Southwest Airlines pilots were unfamiliar with a new braking procedure and unaware of landing rules in sloppy conditions, leading to a 2005 accident in which a flight from Baltimore skidded off a snowy Chicago runway and killed a child, the National Transportation Safety Board concluded yesterday.
The jet crashed through two fences at Midway Airport and hit several vehicles, crushing a 6-year-old boy in a car, injuring 10 others on the ground and causing minor injuries to about 20 people aboard the jet - the worst accident in Southwest's 36-year history.
Southwest, the dominant carrier at Baltimore-Washington International Thurgood Marshall Airport, began retraining its pilots immediately after the fatal accident, airline spokeswoman Marilee McInnis said last night.
"We've been actively making changes since the incident," she said. "We've made adjustments to the training program and our flight operations manual so it is clear and concise as it can be."
The pilots' lack of experience with the Boeing 737-700's auto-braking system distracted them from engaging the engine thrust-reversers until just before the plane skidded off the runway, the NTSB concluded in determining the likely cause of the accident.
A new Southwest rule required auto-brakes in unfavorable landing conditions, investigators said.
While the probe found that much of the responsibility rested with the pilots, the NTSB said Southwest contributed by failing to provide its pilot corps with "clear and consistent guidance and training" to calculate stopping distances in poor weather.
The captain of Flight 1248 probably would have decided to divert to another airport if he and his co-pilot knew the airline required them to apply the most conservative rating from the mixed reports they had received on runway braking action at Midway, investigators said based on interviews with the crew.
When the pilots touched down, the runway had not been cleared for almost 30 minutes.
"This crew knew they were flying on the edge. The problem was, they didn't really know where the edge was," NTSB member Debbie Hersman said in response to investigators' testimony at a hearing yesterday.
McInnis said the airline has retrained all of its pilots on the use of auto-brakes, which had been installed on all Southwest planes shortly before the accident.
The airline also made it clear that pilots are to use the most conservative weather reports when evaluating whether it is safe to land. That had always been the airline's policy, but not all of the pilots were aware of it, McInnis said.
She said the airline has gone through a full winter since pilots were retrained.
"It would be erroneous to say we're done reviewing our safety procedures, though," she said. "We'll never stop focusing on safety. We'll go through periodic reviews."
Last night, two passengers recounted the harrowing flight on Dec. 8, 2005.
The flight, carrying 98 passengers, was delayed leaving BWI because of poor weather conditions.
"The weather was just really treacherous," said Towson resident Lisa Spallitta. "We hit the ground, but it never really seemed like we slowed down."
Katie Duda of Fells Point, who was continuing on to Seattle, said that during the descent, passengers were anxious because of the storm. "Everyone was clapping when we did land," she said. But that was before the aircraft came to a stop.
When the jet finally halted, "you looked out the left side of the plane and there was a house, and out the right window there was a stoplight," Spallitta said.
Both Spallitta and Duda continue to fly Southwest, though Spallitta says she avoids Midway.
In the NTSB review, investigators found that pilots who landed before Flight 1248 rated the runway condition as "good" to "fair" on the front end and "poor" on the second half. One Southwest flight crew flying to Midway decided to divert to another airport nine minutes before the accident, when the snowstorm intensified.
"The reports on stopping distance were mixed, but all included the term 'poor,'" said Katherine Lemos, a human performance expert with the NTSB.
Chicago aviation officials reported to the Federal Aviation Administration that the runway condition was good, based on friction tests that correlate with aircraft braking power. The FAA passed along that assessment to Flight 1248, along with the ratings from other pilots who had landed.
As Flight 1248 approached Midway, the onboard computer calculated a stopping margin of 560 feet left on the runway after the plane would stop, based on a "fair" rating of the runway. If a "poor" rating were used, the calculated margin would be only 40 feet, investigators said.
Three other Southwest planes - their crews apparently also uninformed about Southwest's rules on runway conditions - landed at Midway during the storm before the accident, Lemos said, leaving investigators astonished.
"It is challenging landing at Midway in normal conditions," said Robert Benzon, the NTSB's chief investigator in the case.
NTSB member Kitty Higgins characterized the pilots as "incredibly conscientious."
But another member, former airline pilot Steven Chealander, said: "The crew made a bad decision to land that day. When you are sitting in the [captain's] seat, it is your ultimate responsibility to make the correct decision."
The Chicago Tribune and the Associated Press contributed to this article.