NASHVILLE, TN, USA
N53SW
Boeing 737-200
During the takeoff roll, after V1 was called by the first officer, a bird was ingested in the left engine, resulting in a compressor stall. The captain (capt) initiated a rejected takeoff as VR was called. The airplane continued accelerating momentarily, & V1 was exceeded by 10 kts, resulting in an overrun of the runway. After stopping on the overrun, the capt made a PA announcement for the passengers to remain seated. Fire/rescue personnel arrived, confirmed there was no fire, & noted the tires were deflating & smoking (due to excessive brake temperature from the rejected takeoff which melted the fuse plugs & deflated the tires). Evacuation slides were dearmed, & the cabin doors were opened for ventilation. Fire erupted from the right brake & was immediately extinguished by fire personnel. Hearing a fireman shout 'fire,' the flight attendants (FAs) at the forward & aft entry doors commanded an evacuation without informing the capt that a fire had been reported, without communicating 1st with each other, & without determining the location of the fire. To evacuate, they closed the cabin doors, rearmed the slides, & began the evacuation. During evacuation, 1 passenger was seriously injured; 4 received minor injuries. The airline company did not provided 'joint' Crew Resource Management (CRM) training to flight deck crews & FAs. Two of 3 FAs said they had not received company CRM training.
HISTORY OF FLIGHT On July 8, 1996, about 0741 central daylight time (CDT), a Boeing 737-200, N53SW, received minor damage during a rejected takeoff (RTO) on runway 20C at the Nashville Metropolitan Airport, Nashville, Tennessee. There were 5 crew members, and 122 passengers on board the airplane. None of the crew members were injured, however, one passenger received serious injuries, and 4 passengers received minor injuries. All injuries were incurred during the emergency evacuation. The airplane was operated as a scheduled, domestic, passenger flight, under the provisions of Title 14 CFR Part 121, by Southwest Airlines, Company, as Flight 436. Visual meteorological conditions existed at the time, and an instrument flight rules flight plan was in effect for the flight. The flight was departing Nashville, Tennessee (BNA), with a destination of Chicago, Illinois (MDW). According to the flight crew, a rolling takeoff was performed because the flight was cleared for departure prior to reaching the runway. However, the transcript of radio communications indicated that at 0738:39, the flight was cleared to taxi onto the runway and hold its position, pending the takeoff of another flight on a parallel runway. According to the transcript of communications, Flight 436 was cleared for takeoff one minute and 22 seconds later. Sounds of brake release were heard on the cockpit voice recorder (CVR) after the flight was cleared for takeoff. During the takeoff roll, according to the captain, he observed an object flash past the airplane. The first officer reported he saw a bird on the right of the nose of the airplane. Shortly afterwards, they heard a loud "explosion." Additionally, the captain reported that the airplane yawed left. The flight crew stated that the last airspeed they observed immediately prior to the engine bang was 135 knots, indicated airspeed, and V1 had not been called. The captain reported that the explosion, louder than any compressor stall he had ever experienced, created a shudder in the airplane. He stated he thought that a catastrophic engine failure had occurred. According to the captain, the event occurred about the 3,000 foot runway remaining marker. A high speed rejected takeoff was initiated. The airplane could not be stopped on the runway. The captain stated that because he recalled a failure of an engine on an MD-80 the previous week, which resulted in engine components penetrating the cabin, he elected not to engage reverse engine thrust. As the airplane rolled off the paved surface, the captain steered it around the Instrument Landing System antenna The airplane was subsequently stopped approximately 750 feet off the departure end of runway 20C, and about 100 feet east of the runway extended centerline. After the airplane had been stopped, the captain reported, he made a public address announcement for the passengers to remain seated. After completing the checklist, he entered the cabin and assured the passengers that fire department assistance had been requested, and ascertained that there was no fire. He returned to the cockpit and noted that the fire department equipment had arrived. An unsuccessful attempt was made to lower the airstairs at the main entry door. The auxiliary power unit was not started because of the lack of information regarding damage to the airplane. According to the flight crew and the cabin crew, the evacuation slides were disarmed, and the cabin doors were opened to provide ventilation. The captain and the Airport Rescue and Fire Fighting (ARFF) on-scene supervisor stated that they had established voice communications through the captain's open cockpit window. The ARFF supervisor reported to the captain that the tires were smoking and were deflating. According to the airport authority incident report, the right main gear became involved with fire and foam was applied to the wheels. According to the flight attendants located at the forward entry door and the aft entry door, they independently heard a fireman call "fire," which prompted each to initiate an evacuation of the airplane by closing the cabin doors, rearming the evacuation slides by re-engaging the girt bar, and re-opening the doors activating the slides. The captain, who was in his seat in the cockpit, was not notified that an evacuation was being initiated, nor did the flight attendants located at the front and rear cabin entry doors, communicate with each other regarding the conditions, or that an evacuation was being initiated. The captain stated he heard noises in the cabin and noted that an evacuation was being initiated and elected not to change the evacuation