Southwest incident and swiss cheese

I wonder if an ASRS report would be appropriate?
 
RotorAndWing said:
OK, I'll play along.

1) they had to be not be utilizing or paying attention to the GPS

Unknown at this point.

2) they had a visual approach, but they still could have had the localizer frequency set, but did not

Unknown at this point.

3) The tower at Branson either did not have radar surveillance, or if they did, the controller was not paying attention

Unknown at this point.

4) the pilot not flying did not pick up on the error

Unknown at this point.

5) someone in the last 15 minutes during the approach just happened to activate the pilot controlled lighting at Clark field on 122.7.

Unknown at this point.


The "Swiss Cheese Model" also known as "cumulative act effect" was developed by James Reason and Dante Orlandella (University of Manchester).

There is a lot written on it and I spent a great deal of time using it and doing analysis as part of Aviation Safety at the MMAC in OKC (FAA Academy)

In order to do an analysis you have to start with facts, not speculation. Speculation will only skew the results.

We need to know the following:

Aircraft make and model? I realize it was a B-737 but which variant? How was the aircraft equipped?

Any MEL/CDL items in effect at the time of the flight?

SWA procedures for approach at night (visual)?

Duties of PF/PNF during approach (SWA procedures)?

Briefing. Was there an approach briefing detailing the arrival and approach? Where fixes identified, verified on the chart as well as the FMS? Was the NAV accuracy verified on the FMS? What is the maximum drift allowed? Where the Navaids hard tuned or where they auto tuned? Was the airport diagram referenced in the briefing pertaining to approach lighting, landing aids and exiting the runway? How were the respective ND's and PFD's configured for the approach?

ATC. What altitude does radar coverage go down to? Does the tower at Branson have a scope? Did any controllers notice the aircraft was off course? Was the crew asked to verify position?

Human Factors? How long had the crew been on duty? Was this their first?second?third?forth? sector of the day and what day was the trip sequence in (first, second, third, forth?) How much sleep did the crew have in the previous 24 hours? 36 hours? 48 hours? Was there a change in their schedules? Recency of flight (day or night) into this airport for either crewmember?

What do the Captain and FO's training records look like? Any problem areas?

Any other carriers or SWA had previous problems with this airport in the past? Ongoing issues?

This is just a small sampling of questions just to begin the process. I don't think anyone here (unless someone from the FAA or NTSB working the investigation) has these answers yet.
Click to expand...

Like the way this is laid out
 
Anybody know how much runway was used for the takeoff.
 
drgwentzel said:
:nono: Here is a paste in of my metaphor: "...if you had several pieces of dissimilar Swiss cheese slices...".

I qualified it by saying "dissimilar"

Gene
Click to expand...
Reason's "swiss cheese" model was a big component of early Safety Management System theory as developed by ICAO and in the early efforts by FAA. It has largely fallen by the wheyside as more sophisticated models have emerged.

It's a matter of trying to get existing controls to defeat anticipated hazards. The problem with that approach is that some hazards can't be anticipated.

"The difference between genius and stupidity is that genius has its limits." -- Unknown, but often erroneously attributed to Albert Einstein.
 
sdflyer said:
OK so if PhD writing a paper it usually "peer" reviewed by high school students?
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Why not? Who is to say that they won't be able to understand and offer anything to the discussion? Who is to say that they won't learn anything in the process. But your analogy is flawed, any way. I presume you are trying to create an image of material that is so far beyond the "high school" student that it's pointless. That isn't the case here at all. Those on this site having varying levels of knowledge and experience. Additionally all have self selected for an interest level, and most are looking to learn something. That process is valuable. Stop acting like the discussion police. You have no right to shout anyone down.
 
JeffDG said:
The metaphor has a fatal flaw.

If you take successive slices off a block of Swiss cheese, the holes will almost certainly line up...that's where "Groupthink" enters the equation
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Not if you rotate or flip the slices. See, no ATP necessary. You're welcome.
 
Every time I see this thread title I think it says "String Cheese Incident".

Maybe because I like those guys.

...

;)
 
Ken Ibold said:
Reason's "swiss cheese" model was a big component of early Safety Management System theory as developed by ICAO and in the early efforts by FAA. It has largely fallen by the wheyside as more sophisticated models have emerged.

