# NTSB ATL96FA101: Boeing 737-200, N53SW, Nashville, TN, July 8, 1996 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: July 8, 1996, 07:41 local (12:41 UTC) - Place: Nashville, TN - Coordinates: 36.15937, -86.670951 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.1594&lon=-86.6710&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 4 minor, 122 uninjured - Status: Completed, report December 15, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 3654 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL96FA101 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3654/pdf - Page: https://openairdocs.org/ntsb/ATL96FA101 ## Probable cause the captain's improper rejected takeoff, in that the takeoff was rejected after V1, and the flight attendants' improper use of the evacuation procedure, in that an evacuation was independently initiated without the captain's approval, and without assessing the condition and location of the fire. Factors related to the accident were: bird ingestion in the left engine near lift-off speed during the takeoff roll, and company's inadequate Crew Resource Management (CRM) training for flight attendants. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, takeoff - roll/run - object - bird(s) (contributing factor) - 1 engine - foreign object - misc,engine compressor stall/surge - Overrun, takeoff - aborted - abort above v1 - performed, pilot in command (cause) - Fire, standing - landing gear,normal brake system - overtemperature - landing gear,normal brake system - fire - Miscellaneous/other, standing - evacuation - initiated, flight attendant (cause) - improper use of procedure, flight attendant (cause) - inadequate training(emergency procedure(s)), flight attendant (contributing factor) - insuff standards/requirements,operation/operator, company/operator mgmt (contributing factor) ## Analysis During the takeoff roll, after V1 was called by the first officer, a bird was ingested in the left engine, resulting in a compressor stall. The captain (capt) initiated a rejected takeoff as VR was called. The airplane continued accelerating momentarily, & V1 was exceeded by 10 kts, resulting in an overrun of the runway. After stopping on the overrun, the capt made a PA announcement for the passengers to remain seated. Fire/rescue personnel arrived, confirmed there was no fire, & noted the tires were deflating & smoking (due to excessive brake temperature from the rejected takeoff which melted the fuse plugs & deflated the tires). Evacuation slides were dearmed, & the cabin doors were opened for ventilation. Fire erupted from the right brake & was immediately extinguished by fire personnel. Hearing a fireman shout 'fire,' the flight attendants (FAs) at the forward & aft entry doors commanded an evacuation without informing the capt that a fire had been reported, without communicating 1st with each other, & without determining the location of the fire. To evacuate, they closed the cabin doors, rearmed the slides, & began the evacuation. During evacuation, 1 passenger was seriously injured; 4 received minor injuries. The airline company did not provided 'joint' Crew Resource Management (CRM) training to flight deck crews & FAs. Two of 3 FAs said they had not received company CRM training. ## Factual narrative HISTORY OF FLIGHT On July 8, 1996, about 0741 central daylight time (CDT), a Boeing 737-200, N53SW, received minor damage during a rejected takeoff (RTO) on runway 20C at the Nashville Metropolitan Airport, Nashville, Tennessee. There were 5 crew members, and 122 passengers on board the airplane. None of the crew members were injured, however, one passenger received serious injuries, and 4 passengers received minor injuries. All injuries were incurred during the emergency evacuation. The airplane was operated as a scheduled, domestic, passenger flight, under the provisions of Title 14 CFR Part 121, by Southwest Airlines, Company, as Flight 436. Visual meteorological conditions existed at the time, and an instrument flight rules flight plan was in effect for the flight. The flight was departing Nashville, Tennessee (BNA), with a destination of Chicago, Illinois (MDW). According to the flight crew, a rolling takeoff was performed because the flight was cleared for departure prior to reaching the runway. However, the transcript of radio communications indicated that at 0738:39, the flight was cleared to taxi onto the runway and hold its position, pending the takeoff of another flight on a parallel runway. According to the transcript of communications, Flight 436 was cleared for takeoff one minute and 22 seconds later. Sounds of brake release were heard on the cockpit voice recorder (CVR) after the flight was cleared for takeoff. During the takeoff roll, according to the captain, he observed an object flash past the airplane. The first officer reported he saw a bird on the right of the nose of the airplane. Shortly afterwards, they heard a loud "explosion." Additionally, the captain reported that the airplane yawed left. The flight crew stated that the last airspeed they observed immediately prior to the engine bang was 135 knots, indicated airspeed, and V1 had not been called. The captain reported that the explosion, louder than any compressor stall he had ever experienced, created a shudder in the airplane. He stated he thought that a catastrophic engine failure had occurred. According to the captain, the event occurred about the 3,000 foot runway remaining marker. A high speed rejected takeoff was initiated. The airplane could not be stopped on the runway. The captain stated that because he recalled a failure of an engine on an MD-80 the previous week, which resulted in engine components