Southwest incident and swiss cheese

drgwentzel

drgwentzel

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Fellow Pilots,

We all know that these incidents happen due to a chain of events. Here are the ones that I can identify:

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

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

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

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

And the last link in this chain of events that I can think of and find most ironic:

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

If anyone is a member of pilotworkshops.com someone there just mentioned the phrase: "The Swiss Cheese Factor", or words to that effect.

The meaning is that if you had several pieces of the dissimilar Swiss cheese slices representing layers of safety, it would be quite a coincidence that have 5 pieces with holes that lineup in the exact same place for a pilot to fly through all of them in a straight line ending up in an accident.

But every now and then the holes do line up, and in this case they surely did.

If anyone else can think of another slice of cheese that I've messed please chime in.
 
drgwentzel said:
4) the pilot not flying did not pick up on the error
Click to expand...

Or the most obvious one:

The pilot flying did not pick up on the error.

Or, the runway numbers or ground track on final don't match the intended runway.

Or, the terminal and related development is on the wrong side of the runway.

My guess is the crew had no suspicion they were approaching the wrong runway until after they touched down.
 
Last edited:
drgwentzel said:
Fellow Pilots,

We all know that these incidents happen due to a chain of events. Here are the ones that I can identify:

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

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

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

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

And the last link in this chain of events that I can think of and find most ironic:

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

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?
 
Brad Z said:
Or the most obvious one:

The pilot flying did not pick up on the error.

Or, the runway numbers or ground track on final don't match the intended runway.
Click to expand...

Actually, here is a question from a humble SEL pilot to you commercial folks - what is a practical "go around" in these birds? say the pilot noticed the error on final - how late is too late to jump push it in and go to the right airport?
 
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...

I don't think he suggesting that those are what happened necessarily, just that those items are factors at play. Sure, they could have intentionally landed at the wrong airport...I guess we'll have to wait for the report to come out to be sure... :rolleyes2:
 
Brad Z said:
I don't think he suggesting that those are what happened necessarily, just that those items are factors at play. Sure, they could have intentionally landed at the wrong airport...I guess we'll have to wait for the report to come out to be sure... :rolleyes2:
Click to expand...

How does he know "those items are factors in play"? Does he have access to SWA cockpits and procedures? Is he typed on a 737 and understand the systems? Has he flown this route with SWA in the cockpit of a 737 and observed such items?

Or is he a PP trying to base his assumptions on the 172 he flies?
 
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...

Point well taken and I have to admit it made me smile.

In defense, if someone would walk into my house with an umbrella, a raincoat and galoshes which are all soaking wet and dripping on my floor, I would not need a major federal investigation to discover that it's raining outside.
 
It will be months before know the actual chain of events, but in the meantime it is entirely proper and instructive to consider possible reasons why an incident like this may have happened.
 
tinerj said:
It will be months before know the actual chain of events, but in the meantime it is entirely proper and instructive to consider possible reasons why an incident like this may have happened.
Click to expand...


"entirely proper and instructive to consider possible reasons".......

How about using some actually facts first? :rolleyes2:
 
drgwentzel said:
In defense, if someone would walk into my house with an umbrella, a raincoat and galoshes which are all soaking wet and dripping on my floor, I would not need a major federal investigation to discover that it's raining outside.
Click to expand...

Obviously some people would need a major federal investigation...
 
RotorAndWing said:
How does he know "those items are factors in play"? Does he have access to SWA cockpits and procedures? Is he typed on a 737 and understand the systems? Has he flown this route with SWA in the cockpit of a 737 and observed such items?

Or is he a PP trying to base his assumptions on the 172 he flies?
Click to expand...

Does it matter? This is a board of mostly GA pilots. I guess we'll all just have to shut up and wait for the NTSB report. Oh wait, there's no certainty that there will be a NTSB investigation.

The crew landed at the wrong freakin airport. It doesn't take a 737 Typed ATP to figure out something went wrong that was easily avoidable.
 
Brad Z said:
Fact #1:

They landed at the wrong airport.
Click to expand...

Not entirely factual. How do we know they landed?
Fact #1: The wrong runway appeared under the plane at some point in time. :p

I love how pilots are worse rubber-neckers and armchair quarterbacks than almost anyone else in these sorts of situations (myself equally guilty).
 
Brad Z said:
Does it matter? This is a board of mostly GA pilots. I guess we'll all just have to shut up and wait for the NTSB report. Oh wait, there's no certainty that there will be a NTSB investigation.

The crew landed at the wrong freakin airport. It doesn't take a 737 Typed ATP to figure out something went wrong that was easily avoidable.
Click to expand...

