NTSB/AAB-02/04 

E PLURIBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Aircraft Accident Brief 

Accident Number: DCA00MA030 

Operator/Flight Number: Southwest Airlines flight 1455 

Aircraft and Registration: Boeing 737-300, N668SW 

Location: Burbank, California 

Date: March 5, 2000 

Adopted On: June 26, 2002 

HISTORY OF FLIGHT 

On March 5, 2000, about 1811 Pacific standard time (PST),1 Southwest Airlines, Inc., 

flight 1455, a Boeing 737-300 (737), N668SW, overran the departure end of runway 8 after 

landing at Burbank-Glendale-Pasadena Airport (BUR), Burbank, California. The airplane 

touched down at approximately 182 knots, and about 20 seconds later, at approximately 32 knots, 

collided with a metal blast fence and an airport perimeter wall. The airplane came to rest on a 

city street near a gas station off of the airport property. Of the 142 persons on board, 

2 passengers sustained serious injuries; 41 passengers and the captain sustained minor injuries; 

and 94 passengers, 3 flight attendants, and the first officer sustained no injuries. The airplane 

sustained extensive exterior damage and some internal damage to the passenger cabin. During 

the accident sequence, the forward service door (1R) escape slide inflated inside the airplane; the 

nose gear collapsed; and the forward dual flight attendant jumpseat, which was occupied by two 

flight attendants, partially collapsed. The flight, which was operating on an instrument flight 

rules flight plan, was conducted under 14 Code of Federal Regulations (CFR) Part 121. Visual 

meteorological conditions (VMC) prevailed at the time of the accident, which occurred in 

twilight lighting conditions. 

 According to Southwest Airlines records, the accident flight was the flight crewís first 

flight of what was scheduled to be a 3-day flight sequence that consisted of five flights. The 

accident flight originated at McCarran International Airport (LAS), Las Vegas, Nevada, and was 

scheduled to depart about 1445 for BUR. The first officer of the accident flight stated to National 

Transportation Safety Board investigators that he arrived at LAS about 1245, and the captain 

indicated that he arrived about 1400. The first officer reported in a postaccident interview that he 

met the captain on the way to the gate. Southwest Airlines records indicate that the accident 

 

1

 Unless otherwise indicated, all times in this report are PST, based on a 24-hour clock, and are taken from the 

cockpit voice recorder (CVR) transcript. In some instances, the air traffic control (ATC) transcript indicates times 

that are different from those in the CVR transcript. 
2 

NTSB/AAB-02/04 

airplane arrived at LAS from Los Angeles International Airport, Los Angeles, California, 

about 1630, almost 2 hours behind schedule, because of rain and gusting winds in the LAS area. 

The accident flight crew indicated that the preflight inspection was normal and that no 

maintenance discrepancies were noted. 

 Flight 1455 departed the gate about 1650, more than 2 hours behind schedule. During 

postaccident interviews, the flight crew indicated to Safety Board investigators that the takeoff 

and en route portions of the flight to BUR were normal and uneventful. The first officer stated 

that after the flight crossed the PMD very high frequency omni-directional radio range (VOR)2

navigation transmitter at 8,000 feet, he obtained information Oscar from the BUR airport 

terminal information service (ATIS), which indicated that winds were from 260° at 18 knots, 

gusting to 26 knots, and that aircraft were landing on runways 33 and 26. At 1754:21, the captain 

stated, ìplan on [runway] three three at the moment. [A]pproach descent checklist when you get 

the chance.î 

At 1802:52, the flight crew was advised by the Southern California terminal radar 

approach control (SCT) Woodland controller that the current ATIS was information Papa and 

that they should expect an instrument landing system (ILS) landing on runway 8. At 1803:29, 

when the airplane was about 20 nautical miles (nm) north of the BUDDE outer marker3

 at an 

altitude of about 8,000 feet mean sea level (msl), the Woodland controller instructed flight 1455 

to turn left to a heading of 190° and to descend to and maintain 6,000 feet msl. The first officer 

acknowledged the instructions. 

 At 1804:02, when the airplane was about 19 nm north of the BUDDE outer marker at an 

altitude of about 7,800 feet msl, the SCT Woodland controller stated, ìSouthwest fourteen fifty 

five, maintain two thirty or greater ëtil advised please.î The captain acknowledged the airspeed 

adjustment assignment.4 The Woodland controller indicated in a postaccident interview that he 

imposed the speed restriction as part of sequencing Southwest flight 1455 between Southwest 

flight 1713 and Executive Jet flight 278. 

After the first officer obtained information Papa, he switched back to the approach 

control frequency. At 1804:42, he informed the captain that the target airspeed for the approach 

would be 138 knots and, at 1804:49, that winds were ìdown to six knots.î A few seconds later, 

he confirmed that aircraft were landing at BUR on runway 8. At 1805:08, when the airplane was 

about 16 nm north of the BUDDE outer marker at an altitude of about 6,000 feet msl, the SCT 

Woodland controller instructed flight 1455 to ìturn left heading one six zero.î At 1805:13, the 

captain indicated to the first officer that ATC ìwants two hundred thirty knots or greater, for a 

while.î 

 

2

 The PMD VOR, which is located in Palmdale, California, is 30 miles northeast of BUR. 

3

 The BUDDE outer marker is located 6 miles west of BURís runway 8 threshold. 

4

 The first officer indicated in postaccident interviews that while he was obtaining the new ATIS information, 

the captain communicated with ATC. 
3 

NTSB/AAB-02/04 

 At 1805:54, the SCT Woodland controller cleared flight 1455 to descend to and maintain 

5,000 feet and advised the pilots that they were following company traffic (Southwest Airlines 

flight 1713) that was at their ìone oíclock and twelve miles [ahead of them] turning onto the 

final out of forty six hundred.î The first officer acknowledged the clearance. At 1807:43, the 

Woodland controller cleared flight 1455 to descend to and maintain 3,000 feet. The first officer 

acknowledged the clearance. At 1808:18, the first officer notified ATC that he had the Southwest 

traffic in sight. At 1808:19, the Woodland controller issued an altitude restriction by stating, 

ìcross Van Nuys at or above three thousand,[5] cleared visual approach runway eight.î6 The first 

officer acknowledged the clearance. At 1808:36, as the airplane was descending through about 

3,800 feet msl, the captain began turning to the left for the final approach. 

 In postaccident interviews, the flight crew told investigators that, during the approach, the 

captainís navigation radio was tuned to the ILS frequency for runway 8, and the first officerís 

radio was tuned to the Van Nuys VOR. They indicated that the autopilot was engaged in the 

VOR/LOC mode7 and that the airplane captured the localizer course but then overshot the 

centerline before correcting back.8 The captain stated to investigators that as the flight passed 

about 2 miles west of Van Nuys at 3,000 feet at approximately 220 to 230 knots, he deployed the 

speed brakes. 

According to the CVR, at 1809:28, when the airplane was at an indicated airspeed of 

about 220 knots, the captain called for ìflaps five.î At 1809:32, the flaps began to extend. 

