Investigation brief · generated 2026-10-09 · source: NTSB public docket and accident database
BOEING 737 — Charleston, WV, USA, 2009-07-13
NTSB number
DCA09FA065
Operator
SOUTHWEST AIRLINES CO
Registration
N387SW
Highest injury
No injury
Regulation
Part 121
Damage
Substantial
Cohort
Part 121 airline
Recorder data
Tier 1 — decoded recorder tables
Every sentence below is taken directly from NTSB records — the accident database, the docket's recorder reports and the Board's findings — with its source noted. Nothing is paraphrased or inferred.
NTSB summary
Flight data recorder data revealed that the airplane took off and climbed for about 25 minutes to an altitude of approximately 35,000 feet, at which point the cabin altitude warning activated, and the captain disengaged the autopilot. Postincident examination of the airplane revealed fatigue cracking of the fuselage skin near the leading edge of the vertical stabilizer adjacent to the rupture. The fatigue cracking penetrated the fuselage skin and created an approximate 18-inch by 12-inch flap in the skin that depressurized the airplane.
The fuselage skin assembly near the leading edge of the vertical stabilizer was manufactured by bonding two full aluminum sheets together, then selectively chemically milling away pockets (bays) of the inner sheet. Continuous fatigue cracks initiated from multiple origins on the inner surface of the skin adjacent to the step formed at the edge of the chemically milled area and propagated outward.
Following the Southwest Airlines (SWA) flight 2294 event, on September 3, 2009, Boeing issued Service Bulletin (SB) 737-53A1301, calling for repetitive external inspections to detect cracks in the fuselage skin along the chemically milled step at stringers S-1 and S-2 right and between BS 827 and BS 847. (The hole from the SWA event was within those boundaries.) If cracks are detected, operators are to contact Boeing for repair instructions. On January 12, 2010, the Federal Aviation Administration issued Airworthiness Directive 2010-01-09, which mandated the inspection requirements in SB 737-53A1301.