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Cases › DCA19IA036 › The analyst

Boeing 737Southwest 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.

36
timed facts
8
precedents
193
passages to ask

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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

36 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. 8:10 PSTFDRDeparturep.3
    Aircraft departed KOAK for approximately 52 minute flight on southeasterly heading
    see the traces at this moment ↗
  2. 08:22:21.2CVR CAMwarningp.8
    “[sound similar to altitude alert]”
    read in context ↗
  3. 08:29:18.6CVR HOT-2calloutp.15
    “minimums?”
    read in context ↗
  4. 08:30:19.1CVR HOT-2warningp.16
    “yeah there's that couple who bought that boat are still in their apartment so I just crash over there lots of times. we were supposed to sail yesterday but it was so crappy in the morning we blew it off. yeah. we tried to sail the day before that but we got about fifteen minutes of good sailing in and then the wind just went to # just [sound of flatulence]. we're just sitting there like a # bobber.”
    read in context ↗
  5. 08:40:19.8CVR HOT-1warningp.25
    “you're gonna get a clacker.”
    read in context ↗
  6. 08:50:58.7CVR CAMwarningp.34
    “[sound similar to altitude alert]”
    read in context ↗
  7. 08:51:48.9CVR CAMwarningp.35
    “[sound similar to altitude alert]”
    read in context ↗
  8. 08:53:19.5CVR CAMwarningp.36
    “[sound similar to altitude alert]”
    read in context ↗
  9. 08:57:59.4CVR HOT-2p.42
    “six knots on the beak. and they're callin five knot tailwind so.”
    read in context ↗
  10. 8:58 PSTFDRApproachp.3
    Aircraft turned on to final heading and captured the glideslope and localizer
    see the traces at this moment ↗
  11. 08:58:05.4CVR HOT-1p.42
    “so it'll swap around here somewhere I guess.”
    read in context ↗
  12. 08:58:17.3CVR HOT-1calloutp.42
    “landing gear down.”
    read in context ↗
  13. 08:58:57.1CVR RDO-2p.43
    “switching we'll see you guys.”
    read in context ↗
  14. 8:59 PSTFDRApproachp.3
    Final flaps selected and airspeed decelerated to 133-136 knots while groundspeed was 144-145 knots
    see the traces at this moment ↗
  15. 08:59:04.1CVR HOT-2p.43
    “okay.”
    read in context ↗
  16. 09:02:00.5CVR HOT-2calloutp.49
    “minimums. you got *?”
    read in context ↗
  17. 09:02:01.8CVR CAMwarningp.49
    “[sound similar to autopilot disconnect]”
    read in context ↗
  18. 09:02:27.5CVR CAMp.49
    “thirty. [automated voice]”
    read in context ↗
  19. 09:02:30.7CVR CAMp.49
    “ten. [automated voice] DCA19IA036 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  20. 9:02:35 PSTFDRLandingp.3
    Aircraft touched down at an airspeed of 126 knots and groundspeed of 149 knots
    see the traces at this moment ↗
  21. 09:02:55.7CVR CAMwarningp.50
    “[sounds of impact]”
    read in context ↗
  22. 09:05:14.6CVR BURwarningp.53
    “Crash two Burbank Tower. proceed as requested. cross all runways as necessary.”
    read in context ↗
  23. 09:06:40.4CVR BURwarningp.54
    “Crash two Burbank tower did you copy all that? DCA19IA036 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  24. 09:06:52.3CVR BURwarningp.55
    “Crash two thank you.”
    read in context ↗
  25. 09:14:27.4CVR BURp.4
    “winds are two eight zero at one one gust one niner. 0916:08.7 information mike is now current. wind two niner”
    read in context ↗
  26. 09:14:27.4CVR OPSwarningp.6
    “Radio transmission from Southwest Burbank Operations Crash2 Radio transmission from Crash 2 VAN41 Radio transmission from Van 41 CAR43 Radio transmission from Car 43 -1 Voice identified as the captain -2 Voice identified as the first officer -3 Voice identified as a flight attendant -4 Voice identified as a flight attendant -? Voice unidentified * Unintelligible word # Expletive @ Non-pertinent word [ ] Editorial insertion Note 1: Times are expressed in pacific daylight time (PST). Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed. Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words as spoken. Note 4: A non-pertinent word, where noted, refers to a word not directly related to the operation, control or condition of the aircraft. DCA19IA036 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  27. 09:15:37.5CVR CAM-1calloutp.64
    “yeah yeah. well we were coming in to uh Burbank for the uh I-L-S eight and uh it's heavy rain. we had the radar on. it was showing uh um you know green and uh a— a little bit of red. uh we had it all configured by the final approach fix and uh came down. um the tower said the aircraft in front of us went around for uh um a wind shift or something like that and we continued on. we had uh about a— a nine knot uh tailwind component at about a thousand feet and then uh but you know pretty heavy rain and caught the uh runway um just a little bit before minimums. landed. deployed the autobrake. uh the um antiskid was in max went to max braking and the aircraft uh just did not seem to decelerate and we went into the overrun um probably maybe like at about fifteen knots— ten to fifteen knots.”
    read in context ↗
  28. 09:17:20.4CVR BURwarningp.65
    “Crash two Burbank Tower.”
    read in context ↗
  29. 09:22:18.9CVR INT-1final secondsp.68
    “thank you.”
    read in context ↗
  30. 09:22:19.4CVR INT-3final secondsp.68
    “thank you. DCA19IA036 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  31. 09:22:19.9CVR INT-4final secondsp.69
    “thanks.”
    read in context ↗
  32. 09:22:20.3CVR CAM-2final secondsp.69
    “it's behind you.”
    read in context ↗
  33. 09:22:21.5CVR CAM-1final secondsp.69
    “so.”
    read in context ↗
  34. 09:22:22.0CVR CAM-2final secondsp.69
    “if you slide up I'll get it.”
    read in context ↗
  35. 09:22:25.2CVR CAMfinal secondsp.69
    “[sound similar to seat track movement]”
    read in context ↗
  36. 09:22:27.8CVR CAM-2final secondsp.69
    “alright.”
    read in context ↗
Recorder events without a clock time
  • Cruise (~16 min)Cruise portion of flight at 33,000 ft and about 269 knots computed airspeed
  • Descent below 7,000 ftAccelerations consistent with light to moderate turbulence were recorded
  • At touchdownAutobrakes, auto speedbrakes, and ground spoilers were all activated; both thrust reversers transitioned and were fully deployed within 3 seconds of touchdown and engines spooled up with thrust reversers deployed
  • 7 seconds after touchdownBrake pressure reached its max of 3,000 psi
  • 0-17 seconds after touchdownAircraft reached and maintained a deceleration rate of about 0.3-0.4 g; groundspeed reached 44 knots
  • 17-22 seconds after touchdownDeceleration rate decreased to 0.15 to 0.2 g, slowing to a groundspeed of about 33 knots
  • After 22 seconds post-touchdownDeceleration rate increased to its maximum of about 0.6 g until the aircraft stopped; high rate was consistent with the aircraft decelerating in the EMAS
FLIGHT DATA RECORDER SPECIALIST'S FACTUAL REPORT · 11 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER GROUP CHAIRMAN FACTUAL REPORT · 32 of 608 lines shownATC AUDIO - BUR - LC · 59 min· not yet aligned to a clockATC AUDIO - SCT - RM · 13 min· not yet aligned to a clockATC AUDIO - SCT - RW · 19 min· not yet aligned to a clockATC AUDIO - ZLA - R13 · 14 min· not yet aligned to a clockATC AUDIO - ZLA - R15 · 15 min· not yet aligned to a clockATC AUDIO - ZLA - R26 · 19 min· not yet aligned to a clock
How the Board coded the sequence
  1. Landing: Runway excursion