Please explain to us how the FMS and FMGS of the 737 works, the relationship of the IRS and GPS as well as auto tuning of the local navaids.

What is the maximum allowable drift of any one IRS in the system and how would that affect nav accuracy?
 
Has anyone considered the possibility that they just hadn't gotten enough sleep?

sleepers.jpg
 
RotorAndWing said:
"entirely proper and instructive to consider possible reasons".......

How about using some actually facts first? :rolleyes2:
Click to expand...

I'm glad you posted this.

I thought the whole idea of these *discussion* boards was to actually discuss a topic and provide our thoughts, opinions and insights that stimulates discussions and conversations we are interested in.

Although your point is well taken, it just seems your initial response was intended and crafted to belittle, embarrass or stifle. Although I am a big boy and can take it, I don't think this group has to remain muted until an official report or all the facts are released to discuss our thoughts.
 
All good information we lowly GA pilots can learn from too. Thanks for speculating. You are not allowed to do that on Van's Air Farce.
 
RotorAndWing said:
How does he know "those items are factors in play"? Does he have access to SWA cockpits and procedures? Is he typed on a 737 and understand the systems? Has he flown this route with SWA in the cockpit of a 737 and observed such items?

Or is he a PP trying to base his assumptions on the 172 he flies?
Click to expand...

Lighten up!!! It's just a discussion board! This isn't the NTSB investigation...
Sheesh...
 
drgwentzel said:
Fellow Pilots,

We all know that these incidents happen due to a chain of events. Here are the ones that I can identify:

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

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

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

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

And the last link in this chain of events that I can think of and find most ironic:

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

If anyone is a member of pilotworkshops.com someone there just mentioned the phrase: "The Swiss Cheese Factor", or words to that effect.

The meaning is that if you had several pieces of the dissimilar Swiss cheese slices representing layers of safety, it would be quite a coincidence that have 5 pieces with holes that lineup in the exact same place for a pilot to fly through all of them in a straight line ending up in an accident.

But every now and then the holes do line up, and in this case they surely did.

If anyone else can think of another slice of cheese that I've messed please chime in.
Click to expand...


The most ironic thing in all of above is that being a member of pilotworkshops doesn't not qualify you to be NTSB or FAA investigator.
In my opinion passing judgement without having relative experience in similar conditions or similar airplanes is just another case of wide spread ignorance.
 
sdflyer said:
In my opinion passing judgement without having relative experience in similar conditions or similar airplanes is just another case of wide spread ignorance.
Click to expand...

Part of the scientific method is peer review. Thus, kicking thoughts around for others to critique is part of the process. Just because you present a hypothesis doesn't mean you have reached a judgment. I frankly think the kicking around is quite helpful and often illuminating.
 
PPC1052 said:
Part of the scientific method is peer review. Thus, kicking thoughts around for others to critique is part of the process. Just because you present a hypothesis doesn't mean you have reached a judgment. I frankly think the kicking around is quite helpful and often illuminating.
Click to expand...


OK so if PhD writing a paper it usually "peer" reviewed by high school students?
 
sdflyer said:
The most ironic thing in all of above is that being a member of pilotworkshops doesn't not qualify you to be NTSB or FAA investigator.
In my opinion passing judgement without having relative experience in similar conditions or similar airplanes is just another case of wide spread ignorance.
Click to expand...

This isn't Airline Pilots of America. If we only allowed ATPs to discuss airline matters, military to discuss military, helicopter to helicopter, etc, etc, it would be a pretty boring website. Sometimes we critique things that we're not intimately familar with. Strangely enough, even people who never served in govt critique govt issues. That's the nature of this website.

Having sat through endless aviation safety classes I agree with OP that something like this is a chain of events or "swiss cheese" if you will. While he isn't presenting facts, his assumptions are probably pretty close to the facts when they do come out. As long as its in good taste, nothing wrong with forming and opinion on an accident, incident, or occurrence.
 
Velocity173 said:
This isn't Airline Pilots of America. If we only allowed ATPs to discuss airline matters, military to discuss military, helicopter to helicopter, etc, etc, it would be a pretty boring website. Sometimes we critique things that we're not intimately familar with. Strangely enough, even people who never served in govt critique govt issues. That's the nature of this website.

Having sat through endless aviation safety classes I agree with OP that something like this is a chain of events or "swiss cheese" if you will. While he isn't presenting facts, his assumptions are probably pretty close to the facts when they do come out. As long as its in good taste, nothing wrong with forming and opinion on an accident, incident, or occurrence.
Click to expand...