It's a matter of trying to get existing controls to defeat anticipated hazards. The problem with that approach is that some hazards can't be anticipated.

"The difference between genius and stupidity is that genius has its limits." -- Unknown, but often erroneously attributed to Albert Einstein.
Click to expand...

Correct.
 
RotorAndWing said:
There is a lot written on it and I spent a great deal of time using it and doing analysis as part of Aviation Safety at the MMAC in OKC (FAA Academy)
Click to expand...
I appreciate and respect that you're knowledgeable in the field Aviation Safety.

RotorAndWing said:
In order to do an analysis you have to start with facts, not speculation. Speculation will only skew the results.
Click to expand...
I think speculation is really only harmful if it's the actual investigators doing the speculating. But I think that the OP just wanted to discuss the incident, and any "results" would just be topics for debate.

RotorAndWing said:
We need to know the following:
...
Click to expand...
Until we know the facts, I'm fine with speculation. It's just a discussion board.

drgwentzel said:
When did this group start attacking each other?!
Click to expand...
'Merica! :incazzato:
 
So...I think they might have been overcome with the god-awful boredom of gps and automatic routine boring procedures that they just went off and decided to do a "real for sure short field landing".
Good show!
 
...one thing is for certain...a couple probably otherwise pretty good pilots made a pretty big mistake and they'll likely be lucky to come back flying boxes on Caravan's in North Dakota in a year or two.
 
RotorAndWing said:
I don't know. Neither does anyone else here.

The investigation is not yet over and we're already concluding punishment?? :dunno:
Click to expand...

I'm telling ya', the old farts hijacked the plane.

There a helluva Sunday buffet at the Keeter Center (college of the ozarks) immediately adjacent to PLK and they didn't want to waste any time getting into line!

http://www.keetercenter.edu
 
RotorAndWing said:
OK, I'll play along.

1) they had to be not be utilizing or paying attention to the GPS

Unknown at this point.

2) they had a visual approach, but they still could have had the localizer frequency set, but did not

Unknown at this point.

3) The tower at Branson either did not have radar surveillance, or if they did, the controller was not paying attention

Unknown at this point.

4) the pilot not flying did not pick up on the error

Unknown at this point.

5) someone in the last 15 minutes during the approach just happened to activate the pilot controlled lighting at Clark field on 122.7.

Unknown at this point.


The "Swiss Cheese Model" also known as "cumulative act effect" was developed by James Reason and Dante Orlandella (University of Manchester).

There is a lot written on it and I spent a great deal of time using it and doing analysis as part of Aviation Safety at the MMAC in OKC (FAA Academy)

In order to do an analysis you have to start with facts, not speculation. Speculation will only skew the results.

We need to know the following:

Aircraft make and model? I realize it was a B-737 but which variant? How was the aircraft equipped?

Any MEL/CDL items in effect at the time of the flight?

SWA procedures for approach at night (visual)?

Duties of PF/PNF during approach (SWA procedures)?

Briefing. Was there an approach briefing detailing the arrival and approach? Where fixes identified, verified on the chart as well as the FMS? Was the NAV accuracy verified on the FMS? What is the maximum drift allowed? Where the Navaids hard tuned or where they auto tuned? Was the airport diagram referenced in the briefing pertaining to approach lighting, landing aids and exiting the runway? How were the respective ND's and PFD's configured for the approach?

ATC. What altitude does radar coverage go down to? Does the tower at Branson have a scope? Did any controllers notice the aircraft was off course? Was the crew asked to verify position?

Human Factors? How long had the crew been on duty? Was this their first?second?third?forth? sector of the day and what day was the trip sequence in (first, second, third, forth?) How much sleep did the crew have in the previous 24 hours? 36 hours? 48 hours? Was there a change in their schedules? Recency of flight (day or night) into this airport for either crewmember?

What do the Captain and FO's training records look like? Any problem areas?

Any other carriers or SWA had previous problems with this airport in the past? Ongoing issues?

This is just a small sampling of questions just to begin the process. I don't think anyone here (unless someone from the FAA or NTSB working the investigation) has these answers yet.
Click to expand...

FMS database? Who is the supplier of the database? What charts (EFB ) are being used in the cockpit?
 
