45:52.4
HOT-1
the weather... thank you. the weather out here is
rosey.
18:45:55.0
HOT-2 ohp sorry.
18:45:55.9
HOT-1 still good uh?
18:45:56.7
HOT-2 yea looks real good.
18:45:59.3
HOT-2 oh the weather out -- here's Detroit.
18:46:03.9
HOT-1 [sound of whistling].
18:46:03.9
HOT-2 a one and a half.
18:46:08.2
HOT-1 light snow there.
18:46:09.7
HOT-2 yeah (fourteen it may not send it).
18:46:10.6
HOT-1 did they send that to us too?
18:46:12.0
HOT-2 no I just typed that in.
18:46:13.1
HOT-1 okay
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Attachment II – Transcript - Page 113
18:46:15.3
HOT-2 light to moderate rime.
18:46:16.3
CTR
and Southwest twelve forty eight ah are you flyin'
inbound ahm on the Chicago Heights one fifty (*) radial
ah right hand turns or do ya are you set up for somethin'
else.
18:46:27.1
RDO-2
uh that that’s what we're set up for we're doin' a parallel
entry so we're gonna make a left turn back to the fix in
about four more miles.
18:46:35.1
CTR Southwest twelve forty eight roger thanks.
18:46:41.8
HOT-1 very good.
18:46:42.6
HOT-2 we're not doin' a parallel the mighty box is.
18:46:45.1
HOT-1 yeah.
18:46:47.7
HOT-2
I always check and I hate when they give you fixes
that aren't on your route because then you gotta go
diggin' through the charts to see how they're depicted.
It would be easier if they just gave you the whole
instruction.
18:46:52.2
HOT-1 yeah. yeah.
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Attachment II – Transcript - Page 114
18:47:01.9
HOT-1 here we go.
18:48:01.6
HOT-1 this is awesome.
18:48:02.7
HOT-2 [sound similar to laughter].
18:48:05.7
HOT-2 we're in a three hundred it wouldn't be so awesome.
18:48:07.5
HOT-1 no.
18:48:16.5
CTR
Southwest twelve forty eight descend and maintain
seven thousand.
18:48:20.5
RDO-2 seven thousand Southwest twelve forty eight.
18:48:23.6
HOT-1 seven thousand.
18:48:24.2
HOT-2 seven.
18:48:26.5
HOT-2 glad we're not in a two hundred.
18:48:28.4
HOT-1 oh man. done enough of that.
18:48:31.5
HOT-2 yea I bet you have.
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18:48:43.0
HOT-1
let's see. we got ah okay AWSUM HALIE we
probably can - get rid of those but we got -
18:48:50.4
HOT-2 yeah (he said he) ah.
18:48:52.2
HOT-1 bring bring HILLS up or something.
18:48:53.6
HOT-2
I was gonna put in COKED an HEIGHTS but. he
said he'll probably take us to like a vector for the
thirty one center or somethin'.
18:48:59.4
HOT-1 yea.
18:49:02.3
HOT-2
HEIGHTS we could do 'cause that’s really what's
what's next. will it take you out of the hold though?
18:49:09.0
HOT-1 hmmm.
18:49:09.9
HOT-2
if we put in HEIGHTS now like in the discontinuity
it'll take you out of the hold next time won't it?
18:49:14.8
HOT-1 I'm not sure.
18:49:16.3
HOT-2 I I think it does.
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Attachment II – Transcript - Page 116
18:49:22.4
HOT-2 I think it would draw a line.
18:49:26.6
HOT-2 ah no I guess it didn't. yea it did.
18:49:35.6
HOT-2 yea it draws the line so.
18:49:37.1
HOT-1 yeah its over there.
18:49:37.2
CTR
Southwest three twenty one ah fly heading of a two
seven five intercept three one center localizer cleared to
Midway airport via radar vectors and maintain ah six
thousand.
18:49:38.2
CAM-2 that’s right. yeah.
18:49:44.8
HOT-1 alright.
18:49:45.7
CAM-2 that's good.
18:49:48.4
CAM-2 we're next they're at six thousand.
18:50:12.9
HOT-2 ah we might get one more.
18:50:20.7
HOT-1 alright. eh.
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18:50:25.8
HOT-2 what ya do before? where did you fly before?
18:50:29.0
HOT-1 what'd I fly before?
18:50:30.0
HOT-2 yeah.
18:50:30.4
HOT-1 I was Air Force guy.
18:50:31.6
HOT-2 how how long, did you retire?
18:50:32.9
HOT-1 eight for seven.
18:50:33.8
HOT-1 I was ah I been ah here eleven years so.
18:50:36.7
HOT-2 eleven years.
18:50:37.4
HOT-1 yeah.
18:50:38.8
CAM [sound similar to altitude warning horn].
18:50:38.9
HOT-1 on my eleventh year.
18:50:42.0
CAM-2 how long did you stay in the Air Force for?
18:50:43.6
HOT-1 twenty six.
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18:50:44.4
CAM-2 twenty six years how old are you?
18:50:46.8
HOT-1 I'm fifty nine.
18:50:47.9
HOT-2 are you serious?
18:50:48.5
HOT-1 yeah.
18:50:49.2
HOT-2
jeeze you'd never freakin' know it you gonna make it
its gonna change? (whaddya).
18:50:52.8
HOT-1
I don't know if the if they cha- I a November I've got
ah till November eight.
18:50:58.5
CAM-2 I hope it does.
18:51:00.2
HOT-1 yeah I hope so.
18:51:00.9
HOT-2
some of my favorite people had to go and it was too
bad $ he was * awesome guy to fly with outta
Chicago.
18:51:07.6
HOT-2 I flew ah with $ his second to last night.
18:51:11.9
HOT-1 is that right?
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18:51:12.6
CAM-2 # there's some good guys and it just # to see 'em go.
18:51:14.9
HOT-1 you ever fly with ah $?
18:51:22.8
CAM-2 fifty nine man. you'd never know it.
18:51:25.7
HOT-1 ha tell me about it.
18:51:27.6
CAM-2 my #.
18:51:31.3
CAM-1 seven thousand feet here we are.
18:51:33.4
CAM-2 seven.
18:51:52.1
HOT-2
ah I'm gonna give em a quick update since we told
'em fifty.
18:51:54.2
HOT-1 'kay.
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18:51:56.4
PA
ah folks just to give you a fast update we are
estimating one more turn in the hold they're accepting
aircraft back in ah Chicago Midway right now I think
we're about three or four in the stack so hopefully
we'll be heading that way as soon as we are we'll get
back to ya but in the meantime folks thanks so much
for your patience and hopefully we'll have you
headin' towards the airport here in just a couple a
minutes thanks.
18:52:18.6
HOT-1 well eighteen thirty's goin'.
18:52:21.9
HOT-2
yea and there is one more behind them and eh I
thought they're at six the guys in front of us but.
18:52:26.4
HOT-1 yeah.
18:52:33.0
HOT-1 the other two seven zero.
18:52:34.7
HOT-2 yeah they're heading back up.
18:52:46.1
HOT-2 it's good that they're plowin'.
18:52:58.9
HOT-1 Uniform.
18:53:00.5
HOT-2 yeah that's another new one.
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18:53:03.4
HOT-2 zero zero two four
18:53:03.9
HOT-1 light snow three quarter mile three hundred alright.
