B737, New York La Guardia USA, 2013
From SKYbrary Wiki
Revision as of 22:37, 6 December 2018 by Integrator3
|On 22 July 2013 the Captain of a Boeing 737-700 failed to go around when the aircraft was not stabilised on final approach at La Guardia and then took control from the First Officer three seconds before touchdown and made a very hard nose first touchdown which substantially damaged the aircraft. The Investigation concluded that the accident had been a consequence of the continued approach and the attempt to recover with a very late transfer of control instead of a go around as prescribed by the Operator. The aircraft was "substantially damaged".|
|Actual or Potential
|Human Factors, Loss of Control, Runway Excursion|
|Type of Flight||Public Transport (Passenger)|
|Origin||Nashville International Airport|
|Intended Destination||LaGuardia Airport|
|Take off Commenced||Yes|
|Location - Airport|
|Tag(s)||Approach not stabilised,|
Approach Unstabilised after Gate-no GA,
Unplanned PF Change less than 1000ft agl
|Tag(s)||Inappropriate crew response - skills deficiency,|
Plan Continuation Bias,
Procedural non compliance,
Ineffective Monitoring - PIC as PF,
Ineffective Monitoring - SIC as PF
|Tag(s)||Flight Management Error,|
Landing Performance Assessment,
Off side of Runway
|Damage or injury||Yes|
|Causal Factor Group(s)|
On 22 July 2013, the crew of a Boeing 737-700 (N753SW) being operated by Southwest Airlines on a scheduled domestic passenger flight from Nashville to New York La Guardia landed hard, nose first on Runway 04 at destination after an unstabilised approach had been continued in day VMC. The aircraft was substantially damaged and an emergency evacuation was performed with eight of the 149 occupants sustaining minor injuries.
The First Officer was PF for the flight and, when briefing the La Guardia 04 ILS approach, had accepted the Captain's suggestion that a Flap 40 configuration should be used. However, after passing the prescribed Stabilised Approach Gate at 1000 feet, the Captain reported realising that the flaps were not configured at 40º as briefed and she then set them to 40 degrees as the aircraft was descending through about 500 feet agl - less than a minute prior to touchdown. As descent continued below 200 feet agl, the aircraft was slightly above both the ILS GS and the correct PAPI indication and the Captain repeatedly said "get down" to the First Officer about 9 seconds before touchdown. Then, at about 3 seconds before touchdown with the aircraft about 27 feet agl, she announced "I got it" indicating that she was taking control and First Officer acknowledged "OK, you got it."
FDR data showed that the runway threshold was crossed at 60 feet agl and that after the transfer of control, "the control column was relaxed to a neutral position and the throttles were not advanced until about 1 second before touchdown". Touch down occurred with a 960 fpm rate of descent, a pitch rate of -2.8 º /second and a nose-down pitch attitude of -3.1º degrees. The touchdown at about 560 metres beyond the threshold was very hard and nose first and the aircraft came to a stop nose down partly off the right side of the 45 metre wide runway and about half way along its 2134 metre length.
The R1 and R2 door slides and the right overwing exits were used by both the 5 crew and the 144 passengers to evacuate the aircraft. The main passenger door (L1) was reported to have opened about 15cm during the impact sequence and it was reported that the other left side exits were not used because of the presence of smoke outside on the left which had subsequently entered the cabin.
Damage to the aircraft was caused by the penetration of the electronic equipment bay by the NLG tyre assembly which fractured from the NLG leg and to the right engine nacelle and the fuselage was "scraped and wrinkled". The runway surface was damaged due to impact forces.
The weather report for La Guardia shortly after the accident gave the surface wind as from 040º at a mean speed of 8 knots with a temperature of 25 º C.
The 49 year-old Captain had been a First Officer with Southwest since 2000 after obtaining a 737 type rating. She had been promoted to Captain in 2007 and had nearly 8000 flying hours on the 737, including 2659 since becoming a Captain. It was noted that she had been provided with refresher CRM training in 2010 "as a result of complaints received by the Chief Pilot from First Officers who had flown with her" and that the Chief Pilot had received no further complaints after completion of the refresher training.
The 44 year old First Officer had been a First Officer with Southwest since January 2012 after obtaining a 737 type rating in August 2011. He had about 5200 total flying hours including just over 1000 on 737s.
The Investigation concluded that although Southwest procedures allow the Captain to take control of the aircraft for safety reasons at any time, the decision of the Captain in this case to take control at 27 feet agl "did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway". It was also considered that this late transfer of control "resulted in neither pilot being able to effectively monitor the airplane's altitude and attitude". It was concluded that "The Captain should have called for a go-around when it was apparent that the approach was unstabilised well before the point that she attempted to salvage the landing by taking control of the airplane at a very low altitude". It was noted that the Captain had not followed Standard Operating Procedures (SOPs) on callouts at several points during the approach and concluded that, overall, "the flight crew's performance was indicative of poor crew resource management".
The Probable Cause of the accident was determined to have been "the Captain's attempt to recover from an unstabilised approach by transferring aircraft control at low altitude instead of performing a go-around".
A Contributory Factor in the accident was determined as "the Captain's failure to comply with Standard Operating Procedures".
The Final Report was released on 22 July 2015. No Safety Recommendations were made.