...I know we all make mistakes...even those guys probably do at least a few times during a flight. But, in the year 2014 with all the GPS's, gizmo's, flight computers, etc... I just cannot see how anyone - especially a 737 captain with 15 years experience and over a hundred souls on board puts his plane down on the wrong field. A lot has to go wrong for him to screw it up plus ATC to clear him to land and see (or not see) that he's 6+ miles away from where he needs to be and no one figures it out.

My previous comment was pure speculation but SWA does pride themselves on having the best group of pilots in the fleet and if you can't get fired for landing in the wrong place and all the hoopla and expense that goes with that...then I guess I'm just too naive about how the process works. I'm not saying the guy will never fly again - certainly depends on past history and other factors for sure...but good lord...

I'll tell you one thing it's sure embarassing as a pilot...not many people I associate with know another one besides me...to try to explain how that happens. I just can't, at least not at that level...
 
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RotorAndWing said:
So I guess the FAA can call off their investigation and just use your findings? :rolleyes2:

Thanks for jumping right on this! How soon before you have the FDR and CVR tapes available?
Click to expand...

Boy, oh boy - you really skewered him!! Yessirree, there is no doubt he's shaking in his Nikes now, cause man - that was one snarky tongue lashing about his ideas and theories.

I can't wait for your op-ed, dead eye analysis with it's killer insightful and elegant turn of phrase. ;)
 
I'll agree that we don't know all of the facts. But I believe we have enough facts to reasonably infer that these pilots definitely made an error in landing at the wrong airport. There was no airplane or airport emergency declared or otherwise reported, so there really was no excuse, other than pilot error, to be landing at that airport. There are many reasons this could happen, but it still boils down to pilot error. Everyone makes mistakes. I certainly deserve the punishments of the errors I commit. There are certainly differing levels of errors. Even though the outcome of this error was only only considerable discomfort and inconvenience, it was a fairly serious error. Is it worthy of termination? I don't think so. They still safely handled the aircraft, and they still safely brought the aircraft down to a landing, albeit at the wrong airport.

That being said, these guys did a fantastic job of getting that aircraft down and stopped in the space allotted, considering they likely did not realize it until they were committed to the landing. They, quite obviously, know their aircraft and its capabilities very well. A little refreshing training in verifying the terminal area procedures would be all it would take, depending on the pilots' attitude and history. I would think it would be more expense to train new pilots for the role, rather than retrain an otherwise qualified pilot.
 
Aztec Driver said:
A little refreshing training in verifying the terminal area procedures would be all it would take, depending on the pilots' attitude and history. I would think it would be more expense to train new pilots for the role, rather than retrain an otherwise qualified pilot.
Click to expand...

Assuming that this was just an error on the part of the pilots, my guess is that they will never make this kind of mistake again, with or without any refresher training.
 
Aztec Driver said:
Everyone makes mistakes. I certainly deserve the punishments of the errors I commit. There are certainly differing levels of errors. Even though the outcome of this error was only only considerable discomfort and inconvenience, it was a fairly serious error. Is it worthy of termination? I don't think so.

That being said, these guys did a fantastic job of getting that aircraft down and stopped in the space allotted, considering they likely did not realize it until they were committed to the landing. They, quite obviously, know their aircraft and its capabilities very well. A little refreshing training in verifying the terminal area procedures would be all it would take, depending on the pilots' attitude and history. I would think it would be more expense to train new pilots for the role, rather than retrain an otherwise qualified pilot.
Click to expand...

I consider this a terminating event. I work in IT, and years ago I worked with a guy who went into a bank building to work on a mainframe and punched the Emer Power Off button on the wall. Sadly, he took down the wrong mainframe and caused hours of outage for the bank. No one was hurt, no one faced imminent danger but the financial results were horrible. He was marched out of the building, stripped of his badge and terminated immediately for cause.

This is the kind of stuff that makes for better decisions, when the consequence of mistakes is the loss of income. You can't tie unacceptable behaviors to outcomes and clearer than taking away someone's income with the exception of a fatal, or injury event.

