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Cases › DCA16LA032 · Part 121 airline

BOEING 737 3H4Southwest Airlines

Nashville, TN, USA · 2015-12-15·N649SW

0
fatal
0
serious
No injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

On December 15, 2015, at 5:23pm central standard time (CST), Southwest Airlines flight 31, a Boeing 737-300, N649SW, exited the taxiway while taxing to the gate and came to rest in a ditch at the Nashville International Airport (BNA), Nashville, Tennessee.  Nine of the 138 passengers and crew onboard received minor injuries during the evacuation and the airplane was substantially damaged.  The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from William P. Hobby Airport (HOU), Houston, Texas. Weather was not a factor, light conditions were dark just after sunset.  The airplane landed normally on runway 20R and exited at taxiway B2.  The flight crew received and understood the taxi instructions to their assigned gate.  As the crew proceeded along taxiway T3, the flight crew had difficulty locating taxiway T4 as the area was dark, and there was glare from the terminal lights ahead.  The crew maneuvered the airplane along T3 and onto T4, and then turned back to the right on a general heading consistent with heading across the ramp toward the assigned gate.  The flight crew could not see T4 or the grassy area because the taxiway lights were off and the glare from the terminal lights.  As a result, the airplane left the pavement and came to rest in a drainage ditch resulting in substantial damage to airplane.  The cabin crew initially attempted to keep the passengers seated, but after being unable to contact the flight crew due to the loud alarm on the flight deck, the cabin crew properly initiated and conducted an evacuation. As a result of past complaints regarding the brightness of the green taxiway centerline lights on taxiways H, J, L and T-6, BNA tower controllers routinely turned off the taxiway centerline lighting.  Although the facility had not received any requests on the day of the accident, about 30 minutes prior to the event the tower controller in charge (CIC) turned off the centerline lights as a matter of routine.  In doing so, the CIC inadvertently turned off the "TWY J & Apron 2" selector, which included the taxiway lights in the vicinity of the excursion.  The airfield lighting panel screensaver feature prevented the tower controllers from having an immediate visual reference to the status of the airfield lighting.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
340ax - Southwest Airlines Boeing 737-300, N649SW@LAS,01.03.2005 - Flickr - Aero Icarus
Aero Icarus from Zürich, Switzerland · CC BY-SA 2.0 · Wikimedia Commons

Probable cause

the Board's determination
the flight crew's early turn towards the assigned gate because taxiway lighting had been inadvertently turned off by the controller-in-charge which resulted in the airplane leaving the paved surface. Contributing to the accident was the operation of the screen-saver function on the lighting control panel that prevented the tower controllers from having an immediate visual reference to the status of the airfield lighting.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Taxi-from runway
    Collision with terr/obj (non-CFIT)
  2. 2 · Taxi-from runway
    Landing gear collapse
    defining event

Findings

5 causal · 0 contributing
  • CAUSE
    Environmental issues › Operating environment › Airport facilities/design › Taxiway lighting — Contributed to outcome
  • CAUSE
    Organizational issues › Development › Design › Equipment design — ATC
  • CAUSE
    Personnel issues › Physical › Sensory ability/limitation › Visual function — Pilot
  • CAUSE
    Aircraft › Aircraft handling/service › Towing and taxiing › Taxiing — Not specified
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of equip/system — ATC personnel

Sequence of events

13 timed eventsfrom the FDR factual report · claude-sonnet-5
  1. 1725 CST (event time)Taxip.1
    Southwest Airlines flight 31 departed taxiway T4 and came to rest in a ditch at Nashville International Airport (BNA)
  2. 15:49:30 CSTOverviewp.3
    Start of overview plot capturing all phases of flight (Figure 1)
  3. 17:20:33 CSTLanding rolloutp.3
    Aircraft began its landing rollout, WOW parameter transitioned to ground; groundspeed 137 knots with heading 200 degrees
  4. 17:20:33 CST (concurrent)Landing rolloutp.3
    Throttle lever angle (TLA) moved to a position consistent with thrust reverser deployment
  5. shortly after 17:20:33 CSTLanding rolloutp.3
    Aircraft's groundspeed continued to decrease until 30 knots at which the TLAs were moved to a setting consistent with idle
  6. 17:20:57 CSTTaxip.3
    Heading began a left turn to 150 degrees
  7. during turnTaxip.3
    Aircraft's groundspeed decreased to around 15 knots and maintained this groundspeed until about 17:23:30 CST
  8. 17:20:57 to 17:23:14 CST (approx 2 min 18 sec)Taxip.3
    Heading continued to change consistent with an aircraft taxiing
  9. 17:23:14 CSTTaxip.3
    Heading showed a turn to the left from 90 to 64 degrees
  10. 17:23:22 CSTTaxip.3
    Heading showed a right turn back to 90 degrees
  11. 17:23:31 CSTAccident sequencep.3
    Vertical acceleration began to increase; pitch and roll indicated 10 degrees nose down and 14 degrees right wing down
  12. 17:23:31 CST (concurrent)Accident sequencep.3
    Nose WOW and gear down and lock parameters indicated not on ground and not down and locked, respectively
  13. 17:23:41 CSTOverviewp.3
    End of overview plot capturing all phases of flight (Figure 1)

NTSB analysis

from the final report

On December 15, 2015, at 5:23pm central standard time (CST), Southwest Airlines flight 31, a Boeing 737-300, N649SW, exited the taxiway while taxing to the gate and came to rest in a ditch at the Nashville International Airport (BNA), Nashville, Tennessee.  Nine of the 138 passengers and crew onboard received minor injuries during the evacuation and the airplane was substantially damaged.  The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from William P. Hobby Airport (HOU), Houston, Texas. Weather was not a factor, light conditions were dark just after sunset.  The airplane landed normally on runway 20R and exited at taxiway B2.  The flight crew received and understood the taxi instructions to their assigned gate.  As the crew proceeded along taxiway T3, the flight crew had difficulty locating taxiway T4 as the area was dark, and there was glare from the terminal lights ahead.  The crew maneuvered the airplane along T3 and onto T4, and then turned back to the right on a general heading consistent with heading across the ramp toward the assigned gate.  The flight crew could not see T4 or the grassy area because the taxiway lights were off and the glare from the terminal lights.  As a result, the airplane left the pavement and came to rest in a drainage ditch resulting in substantial damage to airplane.  The cabin crew initially attempted to keep the passengers seated, but after being unable to contact the flight crew due to the loud alarm on the flight deck, the cabin crew properly initiated and conducted an evacuation. As a result of past complaints regarding the brightness of the green taxiway centerline lights on taxiways H, J, L and T-6, BNA tower controllers routinely turned off the taxiway centerline lighting.  Although the facility had not received any requests on the day of the accident, about 30 minutes prior to the event the tower controller in charge (CIC) turned off the centerline lights as a matter of routine.  In doing so, the CIC inadvertently turned off the "TWY J & Apron 2" selector, which included the taxiway lights in the vicinity of the excursion.  The airfield lighting panel screensaver feature prevented the tower controllers from having an immediate visual reference to the status of the airfield lighting.