In contrast, sometimes too much critiques of "home grown specialists" may shift POA site from boring to annoying. :lol:

The only fact I know so far is that Southwest airplane landed on the wrong airfield, and they are damn good at short field landing. Everything else is pure speculation.;)
 
Velocity173 said:
This isn't Airline Pilots of America. If we only allowed ATPs to discuss airline matters, military to discuss military, helicopter to helicopter, etc, etc, it would be a pretty boring website. Sometimes we critique things that we're not intimately familar with. Strangely enough, even people who never served in govt critique govt issues. That's the nature of this website.

Having sat through endless aviation safety classes I agree with OP that something like this is a chain of events or "swiss cheese" if you will. While he isn't presenting facts, his assumptions are probably pretty close to the facts when they do come out. As long as its in good taste, nothing wrong with forming and opinion on an accident, incident, or occurrence.
Click to expand...

:yeahthat::yeahthat:
 
I have flown into both airports. They don't look anything alike. One is very near Branson, KPLK, and the other one is 8 miles out in the sticks, KBBG.
 
sdflyer said:
In contrast, sometimes too much critiques of "home grown specialists" may shift POA site from boring to annoying. :lol:

The only fact I know so far is that Southwest airplane landed on the wrong airfield, and they are damn good at short field landing. Everything else is pure speculation.;)
Click to expand...

Other facts:
It was night.
Nobody was injured.
The airplane flew out this afternoon.
There was no mayday or distress call.
 
TMetzinger said:
Other facts:
It was night.
Nobody was injured.
The airplane flew out this afternoon.
There was no mayday or distress call.
Click to expand...

Yes Also now both captains are suspended.
 
TMetzinger said:
Done them both at night?
Click to expand...

Nope, nor have I landed a 737 at either one. I have landed at each with a licensed pilot in each front seat though. Does that count?

I will commend them on getting stopped. KPLK has no overrun.
 
sdflyer said:
The most ironic thing in all of above is that being a member of pilotworkshops doesn't not qualify you to be NTSB or FAA investigator.
In my opinion passing judgement without having relative experience in similar conditions or similar airplanes is just another case of wide spread ignorance.
Click to expand...

Who's passing judgment? I just put out thoughts that I think any pilot would ask if they were in a similar situation or incident.

We all review and study NTSB accident reports and articles, such as, I Learned about Flying From That, Never Again, etc. to gain knowledge, virtual experience and to be safer and more competent pilots. We share our own stories and experiences to learn from each other here. Bravo! Let's keep it up.

And I never asserted that I am any kind of expert because I watch online videos on pilotworkshops!! We're members of a pilots discussion group...that's what we do here...we discuss and we share conversation about our thoughts.

When did this group start attacking each other?! I remember a lot people on this board didn't walk away from the last Aviation Newsgroup...but sprinted away to avoid such bad-mannered and intolerant treatment.

Gene
 
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
 
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
Click to expand...

You mean, like Asiana? I buy that.

FO: "Hey man you're about to.."
CA: "SILENCE!!"
*twoop twoop TERRAIN. twoop twoop PULL. UP.*
:rolleyes2:

Good ol CRM. The more things change, the more they stay the same...
http://www.youtube.com/watch?v=gmxiZZZ-2_4
:D
 
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
Click to expand...

: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
 
drgwentzel said:
In defense, if someone would walk into my house with an umbrella, a raincoat and galoshes which are all soaking wet and dripping on my floor, I would not need a major federal investigation to discover that it's raining outside.
Click to expand...

Or

1) your sprinkler pipe broke or

2) your neighbor is washing his car and being careless . . .

3) or its raining.
 
drgwentzel said:
I'm glad you posted this.

I thought the whole idea of these *discussion* boards was to actually discuss a topic and provide our thoughts, opinions and insights that stimulates discussions and conversations we are interested in.

Although your point is well taken, it just seems your initial response was intended and crafted to belittle, embarrass or stifle. Although I am a big boy and can take it, I don't think this group has to remain muted until an official report or all the facts are released to discuss our thoughts.
Click to expand...


drgwentzel said:
Fellow Pilots,

We all know that these incidents happen due to a chain of events. Here are the ones that I can identify:

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

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

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

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

And the last link in this chain of events that I can think of and find most ironic:

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

If anyone is a member of pilotworkshops.com someone there just mentioned the phrase: "The Swiss Cheese Factor", or words to that effect.

The meaning is that if you had several pieces of the dissimilar Swiss cheese slices representing layers of safety, it would be quite a coincidence that have 5 pieces with holes that lineup in the exact same place for a pilot to fly through all of them in a straight line ending up in an accident.

But every now and then the holes do line up, and in this case they surely did.

If anyone else can think of another slice of cheese that I've messed please chime in.
Click to expand...

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.
 
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...

Nice template for discussion! It will be interesting to watch as the investigation proceeds, and facts are revealed.
 
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