Also, you don't get any points, or recognition of doing a 'fantastic job' handling an emergency that is of your own making. The plane was not broke, the Branson airport was open and functional, the instrumentation was available(I will assume), and they just screwed the pooch. Do not pass Go, do not collect $200. I guess short of sending them off to jail, they will be in some other industry for the rest of their lives, and for the remaining pilots on the payroll, it will serve as a clear and convincing example; "Is that our field?" "Hmmm, not sure, but let's double and triple check, cause we don't want to wind up like those turkeys down in Branson, who are now pouring concrete for a living."
 
Honeck vs Chien
docmirror vs RotorandWing

Motel owner vs Senior AME on medical issue
IT guy vs FAA trained professional on accident issue

Who are our next contestants in the next round? Step up, don't be shy.
 
RichNY said:
Honeck vs Chien
docmirror vs RotorandWing

Motel owner vs Senior AME on medical issue
IT guy vs FAA trained professional on accident issue

Who are our next contestants in the next round? Step up, don't be shy.
Click to expand...

Oops, it was docmirror and fearless tower this time. But, the general point is accurate.

I just like folks that provide lots of criticism but refuse to provide any contributory commentary. Everyone's a critic, but would they give an opinion, or make a stand on anything? Of course not! Just like the 'crats. :lol:
 
docmirror said:
User CP > Edit Ignore list > Add member to ignore list > [docmirror] > Add(button).
Click to expand...

Sorry about that. My bad. The fact that I can see this means I screwed up- somehow confused docmirror with climbnsink who is indeed a troll and the only POA member on my ignore list. Not sure how I got them confused.

I could care less if he ignores me or not, but I would appreciate it if someone will quote this so he can at least see my apology.
 
RichNY said:
Honeck vs Chien
docmirror vs RotorandWing

Motel owner vs Senior AME on medical issue
IT guy vs FAA trained professional on accident issue

Who are our next contestants in the next round? Step up, don't be shy.
Click to expand...

More entertaining than watching American Idol. :lol:
 
Fearless Tower said:
Sorry about that. My bad. The fact that I can see this means I screwed up- somehow confused docmirror with climbnsink who is indeed a troll and the only POA member on my ignore list. Not sure how I got them confused.

I could care less if he ignores me or not, but I would appreciate it if someone will quote this so he can at least see my apology.
Click to expand...

No worries. I do belong on some folks ignore list perhaps. Thanks for clarification. ;)
 
docmirror said:
Boy, oh boy - you really skewered him!! Yessirree, there is no doubt he's shaking in his Nikes now, cause man - that was one snarky tongue lashing about his ideas and theories.

I can't wait for your op-ed, dead eye analysis with it's killer insightful and elegant turn of phrase. ;)
Click to expand...


docmirror said:
Oops, it was docmirror and fearless tower this time. But, the general point is accurate.

I just like folks that provide lots of criticism but refuse to provide any contributory commentary. Everyone's a critic, but would they give an opinion, or make a stand on anything? Of course not! Just like the 'crats. :lol:
Click to expand...


Guess you missed this post :rolleyes:

RotorAndWing said:
OK, I'll play along.

1) they had to be not be utilizing or paying attention to the GPS

Unknown at this point.

2) they had a visual approach, but they still could have had the localizer frequency set, but did not

Unknown at this point.

3) The tower at Branson either did not have radar surveillance, or if they did, the controller was not paying attention

Unknown at this point.

4) the pilot not flying did not pick up on the error

Unknown at this point.

5) someone in the last 15 minutes during the approach just happened to activate the pilot controlled lighting at Clark field on 122.7.

Unknown at this point.


The "Swiss Cheese Model" also known as "cumulative act effect" was developed by James Reason and Dante Orlandella (University of Manchester).

There is a lot written on it and I spent a great deal of time using it and doing analysis as part of Aviation Safety at the MMAC in OKC (FAA Academy)

In order to do an analysis you have to start with facts, not speculation. Speculation will only skew the results.

We need to know the following:

Aircraft make and model? I realize it was a B-737 but which variant? How was the aircraft equipped?

Any MEL/CDL items in effect at the time of the flight?

SWA procedures for approach at night (visual)?

Duties of PF/PNF during approach (SWA procedures)?

Briefing. Was there an approach briefing detailing the arrival and approach? Where fixes identified, verified on the chart as well as the FMS? Was the NAV accuracy verified on the FMS? What is the maximum drift allowed? Where the Navaids hard tuned or where they auto tuned? Was the airport diagram referenced in the briefing pertaining to approach lighting, landing aids and exiting the runway? How were the respective ND's and PFD's configured for the approach?

