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Cases › CEN09IA294 › The analyst

BOEING 737SOUTHWEST AIRLINES CO

What the docket says, assembled. No language model is involved, so nothing on this page can be invented — every line traces to a recorder, a report page or the Board's own record.

2
timed facts
8
precedents
13
passages to ask

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passages, not paraphrases
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Every answer is a passage of the docket with the page it came from, or the words “not in the docket”. Nothing is summarised or reasoned for you — read the source.

One timeline

2 timed factsthe recorder events from the FDR report, with the transcript's warnings, callouts, the words nearest each event and the final seconds — on one clock, as printed in each report
  1. about 19:45:31-19:45:32 CDTFDRtouchdownp.4
    Touchdown and landing roll: recorded left brake pressure 770 psi at 19:45:31 while the right brake pressure peaked at 1,430 psi at about 19:45:32 (tires blew at touchdown)
    see the traces at this moment ↗
  2. 19:45:57 and 19:46:03 CDTFDRlanding rollp.4
    Maximum left brake pressure 990 psi recorded twice during the landing roll; plot 3 ends when ground speed reaches zero
    see the traces at this moment ↗
Recorder events without a clock time
  • approach into KHOU (plots 1-2)Basic, landing gear and brake parameters plotted from just before gear extension to about two minutes after engine shutdown
Flight Data Recorder 10 - Specialist's Factual Report · 3 events extracted by claude-fable-5-1 (in-session)
How the Board coded the sequence
  1. Prior to flight: Miscellaneous/other→
  2. Landing-landing roll: Fire/smoke (non-impact)→
  3. Post-impact: Fire/smoke (post-impact)→
  4. Post-impact: Evacuation

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA13FA1312013-07-22substantialmatch 62
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
  • DCA23LA4682023-09-30substantialmatch 60
    BOEING 737-9 · UNITED AIRLINES INC
    Denver, CO
    • ●Personnel issues › Action/decision › Action
    Fire/smoke (non-impact)
  • ERA22FA0042021-10-052 fatalmatch 57
    DASSAULT Falcon 20 · Pak West Airlines Inc.
    Thomson, GA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    Miscellaneous/other
  • DCA17IA0202016-10-27no fatalitiesmatch 57
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
  • CEN19MA1902019-06-3010 fatalmatch 55
    Textron Aviation B-300 · S&H Aircraft
    Addison, TX
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    Fire/smoke (post-impact)
  • DCA12IA1412012-09-05no fatalitiesmatch 54
    DE HAVILLAND DHC8 · ERA AVIATION INC
    Soldotna, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
  • WPR10IA4302010-08-26no fatalitiesmatch 54
    AIRBUS A320-232 · JETBLUE AIRWAYS CORP
    Sacramento, CA
    • ●Personnel issues › Action/decision › Action
    Miscellaneous/other
  • MIA06IA1332006-08-31no fatalitiesmatch 54
    Boeing 737-400 · US Airways
    Miami, FL
    matched on what happened, as the Board wrote it · same aircraft family

What the record says

a pattern, not a findingacross the 8 closest cases · 7 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 2 of 8Miscellaneous/other
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Action/decision › Action
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Action/decision › Info processing/decision
  • Task performance › Use of equip/info

A teaching device, not a verdict: what the record would have looked at, next to what the Board found.

In the Board’s words — the closest cases
  • DCA13FA1312013-07-22 · BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.
  • DCA23LA4682023-09-30 · BOEING 737-9 · UNITED AIRLINES INC
    Overheated brakes due to the extended taxi at a higher power setting in an attempt to burn off fuel to achieve the proper takeoff weight that resulted in a wheel fire during takeoff.
  • ERA22FA0042021-10-05 · DASSAULT Falcon 20 · Pak West Airlines Inc.
    The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety mana…
  • DCA17IA0202016-10-27 · BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    The first officer's failure to attain the proper touchdown point and the flight crew's failure to call for a go-around, which resulted in the airplane landing more than halfway down the runway. Contributing to the incident were, the first officer's initiation of the landing flare at a relatively high altitude and his delay in reducing the throttles to idle, the captain's delay in manually deploying the speed brakes after touchdown, the captain's lack of command authority, and a lack of robust training provided by t…
  • CEN19MA1902019-06-30 · Textron Aviation B-300 · S&H Aircraft
    The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff. The reason for the reduction in thrust could not be determined. Contributing to the accident was the pilot’s failure to conduct the airplane manufacturer’s emergency procedure following a loss of power in one engine and to follow the manufacturer’s checklists during all phases of operation.
What it recommended after them
  • A-14-022TO THE FEDERAL AVIATION ADMINISTRATION: Conduct a comprehensive audit of the regulatory compliance and operational safety programs in place at operators owned by HoTH, Inc., to include an assessment of their flight operations, training, mai… · DCA12IA141Closed - Acceptable Action
  • A-14-023TO THE FEDERAL AVIATION ADMINISTRATION: Conduct a comprehensive audit of the Federal Aviation Administration (FAA) oversight of 14 Code of Federal Regulations Part 135 and Part 121 certificates held by operators owned by HoTH, Inc., and ens… · DCA12IA141Closed - Acceptable Action

This is the pattern in the NTSB’s own record across similar accidents — which findings it cited, what it coded, what it recommended. It is drawn from the record, not written about this case, and it never assigns blame: investigations exist to prevent the next accident (ICAO Annex 13).