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Cases › DCA23FA149 › The analyst

BOEING 737-79PSOUTHWEST 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.

0
timed facts
8
precedents
62
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One timeline

0 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

No timed facts: this docket has no extracted recorder sequence and no transcript.

FLIGHT DATA RECORDER - SPECIALIST'S FACTUAL REPORT · 3 events extracted by claude-sonnet-5
How the Board coded the sequence
  1. Takeoff: Runway incursion veh/AC/person→
  2. Approach-IFR missed approach: Near midair/TCAS alert/loss of separation

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • OPS15IA0172015-04-12no fatalitiesmatch 64
    BOEING 767 34AF · United Parcel Service
    Miami, FL
    • ●Personnel issues › Action/decision › Info processing/decision
    Near midair/TCAS alert/loss of separationRunway incursion veh/AC/person
  • DCA23LA1252023-01-14no fatalitiesmatch 61
    BOEING 737-900ER · Delta Air Lines
    Queens, NY
    • ●Personnel issues › Psychological › Attention/monitoring
    Runway incursion veh/AC/person
  • DCA22LA1262022-06-08no fatalitiesmatch 60
    BOEING 757-236 · Federal Express Corporation
    Tulsa, OK
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Psychological › Attention/monitoring
    • ●Personnel issues › Task performance › Communication (personnel)
  • OPS16IA0042016-01-29no fatalitiesmatch 60
    AIRBUS A321 231 · Spirit Airlines
    Fort Lauderdale, FL
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
    Runway incursion veh/AC/person
  • OPS17IA0032016-10-21no fatalitiesmatch 58
    DOUGLAS DC 9 83 · ALLEGIANT AIR LLC
    Westfield, MA
    • ●Personnel issues › Action/decision › Info processing/decision
    Runway incursion veh/AC/person
  • DCA17IA0202016-10-27no fatalitiesmatch 53
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA25LA1632025-03-20no fatalitiesmatch 53
    BOEING 737-8H4 · SOUTHWEST AIRLINES CO
    Orlando, FL
    • ●Personnel issues › Action/decision › Info processing/decision
  • OPS23FA0102023-08-11no fatalitiesmatch 52
    BOEING 737-7BD · SOUTHWEST AIRLINES CO
    San Diego, CA
    • ●Personnel issues › Action/decision › Info processing/decision

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 incursion veh/AC/person
  • 2 of 8Wrong surface or wrong airport
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Action/decision › Info processing/decision
  • Psychological › Attention/monitoring
  • Task performance › Communication (personnel)
Cited here, not seen in the precedents
  • Support/oversight/monitoring › Enforcement
Common in the precedents, not cited here
  • Action/decision › Action
  • 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
  • OPS15IA0172015-04-12 · BOEING 767 34AF · United Parcel Service
    The controller's issuance of a landing clearance to an arriving aircraft while another aircraft was in position on the same runway. Contributing to the incident was the controller's non-compliance with traffic advisory procedures, and insufficient requirements for use of memory aids to track arrival and departure operations.
  • DCA23LA1252023-01-14 · BOEING 737-900ER · Delta Air Lines
    The American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the ru…
  • DCA22LA1262022-06-08 · BOEING 757-236 · Federal Express Corporation
    The flight crew’s misidentification of the intended landing runway. Contributing to the incident were (1) the flight crew’s failure to perceive and correctly interpret visual and auditory indicators – including electronic guidance – that they were approaching the incorrect runway which was likely the result of a degradation in cognitive function brought on by working within their window of circadian low, increased workload, and fatigue, and (2) the air traffic controller’s failure to monitor the arriving flight af…
  • OPS16IA0042016-01-29 · AIRBUS A321 231 · Spirit Airlines
    The air traffic controller's failure to ensure the runway surface area was clear of vehicles before clearing an aircraft for takeoff. Also causal was the flight crew's decision to initiate a takeoff while the Runway Status Lights (RWSL) Takeoff Hold Lights (THLs) were activated. Contributing to the incident was the lack of a standard procedure for vehicle operators to request runway clearances and resultant "hear back/read back" error between the vehicle operator and the air traffic controller.
  • OPS17IA0032016-10-21 · DOUGLAS DC 9 83 · ALLEGIANT AIR LLC
    The air traffic controller issuing the aircraft a clearance to land while there was a vehicle authorized to be on the same runway. Contributing to the incident was the air traffic controller's decision to not simulcast the local control and ground control frequencies, and, the reduced visibility at the airport as a result of the weather.
What it recommended after them
  • 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
  • A-24-006TO THE FEDERAL AVIATION ADMINISTRATION: Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A-24-4. (Supersedes A-00-66) · DCA23LA125Open - Unacceptable Response
  • A-24-007TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the effectiveness of the activation logic for the runway status light system considering the circumstances of this incident. · DCA23LA125Open - Acceptable Response
  • A-24-008TO THE FEDERAL AVIATION ADMINISTRATION: Using the findings of the evaluation conducted in response to Safety Recommendation A-24-7, update the runway status light system activation logic as necessary to improve system effectiveness. · DCA23LA125Open - Acceptable Response
  • A-24-009TO THE FEDERAL AVIATION ADMINISTRATION: Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (Supersedes A… · 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).