Source: http://www.ntsb.gov/investigations/summary/AAR0706.html
Timestamp: 2014-04-16 22:09:45
Document Index: 249825096

Matched Legal Cases: ['art 121', 'art 121', 'art 121', 'art 121', 'art 121', 'art 121', 'art 121', 'art 121']

Runway Overrun and Collision Southwest Airlines Flight 1248 Boeing 737-7H4, N471WN Chicago Midway International Airport
December 8, 2005 NTSB Number: AAR-07-06
Adopted October 2, 2007
On December 8, 2005, about 1914 central standard time, Southwest Airlines (SWA) flight 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 flight 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 flight, which operated on an instrument flight rules flight plan. Probable Cause
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' first experience and lack of familiarity with the airplane's autobrake system distracted them from thrust reverser usage during the challenging landing.
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 classified "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-flying (monitoring) pilot to check and confirm 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)
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 outfitting 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 This Accident Investigation and Classified in this Report
As a result of the SWA flight 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 classified "Open-Unacceptable Response" on May 8, 2007) is classified "Closed-Unacceptable Action/Superceded" by Safety Recommendation A-07-57 in section 2.3 of this report.