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Cases › DCA11IA047 › The analyst

BOEING 737-7Q8SOUTHWEST 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.

42
timed facts
8
precedents
97
passages to ask

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One timeline

42 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. 11:05 CDTFDRtakeoffp.2
    Takeoff; cruising altitude of 37,000 ft reached about 18 minutes later
    see the traces at this moment ↗
  2. 11:39:17.3CVR STARTp.8
    “OF RECORDING”
    read in context ↗
  3. about 12:15 CDTFDRdescentp.2
    Initial descent began
    see the traces at this moment ↗
  4. 12:44:18.9CVR CAMwarningp.23
    “[sound of tone, similar to altitude alert]”
    read in context ↗
  5. 12:45 CDTFDRholdingp.2
    Series of right holding turns for about 30 minutes, then final descent for landing
    see the traces at this moment ↗
  6. 12:45:06.7CVR HOT-1p.23
    “alllrrrright um.”
    read in context ↗
  7. 12:48:41.1CVR CAMwarningp.26
    “[sound of tone, similar to altitude alert]”
    read in context ↗
  8. 12:55:44.3CVR CAMwarningp.29
    “[sound of tone, similar to altitude alert]”
    read in context ↗
  9. 12:58:42.5CVR CAMwarningp.30
    “[sound of tone, similar to altitude alert]”
    read in context ↗
  10. 13:17:10.9CVR CAMwarningp.38
    “[sound of tone, similar to altitude alert]”
    read in context ↗
  11. 13:23:35.6CVR CAMwarningp.45
    “[sound of low tone, similar to altitude alert]”
    read in context ↗
  12. 13:29:23.1CVR HOT-1calloutp.50
    “alright that's close enough for me let's go landing gear down.”
    read in context ↗
  13. 13:29:26.9CVR HOT-2calloutp.50
    “landing gear down.”
    read in context ↗
  14. 13:29:53.1CVR HOT-2warningp.51
    “aw and we're overspeed *.”
    read in context ↗
  15. 13:30:47.4CVR TWRcalloutp.53
    “airport nineteen nineteen Midway tower you are following traffic short final runway one three center cleared to land. winds two one zero at niner. the rain is moving to the east to north east.”
    read in context ↗
  16. 13:31:00.5CVR RDO-2calloutp.53
    “ah one three center cleared to land thanks Southwest nineteen nineteen.”
    read in context ↗
  17. 13:31:37.2CVR HOT-1calloutp.54
    “alright approaching minimums.”
    read in context ↗
  18. 13:31:43.7CVR HOT-2calloutp.54
    “yeah okay approaching minimums.”
    read in context ↗
  19. 13:31:47.1CVR CAMwarningp.54
    “[sound of three warning horns, similar to autopilot disconnect warning]”
    read in context ↗
  20. 13:31:48 CDTFDRapproachp.3
    Autopilot disengaged
    see the traces at this moment ↗
  21. 13:31:49.6CVR HOT-2p.54
    “minimums.”
    read in context ↗
  22. 13:31:50.1CVR HOT-1p.54
    “landing.”
    read in context ↗
  23. 13:32:51.5CVR TWRcalloutp.55
    “Southwest three seventy six Midway tower company departure to cross prior to your arrival wind two two zero at one zero gust one seven runway one three center cleared to land.”
    read in context ↗
  24. 13:32:56.5CVR HOT-2p.56
    “ah fifty.”
    read in context ↗
  25. 13:33 CDTFDRlandingp.3
    During the landing roll the aircraft made a left excursion from the runway heading and stopped on a magnetic heading of 101 degrees; last recorded data point at 13:33
    see the traces at this moment ↗
  26. 13:33:00.8CVR HOT-2p.56
    “ten.”
    read in context ↗
  27. 13:33:04 CDTFDRlandingp.3