18:53:08.4
HOT-2
zero nine zero at eleven I think I'm gonna put that in
there.
18:53:10.3
CAM [sounds similar to two very faint clicks].
18:53:12.3
HOT-1 alright.
18:53:13.3
CAM-2 just in case.
18:53:19.2
CAM-2 well this this for sure kills Salt Lake City for me.
18:53:23.5
CAM-1 yeah.
18:53:32.7
HOT-2 zero nine zero at eleven.
18:53:40.3
HOT-2 thirty oh seven now oh we got that.
18:53:44.8
HOT-1 on the altimeter? okay.
18:53:44.8
HOT-2 three zero zero seven.
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18:53:49.0
HOT-2
at three quarters I could probably undo the RVR less
than four thousand. we'll leave it in just in case.
18:53:53.1
HOT-1
ahhhh well leave it in for now yeah that’s the worst
case.
18:54:02.6
HOT-1 well yeah.
18:54:04.4
HOT-2 eight knot tailwind.
18:54:10.4
CTR
Southwest ah twelve forty eight fly heading of ah two
two zero.
18:54:14.8
RDO-2 heading two two zero Southwest twelve forty eight.
18:54:17.4
HOT-1 two two zero here we go.
18:54:39.9
CAM [sound similar to two loud clicks]
18:54:47.5
HOT-2 HILLS that sounds good.
18:54:47.6
HOT-1 I got a HILLS up there but.
18:54:53.5
CAM-1 I guess we can do that and extend it.
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18:54:56.4
CAM-2 cool.
18:55:06.8
HOT-2 two fifty.
18:55:07.3
HOT-1 'kay.
18:55:07.8
CTR
Southwest twelve forty eight maintain ah two one five
knots please.
18:55:11.6
RDO-2
okay ah two fifteen on the knots Southwest twelve forty
eight.
18:55:14.3
HOT-1 three one five.
18:55:16.6
HOT-1 how's that look to you.
18:55:17.8
CAM-2 s'good.
18:55:18.8
CAM-1 'kay.
18:55:28.7
HOT [Morse code signal for G S H].
18:55:28.8
HOT-1 fifteen.
18:55:43.4
HOT-1 (oh).
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Attachment II – Transcript - Page 124
18:55:44.0
CAM-2 my side's up (the) DME for thirty one center.
18:55:44.0
HOT [Morse code signal for I M X T].
18:55:47.1
HOT-1 okay.
18:55:50.2
HOT-2 and (then) my side ID's.
18:55:52.5
HOT-1 I might as well come over there with ya.
18:55:57.8
CTR
Southwest twelve forty eight turn further right heading
zero one zero.
18:56:01.7
RDO-2 heading zero one zero southwest twelve forty eight.
18:56:03.7
CAM-1 wow right turn zero one zero.
18:56:05.9
CAM-2 yeah.
18:56:15.4
HOT [Morse code signal for I M X T].
18:56:19.6
CAM-2
your side ID's so I'm gonna take off just for real
quick second.
18:56:22.3
CAM-1 'kay.
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Attachment II – Transcript - Page 125
18:56:23.6
RDO-2 hey Midway twelve forty eight.
18:56:25.5
HOT-1 lookin' good, still lookin' good okay.
18:56:26.1
OPS twelve forty eight go.
18:56:27.7
RDO-2
hey guys ha sorry for the late update looks like about
ten after now they're just lettin' us leave holding now.
18:56:36.1
OPS okay copy that sir.
18:56:37.5
RDO-2 thank you.
18:56:40.7
PA
and folks good news we're headin' towards the airport
forty seven miles to go should be in the gate by about
ten after thanks so much. and again everybody have a
great night thanks so much for your patience.
18:56:50.1
HOT-2 I'm back.
18:56:51.2
HOT-1 okay.
18:56:52.2
CTR
Southwest twelve forty eight turn further right heading
zero two zero.
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Attachment II – Transcript - Page 126
18:56:55.9
RDO-2 zero two zero Southwest twelve forty eight.
18:56:57.9
HOT-1 zero two zero now.
18:57:00.2
HOT-2 whohoo.
18:57:10.1
HOT-1 they're everywhere they're everywhere, okay.
18:57:11.2
HOT-2 I know it.
18:57:13.1
HOT-1 well I'll be sittin' up lookin'.
18:57:27.1
HOT-1
we're gonna have a ah zero eight zero. or was it one
zero zero?
18:57:32.4
HOT-2
uhm you know what I'm sorry I didn't (even) write it
down.
18:57:34.1
CTR
Southwest twelve forty eight turn right heading zero
five zero.
18:57:37.5
RDO-2 zero five zero for Southwest twelve forty eight.
18:57:39.5
HOT-1 zero five zero.
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Attachment II – Transcript - Page 127
18:57:40.4
HOT-2 it was.
18:57:41.0
HOT-1 one hundred. at nine.
18:57:41.8
HOT-2 yea * I think it was ninety. T-U-V.
18:57:45.3
HOT-1 zero five zero.
18:57:47.6
HOT-2 zero nine zero at eleven.
18:57:48.8
HOT-1 alright zero nine zero so.
18:57:50.3
HOT-2 little bit of a right crosswind.
18:57:51.5
HOT-1
right cross so. comin' like this so I'll be lookin out
this way here. little bit *.
18:57:57.4
HOT-2 yeah.
18:58:05.7
HOT-1
we'll be kinda doin' HUD. * doin' it on the HUD.
once we get down there.
18:58:09.9
HOT-2 yeah HGS.
18:58:14.6
HOT-2 whatta we got six?
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Attachment II – Transcript - Page 128
18:58:15.3
HOT-1 two hundred.
18:58:16.8
HOT-2 six thirteen.
18:58:18.5
HOT-1 at six thirteen sixty five twenty two at three degrees.
18:58:20.9
HOT-2
three degrees and three one center is sixty five twenty
two.
18:58:27.6
HOT-2 alright.
18:58:30.2
HOT-2 # this is a long Chicago flight.
18:58:33.6
HOT-2 I probably could have finished that revision.
18:58:36.2
HOT-1 yeah so what'll they do ma- a stop ya here?
18:58:39.8
CAM-2
I don’t know ah say we got out a here by it would be
stupid to push us back have a half hour de-icing and
then have it be a four hour five minute.
18:58:49.6
CAM-2
right now nineteen. its four hours and five minutes of
block to Vegas. so say nineteen forty five at the
earliest.
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Attachment II – Transcript - Page 129
18:59:00.2
CAM-1 Hmmum.
18:59:05.6
CAM-2 so it'll be nineteen *.
18:59:11.0
CAM-2
yea I could go to Vegas I'd have twenty five minutes
extra. even if we get out by twenty hundred.
18:59:18.5
HOT-1 twenty hundred outta hear?
18:59:19.8
CAM-2 That'd be five about five minutes early. and I.
18:59:22.5
CAM-1 you got an hour.
18:59:23.5
CAM-2 if it's.
18:59:24.8
CAM-1 to get outta here.
18:59:26.0
CAM-2 yea. that would give us five minutes. if it was.
18:59:30.3
HOT-2
I mean if it was five minutes on the other end would
you care if we called it in early so I didn't make a big
problem? you know.
18:59:36.5
HOT-1 no no I don't have a problem.
