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Cases › DCA13FA131 › The analyst

BOEING 737 7H4SOUTHWEST 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.

37
timed facts
8
precedents
72
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

37 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. 15:37:25-15:49:12 EDTFDRpre-flightp.3
    On the ground at Nashville between flight control check and takeoff roll, control column position biases of -0.47 (captain) and 0.58 (first officer) and average force transducer readings of -0.84 lb (captain) and -3.03 lb (first officer) were determined and offset to identify the pilot flying
  2. 15:39:47.5CVR STARTp.8
    “OF RECORDING”
    read in context ↗
  3. 17:17:01.1CVR HOTwarningp.13
    “[sound similar to altitude alert]”
    read in context ↗
  4. 17:30:41.4CVR HOT-2calloutp.28
    “* you want to go around that way? ***. [stepped on by ATC transmission to other aircraft]”
    read in context ↗
  5. 17:31:05.9CVR HOTwarningp.29
    “[sound similar to altitude alert]”
    read in context ↗
  6. 17:36:02.6CVR HOTwarningp.34
    “[sound similar to altitude alert]”
    read in context ↗
  7. 17:38:45.1CVR HOTwarningp.37
    “[sound similar to altitude alert]”
    read in context ↗
  8. 17:40:59.1CVR HOT-2p.39
    “alright clear to land. DCA13FA131”
    read in context ↗
  9. 17:41:00 EDTFDRapproachp.4
    Start of plotted approach: autopilot engaged, autothrottle in MCP speed mode with 210 knots selected as the heading intercepts the runway 04 localizer; descent begins from the 2,700 ft MSL step-down altitude
  10. 17:41:00.1CVR HOT-1p.40
    “seventeen.”
    read in context ↗
  11. 17:41:05.4CVR HOTwarningp.40
    “[sound similar to altitude alert]”
    read in context ↗
  12. 17:41:11.5CVR HOT-1p.40
    “five.”
    read in context ↗
  13. 17:41:14 EDTFDRapproachp.4
    MCP selected airspeed decreased to 180 knots while descending on glideslope; changed to 150 knots at 17:41:54 and to 134 knots at 17:42:36, where it remained
  14. 17:41:15.4CVR HOT-1p.40
    “remember you're on that so it's going to try to maintain that speed first and not go down.”
    read in context ↗
  15. 17:41:36.4CVR HOT-2calloutp.41
    “alright let's go landing gear down please.”
    read in context ↗
  16. 17:41:38.1CVR HOT-1calloutp.41
    “landing gear down.”
    read in context ↗
  17. 17:43:45.7CVR HOT-1p.46
    “five hundred.”
    read in context ↗
  18. 17:43:49 EDTFDRapproachp.4
    Autothrottle disengaged for the remainder of the flight
  19. 17:43:49.6CVR CAMwarningp.46
    “[sound similar to autopilot disconnect]”
    read in context ↗
  20. 17:43:50 EDTFDRfinal approachp.4
    Autopilot disengaged; radio altitude between 385 and 361 ft, pressure altitude roughly 470 ft MSL; aircraft tracking the runway heading of around 044 degrees; control column data show the pilot flying manipulating the controls, with the first officer's column force transducer reading greater than the captain's in both push and pull
  21. 17:43:52.4CVR HOT-1p.46
    “people are crossing. they're out of your way. DCA13FA131”
    read in context ↗
  22. 17:44:11 EDTFDRfinal approachp.4
    ILS glideslope deviation began a fly-down trend (aircraft above glideslope), reaching a maximum at 17:44:23 just before touchdown; just before the maximum, captain and first officer column forces became closely aligned
  23. 17:44:12.2CVR HOT-1p.47
    “ooh.”
    read in context ↗
  24. 17:44:12.9CVR HOT-2p.47
    “uhh come on.”
    read in context ↗
  25. 17:44:23.0CVR HOT-1p.47
    “I got it.”
    read in context ↗
  26. 17:44:23.6CVR HOT-2p.47
    “okay you got it.”
    read in context ↗
  27. 17:44:26.8CVR CAMwarningp.47
    “[sound of impact] DCA13FA131”
    read in context ↗
  28. 17:44:27 EDTFDRlandingp.4
    Touchdown with vertical acceleration peaking at 3.18 g
  29. 17:44:45.5CVR CAM-1final secondsp.48
    “oh my God.”
    read in context ↗
  30. 17:44:46 EDTFDRlandingp.4
    Aircraft came to rest
  31. 17:44:46.3CVR CAM-?final secondsp.48
    “you guys okay?”
    read in context ↗
  32. 17:44:46.9CVR CAM-1final secondsp.48
    “sorry.”
    read in context ↗
  33. 17:44:47.7CVR CAM-1final secondsp.48
    “yes *.”
    read in context ↗
  34. 17:44:48.5CVR CAM-?final secondsp.48
    “you guys okay?”
    read in context ↗
  35. 17:44:49.3CVR CAM-1final secondsp.48
    “remain seated.”
    read in context ↗
  36. 17:44:49.6CVR CAMfinal secondsp.48
    “[sounds of movement in cockpit]”
    read in context ↗
  37. 17:44:52.9CVR CAM-1final secondsp.48
    “we need to shut this down.”
    read in context ↗
Recorder events without a clock time
  • before touchdownEngine 1 and 2 throttle resolver angles decreased to around 35 degrees with N1 following a decreasing trend; pitch entered a nose-down trend reaching a minimum airborne value of -3.87 degrees; column positions near zero just before touchdown
Flight Data Recorder - Specialist's Factual Report · 9 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder - Group Chairman's Factual Report · 29 of 439 lines shown
How the Board coded the sequence
  1. Landing-flare/touchdown: Hard landing→
  2. Landing-flare/touchdown: Landing gear collapse

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA17IA0202016-10-27no fatalitiesmatch 72
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA18IA0262017-11-29no fatalitiesmatch 67
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • CEN19MA1902019-06-3010 fatalmatch 63
    Textron Aviation B-300 · S&H Aircraft
    Addison, TX
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA23LA1722022-12-19no fatalitiesmatch 63
    BOEING 777 · UNITED AIRLINES INC
    Kahului, HI
    • ●Personnel issues › Task performance › Use of equip/info
  • ERA17FA1952017-06-031 fatalmatch 63
    PIPER PA23 · AIR AMERICA INC
    San Juan, PR
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA11FA0352011-03-23substantialmatch 63
    AIRBUS F4-622R · United Parcel Service Company
    Albuquerque, NM
    • ●Personnel issues › Task performance › Use of equip/info
    Hard landing
  • CEN09IA2942009-05-13no fatalitiesmatch 62
    BOEING 737 · SOUTHWEST AIRLINES CO
    Houston, TX
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
  • ANC16FA0172016-04-083 fatalmatch 60
    CESSNA 206 · SUNRISE AVIATION
    Angoon, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Task performance › Use of equip/info

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 8Fire/smoke (post-impact)
  • 2 of 8Loss of control in flight
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
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Action/decision › Info processing/decision

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
  • 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…
  • 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.
  • DCA23LA1722022-12-19 · BOEING 777 · UNITED AIRLINES INC
    The flight crew’s failure to manage the airplane’s vertical flightpath, airspeed, and pitch attitude following a miscommunication about the captain’s desired flap setting during the initial climb.
  • ERA17FA1952017-06-03 · PIPER PA23 · AIR AMERICA INC
    The pilot's failure to maintain adequate airspeed, properly correct for left yaw, and his exceedance of the airplane's critical angle of attack during initial climb, which resulted in an aerodynamic stall and subsequent uncontrolled descent into water.

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).