SEA04IA045

NTSB incident investigation · Boeing 737-300 · Seattle, WA · February 24, 2004

Incident · No injuriesIncident investigationFinal report
Date
February 24, 2004, 09:30 local (17:30 UTC)
Place
Seattle, WA
Injuries
94 uninjured
Damage
No damage
Phase of flight
Approach
Aircraft
N368SWBoeing 737-300
Weather
Visual (VMC)
Status
Completed · report June 8, 2005
Report
Approved by Office Director
Parties
Seattle FSDO
Case key
58851

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The First Officer's misidentification of the parallel taxiway as the active runway, resulting in the need for a sidestep maneuver while on short final for a full-stop landing. Factors include sun-glare from wet paved surfaces, a visual illusion created by the size and shape of the taxiway, and the Captain's failure to adequately monitor the First Officer’s approach.

Analysis

While west of the airport, the flight crew was cleared for the Bay Visual Approach to Runway 16 Right. The First Officer, who was flying at the time, made a right turn over Elliott Bay and lined up on what he believed to be Runway 16 Right, but was in fact Taxiway Tango. When the aircraft was about one mile from the end of the taxiway, the first officer noticed a yellow X located just off the northern end of the surface he intended to land on. Upon realizing he was lined up on the wrong surface, he initiated a sidestep to Runway 16 Right. He subsequently completed an uneventful landing on Runway 16 Right, and taxied to the gate for a normal deplanement of the passengers. According to recorded radar tracking data, at the time of the turn to initiate the sidestep, the aircraft was approximately 600 feet above the ground (AGL). The size and shape of the taxiway made it look very much like a runway to the First Officer, and although he was eventually able to see the Runway 16 Right identification markings, because of the glare on the wet surfaces, he never did clearly see any markings that indicated Taxiway Tango was a taxiway. Although the Captain had correctly identified the runway surface when the aircraft first rolled out on final, flight deck distractions kept him from realizing that the first Officer was lined up on the taxiway until the sidestep maneuver was initiated.

Factual narrative

The factual narrative761 words

On February 24, 2004, approximately 0930 Pacific standard time, the First Officer of a Southwest Airlines 737-300, N368SW, inadvertently aligned the aircraft for a landing on Taxiway Tango at Seattle-Tacoma International Airport (SEATAC), Seattle, Washington. There were no injuries to the flight crew, three flight attendants, or any of the 89 passengers, and there was no damage to the aircraft, which is owned and operated by Southwest Airlines Company. The scheduled Part 121 domestic passenger flight, which departed Oakland, California, about 85 minutes prior to the incident, was being operated in visual meteorological conditions at the time of the subject event. The flight had been on an IFR flight plan, and had been cleared for a visual approach to Runway 16 Right at SEATAC.

According to the flight crew, while they were west of the airport, the flight was cleared for the Bay Visual Approach to Runway 16 Right. The First Officer, who was flying at the time, made a right turn over Elliott Bay and lined up on what he believed to be Runway 16 Right. When the aircraft was about one mile from the end of the taxiway, the first officer noticed a yellow X located just off the northern end of the surface he intended to land on. Upon realizing he was lined up on the wrong surface, he initiated a sidestep to Runway 16 Right. He subsequently completed an uneventful landing on Runway 16 Right, and taxied to the gate for a normal deplanement of the passengers. According to recorded radar tracking data, at the time of the turn to initiate the sidestep, the aircraft was approximately 600 feet above the ground (AGL).

In a post-incident interview, the First Officer said that he did not realize he was lined up to land on the wrong surface until he saw the yellow X. He also said that there were varying degrees of reflection and glare at different areas of the airfield environment, and that the size and shape of the taxiway made it look very much like a runway. He further stated that although he was eventually able to see the Runway 16 Right identification markings, he never did clearly see any markings that indicated Taxiway Tango was a taxiway. When advised that there was also a temporary lighted-X near the permanent yellow X, he responded that the only X he had seen was the solid yellow X. When told that the Runway 16 centerline lights were on in the dim position, he said that he did not remember seeing them, even after executing the sidestep maneuver.

In a post-incident interview with the Captain, he stated that he knew which surface was the runway and which was the taxiway soon after the aircraft rolled out on final, but at the time he first visually acquired the runway environment, it looked to him like the First Officer was lining up on Runway 16 Right. The Captain explained that since they had been cleared to land long, his attention was diverted from the runway environment while he explained the landing/deceleration technique he wanted the first Officer to use, and then waited for the First Officer's response. He added that almost immediately after the First Officer confirmed that he understood his instructions, the First Officer made a comment and started a shallow left turn. At that point, the Captain briefly checked the airspeed, and then returned his attention to the runway/taxiway environment. He said that it was at that point in time when he realized that the First Officer had lined up to the right (west) of Runway 16 Right, and was now correcting to it. He also mentioned that he too briefly saw the yellow X at that point in time. The Captain said that he thought briefly about a go-around, but since the bank angle was shallow, and the runway very nearby, he elected to let the First Officer continue the sidestep.

At the time of the event, the airport's paved surfaces were wet from a recent rain shower, and although the Captain was aware of the note on the airport diagram advising crews not to mistake Taxiway Tango for a landing surface, this note was not discussed prior to or during the approach sequence. He said that because the ILS was out, they had no localizer backup. Both crew members mentioned that there was a need for a better/clearer identification of the runways, but that some type of markings making it clear that Taxiway Tango is not a runway was the most important action that could be taken.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherApproach - vfr pattern - final approach
Wrong runway - selectedCopilot/second pilotCause
Visual illusionCopilot/second pilotFactor
Monitoring - inadequatePilot in commandFactor
Airport facilities,runway/landing area condition - wetFactor
Light condition - sunglareFactor

Aircraft

Registration
N368SW
Reported as
Boeing 737-300
Category
Airplane
Serial number
26579
Airframe hours
36,024
Engine
General Electric CFM-56, 20,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 2, 2003 · 640 hours before
Departed
OAK · Oakland, CA
Destination
SEA · Seattle, WA
Flight plan
IFR
Airport
KSEA · Seattle-Tacoma Inyternational, runway 16R, 9,426 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
December 21, 2003
Seat
Left
Flight hours
25,000 total · 12,000 in this make and model · 10,000 as pilot in command · 240 in the last 90 days · 80 in the last 30 days · 6 in the last 24 hours
Role
Co-pilot
Age
34
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
November 3, 2003
Seat
Right
Flight hours
6,700 total · 2,500 in this make and model · 3,500 as pilot in command · 240 in the last 90 days · 80 in the last 30 days

Weather

Conditions
Visual (VMC)
Wind
170° at 4 knots
Visibility
10 statute miles
Lowest ceiling
17,000 ft broken
Temperature
50 °F, dew point 39 °F
Altimeter
29.62 inHg
Observed at
SEA, 2 nm away

Other investigations on N368SW · 1

Matched to the same aircraft by N-number and date.