At 1809:43, the captain called for ìgear down.î The captain indicated in a postaccident 

interview that at this point in the flight, he noted a 20-knot tailwind indication on the flight 

management system (FMS) screen.9

 At 1809:53, the BUR tower controller stated, ìSouthwest 

fourteen fifty five, wind uhÖtwo one zero at six [knots], runway eight, cleared to land.î 

Simultaneously, the captain called for ìflaps fifteen.î10 At 1810:01, the captain again called for 

ìflapsÖfifteenî and ì[flaps] twenty five.î 

From 1810:24 until 1810:59, the ground proximity warning system (GPWS) alerts were 

being continuously broadcast in the cockpit, first as ìsink rateî and then, at 1810:44, switching to 

ìwhoop, whoop, pull up.î At 1810:29, the captain stated, ìflaps thirty, just put it down.î 

At 1810:33, the captain stated, ìput it to [flaps] forty. [I]t wonít go, I know that. [I]tís all right. 

 

5

 According to the Pilot/Controller Glossary, restrictions are defined as ì[a]n altitude or altitudes, stated in the 

order flown, which are to be maintained until reaching a specific point or time. Altitude restrictions may be issued 

by ATC due to traffic, terrain, or other airspace considerations.î 6

 Flight 1455ís 230-knot airspeed adjustment assignment was no longer applicable after the SCT Woodland 

controller issued the visual approach clearance. (For more information about speed adjustment assignments, see the 

section titled, ìCompany Procedures.î) In a postaccident interview with Safety Board investigators, the controller 

stated that he did not know why he did not cancel the restriction sooner. 7

 The VOR/LOC mode is used to command the autopilot to intercept the selected localizer radio course. 

8

 FAA radar data show that the airplane crossed the BUDDE outer marker at about 3,200 feet msl at an indicated 

airspeed of about 225 knots. 9

 No evidence exists on the CVR transcript of a discussion between the pilots about the tailwind. 

10 At 1809:54, the flaps extended to 5°; at 1810:01, the flaps extended to 10°; at 1810:08, the flaps extended to 

25°; at 1810:29, the flaps extended to 30°; and at 1811:05, the flaps extended to between 30° and 40°. 
4 

NTSB/AAB-02/04 

[F]inal descent checklist.î After the GPWS ìwhoop, whoop, pull upî alert sounded at 1810:47, 

the captain stated, ìthatís all right,î at 1810:53. A final ìsink rateî warning was recorded 

at 1810:55. The first officer stated in a postaccident interview that instead of reading the final 

descent checklist,11 he visually confirmed the checklist items and remembered seeing the captain 

arm the ground spoilers. The first officer also stated that when the captain called for flaps 40°, 

the airspeed was about 180 knots and went as high as 190 knots during the approach.12 The first 

officer indicated that he pointed to his airspeed indicator to alert the captain of the flap limit 

speed of 158 knots at flaps 40°. 

The captain told Safety Board investigators that he remembered hearing the ìsink rateî 

warning from the GPWS but that he did not react to the warning because he did not feel that he 

had to take action. He stated that he did not remember any other GPWS warnings during the 

approach. The first officer indicated in a postaccident interview that he heard both the ìsink rateî 

and the ìpull upî GPWS warnings but that he believed that the captain was correcting. 

The first officer also indicated to investigators that he selected the ìProgressî page13 on 

the FMS cockpit display unit but that he could not recall what the wind values were during the 

approach. He stated to investigators that he was concerned that the ground speed was faster than 

normal but added that he did not verbalize his concern to the captain. The first officer further 

indicated to investigators that he felt that the approach was stabilized and that they were in a 

position to land. 

 The captain stated in a postaccident interview that he was aware that Southwest Airlinesí 

standard procedure14 was for the captain and first officer to call ì1,000 [feet above ground level 

(agl)], airspeed, and sink rateî when descending through 1,000 feet. However, no such callouts 

were recorded by the CVR. The captain also stated in a postaccident interview that he visually 

perceived that the airplane was ìfastî as it crossed the approach end of runway 8. CVR and FDR 

data indicate that the airplane touched down at 1810:58 with flaps extended to 30° at about 

182 knots; flaps then extended to 40° during the ground roll at about 145 knots. 

The captain stated to Safety Board investigators that after touchdown, the end of the 

runway appeared to be closer than it should have been and that he thought they might hit the blast 

fence wall. The captain indicated that he braked ìpretty goodî while attempting to stop the 

airplane. FDR data indicate that the captain unlocked the thrust reversers 3.86 seconds after 

touchdown and that the thrust reversers deployed 4.91 seconds after touchdown. The first officer 

stated to investigators that the captain applied the wheel brakes before the airplane had 

 

11 The final descent checklist includes notifying the flight attendants, checking the flight and navigational 

instruments, placing the landing gear down, arming the speed brake, positioning the wing flaps, and disengaging the 

autopilot. 12 Flight data recorder (FDR) and radar data indicate that at 1810:33, the airspeed was about 190 knots. 

13 The ìProgressî page indicates dynamic flight and navigation data, including track, path, temperature, speed, 

and headwind or tailwind information. 14 For more information about Southwest Airlinesí procedures, see the section titled, ìCompany Information.î 
5 

NTSB/AAB-02/04 

decelerated to 80 knots15 and that, as the airplane passed the Southwest Airlines passenger 

boarding gates,16 he joined the captain in braking the airplane and applied the brakes as hard as 

he could. The captain indicated that as the airplane neared the end of the runway, he initiated a 

right turn using only the nosewheel steering tiller (not the rudder pedals). 

 At 1811:20, the cockpit area microphone (CAM) recorded impact sounds. The airplane 

departed the right side of the runway about 30° from the runway heading, penetrated a metal blast 

fence and an airport perimeter wall, and came to a stop on a city street off of the airport property. 

An emergency evacuation ensued, and all crewmembers and passengers successfully exited the 

airplane.17 

PERSONNEL INFORMATION 

Both flight crewmembers were certificated pursuant to Southwest Airlines and Federal 

Aviation Administration (FAA) certification requirements. A review of FAA records indicated 

that the flight crewmembers had no history of airplane accidents or enforcement actions. In 

addition, both flight crewmembers held valid driverís licenses for the states in which they lived. 

Records at the National Driver Register found no indication of driverís license revocation or 

suspension for either pilot. Further, both flight crewmembers provided urine specimens and 

breath samples for postaccident drug and alcohol testing, the results of which were negative. 

The Captain 

 At the time of the accident, the captain, age 52, held an airline transport pilot (ATP) 

certificate, issued October 25, 1979, with the ratings and limitations of airplane multiengine land; 

commercial privileges for airplane single engine land; and type ratings for 737, 

Gulfstream G-159, and Convair CV-240, -340, and -440 airplanes. His most recent FAA 

first-class medical certificate was issued on October 19, 1999, with the limitation that he must 

possess corrective glasses while flying.18 

 According to the captain, he served as a pilot in the U.S. Air Force (USAF) from 1970 to 

1975 at Mather Air Force Base, Sacramento, California. In 1976, he acquired his 737 type rating 

through United Airlines and, from 1977 to 1979, flew as a 737 first officer for Wien Air Alaska. 

From 1979 to 1980, he flew Gulfstream G-159s and King Airs as a captain for Coleman Air 

Transport. From 1980 to 1988, he was employed by the EG&G Corporation and flew 737s as 

captain and first officer. 