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Attachment II – Transcript - Page 130
18:59:37.3
HOT-2 if it's gonna be close then.
18:59:38.6
HOT-1 yea do whatever you got the pencil.
18:59:41.5
HOT-2 okay.
18:59:42.2
HOT-1 [sound similar to laughter].
18:59:48.2
HOT-2 looking good.
18:59:48.3
HOT-1 we're looking good man.
18:59:50.1
CAM-2 looking good Billy Ray.
18:59:54.4
CAM-2 feeling good Mortimer.
19:00:23.1
CAM-2
I bet they're gonna switch me here and do something
else.
19:00:26.0
CAM-1 think so?
19:00:26.7
CAM-2 probably.
19:00:28.6
CAM-1 I don't know if they've got that far ahead --
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Attachment II – Transcript - Page 131
19:00:30.5
CAM-2 yea.
19:00:30.7
CAM-1 they can think that far ahead today.
19:00:40.0
CAM-1 you might wanna call 'em I don't know.
19:00:41.1
CAM-2 yea I'm gonna just give 'em a (call).
19:00:44.9
CAM-2 he said call me at Midway.
19:00:45.5
CTR
Southwest twelve forty eight fly heading of ah zero
three zero.
19:00:48.8
RDO-2 zero three zero southwest twelve forty eight.
19:00:52.6
HOT-1 zero tree zero here we go.
19:00:54.5
HOT-2 yeah V-P-Z Valperazo.
19:01:11.7
HOT-1 he might take us through uh.
19:01:13.4
HOT-2 yea I'm going to hard altitude these.
19:01:15.9
CTR
Southwest twelve forty eight descend and maintain six
thousand.
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Attachment II – Transcript - Page 132
19:01:19.3
RDO-2 six thousand Southwest twelve forty eight
19:01:21.4
HOT-1 down to six.
19:01:24.1
CAM-2 six.
19:01:27.3
CAM-2 seven for six.
19:01:33.9
CAM [sound similar to altitude warning horn].
19:01:35.5
HOT-1 six point nine for six.
19:01:41.3
HOT-1 its alive we're gonna go through it, yea.
19:01:43.1
HOT-2 yea.
19:01:53.1
RDO-2
you don't want us Southwest twelve forty eight to join
do ya?
19:01:55.5
CTR
ah not yet sorry about that vector through the localizer
fly heading of ah three six zero please.
19:02:01.0
RDO-2
heading three six zero no problem Southwest twelve
forty eight.
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Attachment II – Transcript - Page 133
19:02:06.0
HOT-1 three six zero.
19:02:27.1
CTR
Southwest twelve forty eight turn further left heading of
ah three er correction a two niner zero intercept three
one center localizer.
19:02:35.1
RDO-2
heading two nine zero to join three one center loc
Southwest twelve forty eight.
19:02:39.0
HOT-1 two nine zero to intercept.
19:02:40.2
CAM-2 two ninety.
19:03:02.6
EXEC 902
ah yes sir do you know if the runway is contaminated at
Midway?
19:03:05.7
CAM-2 [sound similar to laugh].
19:03:06.8
CTR it is contaminated?
19:03:08.7
EXEC 902 that's the question is it contaminated?
19:03:13.0
HOT-1 don't even think that. [sound similar to laughter].
19:03:13.9
CTR exec jet nine zero two standby.
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Attachment II – Transcript - Page 134
19:03:15.2
HOT-2
there's the ah extended if you wanna use the L-NAV
again.
19:03:19.2
HOT-1 okay.
19:03:24.0
HOT-1 we'll pick one.
19:03:25.3
HOT-2
[sound similar to laughter]. whichever one it likes
better.
19:03:31.6
CTR
Southwest twelve forty eight contact Chicago approach
one one eight point four.
19:03:35.5
RDO-2
eighteen four you have a great night Southwest twelve
forty eight.
19:03:39.5
HOT-1 it's alive.
19:03:40.6
HOT-2 yea.
19:03:41.6
RDO-2
hello Chicago Southwest twelve forty eight at six
thousand.
19:03:44.3
APR
Southwest twelve forty eight Chicago approach Victor
current intercept three one center localizer runway three
one center RVR five thousand five hundred.
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Attachment II – Transcript - Page 135
19:03:50.3
HOT-1 alright.
19:03:50.7
RDO-2
thanks alot southwest twelve forty eight we'll get
Victor.
19:03:53.2
CAM-2 we're on Victor?
19:03:53.3
CAM-1 * backup.
19:03:57.5
HOT-2 time we got.
19:04:06.0
HOT-2 * capture.
19:04:06.9
CAM-1 alright capturing.
19:04:08.8
CAM-1 victory.
19:04:11.0
CAM-2 half a mile four hundred over thirty o' six.
19:04:12.8
APR
Southwest twelve forty eight is one eight miles from
GLEAM cross GLEAM at four thousand cleared ILS
three one center approach maintain ah you're doin' two
ten correct?
19:04:14.3
CAM-1 I don't think that means - they can't keep up *.
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Attachment II – Transcript - Page 136
19:04:17.4
CAM-1 fifty five hundred (is the).
19:04:20.2
HOT-1 beautiful day.
19:04:20.7
RDO-2
we're at two ten cleared for the ILS three one center *
missed altitude if you gave us one.
19:04:24.8
APR ah four thousand cross GLEAM and two ten speed.
19:04:28.3
RDO-2
GLEAM at four thousand two ten speed and we're
cleared for the ILS three one center southwest twelve
forty eight.
19:04:32.5
CAM-1 alright here we go.
19:04:32.6
APR
Southwest twelve forty eight braking action reported
fair except at the end its ah poor.
19:04:37.1
RDO-2 okay thanks.
19:04:38.8
HOT-1 we got fair in there right?
19:04:40.2
HOT-2 yea.
19:04:40.7
HOT-1 we got the max?
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Attachment II – Transcript - Page 137
19:04:42.6
HOT-2
[sound similar to laughter] we're all we're all
counting on you.
19:04:44.2
HOT-1 [sound similar to laughter].
19:04:48.8
HOT-2 picked the wrong day to stop sniffin' glue.
19:04:51.0
HOT-1 yea.
19:04:52.4
CAM [sound similar to two clicks].
19:04:53.3
HOT-2 one more look for good measure.
19:04:56.3
HOT-2 I think you look good and clean my man.
19:04:58.0
HOT-1 alright.
19:05:02.4
HOT-2 four until GLEAM.
19:05:03.3
HOT-1 cleared the approach huh?
19:05:04.8
HOT-2 yea.
19:05:12.8
HOT-1 HILLS at four GLEAM at four.
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Attachment II – Transcript - Page 138
19:05:14.1
HOT-2
well yea he said GLEAM at four so we just have to
make sure it doesn't wanna take you lower than
GLEAM. lower than four at GLEAM.
19:05:20.4
HOT-1 yea okay.
19:05:22.7
HOT-2 I don't think it does but.
19:05:26.6
HOT-1 cleared the approach though.
19:05:31.0
HOT-2 one hundred at eleven.
19:05:33.7
HOT-2 that's just about a *.
19:05:34.1
HOT-1 [sound similar to autopilot disconnect warning horn].
19:05:38.5
HOT-1 well that was nice.
19:05:39.5
HOT-2 yea.
19:05:40.0
HOT-1 [sound similar to laughter].