order. During the evacuation, the slides at the forward entry (L1), forward galley (R1) and the aft entry (L2) doors were used. The overwing exits were not used. One passenger sustained a broken leg during his descent on the slide at the aft entry door. PERSONNEL INFORMATION The captain held an airline transport pilot certificate and a B-737 type rating. His last proficiency check flight was January 21, 1996. He possessed a Class 1 medical certificate, with no limitations or waivers, with his last examination for the medical certificate having been conducted on January 12, 1996. According to the captain he had about 6,000 total flight hours, with 3,600 total flight hours in the B-737.The operator's report indicated he had 4,400 hours in the 737 airplane. At the time of the accident, he had 233 flight hours as the pilot in command of the B-737. According to the operator's report of the accident, within the 90 days prior to the accident, the captain had 180 total flight hours, all as captain in the B-737,. He had 110 and 6 total flight hours as captain within the previous 30 days and 24 hours, respectively. He stated he had been with Southwest Airlines for about 51/2 years. His previous experience was as an Air Force pilot where he flew the T-38, T-37, and F-16. Immediately prior to his hiring at Southwest, he was an F-16 instructor pilot. During the captain's interview, he stated that he had received Crewmember Resource Management Training (CRM) when initially hired, during a refresher course, and at his captain upgrade in January, 1994. Additionally, he had CRM each year during recurrent ground training or at emergency procedures training. He stated that at one point CRM was conducted with flight attendants, but he did not believe that was currently being done. The captain also stated that most of the V1 cut training that he had, had resulted in continuing the takeoff. He did not recall how much RTO training he had prior to the accident, and stated that RTO training may be waived. He indicated that he had not previously experienced an RTO, other than in training. According to the captain's training records, he received the following RTO and CRM training: * 04/27/91-Rejected Takeoff Anti-skid Operative-Initial cockpit procedures training-first officer * 05/04/91-Rejected takeoff-initial/upgrade proficiency training-first officer * 05/08/91-Rejected takeoff-Simulator proficiency check (waived)-first officer * 05/14/91-Initial CRM Completed * 04/10/92-Rejected Takeoff-Proficiency Check (waived)-first officer * 04/30/93-Takeoff Safety Home-Study Guide/Examination-first officer * 12/03/93-Rejected takeoff-Proficiency Check (waived)-first officer * 12/23/94-Rejected Takeoff-Proficiency Training-first officer * 01/03-10/95-Upgrade Training that included one day CRM * 01/12/95-Rejected Takeoff-Upgrade Proficiency Training-captain * 01/13/95-Rejected Takeoff-Upgrade Proficiency Training-captain * 01/14/95-Rejected Takeoff-Upgrade Proficiency Training-captain * 01/15/95-Rejected takeoff-Proficiency Check-captain The first officer held an airline transport certificate with a type rating in the B-737 airplane. His last proficiency flight check was on December 13, 1995. He possessed a first class medical certificate with no limitations or waivers. His last examination for a medical certificate was on September 7, 1995. According to the operator's report of the accident, the first officer had 12,262 total flight hours with 3,250 total flight hours in the B-737 airplane. He had1,365 flight hours as the pilot in command of the B-737. Within the previous 90 days, 30 days, and 24 hours, the first officer had 208,76, and 8 total flight hours, respectively. The first officer stated that, prior to flying for Southwest Airlines, he had flown for Morris Airlines, flying B-737 airplanes as first officer and as captain. Additionally, he had flown the B-727 as flight engineer and as first officer, the A300 as flight engineer, and corporate propeller driven airplanes. The first officer stated that he had received CRM training once with Southwest, when he was newly hired about 15 months prior to the accident. He indicated that there were no flight attendants in the class, which was made up of new hire pilots, only. The first officer said he had not experienced a RTO other than during training in the simulator. Training records for the first officer indicated the following RTO training: * 02/13/95 Rejected Takeoff-Initial Proficiency Training * 02/15/95-Rejected Takeoff-Proficiency Check (waived) * 12/13/95-Rejected Takeoff-Proficiency Check (waived) According to the statement by the lead flight attendant, who sat at the L-1 door, he had worked as a flight attendant for Southwest Airlines since 1993. Prior to that he was a flight attendant with America West from 1987 to 1993. He had previous experience as a flight attendant on B-737, 757, and 747 airplanes, plus the Dash 8 and the Airbus A320. His last recurrent training was in October 1995. He indicated that he had not received CRM training. The "A" flight attendant stated that the emergencies he had been involved with previously included an engine failure over the Pacific Ocean, and he had provided cardio-pulmonary resuscitation to a passenger who had suffered a heart attack. His recurrent training had included numerous evacuations with varied circumstances. He stated that he initiated the evacuation because of the following statement in the Flight Attendant Manual: "In that no two emergencies are exactly alike, the procedures given in this Manual are intended primarily as guidelines and in no way should restrict the use of the Flight Attendant's own personal judgment and initiative. The procedures may be modified as you feel necessary." According to his statement, the L-2 door flight attendant, who was stationed at the rear of the airplane, began working as a flight attendant with Southwest Airlines in September, 1995. He had received initial and one recurrent training session. He stated that there were no pilots in his training classes that included evacuation