 

15 For more information about Southwest Airlinesí braking procedures, see the section titled, ìCompany 

Information.î Pilots are advised to initiate braking after 80 knots under normal landing conditions or before 

80 knots if conditions require earlier use. 16 The Southwest Airlines passenger boarding gates are parallel to runway 8 and are located about 1,000 feet 

before the end of the runway. 17 For more information about the emergency evacuation, see the section titled, ìSurvival Aspects.î 

18 The captain indicated to Safety Board investigators that he normally wore glasses while flying at night. 
6 

NTSB/AAB-02/04 

The captain began his employment at Southwest Airlines on July 7, 1988. According to 

the captain, at the time of the accident, he had accumulated a total of approximately 11,000 hours 

of flight time. He had flown 737s for Southwest Airlines for a total of 9,870 hours, 5,302 of 

which were as pilot-in-command. The captain had flown for Southwest Airlines 123.3, 88.8, 

52.1, and 15 hours in the 90, 60, 30, and 7 days, and 1.4 hours in the 24 hours, before the 

accident, respectively. The captainís most recent systems training took place on October 10, 

1999, and his most recent proficiency check and training took place on October 11, 1999. His 

most recent 737 line check was on October 29, 1999. 

 During postaccident interviews, a first officer at Southwest Airlines with whom the 

accident captain had flown described the accident captain as easy to get along with and rated him 

as an average captain. He indicated that he never felt uncomfortable flying with the captain and 

that the captain operated according to company procedures. Another Southwest Airlines captain 

described the accident captain as congenial, mild-mannered, and someone who got along well 

with everyone. 

 At the time of the accident, the captain lived in the Las Vegas, Nevada, area. He 

indicated that, during the 3 days before the accident, he exercised moderately by jogging and 

playing golf. He stated that he normally went to bed about 2300 and awoke between about 0730 

and 0830. The captain stated that on March 4th, he went to bed about midnight and felt well 

rested when he awoke on March 5th about 0830. He indicated that he called crew scheduling 

about 0900, jogged 4 miles, lifted weights, and ate breakfast. He reported that he left his home 

about 1330 and arrived at LAS about 1400. 

The First Officer 

 At the time of the accident, the first officer, age 43, held an ATP certificate, issued 

December 18, 1995, with the ratings and limitations of airplane multiengine land, commercial 

privileges for airplane single engine land, and type rating for the 737. His most recent FAA 

first-class medical certificate was issued on October 18, 1999, with no limitations. 

 The first officer reported to investigators that he had completed 12 years of active duty in 

the USAF during which he flew F-15 fighter airplanes. He stated that, after completing his active 

service, he flew F-16s in the USAF reserve. His total military flight time at the time of the 

accident was approximately 2,500 hours. 

 The first officer was hired by Southwest Airlines on November 14, 1996. According to 

the first officer, at the time of the accident, he had accumulated a total of approximately 

5,022 hours of flight time. He had flown 737s for Southwest Airlines for a total of 2,522 hours. 

The first officer had flown for Southwest Airlines 212.1, 123.8, 60.7, and 22.5 hours in the 90, 

60, 30, and 7 days, and 1.4 hours in the 24 hours, before the accident, respectively. The first 

officer received his initial 737 type rating on December 18, 1995, and completed his 737 initial 

operating experience on December 26, 1996. His most recent systems training took place on 

October 25, 1999, and his most recent proficiency check and training took place on October 31, 

1998. His most recent 737 line check was on October 29, 1999. 
7 

NTSB/AAB-02/04 

 During postaccident interviews, a captain who had flown with the first officer stated that 

the first officer was very well qualified and was an above-average copilot with good aviation 

skills who was likable and pleasant. Another captain who had flown with the first officer 

indicated that, on their flights together, the first officer did a great job and displayed good 

judgment throughout the trip. 

 At the time of the accident, the first officer lived in the Salt Lake City, Utah, area. He 

indicated that, during the 3 days before the accident, he performed light household chores and 

worked at the USAF reserve unit, performing paperwork duties on March 2nd and flying an F-16 

fighter airplane for one flight on March 3rd. He stated that he normally went to bed about or 

before 2300 and awoke between about 0700 and 0730. The first officer stated that he awoke on 

March 5th about 0800. He indicated that he called crew scheduling and notified them that he 

would report directly to LAS for the flight to BUR. He stated that he left his home about 1000; 

boarded the Southwest Airlines flight from Salt Lake City, Utah, to LAS about 1120; and arrived 

at LAS about 1245. 

The Air Traffic Controller 

 The SCT Woodland controller on duty at the time of the accident, who was also a private 

pilot with about 145 hours of flight time, was hired by the FAA in May 1989. He received his 

initial ATC training in Oklahoma City, Oklahoma, and began work at Gillespie Field Airport, 

San Diego, California, as a full performance level controller. In April 1992, he went to Lindbergh 

Airport, San Diego, California, and, in September 1998, he was transferred to SCT. The day of 

the accident was the second day of a 5-day work week for the Woodland controller, who 

was assigned the 1300-to-2100 shift. 

AIRPLANE INFORMATION 

N668SW, a 737-300, serial number (S/N) 23060, was registered to Southwest Airlines on 

January 25, 1996, and was equipped with two CFM International CFM56-3 engines. The 

maximum landing weight of the airplane is 114,000 pounds (lbs).19

 The 737 is configured with a flap load limiter system that prevents the flap panels from 

extending to the 40° position until the airspeed is below 158 knots, even if the flap handle is 

placed in the 40° position above that speed. 

 The 737 has 10 spoiler panels (5 on each wing), 4 of which are flight spoilers that are 

used for maintaining lateral control, reducing airspeed in flight, and aiding braking after 

touchdown, and 6 of which are ground spoilers that are used to aid braking after touchdown. 

 

19 The landing weight of the accident airplane was estimated to be 113,425 lbs. 
8 

NTSB/AAB-02/04 

 According to Southwest Airlines, its 737 autobrake systems are deactivated so that all 

Southwest cockpit configurations will be as similar as possible. Therefore, Southwest pilots 

must use manual braking during landing. 

METEOROLOGICAL INFORMATION 

The transcription of ATIS information Papa follows: 

burbank airport information papa zero one five three zulu wind two four zero at 

six visibility one zero few clouds at six thousand five hundred ceiling niner 

thousand overcast temperature niner dew point one altimeter two niner six five 

i l s runway eight approach in use arriving and departing runway eight and runway 

one five. 

Weather observations at BUR were made by an automated surface observation system 

and augmented by ATC under the limited aviation weather reporting station. Weather conditions 

reported about 1653, about 1 hour and 17 minutes before the accident, were the following: 

wind from 270 degrees at 18 knots gusting to 26 knots, visibility 10 miles, a few 

clouds at 3,900 feet, ceiling overcast at 5,500 feet, temperature 11.1 degrees C 

[Celsius] (52 degrees F [Fahrenheit]), dew point 2.2 degrees C (36 degrees F), 

altimeter 29.60 inches of hg [mercury]. 

Weather conditions reported about 1820, about 10 minutes after the accident, were the 

following: 

wind from 250 degrees true at 6 knots, visibility 10 statute miles, ceiling overcast 

at 9,500 feet, temperature 9 degreesÖ[C] (48 degrees F), dew point temperature 

0 degrees C (32 degrees F), altimeter 29.66 inches ofÖhg. 

The BUR airport reported that 0.77 inch of rain had fallen in the 8 hours before the 

accident and that a wind shift associated with a cold frontal passage had occurred. Runway 8 was 

wet at the time of the accident. 