19:05:42.6
CAM [sound similar to altitude warning horn].
19:05:44.0
HOT-1 alright forty nine for four.
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Attachment II – Transcript - Page 139
19:05:46.2
HOT-2 forty nine for four.
19:05:47.3
HOT-1 try it again.
19:05:51.2
HOT-1 alright.
19:05:51.8
HOT-2
yea it's I remember this you were here for a while
weren't ya.
19:05:55.8
HOT-2 were you based in Chicago for a while?
19:05:57.0
HOT-1 yea.
19:05:58.0
HOT-2 is that where I'd flown with you?
19:06:00.1
HOT-1 it was ah buh five years ago.
19:06:02.2
HOT-2 five but I wasn't I wasn't here that long.
19:06:20.7
HOT-1 what is it gonna be bumpy too or what?
19:06:22.2
HOT-2 [sound similar to laughter] what Chicago sheee.
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Attachment II – Transcript - Page 140
19:06:44.2
APR
southwest nineteen fifty two Chicago approach
intercept three one center localizer Victor's current the
runway three one center RVR now four thousand five
hundred.
19:06:51.5
HOT-2 forty five hundred.
19:06:54.6
HOT-1 # [sound similar to laughter].
19:06:56.8
APR
Southwest twelve forty eight reduce speed one seven
zero to RUNTS contact the tower at RUNTS.
19:07:01.4
RDO-2
one seventy to RUNTS tower there have a great night
southwest twelve forty eight.
19:07:04.1
HOT-1 alright slowin'.
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.
19:07:10.5
HOT-1 go flaps to ah five please.
19:07:12.9
HOT-2 flap-o de cinco.
19:07:19.1
APR southwest ninety fifty two you copy last?
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Attachment II – Transcript - Page 141
19:07:20.8
SW1952 I'm sorry sir no.
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.
19:07:51.2
HOT-1 let's see there's sixteen miles.
19:07:54.1
HOT-1 still GLEAM is at eleven uh?
19:07:55.5
HOT-1 yea.
19:08:00.8
CAM-2
once we get over to tower I'll tell him that you wanna
circle to two two left. [sound similar to laughter].
19:08:05.7
CAM-1 yea.
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.
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Attachment II – Transcript - Page 142
19:08:34.5
HOT-1 oh we don't want him.
19:08:35.5
HOT-2 no [sound similar to laughter].
19:08:37.4
HOT-2 if it's poor we don't wanna hear it.
19:08:38.8
HOT-1 no.
19:08:42.2
HOT-2 GLEAM at four.
19:08:44.3
HOT-2 after GLEAM you can go to twenty five.
19:08:45.0
HOT-1 alright landing gear down here sir.
19:08:47.8
HOT-2 landing gear down.
19:08:50.0
HOT-1 down to twenty five here we go.
19:08:55.0
HOT-1 at eleven point two huh? yea.
19:08:56.2
HOT-2 yea after GLEAM.
19:08:57.2
HOT-1 yea alright.
19:08:57.5
HOT-2 you're close.
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Attachment II – Transcript - Page 143
19:08:58.5
HOT-1 ah we're close.
19:09:00.0
HOT-2 I'll never tell.
19:09:00.8
HOT-1 yea I know.
19:09:08.0
HOT-1 close enough.
19:09:09.0
HOT-2 yea.
19:09:10.6
HOT-2 and after RUNTS we go to seventeen.
19:09:13.1
HOT-1 I'll follow the glideslope down here.
19:09:14.9
HOT-2 that's cool.
19:09:41.6
HOT-1 alright let's go flaps to ah fifteen.
19:09:43.8
HOT-2 flaps fifteen.
19:09:44.2
CAM [sound similar to metallic click].
19:09:46.4
CAM [sound similar to altitude warning horn].
19:09:53.4
HOT-1 hmm.
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Attachment II – Transcript - Page 144
19:09:53.7
RDO-2 Southwest twelve forty eight three one center.
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.
19:10:06.2
RDO-2 thank you.
19:10:07.6
HOT-1 'kay.
19:10:09.4
HOT-2
glideslope's good I'm gonna throw a twenty one for
the missed.
19:10:09.7
HOT-1 good for the first half.
19:10:11.9
HOT-1 RUNTS is six point seven alright.
19:10:16.2
HOT-1 alright glideslope looks like it's captured.
19:10:18.3
HOT-2 yea and twenty one's the missed approach altitude.
19:10:21.1
HOT-1 say again twenty one.
19:10:21.8
HOT-1 okay.
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Attachment II – Transcript - Page 145
19:10:21.9
HOT-2 that's the missed if we need it.
19:10:22.8
HOT-1 alright.
19:10:25.0
HOT-1 ah let's go flaps to thirty sir.
19:10:27.0
HOT-2 flaps thirty.
19:10:38.3
CAM-1 yea good old tailwind *.
19:10:39.9
CAM-2 yea.
19:10:41.2
TWR Gulfstream three Kilo Foxtrot say brakin' action.
19:10:41.4
CAM-1 alright flaps forty.
19:10:43.5
HOT-2 flaps forty.
19:10:46.0
G3KF fair to poor.
19:10:47.6
TWR
Three Kilo Foxtrot than ah thank you very much can
you make a left on Alpha?
19:10:52.8
G3KF standby.
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Attachment II – Transcript - Page 146
19:10:54.1
HOT-1 before landing check.
19:10:54.7
TWR if unable just let me know and go to the end.
19:10:56.1
CAM-2 speedbrake.
19:10:56.5
G3KF yea we can make a left on Alpha.
19:10:57.1
HOT-1 armed green light.
19:10:58.1
HOT-2 landing gear.
19:10:59.2
HOT-1 down three green.
19:10:59.9
HOT-2 flaps
19:11:00.4
HOT-1 forty green light.
19:11:01.4
HOT-2 before landing checks complete.
19:11:03.9
HOT-1 thank you.
19:11:04.4
CAM-2 no landing clearance yet.
19:11:05.9
HOT-1 nope.
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Attachment II – Transcript - Page 147
19:11:16.7
HOT-1
I got (a) A three just disregard the ah approach
warning if we get one.
19:11:20.4
CAM-2 got it.
19:11:31.3
HOT-1 'kay.
19:11:34.6
CAM-2 comin' over HOBEL at seventeen.
19:11:37.0
HOT-1
alright and a thousand feet one thirty six sink is a
nine hundred.
19:11:42.2
HOT-2 you can see the ground already.
19:11:43.4
HOT-1 (yea) * (good).
19:11:44.5
HOT-2 (one).
19:11:46.5
HOT-1 no peaking.
19:11:47.1
HOT-2 we're almost up to a thousand feet.
19:11:50.0
HOT-2 now we're at a thousand feet.
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19:11:51.9
HOT-1
alright yea you're right thousand feet. one thirty two
sink is ah eight fifty.
19:11:53.2
HOT-2 I always.
19:11:57.4
CAM [sound similar to autopilot disconnect warning].
19:12:00.3
HOT-2 we're all counting on you.
19:12:01.6
HOT-1 uhmhmm.
19:12:02.2
HOT-2 [sound similar to laughter].
19:12:07.8
CAM [sound similar to two clicks].
19:12:16.9
HOT-1 never autobraked here huh?
19:12:18.3
HOT-2 yeah. hang on tight [sound similar to laughter].