    Main gear weight-on-wheels registered ground at an airspeed of 136 knots; autothrottle engage parameter turned off 1 second later
    see the traces at this moment ↗
  28. 13:33:05.0CVR HOTp.56
    “[unidentified .03 second sound] (may be sound of mechanical solenoid associated with landing) 13:33:010.0”
    read in context ↗
  29. 13:33:05.0CVR HOT-2p.56
    “gett(in') on the brakes.”
    read in context ↗
  30. 13:33:06 CDTFDRlandingp.3
    Nose gear weight-on-wheels registered ground; autobrake showed applied for one second followed by an increase in left and right brake pressure
    see the traces at this moment ↗
  31. 13:33:18.8CVR HOT-1p.56
    “#”
    read in context ↗
  32. 13:33:20.0CVR HOT-?p.56
    “* power power power * DCA11IA047”
    read in context ↗
  33. 13:33:21 CDTFDRlandingp.3
    Throttle resolver parameters began to move, speed brake handle position increased and the speed brake armed light indicated armed; within 2 seconds thrust reversers fully deployed and spoiler panels fully deployed
    see the traces at this moment ↗
  34. 13:33:42.9CVR TWRcalloutp.57
    “Southwest three seventy six go around climb and maintain three thousand company went off--”
    read in context ↗
  35. 13:42:04.9CVR CAMfinal secondsp.68
    “[sound of two chimes, similar to flight attendant call button]”
    read in context ↗
  36. 13:42:11.0CVR CAMfinal secondsp.68
    “[sound of two chimes, similar to ACARS alert]”
    read in context ↗
  37. 13:42:11.2CVR HOT-7final secondsp.68
    “@”
    read in context ↗
  38. 13:42:12.7CVR HOT-8final secondsp.68
    “yeah.”
    read in context ↗
  39. 13:42:13.5CVR HOT-7final secondsp.68
    “hey which door do you want to use here...they’re asking me...it's this door right...the door I have open...[sigh] oh my God...our aft--our aft entry door...not the one where we use the provisioner...he's comin' up right now with the stairs.”
    read in context ↗
  40. 13:42:57.1CVR CAM-1final secondsp.68
    “hey @ @ @ captain on nineteen nineteen. hey thanks. yep we're in the mud. everybody's okay. no injuries. engines have been shut down. uh fire trucks are here. we're trying to get some airstairs that won't sink in the mud. but everything--...yes---...we're doin'---we're doin'---we're doin' it right now.”
    read in context ↗
  41. 13:43:23.7CVR CAM-1final secondsp.68
    “everybody's fine. no injuries. aircraft is approximately um ten to fifteen feet off of the left end. we did not go into the frangible cement. we steered it into the grass. we're a good hundred feet from the fence line. everybody is here with no injuries....yeah...yep...oh yeah. DCA11IA047”
    read in context ↗
  42. 13:43:55.9CVR CAM-1final secondsp.69
    “no...no no no...the aircraft was...we were landing right at max weight. had wind gusts a storm had just passed through the area. guy in front of us had just called wet fair. ah when we hit the brakes we weren't gettin' anything it was just...it just kept goin'. we both got on the brakes as hard as we could and ah and weren't seeing any deceleration. and we finally got it [end of recording]”
    read in context ↗
Recorder events without a clock time
  • final approachFlaps set to 40 degrees; speed brake armed light not indicated
Flight Data Recorder 10 - Factual Report of Group Chairman · 9 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 34 of 721 lines shown
How the Board coded the sequence
  1. Landing-landing roll: Landing area overshoot