AIRPORT INFORMATION 

 BUR is located about 3 miles northwest of Burbank, California, at an elevation of 

775 feet. The airport is in the east-southeastern end of the San Fernando Valley, between the San 

Gabriel Mountains and the Pacific coastline. BUR is owned by the Burbank-Glendale-Pasadena 

Airport Authority and is operated under contract by a private company, Airport Group 

International. BUR has an FAA-approved airport emergency plan and is certified by the FAA as 
9 

NTSB/AAB-02/04 

an aircraft rescue and firefighting (ARFF) index C20 facility under 14 CFR Part 139. The last 

FAA annual airport certification inspection took place from December 8 through 10, 1999. 

BUR has two grooved asphalt runways, 8/26 and 15/33. During postaccident interviews, 

BUR ATC tower personnel indicated to investigators that runway 8, which is used ìmost of the 

timeî for landings, is the only arrival runway that avoids high terrain and that runway 26 is used 

infrequently by air carriers for landing because of terrain to the south and east of the airport. 

They stated to investigators that runway 33 is used for landings when the tailwind component for 

runway 8 exceeds 10 knots and wind is from the northwest. They also indicated that no 

instrument approach is available for runway 33, and rising terrain is located under the left base 

segment of the traffic pattern to this runway. BUR ATC tower personnel stated that, for 

runway 15, aircraft must be established on final approach for landing before descending out of 

3,000 feet. They indicated that the San Gabriel Mountains are located north of runway 15 and 

that hang glider activity sometimes exists in the area of the final approach to runway 15. 

Runway 8 

 Runway 8, which is 6,032 feet long and 150 feet wide, is configured for precision 

instrument landings and equipped with high-intensity runway edge lights, distance-to-go 

markers, and a medium-intensity approach lighting system with runway alignment indicator 

lights. A precision approach path indicator (PAPI) is located 1,520 feet from the approach end of 

runway 8 on the left side of the runway. 

Runway Safety Areas

Title 14 CFR 139.309 defines the requirements for the provision and maintenance of 

runway safety areas (RSA). The design and construction standards of RSAs are further defined 

in Advisory Circular (AC) 150/5300-13, ìAirport Design,î dated September 29, 1989. The AC 

indicates that the longitudinal dimensions of an RSA should extend for the full length of the 

runway and 1,000 feet beyond the physical threshold of each runway end. The AC further 

indicates that the lateral dimensions of an RSA should extend 250 feet both left and right of the 

runway centerline and for the full length of the longitudinal RSA. 

The lateral dimensions of the runway 8 RSA measure 250 feet on each side of the runway 

centerline, except for the southern edge of runway 8 east of the runway 15/33 intersection, which 

measures 125 feet and is marked with a movement/nonmovement area delineator line. The 

passenger terminal is located south of runway 8 in this area. The longitudinal dimensions of the 

RSA at the arrival end of runway 8 measure 200 feet, and no significant longitudinal RSA exists 

on the departure end of runway 8. A metal blast fence is located 32 feet from the departure end 

of runway 8. 

 

20 According to 14 CFR 139.315 and 139.317, an ARFF index C facility should have two or three firefighting 

vehicles with a total of at least 3,000 gallons of water and aqueous film-forming foam. 
10 

NTSB/AAB-02/04 

On March 16, 2000, the Burbank-Glendale-Pasadena Airport Authority Executive 

Director sent a letter to the Safety Boardís Airport/Emergency Response Group Chairman to 

clarify the status of RSAs at BUR. In his letter, he stated the following: 

The Authority determined that the greatest safety concern and risk to life and 

property was the close proximity of the passenger terminal and the close 

proximity of parked and taxiing aircraft adjacent to both runways. The Authority 

made the decision to pursue replacement of the passenger terminal as its highest 

priorityÖ.Concurrently with the process of replacing the terminal, the Authority 

has pursued the acquisition of clear zone properties and has considered the 

possibility of lowering Hollywood Way for the purpose of creating a[n] overrun 

area. The Authority did successfully acquire some existing parking lots in the 

RPZ (runway protection zone). 

 On August 14, 2000, the airport authority submitted an application to the city of Burbank 

to construct a replacement passenger terminal that would be located 1/2 mile north of the current 

terminal. However, in an April 10, 2002, letter, the Burbank-Glendale-Pasadena Airport 

Authority Executive Director informed the Safety Board that ì58% of the voters of Burbank 

approved an initiative that deprives the Burbank City Council of its power to approve any 

terminal project agreement with the Airport Authority unless and until a lengthy series of 

conditions[22] is met.î As a result, on December 4, 2001, the City of Burbank ìimposed a 

moratorium on the issuance of building permits for any and all activities at the airport that would 

require permitsÖ[which] has effectively halted all development activity at the airport.î 

Engineered Materials Arresting System

 On August 17, 2001, the FAAís Airport Improvement Program awarded $1.9 million to 

BUR to install an engineered materials arresting system (EMAS) at the departure end of 

runway 8.23 The investigation revealed that installation of an EMAS was completed in 

January 2002 and that the system was fully operational. The system is about 170 feet long and 

170 feet wide. No other EMASs are projected to be installed at BUR. 

FLIGHT RECORDERS 

Cockpit Voice Recorder 

 The airplane was equipped with a Fairchild A-100A CVR, S/N 52619. The CVRís 

exterior showed no evidence of structural damage, and the interior sustained no heat or impact 

damage. The recording consisted of good quality audio information, including the captainís and 

first officerís CAMs. The recording started at 1743:16, before the approach to BUR, and 

 

21 The Part 161 study began in December 2001. 

22 These conditions primarily involve the resolution of noise and environmental issues. 

23 EMAS is a system that slows an aircraft when its wheels roll through frangible cellular cement. 
11 

NTSB/AAB-02/04 

continued uninterrupted until 1814:49, shortly after the airplane departed the end of runway 8 

and came to a stop. A transcript was prepared of the 31-minute recording and is available in the 

public docket for this accident. 

Flight Data Recorder 

 The airplane was equipped with an Allied Signal Aerospace solid-state 

FDR model 980-4700-001, S/N 792. A readout of the FDR data was prepared and is available in 

the public docket for this accident. 

WRECKAGE INFORMATION 

 After penetrating a metal blast fence and an airport perimeter wall, the airplane came to 

rest on a four-lane city street east of the airport. Tire marks in a gradual arcing right turn 

originated on the runway about 1,500 feet before the fence. The structure of the airplane was 

intact, and the entire airframe was accounted for at the accident site. Major damage was confined 

to the nose section (mainly on the left side and the nosewheel well area) and fuselage station 

BS 515, which collapsed circumferentially. The nose gear was severed from the drag brace and 

driven aft into the electronics bay after rotating the nose gear assembly 90°. A portion of the nose 

cone and left wing tip were severed from the airframe. The major damage to the left and right 

wings was confined to the leading edge devices. 

 No preimpact failures were noted in the aileron, elevator, or rudder systems or the leading 

and trailing edge flaps and slats. Several spoilers on each wing were damaged during the accident 

sequence. There were no preimpact failures noted to any spoiler system hydraulic line or valve 

in the wheel well area. 

SURVIVAL ASPECTS 

 An emergency evacuation was initiated after the airplane came to a complete stop. 

During the accident sequence, the 1R escape slide inflated inside the airplane. Flight attendants 

reported that the slide began inflating while the airplane was still moving. The inflated slide 

extended nearly across the entire width of the airplane, blocking the aisle from the passenger 

cabin to both forward doors (1R and 1L) and preventing the two flight attendants seated on the 

forward jumpseat from assisting in the evacuation. The 1R escape slide was not deflated until 

after the evacuation (through the overwing exits and the 2L door) was complete. In addition, the 

forward flight attendant jumpseat partially collapsed and impeded the inboard flight attendantís 

exit from the seat. 