FMS database? Who is the supplier of the database? What charts (EFB ) are being used in the cockpit?

ATC. What altitude does radar coverage go down to? Does the tower at Branson have a scope? Did any controllers notice the aircraft was off course? Was the crew asked to verify position?

Human Factors? How long had the crew been on duty? Was this their first?second?third?forth? sector of the day and what day was the trip sequence in (first, second, third, forth?) How much sleep did the crew have in the previous 24 hours? 36 hours? 48 hours? Was there a change in their schedules? Recency of flight (day or night) into this airport for either crewmember?

What do the Captain and FO's training records look like? Any problem areas?

Any other carriers or SWA had previous problems with this airport in the past? Ongoing issues?

This is just a small sampling of questions just to begin the process. I don't think anyone here (unless someone from the FAA or NTSB working the investigation) has these answers yet.
Click to expand...
 
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Five unknowns and about 20 questions.

Contribution value: -20.
 
docmirror said:
I consider this a terminating event. I work in IT, and years ago I worked with a guy who went into a bank building to work on a mainframe and punched the Emer Power Off button on the wall. Sadly, he took down the wrong mainframe and caused hours of outage for the bank. No one was hurt, no one faced imminent danger but the financial results were horrible. He was marched out of the building, stripped of his badge and terminated immediately for cause.

This is the kind of stuff that makes for better decisions, when the consequence of mistakes is the loss of income. You can't tie unacceptable behaviors to outcomes and clearer than taking away someone's income with the exception of a fatal, or injury event.

Also, you don't get any points, or recognition of doing a 'fantastic job' handling an emergency that is of your own making. The plane was not broke, the Branson airport was open and functional, the instrumentation was available(I will assume), and they just screwed the pooch. Do not pass Go, do not collect $200. I guess short of sending them off to jail, they will be in some other industry for the rest of their lives, and for the remaining pilots on the payroll, it will serve as a clear and convincing example; "Is that our field?" "Hmmm, not sure, but let's double and triple check, cause we don't want to wind up like those turkeys down in Branson, who are now pouring concrete for a living."
Click to expand...

What if the investigation uncovers several flaws, such as a database error in the FMS, a deficiency in SWA procedures, a human factors issue such as fatigue, etc?

Do will still condemn the crew?
 
docmirror said:
Five unknowns and about 20 questions.

Contribution value: -20.
Click to expand...

Really?? :rolleyes2:

So how do you think an investigation is handled? My questions I posted were a small sampling of the questions being asked to demonstrate to the readers here the process of this investigation and how "drilling down" could possibly uncover flaws in the system not yet uncovered.

I've offered insight into the discussion using factual information. You? Only anecdotal commentary on some IT tech screwing up and getting fired.

You obviously don't like the messenger (me) and you obviously feel the best solution is to fire these pilots without a proper investigation.
 
RotorAndWing said:
Really?? :rolleyes2:

You obviously don't like the messenger (me) and you obviously feel the best solution is to fire these pilots without a proper investigation.
Click to expand...

Please don't flatter yourself. Just read what I wrote. It has absolutely nothing to do with you personally, but if your contribution is to harass others who've contributed their ideas, but ask only questions, it's pretty clear you don't want to discuss, you want to critique. I get enough of that from She Who Must Be Obeyed.

Have a nice day. :)
 
docmirror said:
Please don't flatter yourself.
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I'm not, just responding to a post (that's how forums work)

docmirror said:
Just read what I wrote.
Click to expand...

I did even though it was rather inane. :rolleyes2:



docmirror said:
It has absolutely nothing to do with you personally, but if your contribution is to harass others who've contributed their ideas, but ask only questions, it's pretty clear you don't want to discuss, you want to critique. I get enough of that from She Who Must Be Obeyed.

Have a nice day. :)
Click to expand...

Reading comprehension is your weak point, we can clearly see that.

Like previously posted (which you ignore) I offered some factual information on the subject and discussion. You? Just inane diatribe. As usual. :rolleyes:
 
I see many instances on internet forums of men saddled with a SWMBO. My condolences.
 
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