The assumptions and decisions made by the crew of Southwest Airlines flight 1248 resulted in serious casualties.
Photo credit: Courtesy of NTSB
This article review common assumptions made by members of fire service and airline industry that can prove fatal.
"Southwest 1248, runway three one center cleared to land, wind zero nine zero at nine, braking action fair to poor. Southwest Airlines (SWA) 1248, a Boeing 737-700, prepared for final approach and landing at Chicago's Midway airport. SWA 1248 was nearly two hours late as a result of weather delays in Chicago that kept the airplane waiting on the ground in Baltimore.
At 1912 hours, SWA1248 was lined up on the Instrument Landing Approach signal that would place them over the threshold of runway 31C. Landing conditions were not the best. Snow had been falling for six hours and visibility was a half-mile in moderate snow and freezing fog with a broken ceiling at 400 feet above ground level. Despite the fact that snow removal crews at Midway had been working steadily for hours, the runway braking conditions were reported as fair for the first half and poor for the second half of the runway.
Fair Versus Poor
Just as firefighters routinely do, the flight crew used information available to them, often based on assumptions that would assist them in making decisions. If the assumptions were incorrect, the resulting decisions could be faulty and potentially deadly. They were using alaptop personal computer (PC) to make a decision concerning their ability to safely land on 31C. The laptop program was not designed to take a mixed runway report (fair on the first half and poor on the second) to develop a calculation regarding how many feet it would take for the aircraft to come to a full stop under the prevailing conditions.
Though not happy with the results derived from the runway calculation, the flight crew agreed that they would pick up several hundred feet of runway margin when reverse thrust was applied. This maneuver would apply engine exhaust to slow the aircraft in combination with conventional braking. Reverse thrust was applied by moving two levers on the throttle console first to a neutral position and then to an engaged one.
"Brakes, Brakes, Brakes"
Traffic into Midway was "stacked" and in the 15 minutes before 1248 landed they listened to four other company flights touch down and roll-out on 31C. Hearing other SWA flights make a successful landing no doubt influenced the crew to attempt a landing in conditions far less than ideal. They also heard reports of deteriorating runway conditions.
SWA 1248 descended through 1,000 feet and picked up the runway dead ahead. They crossed the numbers and glided to a firm touch down about 1,250 feet past the threshold. The pilot was flying the aircraft and the first officer was monitoring. Both would later report being focused on the operation of the automatic braking system since they were using it for the first time. The pilot attempted to move the reverse thrust levers into position and indicated that he had difficulty in doing so. He also said that he felt the aircraft's anti-skid system engage and that the aircraft seemed to pick up speed. The first officer shouted "brakes, brakes, brakes", pushed the pilot's hand away from the reverse thrust levers and successfully engaged them. Manual braking was also applied at this point. Twenty seven seconds had passed since touchdown.
Still moving at 53 knots the aircraft departed the overrun, rolled through a blast fence, an airport perimeter fence, and onto a roadway where it struck a vehicle, killing one passenger and seriously injuring another.
Assumptions and Decisions
As is the case with all significant transportation incidents, the National Transportation Safety Board (NTSB) conducted an investigation. The NTSB found that the flight crew was certified, qualified and unimpaired. Similarly, the aircraft was properly certified, equipped, and maintained. Finally, the airfield was operating appropriately for the weather conditions.
And yet, a fatal accident occurred. Why?
According to the NTSB, the flight crew was effectively overly optimistic about runway conditions and failed to use the most conservative assessment (poor) when making their decision.
The crew was making critical decisions based on incorrect assumptions. They assumed, in fact, that the computed stopping distance did not include the positive effects of full reverse thrust when it did.
They were attempting to execute a new procedure for the first time under very challenging circumstances. This resulted in their being distracted from a routine process, the deployment of the thrust reversers. The failure to deploy the reversers in a timely manner allowed the aircraft to leave the runway.
They were not provided with clear and consistent guidance or training regarding polices and procedures. This included management's failure to employ a familiarization period for a key operational change.
For anyone familiar with long-term trends in firefighter fatalities these findings sound very familiar. It turns out that overly optimistic assumptions and faulty decision making can be found across professions with devastating results.
Three Fatal Assumptions and Fire/Rescue Operations
The crew of SWA 1248 is not alone. The North American fire service continues a lengthy tradition of making routine operational decisions based on assumptions that have been repeatedly proven as faulty to the point of being reckless.
Assumption One: Firefighters Are Not Pre-Disposed To Cardiac Events
Incorrect. The majority of firefighter line-of-duty deaths are cardiac or stroke related. A long term study conducted by the NFPA of 713 of these deaths revealed that "84.6 percent had suffered prior heart attacks, had severe arteriosclerotic heart disease, had undergone bypass surgery or angioplasty/stent replacement or had diabetes." In addition, the United States Fire Administration reports that for 2006, the latest year for which statistics are available, that once again, cardiac events are the leading cause of death.
If you are a leader and you allow known and untreated sufferers of heart disease or inadequately screened staff to conduct field operations, you are participating in the killing of firefighters.
Assumption Two: Apparatus Accidents Will Not Occur And Seatbelts Do Not Need To Be Worn
Incorrect. Serious and fatal apparatus accidents have reached a level that can be described as epidemic. In 2006, 19 firefighters died in accidents. There are undoubtedly a variety of underlying causes. They include increased road traffic, aggressive drivers and greater call volume. The list does not end there.
These fatal firefighter accidents tend to involve single-vehicle roll-overs, often tankers, driven at high speeds with drivers and or other occupants not wearing seatbelts. Firefighters are often ejected during the incident. Finally, since 1990, 69 firefighters have been killed in personal vehicles while responding. Many were speeding and not wearing seatbelts.
If you are a leader and you condone unsafe vehicle operations in either an administrative or operational capacity, you are participating in the killing of firefighters.
Assumption Three: Conditions Will Not Deteriorate And Components Will Not Fail
Incorrect. Wooden I-beams, roofs, canopies, porches and walls are collapsing all about. There are death reports noting flashovers in rooms, floors, wings and entire building trapping and killing firefighters in ones and twos and often many more. Almost always, the buildings are all clear or lack any credible evidence of a savable life. In addition, these buildings can be characterized as "enclosed" i.e., one that has few openings. In fact, a recent study of 444 firefighter fatalities found that 84 percent occurred in these type of structures. Finally, 87 percent of multiple firefighter fatality incidents occurred in enclosed structures. Just as often, fire operations are inadequately resourced, under-staffed and fire fighters are in overly exposed positions where the apparent risk far outweighs any rational benefit.
If you are a leader you have the responsibility to intervene to re-align risks to reflect expected benefits. If you do not, you are participating in the killing of firefighters.
Who's A Leader?
Leaders create and refine culture. Our firefighting culture may be anchored in the past but it must reflect the reality of the present. Our culture is complex and is being woven on many different levels at the same time. We all have the opportunity to lead if we are comfortable with challenging the status quo to save lives.
Many in our industry are not. For them, the status quo is fine even when the result is a profession where reckless and needless injury and death is accepted with false bravado, even with pomp and circumstance.
To change fatal assumptions we must be willing to lead, step out of tradition and possibly face criticism. The longer you've been around the firehouse the more responsibility you have to create a culture based less on myth and needless risk and more on the cold hard facts that are killing fire fighters every day.
ERIC LAMAR lives and works in Washington, D.C. He has been involved in the fire service for 30 years.