Case Study: Accident Analysis through ODM

Case Study: Accident Analysis through ODM

DOI: 10.4018/978-1-4666-8673-1.ch008
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Abstract

This is a case study of what has been called the Midway accident, of flight 1248. It is presented here to provide insight into a high workload, high-stress operation and the dangers associated with task overload and situation awareness breakdown. An examination of the decision making process reveals that this could have been aided by the meaningful evaluation of the cumulative effect of multiple mission critical events that were encountered in the course of this operation. Importantly, the full implication of adverse wind conditions coupled with braking action advisories on a short runway should have been made.
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History Of Flight (Extract Ntsb Report)

“The accident occurred on the first flight of the first day of a scheduled 3-day trip. The flight departed BWI about 2 hours late because of deteriorated weather conditions in the Chicago area. The captain was the flying pilot for the accident flight, and the first officer performed the duties of the monitoring pilot.

“The pilots reported that they had thoroughly reviewed the two weather information and dispatch documents they received from dispatch before they left BWI. A third document authorizing the release of the accident flight was prepared but was not delivered to the pilots before departure. This document revised the expected landing winds (from “calm” to “090° at 11 knots”), runway braking action (from “wet-good” to “wet-fair”), and landing runway (from 04R to 31C) based on the changing weather. The pilots stated that they subsequently received updated MDW weather information and runway condition/braking action reports for runway 31C, which was the runway in use at MDW at the time. Post accident interviews with the pilots and evidence from cockpit voice recorder (CVR) data and air traffic control (ATC) communications indicated that the runway 31C braking action reports were mixed, reporting good or fair braking action for the first half of the runway and poor braking action for the second half.

“The pilots also stated (and CVR evidence confirmed) that they reviewed and discussed the company’s new autobrake system procedures while en route from BWI to MDW; the accident landing was the first time either pilot landed using autobrakes.

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