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA11IA0152010-12-29no fatalitiesmatch 71
    BOEING 757-223 · AMERICAN AIRLINES INC
    Jackson Hole, WY
    • ●Aircraft › Aircraft power plant › Engine exhaust
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Personnel issues › Action/decision › Action
    • +2 more shared findings
  • DCA17IA0202016-10-27no fatalitiesmatch 68
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
    Landing area overshoot
  • DCA18IA0262017-11-29no fatalitiesmatch 64
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA14IA0372014-01-13no fatalitiesmatch 61
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Branson, MO
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA11FA0502011-01-03substantialmatch 57
    BOEING 737-823 · American Airlines
    Los Angeles, CA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA13FA1312013-07-22substantialmatch 56
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA16CA1132016-03-05substantialmatch 56
    BOEING 767 34AF · UNITED PARCEL SERVICE CO
    Albuquerque, NM
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA13MA1202013-07-063 fatalmatch 55
    BOEING 777-200ER · Asiana Airlines
    San Francisco, CA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Psychological › Attention/monitoring

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
  • 2 of 8Runway excursion
  • 2 of 8Tailstrike
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Psychological › Attention/monitoring
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters

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
  • DCA11IA0152010-12-29 · BOEING 757-223 · AMERICAN AIRLINES INC
    a manufacturing defect in a clutch mechanism that prevented the speedbrakes from automatically deploying after touchdown, and the captain’s failure to monitor and extend the speedbrakes manually. Also causal was the failure of the thrust reversers to deploy when initially commanded. Contributing to the incident was the captain’s failure to confirm speedbrake extension before announcing their deployment, and his distraction caused by the thrust reversers’ failure to initially deploy after landing.
  • 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…
  • DCA18IA0262017-11-29 · BOEING 737-932ER · Delta Air Lines
    The flight crewmembers’ failure to properly monitor the airplane’s flightpath, which caused the approach to become unstabilized and resulted in the airplane’s descent below the decision altitude while misaligned with the localizer course. Contributing to the incident were the first officer’s delay in setting go-around thrust after the captain called for the go-around and the captain’s failure to take control of the airplane after go-around thrust was not immediately set, both of which caused the airplane to come wi…
  • DCA14IA0372014-01-13 · BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    The Flight crew's failure to properly identify the airport and runway of intended landing. Contributing to the incident was the flight crew's failure to comply with procedures for use of navigation information and visual cues to verify the airport and runway of intended landing and the air traffic controller's issuance of erroneous airport geographic information without including the location of proximate airports.
  • DCA11FA0502011-01-03 · BOEING 737-823 · American Airlines
    the early rotation of the airplane to an angle at which the fuselage contacted the runway. Contributing to early rotation was the Captain’s reaction to the erroneous V1 automated callout, likely assuming that the airplane was at or close to the correct Vr at the same time. The erroneous automated callout was likely due to a keystroke entry error by the FO when manually entering takeoff data for a newly assigned departure runway.
What it recommended after them
  • A-12-044TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of existing speedbrake-equipped transport-category airplanes to develop and incorporate training to specifically address recognition of a situation in which the speedbrakes do no… · DCA11IA015Closed - Acceptable Action
  • A-12-045TO THE FEDERAL AVIATION ADMINISTRATION: Require all newly type-certificated 14 Code of Federal Regulations Part 25 airplanes to have a clearly distinguishable and intelligible alert that warns pilots when the speedbrakes have not deployed d… · DCA11IA015Open Acceptable Alternate Response
  • A-12-046TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to establish guidance for pilots of all relevant airplanes to follow when an unintended thrust reverser lockout occurs and to provide that guidance to all operators of those airplanes. · DCA11IA015Closed - Reconsidered
  • A-15-009TO THE FEDERAL AVIATION ADMINISTRATION: Amend air traffic control procedures so that controllers withhold landing clearance until the aircraft has passed all other airports that may be confused with the destination airport. · DCA14IA037Open Acceptable Alternate Response
  • A-15-010TO THE FEDERAL AVIATION ADMINISTRATION: Modify the minimum safe altitude warning (MSAW) software to apply the MSAW parameters for the flight plan destination airport to touchdown, rather than automatically reassigning the flight to another… · DCA14IA037Open Acceptable Alternate Response
  • A-14-037TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to develop enhanced 777 training that will improve flight crew understanding of autothrottle modes and automatic activation system logic through improved documentation, courseware, and… · DCA13MA120Closed - Acceptable Alternate Action
  • A-14-038TO THE FEDERAL AVIATION ADMINISTRATION: Once the enhanced Boeing 777 training has been developed, as requested in Safety Recommendation A-14-37, require operators and training providers to provide this training to 777 pilots. · DCA13MA120Closed - Acceptable Alternate Action
  • A-14-039TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to revise its 777 Flight Crew Training Manual stall protection demonstration to include an explanation and demonstration of the circumstances in which the autothrottle does not provide… · DCA13MA120Closed - Acceptable Alternate 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).