training. Although the "B" flight attendant had received CRM training during a pilot training class in college, he stated he had not received CRM training during his tenure as a flight attendant. He also stated that he had initial operating experience (IOE) that included training in the cockpit jumpseat. He described this as sitting in the jumpseat and talking to the pilots. He gained an understanding of the sterile cockpit concept during that IOE. The operator's records indicated that the "B" flight attendant had completed recurrent training on February 2, 1996. He stated that he initiated the evacuation because of the following statement in the Flight Attendant Manual: "In that no two emergencies are exactly alike, the procedures given in this Manual are intended primarily as guidelines and in no way should restrict the use of the Flight Attendant's own personal judgment and initiative. The procedures may be modified as you feel necessary." The R-1 flight attendant indicated in her interview that she had been a flight attendant for Southwest Airlines for 6.5 years and had not worked as a flight attendant previously. Her last recurrent training was completed April 19, 1996, according to the operator's records. She was stationed at the forward galley door, R1, and commented that the slide for that door had deflated after the evacuation. AIRCRAFT INFORMATION N53SW, a B-737-2H4, serial number 21534, was registered to First Security Bank Utah NA Trustee. It was operated by Southwest Airlines Co. The airplane was powered by two Pratt and Whitney JT8D-9 engines, and it was maintained in accordance with a continuous airworthiness program. The airframe total time and time since last inspection was 58,873 and 16 hours, respectively. The left engine, serial number 678086 had 32,992 total flight hours and 36,706 total cycles. The airplane was operated at a takeoff weight of 106,350 pounds for this departure. Maximum operating weight for the airport and conditions was 110,800 pounds. The airplane was not equipped with autobrakes. According to Boeing Commercial Airplane Group records, it was not delivered with "RTO" (rejected takeoff) autobrakes installed. In response to inquiries by this investigator, Boeing indicated that if RTO autobrake function were available, and selected on, autobrakes would come on as soon as the thrust levers were retarded to idle, if the airplane had accelerated past 90 knots. According to the flight crew, they did not feel the anti-skid function on the brake system cycling during the maximum braking of the rejected takeoff. In the captains interview, he stated that the anti-skid function lights in the cockpit operated normally, indicating normal operation of the anti-skid system. Subsequent maintenance evaluation of the anti-skid system indicated that it "checked good" in accordance with the maintenance manual requirements. Additionally, an examination of the wheels and brakes following the accident indicated that their condition was "normal" following a high energy rejected takeoff. A review was conducted of the airplane's maintenance discrepancies between June 7, 1996 and August 8, 1996. No abnormal trends in the discrepancies were noted. According to the manufacturer, Service Bulletin 52-1092R2 had been incorporated on N53SW which deactivated the forward airstair. Boeing also indicated that the airplane's intercommunication system and the public address system are powered by the Hot Battery Bus and the Battery Bus, and would be operable with the battery switch in the ON position, and with the STANDBY POWER switch in the BAT position. The captain's and first officer's brake pedals in the airplane are slaved. Therefore, if both pilots are applying brakes simultaneously, the pilot exerting the greatest pressure will exert the greatest force to the wheel brakes. METEOROLOGICAL INFORMATION Weather information is contained in this report on page four, under the heading titled Weather Information. AERODROME INFORMATION An examination of the accident circumstances relating to the airport was conducted by an Airport Certification Safety Inspector, Federal Aviation Administration. The report indicated that the emergency measures used were complete and correct, and that the emergency response was in compliance with the requirements of Title 14 CFR Part 139. The Wildlife Hazard Management Section of the Metropolitan Nashville Airport Authority's Airport Certification Manual was reviewed by the Safety Board's Airport Operations Specialist. He indicated that the manual appeared to conform to the requirements of Title 14 CFR Part 139.327, "Self-inspection program", and 139.337 "Wildlife hazard management." He reported that FAA certification inspection reports and correspondence for the past three years showed no comments regarding bird strikes. However, the airport authority had published a statement in the Airport Facilities Directory: "Bird activity around airport." An examination of the bird remains recovered from the left engine on N53SW was conducted by Roxie C. Laybourne, National Museum of Natural History, Smithsonian Institution. She identified the remains as a female American Kestrel (Falco sparverius). The average weight of the female American Kestrel is four ounces, she stated. The flight crew indicated in their interviews, that following the rejected takeoff, their communication with ARFF personnel to ascertain the condition of the airplane and the presence or absence of fire, was by loud conversation
the captain's improper rejected takeoff, in that the takeoff was rejected after V1, and the flight attendants' improper use of the evacuation procedure, in that an evacuation was independently initiated without the captain's approval, and without assessing the condition and location of the fire. Factors related to the accident were: bird ingestion in the left engine near lift-off speed during the takeoff roll, and company's inadequate Crew Resource Management (CRM) training for flight attendants.
Source: NTSB Aviation Accident Database
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