SEA05IA040

NTSB incident investigation · Boeing 737-3H4 · Seattle, WA · January 30, 2005

Incident · No injuriesIncident investigationFinal report
Date
January 30, 2005, 11:35 local (19:35 UTC)
Place
Seattle, WA
Injuries
46 uninjured
Damage
No damage
Phase of flight
Approach
Aircraft
N350SWBoeing 737-3H4
Weather
Visual (VMC) · Day
Status
Completed · report July 7, 2005
Report
Approved by Office Director
Parties
Seattle FSDO
Case key
60975

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

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Probable cause

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

The flight crew's failure to maintain an adequate visual lookout while on final for a visual approach. Factors include the failure of both airport operations personnel and the local FAA Airports Inspector to insure that some form of identification marking was placed directly on the taxiway surface after the first seven misalignment events.

Analysis

The First Officer, who was the flying flight crew member during the approach, inadvertently aligned the aircraft with the paved surface of the parallel taxiway as he rolled out on final for a visual approach. He then continued the approach until he noticed the large yellow "X" just off the north end of the taxiway. At that point he realized that the surface that he intended to land on was not an operational runway, so he decided to initiate a go-around. After completing a successful go-around, the flight crew received vectors to a second visual approach final, whereupon they completed an uneventful full-stop landing. Although the FAA Control Tower had the Runway End Identifier Lights (REIL's) for both parallel runways on, the flight crew did not see them during this approach. When they came around for the second approach, the tower had turned on the sequencing approach flashers (rabbit), and it was at that time that they first saw the REIL's for either runway. Both flight crew members said that although the paved surfaces where wet and a little shiny (from an earlier shower), they felt it was the shape, size, and color of the taxiway surface that most directly contributed to the misidentification of the taxiway as a runway. This incident was the eighth in a series of known events wherein flight crews inadvertently aligned their aircraft with the subject taxiway with the intent to land on its surface. During three of these events the aircrews completed their landings on the taxiway surface. Although the airport operations personnel and the local FAA Airports Inspector are aware of this series of events, no markings or visual cues have been placed directly on the taxiway surface to assist crews in more easily identifying Taxiway Tango as a taxiway and not a runway.

Factual narrative

The factual narrative727 words

On January 30, 2005, approximately 1135 Pacific standard time, the crew of a Southwest Airlines 737, N350SW, inadvertently aligned their aircraft for a landing on Taxiway Tango at Seattle-Tacoma International Airport, Seattle, Washington (SeaTac). There were no injuries to any of the crew members, nor to any of the 41 passengers, and the aircraft was not damaged. The 14 CFR Part 121 scheduled domestic passenger flight, which was operating in visual meteorological conditions at the time of the incident, departed Albuquerque International Airport, Albuquerque, New Mexico, at 0940 mountain standard time. The flight crew had filed and activated an IFR flight plan at the initiation of the flight, and they were on a visual approach final at the time of the event.

According to the First Officer, who was the flying flight crew member during the approach, as he rolled out on final after being vectored for a visual approach, he aligned the aircraft with the paved surface that he was convinced was Runway 16 Right, but was actually Taxiway Tango. He then continued the approach until the aircraft was about 500 feet above ground level (AGL), whereupon he noticed the large yellow "X" just off the north end of Taxiway Tango. At that point he realized that the surface that he intended to land on was not an operational runway, so he decided to initiate a go-around. At almost the same time as the First Officer realized he was aligned with the incorrect surface, the Captain came to the same conclusion, and directed the First Officer to execute a go-around. According to data retrieved from the Flight Data Recorder (FDR), the go-around was initiated at 250 feet AGL. After completing a successful go-around, the flight crew received vectors to a second visual approach final, whereupon they completed an uneventful full-stop landing. Although the FAA Control Tower had the Runway End Identifier Lights (REIL's) for both Runway 16 Left and Runway 16 Right on at the time of the first approach, both flight crew members stated that they had not seen the REIL's for either runway during this approach. When they came around for the second approach, the tower had turned on the sequencing approach flashers (rabbit) for Runway 16 Right, and according to the flight crew, it was at that time that they first saw the REIL's for either runway.

In further discussions with the flight crew, it was determined that although in the pre-approach briefing they had not specifically reviewed the notes and diagrams associated with the ongoing Taxiway Tango misidentification problems at SeaTac, they were both aware that other crews had inadvertently lined up on the taxiway in the past. It was further determined that although the First Officer had the localizer displayed on his navigational instruments, once he had identified the surface he was going to land on, he did not continue to monitor the displacement of the localizer needle. During the same interview, the Captain stated that he had the VOR set on his navigational instruments, and that a significant amount of his attention was directed toward looking for traffic around Boeing Field, handling radio communications, and monitoring the flight instruments. Both flight crew members said that although the paved surfaces where wet and a little shiny (from an earlier shower), they felt it was the shape, size, and color of the taxiway surface that most directly contributed to the misidentification.

This incident was the eighth in a series of known events wherein flight crews inadvertently aligned their aircraft with the subject taxiway with the intent to land on its surface. During three of these events the aircrews completed their landings on the taxiway surface. Although both airport operations personnel and the local FAA Airports Inspector were aware of this series of events, no markings or visual cues had been placed directly on the taxiway surface to assist crews in more easily identifying Taxiway Tango as a taxiway and not a runway.

This investigation has also determined that even though in June of 2004 the National Transportation Safety Board recommended the Federal Aviation Administration apply large-scale taxiway identification markings directly to the Taxiway Tango surface, in conjunction with applying a continuous serpentine centerline (Safety Recommendation A-04-48), as of the date of this report, no additional markings or visual cues of any sort have been added to the concrete surface of Taxiway Tango.

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
Visual lookout - inadequateFlightcrewCause
Airport - inadequateAirport personnelFactor
Airport - inadequateFaa(other/organization)Factor

Aircraft

Registration
N350SW
Reported as
Boeing 737-3H4
Category
Airplane
Serial number
24409
Airframe hours
51,686
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 · January 29, 2005 · 11 hours before
Departed
KABQ · Albuquerque, NM
Destination
KSEA · Seattle, WA
Flight plan
IFR
Airport
KSEA · Seattle-Tacoma Int., 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
46
Injuries
None
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
September 6, 2004
Seat
Left
Flight hours
15,000 total · 9,159 in this make and model · 8,000 as pilot in command · 262 in the last 90 days · 77 in the last 30 days
Role
Pilot
Age
43
Injuries
None
Seat
Right

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 7 knots
Visibility
10 statute miles
Lowest ceiling
9,000 ft overcast
Temperature
48 °F, dew point 43 °F
Altimeter
30.37 inHg
Observed at
KSEA, 2 nm away

Other investigations on N350SW · 1

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