19:12:21.6
HOT-1 yeah.
19:12:25.3
HOT-2 five hundred.
19:12:26.6
RDO-2 landing clearance for Southwest twelve forty eight.
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Attachment II – Transcript - Page 149
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.
19:12:35.3
HOT-2 four hundred.
19:12:36.3
HOT-1 alright.
19:12:37.2
HOT-2 five green lights cleared to land.
19:12:41.0
HOT-2 approaching minimums.
19:12:42.4
HOT-1 goin' outside. landing sir.
19:12:45.6
HOT-2 alright.
19:12:46.3
CAM [sound of thump].
19:12:47.2
HOT-1 might help.
19:12:49.9
HOT-2 * a touch high on the glideslope.
19:12:50.6
CAM [sound similar to two thumps].
19:12:56.5
HOT-2 one hundred.
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Attachment II – Transcript - Page 150
19:13:01.4
HOT-2 fifty. thirty. ten.
19:13:02.7
CAM [sound similar to click].
19:13:07.1
CAM [sound similar to click and squeak].
19:13:07.8
CAM [sounds similar to aircraft touchdown].
19:13:08.5
HOT-1 oh baby I guess it comes on.
19:13:11.5
HOT-1 come on baby.
19:13:13.4
CAM-2 about two thousand feet to go.
19:13:14.7
HOT-1 feel it.
19:13:15.9
HOT-2 you jumpin' on the?
19:13:16.3
HOT-1 son of a #.
19:13:17.3
HOT-2 jump on the brakes are ya?
19:13:18.4
HOT-1 ah huh.
19:13:19.5
HOT-2 I'm ahnna.
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Attachment II – Transcript - Page 151
19:13:21.2
CAM-2 whaddya.
19:13:22.3
HOT-1 #.
19:13:23.2
CAM [sound similar to double clunk].
19:13:23.4
HOT-1 get that back there.
19:13:25.3
HOT-1 we aint goin' man.
19:13:27.5
HOT-2 we're #.
19:13:28.7
HOT-1 we are #.
19:13:30.6
HOT-1 alright keep it straight.
19:13:31.2
CAM [sound similar to increased engine noise].
19:13:35.0
HOT-2 #.
19:13:35.4
HOT-1 # hang on.
19:13:35.9
HOT-2 hang on.
19:13:36.5
CAM [sound similar to impact].
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Attachment II – Transcript - Page 152
19:13:37.3
HOT-2 *.
19:13:39.0
CAM [sound similar to impact].
19:13:39.4
HOT-2 oh #.
19:13:42.2
HOT-2 [sound similar to groan].
19:13:43.3
HOT-1 [sound similar to grunt] # me.
19:13:46.5
HOT-2 #.
19:13:47.1
HOT-1 #.
19:13:47.5
TWR
what was that? Southwest twelve forty eight are you
cleared three one center?
19:13:48.1
CAM [sound similar to stick shaker].
19:13:49.1
CAM [sound similar to chime].
19:13:51.0
CAM [sound similar to clunk].
19:13:51.4
RDO-2 Southwest twelve forty eight went over the end.
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Attachment II – Transcript - Page 153
19:13:53.5
TWR say again.
19:13:54.3
RDO-2 we went off the end of the runway.
19:13:54.4
HOT-1 shut down.
19:13:58.4
HOT-2 #.
19:14:00.6
HOT-1 shuttin' down.
[end of recording]
19:14:01.3
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Ap p e n d i x C
FAA sA F e t y Al e r t Fo r op e r A t o r s 06012
Approved by AFS-1 Page 1
SAFO
Safety Alert for Operators
U.S. Department SAFO 06012
of Transportation DATE: 8/31/06
Federal Aviation
Administration Flight Standards Service
Washington, DC
http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo
A SAFO contains important safety information and may include recommended action. SAFO content should be
especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree
of safety in the public interest.
Subject: Landing Performance Assessments at Time of Arrival (Turbojets)
1. Purpose. This SAFO urgently recommends that operators of turbojet airplanes develop
procedures for flightcrews to assess landing performance based on conditions actually existing at
time of arrival, as distinct from conditions presumed at time of dispatch. Those conditions
include weather, runway conditions, the airplane’s weight, and braking systems to be used. Once
the actual landing distance is determined an additional safety margin of at least 15% should be
added to that distance. Except under emergency conditions flightcrews should not attempt to
land on runways that do not meet the assessment criteria and safety margins as specified in this
SAFO.
2. Discussion: This SAFO is based on the FAA’s policy statement published in the Federal
Register on June 7, 2006, and incorporates revisions based on public comments received by the
FAA. Accordingly, the FAA has undertaken rulemaking that would explicitly require the
practice described above. Operators may use Operation/Management Specification paragraph
C382 to record their voluntary commitment to this practice, pending rulemaking.
Operators engaged in air transportation have a statutory obligation to operate with
the highest possible degree of safety in the public interest.
3. Applicability:
a. This SAFO applies to all turbojet operators under Title 14 of the Code of Federal
Regulations (14 CFR) parts 121, 135, 125, and 91 subpart K. The intent of providing this
information is to assist operators in developing methods of ensuring that sufficient landing
distance exists to safely make a full stop landing with an acceptable safety margin on the runway
to be used, in the conditions existing at the time of arrival, and with the deceleration means and
airplane configuration that will be used. The FAA considers a 15% margin between the expected
actual airplane landing distance and the landing distance available at the time of arrival as the
minimum acceptable safety margin for normal operations.
b. The FAA acknowledges that there are situations where the flightcrew needs to know the
absolute performance capability of the airplane. These situations include emergencies or
abnormal and irregular configurations of the airplane such as engine failure or flight control
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malfunctions. In these circumstances, the pilot must consider whether it is safer to remain in the
air or to land immediately and must know the actual landing performance capability (without an
added safety margin) when making these evaluations. This guidance is not intended to curtail
such evaluations from being made for these situations.
c. This guidance is independent of the preflight landing distance planning requirements of
part 121, section 121.195, part 135, section 135.385, and part 91, section 91.1037.
d. This 15% safety margin should not be applied to the landing distance determined for
compliance with any other OpSpec/MSpec requirement. The landing distance assessment of this
guidance is independent of any other OpSpec/MSpec landing distance requirement. The
minimum landing distance should comply with all applicable landing distance requirements.
Hence, the minimum landing distance at the time of arrival should be the longer of the landing
distance in this guidance and that determined to be in compliance with any other applicable
OpSpec/MSpec.
e. This guidance does not apply to Land and Hold Short Operations (LAHSO).
4. Definitions: The following definitions are specific to this guidance and may differ with those
definitions contained in other published references.
a. Actual Landing Distance. The landing distance for the reported meteorological and
runway surface conditions, runway slope, airplane weight, airplane configuration, approach
speed, use of autoland or a Head-up Guidance System, and ground deceleration devices planned
to be used for the landing. It does not include any safety margin and represents the best
performance the airplane is capable of for the conditions.
b. Airplane Ground Deceleration Devices. Any device used to aid in the onset or rate of
airplane deceleration on the ground during the landing roll out. These would include, but not be
limited to: brakes (either manual braking or the use of autobrakes), spoilers, and thrust reversers.
c. At Time of Arrival. For the purpose of this guidance means a point in time as close to
the airport as possible consistent with the ability to obtain the most current meteorological and
runway surface conditions considering pilot workload and traffic surveillance, but no later than
the commencement of the approach procedures or visual approach pattern.
d. Braking Action Reports. The following braking action reports are widely used in the
aviation industry and are furnished by air traffic controllers when available. The definitions
provided below are consistent with how these terms are used in this guidance.