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA20LA0132019-11-11substantialmatch 71
    Embraer EMB145 · Envoy Air Inc.
    Chicago, IL
    • ●Personnel issues › Action/decision › Action
    Runway excursion
  • DCA17IA0202016-10-27no fatalitiesmatch 57
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Personnel issues › Action/decision › Action
    Runway excursion
  • DCA09MA0212008-12-21substantialmatch 57
    BOEING 737-524 · CONTINENTAL AIRLINES INC
    Denver, CO
    • ●Environmental issues › Conditions/weather/phenomena › Wind
    • ●Personnel issues › Action/decision › Action
    Runway excursion
  • DCA19MA1432019-05-04substantialmatch 56
    Boeing 737 · Miami Air International
    Jacksonville, FL
    • ●Personnel issues › Action/decision › Action
    Runway excursion
  • DCA25LA1632025-03-20no fatalitiesmatch 55
    BOEING 737-8H4 · SOUTHWEST AIRLINES CO
    Orlando, FL
    • ●Personnel issues › Action/decision › Action
  • DCA11FA0502011-01-03substantialmatch 54
    BOEING 737-823 · American Airlines
    Los Angeles, CA
    • ●Personnel issues › Action/decision › Action
  • DCA14FA1222014-06-20substantialmatch 54
    BOEING 767 36N · OMNI AIR INTERNATIONAL INC
    Kabul, AF
    • ●Environmental issues › Conditions/weather/phenomena › Wind
  • DCA13CA0432013-01-25substantialmatch 53
    MCDONNELL DOUGLAS MD11 · FEDERAL EXPRESS CORP
    Denver, CO
    • ●Personnel issues › Action/decision › Action