As a result of this accident investigation, on April 26, 2001, the Safety Board issued 

Safety Recommendations A-01-12 and -13 to the FAA. Safety Recommendation A-01-12 asked 

the FAA to ìissue an airworthiness directive to require all operators of Boeing 737-300 through 

-500 series airplanes to replace the slide cover latch brackets on forward slide compartments with 

the type of slide cover latch brackets installed on the forward slide compartments of 

Boeing 737-600 through -900 series airplanes.î Safety Recommendation A-01-13 asked the FAA 
12 

NTSB/AAB-02/04 

to ìissue an airworthiness directive to require initial and periodic inspections (at appropriate 

intervals) of the pivot bracket assemblies on all Trans Aero Industries Model 90835 jumpseats 

installed on Boeing 737-300 through -500 series airplanes.î24 

Emergency Response 

 About 1811, the BUR ATC tower notified the BUR ARFF station of the accident via the 

direct ìcrash phone.î BUR ARFF personnel responded with three ARFF fire trucks, one rescue 

truck, and six firefighters. One of the ARFF trucks radioed that the trucks should use Gate 30025

to access the accident site. After 30 seconds, during which multiple unsuccessful attempts were 

made to open the gate with the Gate 300 access key card, the gate opened,26 and the trucks 

proceeded to the accident site. Firefighters estimated that their response time was between 1 1/2 

and 1 3/4 minutes. Firefighters aided passengers and crewmembers in evacuating the airplane. 

TESTS AND OTHER RESEARCH 

Airplane Performance 

 The Safety Board conducted an airplane performance study in conjunction with this 

accident investigation. FDR and radar data indicate that the airplane began its final descent to 

BUR about 3 nm from the runway 8 threshold. Taking into account the airplaneís altitude of 

3,000 feet msl at the beginning of the descent and the 725-foot msl elevation of the touchdown 

zone (TDZ)27 on runway 8, geometry calculations indicate that the airplane would have had to 

have descended at an average flightpath angle of about 7° to touch down in the runway 8 TDZ.28 

Radar and FDR data show that the airplane descended at an average flightpath angle of about 7° 

until flare, at an average vertical speed of 2,200 feet per minute (fpm), and at indicated airspeeds 

of between 182 and 200 knots. The airplane began to flare about 170 feet agl and flared for about 

9 seconds before touching down at 182 knots indicated airspeed on runway 8. Average ground 

speed during the flare was 195 knots, indicating that the airplane traveled about 3,000 feet during 

the flare. 

 

24 In a June 14, 2001, letter to the Safety Board, the FAA indicated that it would issue a notice of proposed 

rulemaking (NPRM) proposing to adopt an airworthiness directive to address Safety Recommendation A-01-12. The 

FAA further indicated that it was reviewing the design of the jumpseat to determine what actions were needed. On 

August 9, 2001, the Board classified Safety Recommendations A-01-12 and -13 ìOpenóAcceptable Response.î In 

a December 19, 2001, letter to the Board, the FAA indicated that it was still planning on issuing an NPRM to 

address Safety Recommendation A-01-12. The FAA further indicated that it did not believe that action was 

warranted in response to Safety Recommendation A-01-13. On May 17, 2002, the Board classified Safety 

Recommendation A-01-12 ìOpenóAcceptable Responseî and Safety Recommendation A-01-13 ìOpenó

Unacceptable Response.î 25 A gate access key card was required to open Gate 300. 

26 The BUR airport fire chief at the time of the accident indicated to investigators that after the accident, the key 

card for Gate 300 was tested and revealed no anomalies. He further stated that the magnetic key card opening 

system was replaced after the accident with remote openers that can be activated from each ARFF vehicle. 27 The TDZ is the first 3,000 feet of usable runway for landing beginning at the runway threshold, unless 

otherwise specified by the FAA or other applicable authority. 28 Typical flightpath angles for visual and instrument approaches are about 3°. 
13 

NTSB/AAB-02/04 

 At the request of the Safety Boardís Airplane Performance Group, Boeing ran stopping 

distance simulations for this accident wherein maximum, medium, and minimum 737 autobrake 

applications, as well as maximum manual brake applications, were simulated for wet runway 

conditions after the 182-knot touchdown. These data indicate that the accident airplane would 

have required about 5,000 feet of runway length after touchdown to stop using maximum 

autobrakes and about 4,700 feet of runway length after touchdown to stop using maximum 

manual brakes. Boeing stopping distance calculations based on FDR acceleration data show that 

the accident airplane traveled about 4,150 feet from touchdown to impact with the blast fence, 

indicating that the airplane touched down about 2,150 feet beyond the runway 8 threshold in the 

TDZ.29 

COMPANY INFORMATION 

 

 Southwest Airlines is certified to operate as an air carrier and conduct common carrier 

operations under the provisions of 14 CFR Part 121. Southwest Airlines began service on 

June 18, 1971. 

Company Procedures 

Approach Briefing

 The Southwest Airlines FOM,30 ìPerformance,î ìGeneral,î ìOPC [Onboard Performance 

Computer]31 Normal Landing Overviewî (Chapter 10, Section 1), states, in part, the following: 

The [OPC] Landing Module provides advisory landing distance information, 

go-around climb performance, maximum quick turn limitations, and low RVR 

[runway visual range] restrictionsÖthe Landing Module should be used anytime 

landing performance capabilities are in question (approach climb and/or 

maximum quick turnaround limitations) and include (but are not limited to) the 

following landing conditions:ÖTailwindÖHigh gross weightÖShort runway. 

 

29 The Southwest Airlines Flight Operations Manual (FOM) indicates that ì[t]ouchdown should occur between 

1000 and 1500 feet from the landing threshold with the runway centerline between the main landing gear.î For more 

information, see the section titled, ìCompany Procedures.î 30 According to the Flight Reference Manual (FRM) (Chapter 2, Section 1), ìthe Flight Operations and 

Reference Manuals contain comprehensive explanations of Southwest Airlines operating procedures, aircraft 

systems, and related operational considerations. Pilots are required to have a ëworking knowledgeí of information in 

the Flight Operations and Reference Manual[s].î The FOM is required to be carried on all Southwest Airlines flight 

operations, whereas the FRM, which contains information that is not normally referred to in daily operations, is not 

required to be carried on Southwest Airlines flight operations. 31 According to the FOM, the OPC is an approved modified presentation of the performance data contained in 

the aircraft flight manual. The landing module provides operational landing data, including landing distances, 

approach and landing speeds, and go-around power settings. 
14 

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During postaccident interviews, the first officer indicated to Safety Board investigators that he 

did not use the OPC landing module before the accident airplane landed on runway 8. The CVR 

transcript indicates that the captain did not call for the use of the OPC landing module during the 

approach.

Approach Procedures

The Southwest Airlines FOM, ìNormal Operations,î ìIntroduction,î ìChecklist Useî 

(Chapter 3, Section 1), states, in part, the following: 

The success attained by flightcrews in the execution of normal and emergency 

procedures is attributable largely to the dual reliability of the challenge and 

response checklist systemÖ.The checklist will be removed from its holder and 

read out loud in a clear voice. Responses should be equally loud and clear and 

answered as listedÖ.The checklist reader should continue challenging an item 

until a proper response is obtained. The checklist reader is responsible for 

visually confirming that the proper action has been taken. When a checklist is 

completed, the reader will announce: ë_________ Checklist complete.íÖThe 

Approach Descent Checklist will be completed silently by the pilot not flying. 

