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Cases › DCA09FA065 › 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.

4
timed facts
8
precedents
4
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

4 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. 17:39-17:45 EDTFDRemergency descentp.3
    Over the next 6 minutes the aircraft descended to approximately 11,000 ft
    see the traces at this moment ↗
  2. 17:39:04 EDTFDRcruisep.3
    Cabin altitude warning indicated a warning and the autopilot turned off (rapid decompression)
    see the traces at this moment ↗
  3. about 17:51 EDTFDRdescentp.3
    Aircraft began to descend again; cabin altitude warning turned off passing through 8,100 ft
    see the traces at this moment ↗
  4. 18:06:29 EDTFDRlandingp.3
    Aircraft landed uneventfully at Charleston
    see the traces at this moment ↗
Recorder events without a clock time
  • takeoffAircraft took off and climbed for about 25 minutes to approximately 34,500 ft
Flight Data Recorder 10 - Factual Report of Group Chairman · 5 events extracted by claude-fable-5-1 (in-session)
How the Board coded the sequence
  1. Enroute-cruise: Emergency descent initiated→
  2. Enroute-cruise: Aircraft structural failure

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA25LA0612024-12-18substantialmatch 81
    LOCKHEED 382G-44K-30 · LYNDEN AIR CARGO LLC
    St. Mary's, AK
    • ●Aircraft › Aircraft structures › Fuselage
    Aircraft structural failure
  • DCA11FA0042010-10-27substantialmatch 78
    BOEING 757-223 · AMERICAN AIRLINES INC
    Miami, FL
    • ●Aircraft › Aircraft structures › Fuselage
    Aircraft structural failure
  • DCA11MA0392011-04-01substantialmatch 68
    BOEING 737 · SOUTHWEST AIRLINES CO
    Yuma, AZ
    • ●Aircraft › Aircraft structures › Fuselage
    Aircraft structural failure
  • DCA20CA0502019-12-22substantialmatch 65
    Boeing 737 · Southwest Airlines
    Kansas City, MO
    • ●Aircraft › Aircraft structures › Fuselage
  • DCA18CA0562017-12-23substantialmatch 65
    MCDONNELL DOUGLAS DC 9 33F · Everts Air
    Bethel, AK
    • ●Aircraft › Aircraft structures › Fuselage
  • DCA16LA0962016-02-12substantialmatch 63
    LOCKHEED 382G · Lynden Air Cargo
    Iliamna, AK
    • ●Aircraft › Aircraft structures › Fuselage
    Aircraft structural failure
  • ENG14IA0162014-02-25no fatalitiesmatch 55
    DOUGLAS C 118A · TATONDUK OUTFITTERS LIMITED DBA
    Emmonak, AK
    Aircraft structural failure
  • DCA16FA2172016-08-27substantialmatch 49
    BOEING 737-700 · Southwest Airlines
    Pensacola, FL
    • ●Aircraft › Aircraft structures › Fuselage

What the record says

a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 5 of 8Aircraft structural failure
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft structures › Fuselage
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • —

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
  • DCA25LA0612024-12-18 · LOCKHEED 382G-44K-30 · LYNDEN AIR CARGO LLC
    The fatigue failure of the forward pressure bulkhead canted web that originated from stress corrosion cracking areas. Contributing to the failure were inspection procedures and intervals inadequate to identify the fatigue cracks.
  • DCA11FA0042010-10-27 · BOEING 757-223 · AMERICAN AIRLINES INC
    Fatigue failure of the fuselage crown skin due to incorrect manufacturing of the crown skin panel that resulted in a skin thickness less than the manufacturer-specified thickness.
  • DCA11MA0392011-04-01 · BOEING 737 · SOUTHWEST AIRLINES CO
    the improper installation of the fuselage crown skin panel at the S-4L lap joint during the manufacturing process, which resulted in multiple site damage fatigue cracking and eventual failure of the lower skin panel. Contributing to the injuries was flight attendant A's incorrect assessment of his time of useful consciousness, which led to his failure to follow procedures requiring immediate donning of an oxygen mask when cabin pressure is lost.
  • DCA20CA0502019-12-22 · Boeing 737 · Southwest Airlines
    a bird strike during descent
  • DCA18CA0562017-12-23 · MCDONNELL DOUGLAS DC 9 33F · Everts Air
    failure of a cargo tie-down fastener, resulting in unsecured cargo striking the pressure bulkhead.

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).