Good – More braking capability is available than is used in typical deceleration on a non-
limiting runway (i.e., a runway with additional stopping distance available). However, the
landing distance will be longer than the certified (unfactored) dry runway landing
distance, even with a well executed landing and maximum effort braking.
Fair/Medium – Noticeably degraded braking conditions. Expect and plan for a longer
stopping distance such as might be expected on a packed or compacted snow-covered
runway.
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Poor – Very degraded braking conditions with a potential for hydroplaning. Expect and
plan for a significantly longer stopping distance such as might be expected on an ice-
covered runway.
Nil – No braking action and poor directional control can be expected.
NOTE: Conditions specified as “nil” braking action are not considered safe,
therefore operations under conditions specified as such should not be
conducted. Do not attempt to operate on surfaces reported or expected to
have nil braking action.
e. Factored Landing Distance. The landing distance required by 14 CFR part 25, section
25.125 increased by the preflight planning safety margin additives required by the applicable
operating rules. (Some manufacturers supply factored landing distance information in the
Airplane Flight Manual (AFM) as a service to the user.)
f. Landing Distance Available. The length of the runway declared available for landing.
This distance may be shorter than the full length of the runway.
g. Meteorological Conditions. Any meteorological condition that may affect either the air
or ground portions of the landing distance. Examples may include wind direction and velocity,
pressure altitude, and temperature. An example of a possible effect that must be considered
includes crosswinds affecting the amount of reverse thrust that can be used on airplanes with tail
mounted engines due to rudder blanking effects.
h. Reliable Braking Action Report. For the purpose of this guidance, means a braking
action report submitted from a turbojet airplane with landing performance capabilities similar to
those of the airplane being operated.
i. Runway Surface Conditions. The state of the surface of the runway: either dry, wet, or
contaminated. A dry runway is one that is clear of contaminants and visible moisture within the
required length and the width being used. A wet runway is one that is neither dry nor
contaminated. For a contaminated runway, the runway surface conditions include the type and
depth (if applicable) of the substance on the runway surface, e.g., standing water, dry snow, wet
snow, slush, ice, sanded, or chemically treated.
j. Runway Friction or Runway Friction Coefficient. The resistance to movement of an
object moving on the runway surface as measured by a runway friction measuring device. The
resistive force resulting from the runway friction coefficient is the product of the runway friction
coefficient and the weight of the object.
k. Runway Friction Enhancing Substance. Any substance that increases the runway
friction value.
l. Safety Margin. The length of runway available beyond the actual landing distance.
Safety margin can be expressed in a fixed distance increment or a percentage increase beyond
the actual landing distance required.
m. Unfactored Certified Landing Distance. The landing distance required by
section 25.125 without any safety margin additives. The unfactored certified landing distance
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may be different from the actual landing distance because not all factors affecting landing
distance are required to be accounted for by section 25.125. For example, the unfactored
certified landing distances are based on a dry, level (zero slope) runway at standard day
temperatures, and do not take into account the use of autobrakes, autoland systems, head-up
guidance systems, or thrust reversers.
5. Background: After any serious aircraft accident or incident, the FAA typically performs an
internal audit to evaluate the adequacy of current regulations and guidance information in areas
that come under scrutiny during the course of the accident investigation. The Southwest Airlines
landing overrun accident involving a Boeing 737-700 at Chicago Midway Airport in December
2005 initiated such an audit. The types of information that were evaluated in addition to the
regulations were FAA orders, notices, advisory circulars, ICAO and foreign country
requirements, airplane manufacturer-developed material, independent source material, and the
current practices of air carrier operators. This internal FAA review revealed the following
issues:
a. A survey of operators’ manuals indicated that approximately fifty percent of the operators
surveyed do not have policies in place for assessing whether sufficient landing distance exists at
the time of arrival, even when conditions (including runway, meteorological, surface, airplane
weight, airplane configuration, and planned usage of decelerating devices) are different and
worse than those planned at the time the flight was released.
b. Not all operators who perform landing distance assessments at the time of arrival have
procedures that account for runway surface conditions or reduced braking action reports.
c. Many operators who perform landing distance assessments at the time of arrival do not
apply a safety margin to the expected actual landing distance. Those that do are inconsistent in
applying an increasing safety margin as the expected actual landing distance increased (i.e., as a
percentage of the expected actual landing distance).
d. Some operators have developed their own contaminated runway landing performance data
or are using data developed by third party vendors. In some cases, these data indicate shorter
landing distances than the airplane manufacturer’s data for the same conditions. In other cases,
an autobrake landing distance chart has been misused to generate landing performance data for
contaminated runway conditions. Also, some operators’ data have not been kept up to date with
the manufacturer’s current data.
e. Credit for the use of thrust reversers in the landing performance data is not uniformly
applied and pilots may be unaware of these differences. In one case, there were differences
found within the same operator from one series of airplane to another within the same make and
model. The operator’s understanding of the data with respect to reverse thrust credit, and the
information conveyed to pilots, were both incorrect.
f. Airplane flight manual (AFM) landing performance data are determined during flight-
testing using flight test and analysis criteria that are not representative of everyday operational
practices. Landing distances determined in compliance with 14 CFR part 25, section 25.125 and
published in the FAA-approved AFM do not reflect operational landing distances (Note: some
manufacturers provide factored landing distance data that addresses operational requirements.)
Landing distances determined during certification tests are aimed at demonstrating the shortest
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landing distances for a given airplane weight with a test pilot at the controls and are established
with full awareness that operational rules for normal operations require additional factors to be
added for determining minimum operational field lengths. Flight test and data analysis
techniques for determining landing distances can result in the use of high touchdown sink rates
(as high as 8 feet per second) and approach angles of -3.5 degrees to minimize the airborne
portion of the landing distance. Maximum manual braking, initiated as soon as possible after
landing, is used in order to minimize the braking portion of the landing distance. Therefore, the
landing distances determined under section 25.125 are shorter than the landing distances
achieved in normal operations.
g. Wet and contaminated runway landing distance data are usually an analytical computation
using the dry, smooth, hard surface runway data collected during certification. Therefore, the wet
and contaminated runway data may not represent performance that would be achieved in normal
operations. This lack of operational landing performance repeatability from the flight test data,
along with many other variables affecting landing distance, are taken into consideration in the
preflight landing performance calculations by requiring a significant safety margin in excess of
the certified (unfactored) landing distance that would be required under those conditions.
However, the regulations do not specify a particular safety margin for a landing distance
assessment at the time of arrival. This safety margin has been left largely to the operator and/or
the flightcrew to determine.
h. Manufacturers do not provide advisory landing distance information in a standardized
manner. However, most turbojet manufacturers make landing distance performance information
available for a range of runway or braking action conditions using various airplane deceleration
devices and settings under a variety of meteorological conditions. This information is made
available in a wide variety of informational documents, dependent upon the manufacturer.
i. Manufacturer-supplied landing performance data for conditions worse than a dry, smooth
runway is normally an analytical computation based on the dry runway landing performance
data, adjusted for a reduced airplane braking coefficient of friction available for the specific
runway surface condition. Most of the data for runways contaminated by snow, slush, standing
water, or ice were developed to show compliance with European Aviation Safety Agency and
Joint Aviation Authority airworthiness certification and operating requirements. The FAA
considers the data developed for showing compliance with the European contaminated runway
certification or operating requirements, as applicable, to be acceptable for making landing
distance assessments for contaminated runways at the time of arrival.
