According to the NTSB, the flight crew was effectively overly optimistic about runway conditions and failed to use the most conservative assessment (poor) when making their decision.
The crew was making critical decisions based on incorrect assumptions. They assumed, in fact, that the computed stopping distance did not include the positive effects of full reverse thrust when it did.
They were attempting to execute a new procedure for the first time under very challenging circumstances. This resulted in their being distracted from a routine process, the deployment of the thrust reversers. The failure to deploy the reversers in a timely manner allowed the aircraft to leave the runway.
They were not provided with clear and consistent guidance or training regarding polices and procedures. This included management's failure to employ a familiarization period for a key operational change.
For anyone familiar with long-term trends in firefighter fatalities these findings sound very familiar. It turns out that overly optimistic assumptions and faulty decision making can be found across professions with devastating results.
Three Fatal Assumptions and Fire/Rescue Operations
The crew of SWA 1248 is not alone. The North American fire service continues a lengthy tradition of making routine operational decisions based on assumptions that have been repeatedly proven as faulty to the point of being reckless.
Assumption One: Firefighters Are Not Pre-Disposed To Cardiac Events
Incorrect. The majority of firefighter line-of-duty deaths are cardiac or stroke related. A long term study conducted by the NFPA of 713 of these deaths revealed that "84.6 percent had suffered prior heart attacks, had severe arteriosclerotic heart disease, had undergone bypass surgery or angioplasty/stent replacement or had diabetes." In addition, the United States Fire Administration reports that for 2006, the latest year for which statistics are available, that once again, cardiac events are the leading cause of death.
If you are a leader and you allow known and untreated sufferers of heart disease or inadequately screened staff to conduct field operations, you are participating in the killing of firefighters.
Assumption Two: Apparatus Accidents Will Not Occur And Seatbelts Do Not Need To Be Worn
Incorrect. Serious and fatal apparatus accidents have reached a level that can be described as epidemic. In 2006, 19 firefighters died in accidents. There are undoubtedly a variety of underlying causes. They include increased road traffic, aggressive drivers and greater call volume. The list does not end there.
These fatal firefighter accidents tend to involve single-vehicle roll-overs, often tankers, driven at high speeds with drivers and or other occupants not wearing seatbelts. Firefighters are often ejected during the incident. Finally, since 1990, 69 firefighters have been killed in personal vehicles while responding. Many were speeding and not wearing seatbelts.
If you are a leader and you condone unsafe vehicle operations in either an administrative or operational capacity, you are participating in the killing of firefighters.
Assumption Three: Conditions Will Not Deteriorate And Components Will Not Fail
Incorrect. Wooden I-beams, roofs, canopies, porches and walls are collapsing all about. There are death reports noting flashovers in rooms, floors, wings and entire building trapping and killing firefighters in ones and twos and often many more. Almost always, the buildings are all clear or lack any credible evidence of a savable life. In addition, these buildings can be characterized as "enclosed" i.e., one that has few openings. In fact, a recent study of 444 firefighter fatalities found that 84 percent occurred in these type of structures. Finally, 87 percent of multiple firefighter fatality incidents occurred in enclosed structures. Just as often, fire operations are inadequately resourced, under-staffed and fire fighters are in overly exposed positions where the apparent risk far outweighs any rational benefit.
If you are a leader you have the responsibility to intervene to re-align risks to reflect expected benefits. If you do not, you are participating in the killing of firefighters.