Flight SWA 1455 Case Study Workbook - Center for Air ...

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SUMMARYOn 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 ofrunway 8 after landing at Burbank-Glendale-Pasadena Airport (BUR), Burbank,California. The airplane touched down at approximately 182 knots, and about 20seconds later, at approximately 32 knots, collided with a metal blast fence and anairport perimeter wall. The airplane came to rest on a city street near a gasstation off of the airport property. Of the 142 persons on board, 2 passengerssustained serious injuries; 41 passengers and the captain sustained minorinjuries; and 94 passengers, 3 flight attendants, and the first officer sustained noinjuries.PROBABLE CAUSEThe National Transportation Safety Board determines that the probable cause ofthis accident was the flight crew’s excessive airspeed and flightpath angle duringthe approach and landing and its failure to abort the approach when stabilizedapproach criteria were not met. Contributing to the accident was the controller’spositioning of the airplane in such a manner as to leave no safe options for theflight crew other than a go-around maneuver.SIGNIFICANT EVENTS1. Changing surface wind conditions at the destination required the crew tochange their arrival plan2. Air Traffic Control caused the flight to be both fast and high whenbeginning the approach3. Captain attempted to descend to runway without using maximum efforts toslow4. Despite the excessive airspeed pilots continued with their plan to land(and NOT execute a go-around)5. captain delayed application of maximum breaking6. Shortest runway7. Runway closest to public area8. No EMAS systemCopyright Lance Sherry 20092
Reason’s Swiss Cheese Accident ModelWhat do the “Layers of Cheese” represent?What do the “holes” in layers of the cheese represent?When does an accident occur?Copyright Lance Sherry 20093
Page 1: SYST 560/660OR 750Spring 2009Center
Page 5 and 6: is magnified. In a sense then, the
Page 7 and 8: Topographical Map of Surrounding Te
Page 9 and 10: Prevailing Wind Direction:STATION|
Page 11 and 12: Runway 8/26Dimensions: 5801 x 150 f
Page 13 and 14: 6. Precision Approach Path Indicato
Page 15 and 16: Runway Safety AreasTitle 14 CFR 139
Page 17 and 18: Copyright Lance Sherry 200917
Page 19 and 20: 4. What is an EMAS and how does it
Page 21 and 22: Approach Charthttp://204.108.4.16/d
Page 23 and 24: Las Vegas to Burbank RouteSouthwest
Page 25 and 26: 7. When the aircraft passed over PM
Page 27 and 28: 1. What is the Approach Control Fre
Page 29 and 30: At 1808:19, the Woodland controller
Page 31 and 32: 5. What are “speed brakes” (als
Page 33 and 34: 11. Why is it significant that the
Page 35 and 36: penetrated a metal blast fence and
Page 37 and 38: . How much altitude (feet) higher w
Page 39 and 40: “Swiss Cheese” Model Analysis f

Flight SWA 1455 Case Study Workbook - Center for Air ...

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