As indicated previously in the section titled, ìHistory of Flight,î the first officer stated in a 

postaccident interview that he visually confirmed the items on the final descent checklist, which 

includes notifying the flight attendants, checking the flight and navigational instruments, placing 

the landing gear down, arming the speed brake, positioning the wing flaps, and disengaging the 

autopilot. 

The Southwest Airlines FOM, ìNormal Operations,î ìApproach,î ìApproach Target 

Speedsî (Chapter 3, Section 6), states, in part, ìFly Vref[32] + 5 knots for tailwind landings.î The 

CVR transcript indicates that, at 1804:42, the first officer informed the captain that the target 

airspeed would be 138 knots. 

The Southwest Airlines FOM, ìNormal Operations,î ìApproach,î ìVisual Crew 

Coordination and Calloutsî (Chapter 3, Section 6), states, in part, the following: 

 Captain First Officer 

1000 feet above 

TDZE [TDZ elevation] 

Call out, ì1000 feet.î 

Airspeed__________ 

Sink rate__________ 

Call out, ì1000 feet.î 

On Final Approach Radio altimeter callouts below 

200 feet are at the Captainís 

discretion when the First 

Officer is flying. 

Altitudes above TDZE: 

ì500î feet 

ì400î feet 

ì300î feet 

ì200î feet 

 

32 Vref is the target airspeed for the approach. 
15 

NTSB/AAB-02/04 

If Captain lands the aircraft continue callouts 

on radio altimeter. 

ì100î feet 

ì50î feet 

ì30î feet 

ì10î feet 

The Southwest Airlines FOM, ìNormal Operations,î ìApproach,î ìDeviation Callouts 

for All Approachesî (Chapter 3, Section 6), states, in part, the following: 

If any of the following parameters are exceeded, the pilot not flying will make the 

corresponding callout and verify that the pilot flying takes appropriate corrective 

action. The pilot flying will acknowledge the callout verbally or with immediate 

corrective action. 

Parameter Limit Callouts 

Airspeed Target speed minus 5 knots 

Target speed plus 10 knots 

Anytime below VREF

Airspeed 

Localizer ±1 DOT displacement Localizer 

Glideslope ±1 DOT displacement Glideslope 

Sink Rate 2000 fpm (when below 2000í) 

1000 fpm (when below 1000í) 

Significant change (when below 50í) 

Sink Rate 

During postaccident interviews, the first officer indicated that his attention was focused primarily 

outside the airplane and acknowledged that he did not call out airspeed or sink rate deviations to 

the captain. The CVR did not record the first officer or captain making any callouts during the 

final approach. 

 The Southwest Airlines FOM, ìNormal Operations, ìApproach,î ìApproach Envelope 

for All Approachesî (Chapter 3, Section 6), states, in part, the following: 

Go-around must begin whenever adverse factors have piled up against you and the 

aircraft is not in the ìslot.î...Entry Slot 1000í AGL Landing Gear Down Final 

Flaps 

Final ìSlotî Conditions

Proper sink rate and on glidepath Proper speed (for existing conditions) Proper 

runway alignmentóno further turning requiredÖTrimmed for zero stick forces; 

Steady-state thrust setting In final landing configuration IF NOT IN THE 

ìSLOT,î YOU ARE NOT PREPARED FOR A NORMAL LANDING. 

 The Southwest Airlines FOM, ìNormal Operations,î ìApproach,î ìGo-around and 

Missed Approachî (Chapter 3, Section 6), states, in part, the following: 
16 

NTSB/AAB-02/04 

Go-around/missed approach procedures have been designed to make execution of 

the procedure as simple as possible. The procedure is nearly the same for every 

profileÖ.A missed approach must be executed ifÖthe pilot determines that a 

landing cannot be safely accomplished in the touchdown zone. 

In an interview with Safety Board investigators, the Southwest Airlines Vice President of 

Operations indicated that, for VMC approaches, ìa pilot had to be in the slot, on glidepath, on 

airspeed, and in a position to make a landing.î He stated that these conditions should exist at the 

time of the 1,000-feet agl callout when the airplane should be fully configured and meet airport 

and operational restrictions. He also stated that, to be fully configured at 1,000 feet, the flaps 

should be at 5° and the airspeed between about 170 to 180 knots with the airplane on glideslope. 

He indicated that the airplane approach criteria at 500 feet included an airspeed within ±5 knots 

and a rate of descent less than 1,000 fpm. 

When Safety Board investigators asked the captain in a postaccident interview whether he 

was within company operating guidelines at 1,000 and 500 feet, the captain responded, ìNo.î He 

stated that the airport looked normal at 500 feet but that he was not ìin the slotî because his 

airspeed was too high. When Board investigators questioned the captain about whether 

Southwest Airlines had guidance concerning the abandonment of an approach, the captain stated 

that if the airplane was not set up at 1,000 feet, with flaps at 5°, gear extended, and on 

glideslope, a go-around maneuver should be performed. He indicated that he became ìfixated on 

the runway,î and he could not explain why he did not perform a go-around maneuver.

The Southwest Airlines FOM, ìNon-normal Operations,î ìQRH 737-300/-500,î ìGround 

Proximity Alertî (Chapter 11, Section 2), states, in part, the following: 

If an [GPWS] alert occurs when flying under Day and VMC conditions, and 

positive visual verification is made that no hazard exists, the alert may be 

regarded as cautionary and the approach may be continued. If the verification 

cannot be made, immediately check/correct the aircraft flightpath, or go-around if 

necessary. 

 The Southwest Airlines FRM, ìPilot Techniques,î ìFirst Officer Operating Technique,î 

ìClose In Descent Calculationsî (Chapter 4, Section 2), states, in part, the following: 

If you are really behindóthe best choice: Level off, configure all the way to 

flaps 40óthen start down. Remember the flaps blow up to 30 just above 

150 knots flaps 40, Landing Gear down and 140 knots will give about 1000 feet 

per nautical mile (almost 1 for 1). 

In any case, have the engines spooled up by 500 feet AGL. You must lead with 

poweróa good technique is to begin advancing power as the glideslope comes off 

the bottom of the case or the upper VASI [visual approach slope indicator] turns 

pink. 
17 

NTSB/AAB-02/04 

According to the accident flight crew and other Southwest Airlines pilots interviewed after the 

accident, Southwest did not teach special procedures for a ìhigh and hot approachî to expedite 

traffic. The captain indicated that having to keep his speed up (to 230 knots) and the tailwind 

contributed to the fast approach. 

The Aeronautical Information Manual, Section 4-4-11, ìSpeed Adjustments,î states, in 

part, the following: 

If ATC determines (before an approach clearance is issued) that it is no longer 

necessary to apply speed adjustment procedures, they will inform the pilot to 

resume normal speed. Approach clearances supersede any prior speed adjustment 

assignments, and pilots are expected to make their own speed adjustments, as 

necessary, to complete the approach. 