6. Recommended Action:
a. A review of the current applicable regulations indicates that the regulations do not specify
the type of landing distance assessment that must be performed at the time of arrival, but
operators are required to restrict or suspend operations when conditions are hazardous.
b. 14 CFR part 121, section 121.195(b), part 135, section 135.385(b), and part 91, section
91.1037(b) and (c) require operators to comply with certain landing distance requirements at the
time of takeoff. (14 CFR part 125, section 125.49 requires operators to use airports that are
adequate for the proposed operation). These requirements limit the allowable takeoff weight to
that which would allow the airplane to land within a specified percentage of the landing distance
available on: (1) the most favorable runway at the destination airport under still air conditions;
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and (2) the most suitable runway in the expected wind conditions. Sections 121.195(d),
135.385(d), and 91.1037(e) further require an additional 15 percent to be added to the landing
distance required when the runway is wet or slippery, unless a shorter distance can be shown
using operational landing techniques on wet runways. Although an airplane can be legally
dispatched under these conditions, compliance with these requirements alone does not ensure
that the airplane can safely land within the distance available on the runway actually used for
landing in the conditions that exist at the time of arrival, particularly if the runway, runway
surface condition, meteorological conditions, airplane configuration, airplane weight, or use of
airplane ground deceleration devices is different than that used in the preflight calculation. Part
121, sections 121.533, 121.535, 121.537, part 135, section 135.77, part 125, section 125.351, and
part 91, sections 91.3, and 91.1009 place the responsibility for the safe operation of the flight
jointly with the operator, pilot in command, and dispatcher as appropriate to the type of
operation being conducted.
c. Sections 121.195(e) and 135.385(e), allow an airplane to depart even when it is unable to
comply with the conditions referred to in item (2) of paragraph 5b above if an alternate airport is
specified where the airplane can comply with conditions referred to in items (1) and (2) of
paragraph 5b. This implies that a landing distance assessment is accomplished before landing to
determine if it is safe to land at the destination, or if a diversion to an alternate airport is required.
d. Part 121, sections 121.601 and 121.603, require dispatchers to keep pilots informed, or for
pilots to stay informed as applicable, of conditions, such as airport and meteorological
conditions, that may affect the safety of the flight. Thus, the operator and flightcrew use this
information in their safety of flight decision making. Part 121, sections 121.551, 121.553, and
part 135, section 135.69, require an operator, and/or the pilot in command as applicable, to
restrict or suspend operations to an airport if the conditions, including airport or runway surface
conditions, are hazardous to safe operations. Part 125 section 125.371 prohibits a pilot in
command (PIC) from continuing toward any airport to which it was released unless the flight can
be completed safely. A landing distance assessment should be made under the conditions
existing at the time of arrival in order to support a determination of whether conditions exist that
may affect the safety of the flight and whether operations should be restricted or suspended.
e. Runway surface conditions may be reported using several types of descriptive terms
including: type and depth of contamination, a reading from a runway friction measuring device,
an airplane braking action report, or an airport vehicle braking condition report. Unfortunately,
joint industry and multi-national government tests have not established a reliable correlation
between runway friction under varying conditions, type of runway contaminants, braking action
reports, and airplane braking capability. Extensive testing has been conducted in an effort to find
a direct correlation between runway friction measurement device readings and airplane braking
friction capability. However, these tests have not produced conclusive results that indicate a
repeatable correlation exists through the full spectrum of runway contaminant conditions.
Therefore, operators and flightcrews cannot base the calculation of landing distance solely on
runway friction meter readings. Likewise, because pilot braking action reports are subjective,
flightcrews must use sound judgment in using them to predict the stopping capability of their
airplane. For example, the pilots of two identical aircraft landing in the same conditions, on the
same runway could give different braking action reports. These differing reports could be the
result of differences between the specific aircraft, aircraft weight, pilot technique, pilot
experience in similar conditions, pilot total experience, and pilot expectations. Also, runway
surface conditions can degrade or improve significantly in very short periods of time dependent
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on precipitation, temperature, usage, and runway treatment and could be significantly different
than indicated by the last report. Flightcrews must consider all available information, including
runway surface condition reports, braking action reports, and friction measurements.
(1) Operators and pilots should use the most adverse reliable braking action report, if
available, or the most adverse expected conditions for the runway, or portion of the runway, that
will be used for landing when assessing the required landing distance prior to landing. Operators
and pilots should consider the following factors in determining the actual landing distance: the
age of the report, meteorological conditions present since the report was issued, type of airplane
or device used to obtain the report, whether the runway surface was treated since the report, and
the methods used for that treatment. Operators and pilots are expected to use sound judgment in
determining the applicability of this information to their airplane’s landing performance.
(2) Table 1 provides an example of a correlation between braking action reports and
runway surface conditions:
Braking
Action
Dry (not
reported)
Good Fair/Medium Poor Nil
Contaminant Dry Wet
Dry Snow
(< 20mm)
Packed or
Compacted
Snow
Wet Snow
Slush
Standing Water
Ice
Wet ice
Table 1. Relationship between braking action reports and runway surface condition
(contaminant type)
NOTE: Under extremely cold temperatures, these relationships may be less
reliable and braking capabilities may be better than represented. This table
does not include any information pertaining to a runway that has been
chemically treated or where a runway friction enhancing substance has been
applied.
f. Some advisory landing distance information uses a standard air distance of 1000 feet from
50 feet above the runway threshold to the touchdown point. Unfactored dry runway landing
distances in AFMs reflect the distances demonstrated during certification flight testing. These
unfactored AFM landing distance data include air distances that vary with airplane weight, but
are also nominally around 1000 feet. A 1000 foot air distance is not consistently achievable in
normal flight operations. Additionally, the use of automatic landing systems (autoland) and
other landing guidance systems (e.g., head-up guidance systems) typically result in longer air
distances. Operators are expected to apply adjustments to this air distances to reflect their
specific operations, operational practices, procedures, training, and experience.
g. To ensure that an acceptable landing distance safety margin exists at the time of arrival,
the FAA recommends that at least a 15% safety margin be provided. This safety margin
represents the minimum distance margin that must exist between the expected actual landing
distance at the time of arrival and the landing distance available, considering the meteorological
and runway surface conditions, airplane configuration and weight, and the intended use of
airplane ground deceleration devices. In other words, the landing distance available on the
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runway to be used for landing must allow a full stop landing, in the actual conditions and
airplane configuration at the time of landing, and at least an additional 15% safety margin.
h. Operator compliance can be accomplished by a variety of methods and procedurally
should be accomplished by the method that best suits the operator’s current procedures. The
operator’s procedures should be clearly articulated in the operations manual system for affected
personnel. The following list of methods is not all inclusive, or an endorsement of any particular
methods, but provided as only some examples of methods of compliance.
