Cases › DCA16LA032 › The analyst
BOEING 737 3H4Southwest Airlines
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.
11
timed facts
8
precedents
16
passages to ask
Ask the docket
passages, not paraphrasesTry
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
11 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- 15:49:30 CSTFDROverviewp.3Start of overview plot capturing all phases of flight (Figure 1)see the traces at this moment ↗
- 17:20:33 CSTFDRLanding rolloutp.3Aircraft began its landing rollout, WOW parameter transitioned to ground; groundspeed 137 knots with heading 200 degreessee the traces at this moment ↗
- 17:20:33 CST (concurrent)FDRLanding rolloutp.3Throttle lever angle (TLA) moved to a position consistent with thrust reverser deploymentsee the traces at this moment ↗
- shortly after 17:20:33 CSTFDRLanding rolloutp.3Aircraft's groundspeed continued to decrease until 30 knots at which the TLAs were moved to a setting consistent with idlesee the traces at this moment ↗
- 17:20:57 CSTFDRTaxip.3Heading began a left turn to 150 degreessee the traces at this moment ↗
- 17:20:57 to 17:23:14 CST (approx 2 min 18 sec)FDRTaxip.3Heading continued to change consistent with an aircraft taxiingsee the traces at this moment ↗
- 17:23:14 CSTFDRTaxip.3Heading showed a turn to the left from 90 to 64 degreessee the traces at this moment ↗
- 17:23:22 CSTFDRTaxip.3Heading showed a right turn back to 90 degreessee the traces at this moment ↗
- 17:23:31 CSTFDRAccident sequencep.3Vertical acceleration began to increase; pitch and roll indicated 10 degrees nose down and 14 degrees right wing downsee the traces at this moment ↗
- 17:23:31 CST (concurrent)FDRAccident sequencep.3Nose WOW and gear down and lock parameters indicated not on ground and not down and locked, respectivelysee the traces at this moment ↗
- 17:23:41 CSTFDROverviewp.3End of overview plot capturing all phases of flight (Figure 1)see the traces at this moment ↗
Recorder events without a clock time
- 1725 CST (event time)Southwest Airlines flight 31 departed taxiway T4 and came to rest in a ditch at Nashville International Airport (BNA)
- during turnAircraft's groundspeed decreased to around 15 knots and maintained this groundspeed until about 17:23:30 CST
Flight Data Recorder Factual Report · 13 events extracted by claude-sonnet-5
How the Board coded the sequence
- Taxi-from runway: Collision with terr/obj (non-CFIT) →
- Taxi-from runway: Landing gear collapse
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BOEING 767 · Delta Air Lines, Inc.Atlanta Hartsfield Intl. Apt. (KATL), GA
- ●Environmental issues › Operating environment › Airport facilities/design
- MCDONNELL DOUGLAS MD-11F · FEDERAL EXPRESS CORPMemphis, TN
- ●Organizational issues › Development › Design
- ●Personnel issues › Task performance › Use of equip/info
Collision with terr/obj (non-CFIT) - DEHAVILLAND DHC6 · WIGGINS AIRWAYS INCHyannis, MA
- ●Organizational issues › Development › Design
- ●Personnel issues › Task performance › Use of equip/info
Collision with terr/obj (non-CFIT) - BOMBARDIER INC DHC 8 402 · HORIZON AIR INDUSTRIES INCPullman, WA
- ●Environmental issues › Operating environment › Airport facilities/design
- MCDONNELL DOUGLAS AIRCRAFT CO MD-88 · DELTA AIR LINES INCNashville, TN
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 737-8 · United AirlinesDulles, VA
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 737-900ER · Delta Air LinesQueens, NY
- ●Environmental issues › Operating environment › Airport facilities/design
- BOEING 737-8H4 · SOUTHWEST AIRLINES COOrlando, FLmatched on what happened, as the Board wrote it · same aircraft family
What the record says
a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable causeFindings the Board cited in those cases
- 4 of 8Personnel issues › Action/decision › Info processing/decision
- 4 of 8Personnel issues › Task performance › Use of equip/infocited here too
- 3 of 8Environmental issues › Operating environment › Airport facilities/designcited here too
- 2 of 8Organizational issues › Development › Designcited here too
- 2 of 8Personnel issues › Action/decision › Action
Occurrences it coded
- 3 of 8Wrong surface or wrong airport
- 2 of 8Collision with terr/obj (non-CFIT)
- 2 of 8Ground collision
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Operating environment › Airport facilities/design
- Development › Design
- Task performance › Use of equip/info
Cited here, not seen in the precedents
- Aircraft handling/service › Towing and taxiing
- Physical › Sensory ability/limitation
Common in the precedents, not cited here
- Action/decision › Action
- 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
- OPS10IA0012009-10-19 · BOEING 767 · Delta Air Lines, Inc.
The flight crew’s failure to identify the correct landing surface due to fatigue. Contributing to the cause of the incident were (1) the flight crew’s decision to accept a late runway change, (2) the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and (3) the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.
- DCA13CA0352012-12-26 · MCDONNELL DOUGLAS MD-11F · FEDERAL EXPRESS CORP
the operator's failure to provide appropriate training and documentation for ground personnel, leading the marshaller to inadvertently guide the airplane into the collision.
- NYC08FA2182008-06-18 · DEHAVILLAND DHC6 · WIGGINS AIRWAYS INC
The pilot's failure to remove the flight control lock prior to takeoff. Contributing to the accident was the Federal Aviation Administration's failure to issue an airworthiness directive making the manufacturer's previously-issued flight control lock service bulletins mandatory.
- DCA18IA0812017-12-30 · BOMBARDIER INC DHC 8 402 · HORIZON AIR INDUSTRIES INC
the flight crew's misidentification of the taxiway as the landing runway due to the failure of the runway lighting that caused only the taxiway lights to be illuminated.
- DCA13CA1062013-06-13 · MCDONNELL DOUGLAS AIRCRAFT CO MD-88 · DELTA AIR LINES INC
The flight crews failure to maintain clearance from the light pole while taxiing.
What it recommended after them
- A-11-012TO THE FEDERAL AVIATION ADMINISTRATION: Perform a technical review of Airport Surface Detection Equipment–Model X (ASDE-X) to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. · OPS10IA001Closed - Unacceptable Action
- A-11-013tO THE FEDERAL AVIATION ADMINISTRATION: At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment–Model X (A… · OPS10IA001Closed - Unacceptable Action
- A-11-014TO THE FEDERAL AVIATION ADMINISTRATION: Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control pa… · OPS10IA001Closed - Acceptable Action
- A-11-015TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 150/5345-56A, “Specification for L-890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances… · OPS10IA001Closed - Exceeds Recommended Action
- A-24-002TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 91K, 135, and 121 operators to incorporate into their standard operating procedures a procedural crosscheck that requires flight crews to verbalize… · DCA23LA125Open - Unacceptable Response
- A-24-003TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent t… · DCA23LA125Open Acceptable Alternate Response
- A-24-004TO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on… · DCA23LA125Open - Unacceptable Response
- A-24-005TO THE FEDERAL AVIATION ADMINISTRATION: Require that the technology developed in response to Safety Recommendation A-24-4 be installed in all newly certificated transport-category airplanes. (Supersedes A-00-66) · DCA23LA125Open - Unacceptable Response
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).