Investigators who reviewed Southwest Airlines manuals could not find any written guidelines 

describing procedures for pilots to make their own speed adjustments, as necessary, after ATC 

has issued an approach clearance. Southwest Airlines management personnel stated that 

Southwest uses speed adjustment guidance contained in Jeppesen Airway Manuals. 

Landing Procedures

The Southwest Airlines FOM, ìNormal Operations,î ìLanding and Postflight,î ìNormal 

Landing Dry Runwayî (Chapter 3, Section 7), states, in part, the following: 

Once the landing runway has been visually acquired whether from a visual or 

instrument approach, remain on centerline and on the proper glideslope (ILS, 

VASI, PAPI, etc.) until the middle marker or further descent is necessary for a 

safe landing. Maintain briefed target speed and do not descend below the 

glideslope or ìduck underî to solely facilitate an early turn off from the runway. 

Touchdown should occur between 1000 and 1500 feet from the landing threshold 

with the runway centerline between the main landing gear. 

 

At touchdown, verify that the automatic speedbrakes have deployed or deploy 

them manually while lowering the nose to the runway. Initiate reverse thrust as the 

nosewheel touches down by rapidly raising the reverse thrust levers aft to the 

reverse idle interlock. After the interlock is released, modulate reverse thrust as 

required and avoid exceeding engine limits. A minimum of 65 [percent]Öshould 

be attained. When required, maximum allowable go-around thrust may be used. 

At 80 knots, the pilot not flying will call, ì80 knots.î Normally, the pilot flying 

will begin braking at 80 knots and gradually reduce the reverse thrust levers so as 

to be out of reverse thrust when reaching taxi speed. On short runways or with 

adverse landing conditions, do not hesitate to initiate braking prior to 80 knots if 

required. 
18 

NTSB/AAB-02/04 

As indicated in the section titled, ìAirplane Performance,î the accident airplane touched down 

2,150 feet beyond the runway 8 threshold. Further, the CVR indicates that the 80-knot callout 

was not made. As noted in the section titled, ìHistory of Flight,î the first officer stated to Safety 

Board investigators that the captain applied the brakes before 80 knots. FDR data show that the 

brakes were likely applied shortly after touchdown. 

ADDITIONAL INFORMATION 

A comparison of the recorded radar data of the accident airplane to 70 other airplanes that 

had landed at BUR on runway 8 between 1000 and 2200 on June 13 and 14, 2000,33 showed that 

of the 16 airplanes vectored from the north side of BUR to land on runway 8, 12 were vectored to 

intercept the final approach course between 9 and 15 nm west of the runway threshold. 

Flight 1455 was given vectors that resulted in interception of the final approach course about 

8 nm west of the runway threshold. The comparison also showed that the glidepaths of most 

airplanes approaching runway 8 were between 3° and 4°. The accident airplaneís glidepath 

was 7°.

 

33 Ninety-one airplanes landed at BUR during this time period; however, the data for 21 small general aviation 

aircraft were removed from the comparison because these airplanes have different operating characteristics than the 

accident airplane. 
19 

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ANALYSIS 

General 

 The captain and first officer were properly certificated and qualified in accordance with 

applicable Federal regulations and company requirements. 

 Visual meteorological conditions prevailed at the time of the accident. Runway 8 was 

wet, and a 6-knot tailwind existed at the time of the accident. 

 The airplane was properly certificated and equipped in accordance with Federal 

regulations and approved procedures. No evidence indicated preexisting engine, system, or 

structural failures. 

Flight Crew Actions 

 The first officer did not use, and the captain did not call for the use of, the Onboard 

Performance Computer (OPC) landing module during the approach. Southwest Airlines 

procedures indicate that the OPC landing module should be used when landing performance 

capabilities are in question and when tailwind conditions exist, the airplane has a high gross 

weight, or the airplane is landing on a short runway. At 1804:42, after the first officer had 

obtained information Papa, he indicated to the captain that a 6-knot tailwind existed. Further, the 

landing weight of the airplane was estimated to be 113,425 pounds (lbs), which is near the 

maximum landing weight for the Boeing 737 of 114,000 lbs, and runway 8 was 6,032 feet long 

and did not have a 1,000-foot runway safety area, as defined in Advisory Circular 150/5300-13, 

ìAirport Design.î The OPC landing module would have provided the flight crew with useful 

landing information about the configuration and condition data for computation of landing 

distance, speeds, and power settings for the airplaneís actual landing weight. 

 The accident airplaneís airspeed was not reduced to the target airspeed for the approach. 

The Southwest Airlines Flight Operations Manual (FOM), ìNormal Operations,î ìApproach,î 

ìApproach Target Speedsî (Chapter 3, Section 6), states, in part, ìFly Vref + 5 knots for tailwind 

landings.î The cockpit voice recorder (CVR) transcript indicates that at 1804:42, the first officer 

informed the captain that the target airspeed would be 138 knots. This statement indicates that 

the flight crew was aware of the target airspeed for the approach. In addition, the first officer did 

not call out airspeed or sink rate deviations to the captain. Southwest Airlines procedures indicate 

that if certain parameters are exceeded during the approach, including the target airspeed plus 10 

knots and the sink rate, the pilot not flying should make a callout regarding the deviation and 

verify that the pilot flying takes corrective action. The first officer acknowledged during an 

interview that after the captain called for flaps 40°34 at 1810:33, he saw the airspeed go as high as 

190 knots during the approach. He indicated that he pointed to the airspeed indicator to alert the 

captain but noted that his attention was focused primarily outside the airplane. Further, the 

 

34 The flap limit speed for flaps 40° is 158 knots. 
20 

NTSB/AAB-02/04 

ground proximity warning systemís (GPWS) ìsink rateî alert sounded several times during the 

approach. 

Further, the CVR transcript indicates that the first officer did not make, and the captain 

did not question the absence of, the required altitude callouts. Southwest Airlines procedures 

indicate that the first officer should make altitude callouts at 1,000; 500; 400; 300; 200; 100; 50; 

30; and 10 feet. The Safety Board notes that if the first officer had made the airspeed and sink 

rate deviation callouts or altitude callouts, both the captain and the first officer might have been 

further alerted to the fact that the airplaneís airspeed and sink rate were excessive. Flight data 

recorder (FDR) data show that the airplane touched down at about 182 knots, which is 44 knots 

over the reference speed for this flight. The Safety Board concludes that the flight crew landed 

the airplane at an excessive airspeed. 

 Radar and FDR data indicate that the accident airplaneís flightpath angle of 7° during 

descent to the Burbank-Glendale-Pasadena Airport (BUR) was steeper than the typical 

3° flightpath angle used for visual and instrument approaches. During the accident airplaneís 

descent, the GPWS ìsink rateî and ìwhoop, whoop, pull upî alerts sounded several times. The 

GPWS warnings should have given the flight crew a strong indication that the approach was 

unstabilized. Although visual flight rules conditions existed (and, therefore, according to the 

FOM, the approach could be continued after visual verification that no hazard existed), prudent 

pilots should check the cockpit instruments to note the airspeed and sink rate of the airplane. 

This information should have alerted the flight crew that the approach was unstabilized. In a 

postaccident interview, the captain acknowledged that he was not within company operating 

guidelines at 500 feet. He stated that the airport looked normal at 500 feet but that he was not ìin 

the slotî because his airspeed was too high. 