• Establishment of a minimum runway length required under the worst case meteorological
and runway surface conditions for operator’s total fleet or fleet type that will provide
runway lengths that comply with this guidance.
• The requirements of this paragraph could be considered along with the other applicable
preflight landing distance calculation requirements and the takeoff weight adjusted to
provide for compliance at the time of arrival under the conditions and configurations
factored in the calculation. This information, including the conditions/configurations/etc.
used in the calculation, would be provided to the flightcrew as part of the release/dispatch
documents. (However, this method may not be sufficient if
conditions/configurations/etc. at the time of arrival are different than those taken into
account in the preflight calculations; therefore, the flightcrew would need to have access
to the landing performance data applicable to the conditions present upon arrival.
• Tab or graphical data accounting for the applicable variables provided to the flightcrew
and/or dispatcher as appropriate to the operator’s procedures.
• Electronic Flight Bag equipment that has methods for accounting for the appropriate
variables.
NOTE: These are only some examples of methods of compliance. There are
many others that would be acceptable.
7. Summary of Recommendation.
a. Turbojet operators have procedures to ensure that a full stop landing, with at least a 15%
safety margin beyond the actual landing distance, can be made on the runway to be used, in the
conditions existing at the time of arrival, and with the deceleration means and airplane
configuration that will be used. This assessment should take into account the meteorological
conditions affecting landing performance (airport pressure altitude, wind velocity, wind
direction, etc.), surface condition of the runway to be used for landing, the approach speed,
airplane weight and configuration, and planned use of airplane ground deceleration devices. The
airborne portion of the actual landing distance (distance from runway threshold to touchdown
point) should reflect the operator’s specific operations, operational practices, procedures,
training, and experience. Operators should have procedures for compliance with this guidance,
absent an emergency, after the flightcrew makes this assessment using the air carrier’s
procedures, if at least the 15% safety margin is not available, the pilot should not land the
aircraft.
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(1) This assessment does not mean that a specific calculation must be made before every
landing. In many cases, the before takeoff criteria, with their large safety margins, will be
adequate to ensure that there is sufficient landing distance with at least a 15% safety margin at
the time of arrival. Only when the conditions at the destination airport deteriorate while en route
(e.g., runway surface condition, runway to be used, winds, airplane landing
weight/configuration/speed/deceleration devices) or the takeoff was conducted under the
provisions described in paragraph 5 (c) of this guidance, would a calculation or other method of
determining the actual landing distance capability normally be needed. The operator should
develop procedures to determine when such a calculation or other method of determining the
expected actual landing distance is necessary to ensure that at least a 15% safety margin will
exist at the time of arrival.
(2) Operators may require flight crews to perform this assessment, or may establish other
procedures to conduct this assessment. Whatever method(s) the operator develops, its procedures
should account for all factors upon which the preflight planning was based and the actual
conditions existing at time of arrival.
b. Confirm that the procedures and data used to comply with paragraph 6 (a) above for
actual landing performance assessments yield results that are at least as conservative as the
manufacturer’s approved or advisory information for the associated conditions provided therein.
Although the European contaminated runway operations requirements are applied differently
than the requirements of this guidance, the operator may choose to use data developed for
showing compliance with the European contaminated runway operating requirements for making
these landing distance assessments for contaminated runways at the time of arrival.
c. A safety margin of 15% should be added to the actual landing distance and require that the
resulting distance be within the landing distance available of the runway used for landing. Note
that the FAA considers a 15% margin to be the minimum acceptable safety margin.
d. If wet or contaminated runway landing distance data are unavailable, the factors in Table
2 should be applied to the pre-flight planning (factored) dry runway landing distances
determined in accordance with the applicable operating rule (e.g., sections 91.1037, 121.195(b)
or 135.385(b). Table 2 should only apply when no such data are available. The factors in Table
2 include the 15% safety margin recommended by this guidance, and are considered to include
an air distance representative of normal operational practices. Therefore, operators do not need
to apply further adjustments to the resulting distances to comply with the recommendations of
this guidance.
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Runway Condition Reported Braking
Action
Factor to apply to
(factored) dry runway
landing distance*
Wet Runway, Dry Snow Good 0.9
Packed or Compacted Snow Fair/Medium 1.2
Wet snow, slush, standing water, ice Poor 1.6
Wet ice Nil Landing is prohibited
Table 2. Multiplication factors to apply to the factored dry runway landing distances when
the data for the specified runway condition are unavailable.
* The factored dry runway landing distances for use with Table 2 must be based on landing
within a distance of 60% of the effective length of the runway, even for operations where the
preflight planning (factored) dry runway landing distances are based on landing within a distance
other than 60% of the effective length of the runway (e.g., certain operations under part 135 and
subpart K of par t91). To use unfactored dry runway landing distances, first multiply the
unfactored dry runway landing distance by 1.667 to get the factored dry runway landing distance
before entering Table 2 above.
NOTE: These factors assume maximum manual braking, autospoilers (if so
equipped), and reverse thrust will be used. For operations without reverse
thrust (or without credit for the use of reverse thrust) multiply the results of
the factors in Table 2 by 1.2. These factors cannot be used to assess landing
distance requirements with autobrakes.
e. The landing distance assessment should be accomplished as close to the time of arrival as
practicable, taking into account workload considerations during critical phases of flight, using
the most up-to-date information available at that time. The most adverse braking condition,
based on reliable braking reports or runway contaminant reports (or expected runway surface
conditions if no reports are available) for the portion of the runway that will be used for the
landing should be used in the actual landing performance assessment. For example, if the runway
surface condition is reported as fair to poor, or fair in the middle, but poor at the ends, the
runway surface condition should be assumed to be poor for the assessment of the actual landing
distance. (This example assumes the entire runway will be used for the landing). If conditions
change between the time that the assessment is made and the time of landing, the flightcrew
should consider whether it would be safer to continue the landing or reassess the landing
distance.
f. The operator’s flightcrew and dispatcher training programs should include elements that
provide knowledge in all aspects and assumptions used in landing distance performance
determinations. This training should emphasize the airplane ground deceleration devices,
settings, and piloting methods (e.g., air distance) used in determining landing distances for each
make, model, and series of airplane. Elements such as braking action reports, airplane
configuration, optimal stopping performance techniques, stopping margin, the effects of excess
speed, delays in activating deceleration devices, and other pilot performance techniques should
be covered. All dispatchers and flightcrew members should be trained on these elements prior to
operations on contaminated runway surfaces. This training should be accomplished in a manner
consistent with the operator’s methods for conveying similar knowledge to flight operations
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personnel. It may be conducted via operations/training bulletins or extended learning systems, if
applicable to the operator’s current methods of training.
g. Procedures for obtaining optimal stopping performance on contaminated runways should
be included in flight training programs. All flight crewmembers should be made aware of these
procedures for the make/model/series of airplane they operate. This training should be
accomplished in a manner consistent with the operator’s methods for conveying similar
knowledge to flight operations personnel. It may be conducted via operations/training bulletins
or extended learning systems, if applicable to the operator’s current methods of training. In
addition, if not already included, these procedures should be incorporated into each airplane or
simulator training curriculum for initial qualification on the make/model/series airplane, or
differences training as appropriate. All flight crewmembers should have hands on training and
validate proficiency in these procedures during their next flight training event, unless previously
demonstrated with their current employer in that make/model/series of airplane.
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