BOEING 737 7H4SOUTHWEST AIRLINES CO
Branson, MO, USA · 2014-01-13·N272WN
What happened
NTSB summary, verbatimThe flight crew briefed a plan to have radar vectors to the final approach course at Branson Airport and to use the RNAV (GPS) Runway 14 to line up on the final approach. The flight crew programmed the flight management system for the approach and set up the onboard navigation systems accordingly; including the use of distance measuring equipment from another approach navigation aid to provide additional situation awareness. During descent, the flight crew discussed the navigation information displayed, compared it to the lights they could see on the horizon, and confirmed what they believed to be the airport beacon based on that comparison early in the descent. The approach controller cleared the flight direct to the final approach fix depicted on the RNAV approach to the runway of intended landing. While still about 20 miles from the destination airport, the approach controller advised the crew the airport was located at their 11 o'clock position and 15 miles although at the time, that position more closely approximated Downtown Airport. Branson Airport was slightly left at their 10 o'clock position and almost 20 miles. The flight crew called the airport in sight and accepted a visual approach clearance and handoff to Branson control tower. Upon checking in with Branson Tower, the crew was cleared to land on runway 14 at Branson. When the crew identified what they believed to be Branson Airport early in the descent, they did not crosscheck or verify the airport position using onboard navigation after that point. Perceiving they were a little high on the approach into Downtown Airport, they widened the base leg for descent and then descended below approach control radar coverage as they turn onto final approach. Therefore, from the perspective of the approach controller this appeared to be a normal flight path into Branson Airport up to the point when radar contact was lost. Instead, the flight crew lined up on final approach to runway 12 at Downtown Airport and proceeded to land. The captain recognized the error soon after touchdown when he realized the runway was shorter than expected and he applied maximum braking, coming to a stop about 300 feet from the end of the paved surface.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe Flight crew's failure to properly identify the airport and runway of intended landing. Contributing to the incident was the flight crew's failure to comply with procedures for use of navigation information and visual cues to verify the airport and runway of intended landing and the air traffic controller's issuance of erroneous airport geographic information without including the location of proximate airports.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · ApproachAir traffic event
- 2 · LandingWrong surface or wrong airportdefining event
- 3 · ApproachNavigation error
Findings
4 causal · 1 contributing- CAUSEPersonnel issues › Action/decision › Info processing/decision › Identification/recognition — Flight crew
- CAUSEPersonnel issues › Task performance › Use of equip/info › Use of equip/system — Flight crew
- CAUSEPersonnel issues › Task performance › (general) — Flight crew
- CAUSEPersonnel issues › Action/decision › Action › Incomplete action — ATC personnel
- FACTOREnvironmental issues › Operating environment › Air traffic/operating proc — Effect on operation
Safety recommendations
2 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Amend air traffic control procedures so that controllers withhold landing clearance until the aircraft has passed all other airports that may be confused with the destination airport.
TO THE FEDERAL AVIATION ADMINISTRATION: Modify the minimum safe altitude warning (MSAW) software to apply the MSAW parameters for the flight plan destination airport to touchdown, rather than automatically reassigning the flight to another airport based on an observed (and possibly incorrect) trajectory.
Sequence of events
2 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- about 1810 CSTlandingp.1Aircraft mistakenly landed at M. Graham Clark Downtown Airport (PLK) instead of Branson Airport (BBG), 5 nautical miles away, in night visual meteorological conditions; no injuries and no damage
- approachapproachp.3Figure 1 shows basic flight data on approach as the aircraft descends below 10,000 feet through the landing roll; figure 2 shows autopilot data over the same period; figure 3 shows landing performance parameters during the landing roll
NTSB analysis
from the final reportThe flight crew briefed a plan to have radar vectors to the final approach course at Branson Airport and to use the RNAV (GPS) Runway 14 to line up on the final approach. The flight crew programmed the flight management system for the approach and set up the onboard navigation systems accordingly; including the use of distance measuring equipment from another approach navigation aid to provide additional situation awareness. During descent, the flight crew discussed the navigation information displayed, compared it to the lights they could see on the horizon, and confirmed what they believed to be the airport beacon based on that comparison early in the descent. The approach controller cleared the flight direct to the final approach fix depicted on the RNAV approach to the runway of intended landing. While still about 20 miles from the destination airport, the approach controller advised the crew the airport was located at their 11 o'clock position and 15 miles although at the time, that position more closely approximated Downtown Airport. Branson Airport was slightly left at their 10 o'clock position and almost 20 miles. The flight crew called the airport in sight and accepted a visual approach clearance and handoff to Branson control tower. Upon checking in with Branson Tower, the crew was cleared to land on runway 14 at Branson. When the crew identified what they believed to be Branson Airport early in the descent, they did not crosscheck or verify the airport position using onboard navigation after that point. Perceiving they were a little high on the approach into Downtown Airport, they widened the base leg for descent and then descended below approach control radar coverage as they turn onto final approach. Therefore, from the perspective of the approach controller this appeared to be a normal flight path into Branson Airport up to the point when radar contact was lost. Instead, the flight crew lined up on final approach to runway 12 at Downtown Airport and proceeded to land. The captain recognized the error soon after touchdown when he realized the runway was shorter than expected and he applied maximum braking, coming to a stop about 300 feet from the end of the paved surface.