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
  • 4 of 8Runway excursion
  • 3 of 8Tailstrike
  • 2 of 8Landing area overshoot
  • 2 of 8Other weather encounter
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Conditions/weather/phenomena › Wind
  • Action/decision › Action
Cited here, not seen in the precedents
  • Management › Resources
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters
  • Support/oversight/monitoring › Training
  • Action/decision › Info processing/decision
  • Task performance › Use of equip/info

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
  • DCA20LA0132019-11-11 · Embraer EMB145 · Envoy Air Inc.
    The flight crew’s inability to maintain the airplane on the runway centerline after touchdown due to the reduced braking action resulting from the deteriorating weather conditions, which caused the airplane’s departure from the runway surface. Contributing to the accident were the delay in performing the runway assessment for undetermined reasons and failure to close the runway. Also contributing to the accident was the controller’s failure to advise the accident flight crew that braking action was no longer cons…
  • 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…
  • DCA09MA0212008-12-21 · BOEING 737-524 · CONTINENTAL AIRLINES INC
    The captain’s cessation of right rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the excursion, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience. Contributing to the accident were the following factors: 1) an air traffic control system that did not require or facilitate the dissemination of key, available wind information to the air traffic controllers and pilots; and 2) inadequate crosswind training…
  • DCA19MA1432019-05-04 · Boeing 737 · Miami Air International
    An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning. Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments. Contributing to the continuation of an unstabilized approach were 1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and 2) the first officer’s lack of…
  • DCA25LA1632025-03-20 · BOEING 737-8H4 · SOUTHWEST AIRLINES CO
    The captain’s failure to recognize that the airplane’s location did not agree with the assigned departure runway as required per the Southwest Airlines Airplane Operating Manual, and the captain’s plan continuation error when he missed several cues that would have informed him that he was not on the assigned departure runway when he initiated takeoff.
What it recommended after them
  • A-10-105TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research into and document the effects of mountain wave and downslope conditions at airports, such as Denver International Airport, that are located downwind of mountainous terrain (including,… · DCA09MA021Closed - Acceptable Action
  • A-10-106TO THE FEDERAL AVIATION ADMINISTRATION: Archive all low-level windshear alert system (LLWAS) data obtained from Denver International Airport and other airports that experience similar wind conditions and make these data available for additi… · DCA09MA021Closed - Acceptable Action
  • A-10-107TO THE FEDERAL AVIATION ADMINISTRATION: Modify Federal Aviation Administration Order 7110.65 to require air traffic controllers at airports with multiple sources of wind information to provide pilots with the maximum wind component, includi… · DCA09MA021Closed - Unacceptable Action
  • A-10-108TO THE FEDERAL AVIATION ADMINISTRATION: Review the required documentation for all low-level windshear alert system (LLWAS)-equipped air traffic control towers to ensure that a letter to airmen has been published and is easily accessible des… · DCA09MA021Closed - Acceptable Action
  • A-10-109TO THE FEDERAL AVIATION ADMINISTRATION: Require air traffic control towers to locally develop and implement written runway selection programs that proactively consider current and developing wind conditions and include clearly defined cross… · DCA09MA021Closed - Acceptable Alternate Action
  • A-10-110TO THE FEDERAL AVIATION ADMINISTRATION: Gather data on surface winds at a sample of major U.S. airports (including Denver International Airport) when high wind conditions and significant gusts are present and use these data to develop reali… · DCA09MA021Closed - Acceptable Alternate Action
  • A-10-111TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate the realistic, gusty crosswind profiles developed as a result of Safety Recommendation A-10-110 into their pilot… · DCA09MA021Closed - Acceptable Alternate Action
  • A-10-112TO THE FEDERAL AVIATION ADMINISTRATION: Once realistic, gusty crosswind profiles as asked for in Safety Recommendation A-10-110 are developed, develop a standard methodology, including pilot-in-the-loop testing, for transport-category airpl… · DCA09MA021Open Acceptable Alternate 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).