According to Southwest Airlines procedures, a go-around maneuver should be performed 

when the aircraft is not ìin the slot.î Southwest Airlinesí listing of ìslot conditionsî included 

ìproper sink rate and on glidepathî and ìproper speed (for existing conditions).î The first officer 

indicated in postaccident interviews that the approach appeared to be ìout of the slotî and that he 

did not mention this to the captain because it appeared that the captain was correcting back to the 

slot. However, no evidence exists from CVR, FDR, or radar data that the airplane was going to 

be able to reduce its airspeed, vertical speed, or flightpath angle during final descent such that it 

would be ìin the slot.î Therefore, the Safety Board concludes that the accident airplaneís 

approach was unstabilized and not in compliance with Southwest Airlines operating procedures. 

The Safety Board further concludes that because the airplane was not in the proper position to 

land, a go-around maneuver should have been performed. The Southwest Airlines FOM indicates 

that touchdown should occur ìbetween 1000 and 1500 feet from the landing threshold.î The 

accident airplane landed about 2,150 feet from the runway 8 threshold, further indicating that the 

airplane was not in the proper position to land. 

 After the airplane landed, the flight crew applied manual brakes to stop the airplane. The 

first officer indicated (and FDR data confirm) that the captain applied the wheel brakes before 

80 knots. Stopping distance calculations show that the airplane traveled about 4,150 feet from 

touchdown to impact with the blast fence. Stopping distance simulations for wet runway 
21 

NTSB/AAB-02/04 

conditions further indicate that the accident airplane would have required about 4,700 feet of 

runway length after touchdown to stop using maximum manual brakes. The Safety Board 

concludes that even if the accident flight crew had applied maximum manual brakes immediately 

upon touchdown, the airplane would not likely have stopped before impacting the blast fence. 

Air Traffic Control 

 At 1804:02, the Southern California terminal radar approach control (SCT) Woodland 

controller stated, ìSouthwest fourteen fifty five, maintain two thirty or greater ëtil advised 

please.î The captain acknowledged the airspeed adjustment assignment. At 1808:19, the 

Woodland controller stated, ìSouthwest fourteen fifty five, cross Van Nuys at or above three 

thousand, cleared visual approach runway eight.î According to the Aeronautical Information 

Manual, Section 4-4-11, the issuance of an approach clearance cancels an earlier speed 

assignment. Therefore, the 230-knot speed adjustment assignment for flight 1455 was 

automatically cancelled when the controller issued the approach clearance. 

The Safety Board recognizes that the flight crew could have asked the controller to 

remove the speed adjustment assignment before the approach clearance was issued, but the CVR 

transcript indicates that no such request was made. After the SCT Woodland controller instructed 

the flight to descend to 3,000 feet at 1807:43, traffic conditions no longer warranted the speed 

adjustment for flight 1455. Canceling the speed adjustment would have permitted the accident 

captain to begin to reduce his speed about 37 seconds sooner, thereby giving him more time to 

properly execute his approach to land. In a postaccident interview, the Woodland controller 

stated that he did not know why he did not cancel the speed restriction before issuing the 

approach clearance. Flight crew interviews and CVR, FDR, and radar data indicate that the flight 

crew did not extend the speed brakes or flaps until about 1809, more than 1 minute after the 

approach clearance was issued. The captainís delay in reducing airspeed and configuring the 

airplane caused the flight crew to initiate final descent at a higher altitude and a faster airspeed 

than normal, contributing to the unstabilized approach. 

 At 1805:08, the SCT Woodland controller instructed flight 1455 to ìturn left heading one 

six zero.î A comparison of the recorded radar data of the accident airplane to 70 other airplanes 

that had landed at BUR on runway 8 between 1000 and 2200 on June 13 and 14, 2000, showed 

that of the 16 airplanes vectored from the north side of BUR to land on runway 8, 12 were 

vectored to intercept the final approach course between 9 and 15 nm west of the runway 

threshold. Flight 1455 was given vectors that resulted in interception of the final approach course 

about 8 nm west of the runway threshold. This vector put the airplane in an unfavorable position 

for final approach, complicated the accident flight crewís approach planning and execution, and 

contributed to the unstabilized approach. 

 Further, the controllerís restriction to flight 1455 at 1808:19 to ìcross Van Nuys at or 

above three thousandî was ambiguous. According to the Pilot/Controller Glossary, restrictions 

are defined as ì[a]n altitude or altitudes, stated in the order flown, which are to be maintained 

until reaching a specific point or time. Altitude restrictions may be issued by ATC [air traffic 

control] due to traffic, terrain, or other airspace considerations.î The flight was on a 
22 

NTSB/AAB-02/04 

160° heading, and crossing over the specific point of Van Nuys was not part of the accident 

flightís approach. The flight passed abeam of the Van Nuys very high frequency 

omni-directional range navigation transmitter by about 2 miles but was not supposed to cross 

over Van Nuys. This ambiguous clearance might have caused the flight crew to delay descent 

longer than necessary. 

 In summary, the Safety Board concludes that the actions of the SCT Woodland controller 

positioned the airplane too fast, too high, and too close to the runway threshold to leave any safe 

options other than a go-around maneuver. 

Survival Factors 

 The inflation of the forward service door (1R) escape slide inside of the accident airplane 

and the partial collapse of the forward flight attendant jumpseat did not preclude the safe exit of 

crewmembers and passengers from the airplane. However, the evacuation was slowed 

considerably because of the blocked forward exits. If the airplane had caught fire after the 

accident, the unavailability of the forward exits and the prolonged evacuation would have 

dramatically affected the survivability of the occupants. As a result, on April 26, 2001, the Safety 

Board issued Safety Recommendations A-01-12 and -13 to the Federal Aviation Administration 

(FAA). Safety Recommendation A-01-12 asked the FAA to ìissue an airworthiness directive to 

require all operators of Boeing 737-300 through -500 series airplanes to replace the slide cover 

latch brackets on forward slide compartments with the type of slide cover latch brackets 

installed on the forward slide compartments of Boeing 737-600 through -900 series airplanes.î 

Safety Recommendation A-01-13 asked the FAA to ìissue an airworthiness directive to require 

initial and periodic inspections (at appropriate intervals) of the pivot bracket assemblies on all 

Trans Aero Industries Model 90835 jumpseats installed on Boeing 737-300 through -500 series 

airplanes.î35

PROBABLE CAUSE 

The National Transportation Safety Board determines that the probable cause of this 

accident was the flight crewís excessive airspeed and flightpath angle during the approach and 

landing and its failure to abort the approach when stabilized approach criteria were not met. 

Contributing to the accident was the controllerís positioning of the airplane in such a manner as 

to leave no safe options for the flight crew other than a go-around maneuver.

 

35 In a June 14, 2001, letter to the Safety Board, the FAA indicated that it would issue a notice of proposed 

rulemaking (NPRM) proposing to adopt an airworthiness directive to address Safety Recommendation A-01-12. The 

FAA further indicated that it was reviewing the design of the jumpseat to determine what actions were needed. On 

August 9, 2001, the Board classified Safety Recommendations A-01-12 and -13 ìOpenóAcceptable Response.î In a 

December 19, 2001, letter to the Board, the FAA indicated that it was still planning on issuing an NPRM to address 

Safety Recommendation A-01-12. The FAA further indicated that it did not believe that action was warranted in 

response to Safety Recommendation A-01-13. On May 17, 2002, the Board classified Safety Recommendation 

A-01-12 ìOpenóAcceptable Responseî and Safety Recommendation A-01-13 ìOpenóUnacceptable Response.î