BOEING 737-9ALASKA AIRLINES INC

failure of a cargo tie-down fastener, resulting in unsecured cargo striking the pressure bulkhead.

the air boss’s and air show event organizer’s lack of an adequate, prebriefed aircraft separation plan for the air show performance, relying instead on the air boss’s real-time deconfliction directives and the see-and-avoid strategy for collision avoidance, which allowed for the loss of separation between the Boeing B-17G and the Bell P-63F airplanes. Also causal was the diminished ability of the accident pilots to see and avoid the other aircraft due to flight path geometry, out-the-window view obscuration by airc…

The jammed condition of both elevators, which resulted from exposure to localized, dynamic high wind while the airplane was parked and prevented the airplane from rotating during the takeoff roll. Also causal was the failure of Everts Air Cargo, the pilots’ primary employer, to maintain awareness of Boeing-issued, required updates for its manuals, which resulted in the pilots not receiving the procedures and training that addressed the requirement to visually verify during the preflight checks that the elevators ar…

the local controller’s incorrect assumption that the Southwest Airlines (SWA) airplane would depart from the runway before the Federal Express airplane arrived on the same runway, which resulted in a loss of separation between both airplanes. Contributing to the controller’s incorrect assumption were his expectation bias regarding the SWA airplane’s departure, his lack of situational awareness regarding the SWA airplane’s position when the flight crew requested takeoff clearance, and the air traffic control tower’s…

The Federal Aviation Administration’s (FAA) placement of a helicopter route in close proximity to a runway approach path; their failure to regularly review and evaluate helicopter routes and available data, and their failure to act on recommendations to mitigate the risk of a midair collision near Ronald Reagan Washington National Airport (DCA); as well as the air traffic system’s overreliance on visual separation in order to promote efficient traffic flow without consideration for the limitations of the see-and-av…