penetrating the cabin, he elected not to engage reverse engine thrust. As the airplane rolled off the paved surface, the captain steered it around the Instrument Landing System antenna The airplane was subsequently stopped approximately 750 feet off the departure end of runway 20C, and about 100 feet east of the runway extended centerline. After the airplane had been stopped, the captain reported, he made a public address announcement for the passengers to remain seated. After completing the checklist, he entered the cabin and assured the passengers that fire department assistance had been requested, and ascertained that there was no fire. He returned to the cockpit and noted that the fire department equipment had arrived. An unsuccessful attempt was made to lower the airstairs at the main entry door. The auxiliary power unit was not started because of the lack of information regarding damage to the airplane. According to the flight crew and the cabin crew, the evacuation slides were disarmed, and the cabin doors were opened to provide ventilation. The captain and the Airport Rescue and Fire Fighting (ARFF) on-scene supervisor stated that they had established voice communications through the captain's open cockpit window. The ARFF supervisor reported to the captain that the tires were smoking and were deflating. According to the airport authority incident report, the right main gear became involved with fire and foam was applied to the wheels. According to the flight attendants located at the forward entry door and the aft entry door, they independently heard a fireman call "fire," which prompted each to initiate an evacuation of the airplane by closing the cabin doors, rearming the evacuation slides by re-engaging the girt bar, and re-opening the doors activating the slides. The captain, who was in his seat in the cockpit, was not notified that an evacuation was being initiated, nor did the flight attendants located at the front and rear cabin entry doors, communicate with each other regarding the conditions, or that an evacuation was being initiated. The captain stated he heard noises in the cabin and noted that an evacuation was being initiated and elected not to change the evacuation order. During the evacuation, the slides at the forward entry (L1), forward galley (R1) and the aft entry (L2) doors were used. The overwing exits were not used. One passenger sustained a broken leg during his descent on the slide at the aft entry door. PERSONNEL INFORMATION The captain held an airline transport pilot certificate and a B-737 type rating. His last proficiency check flight was January 21, 1996. He possessed a Class 1 medical certificate, with no limitations or waivers, with his last examination for the medical certificate having been conducted on January 12, 1996. According to the captain he had about 6,000 total flight hours, with 3,600 total flight hours in the B-737.The operator's report indicated he had 4,400 hours in the 737 airplane. At the time of the accident, he had 233 flight hours as the pilot in command of the B-737. According to the operator's report of the accident, within the 90 days prior to the accident, the captain had 180 total flight hours, all as captain in the B-737,. He had 110 and 6 total flight hours as captain within the previous 30 days and 24 hours, respectively. He stated he had been with Southwest Airlines for about 51/2 years. His previous experience was as an Air Force pilot where he flew the T-38, T-37, and F-16. Immediately prior to his hiring at Southwest, he was an F-16 instructor pilot. During the captain's interview, he stated that he had received Crewmember Resource Management Training (CRM) when initially hired, during a refresher course, and at his captain upgrade in January, 1994. Additionally, he had CRM each year during recurrent ground training or at emergency procedures training. He stated that at one point CRM was conducted with flight attendants, but he did not believe that was currently being done. The captain also stated that most of the V1 cut training that he had, had resulted in continuing the takeoff. He did not recall how much RTO training he had prior to the accident, and stated that RTO training may be waived. He indicated that he had not previously experienced an RTO, other than in training. According to the captain's training records, he received the following RTO and CRM training: * 04/27/91-Rejected Takeoff Anti-skid Operative-Initial cockpit procedures training-first officer * 05/04/91-Rejected takeoff-initial/upgrade proficiency training-first officer * 05/08/91-Rejected takeoff-Simulator proficiency check (waived)-first officer * 05/14/91-Initial CRM Completed * 04/10/92-Rejected Takeoff-Proficiency Check (waived)-first officer * 04/30/93-Takeoff Safety Home-Study Guide/Examination-first officer * 12/03/93-Rejected takeoff-Proficiency Check (waived)-first officer * 12/23/94-Rejected Takeoff-Proficiency Training-first officer * 01/03-10/95-Upgrade Training that included one day CRM * 01/12/95-Rejected Takeoff-Upgrade Proficiency Training-captain * 01/13/95-Rejected Takeoff-Upgrade Proficiency Training-captain * 01/14/95-Rejected Takeoff-Upgrade Proficiency Training-captain * 01/15/95-Rejected takeoff-Proficiency Check-captain The first officer held an airline transport certificate with a type rating in the B-737 airplane. His last proficiency flight check was on December 13, 1995. He possessed a first class medical certificate with no limitations or waivers. His ## Aircraft - Registration: [N53SW](https://openairdocs.org/deregistered/N53SW-1999-04-02), registration cancelled 1999-04-02, S/N 21534 (OpenAirDocs) - Reported make and model: Boeing 737-200 - Registry model: [Boeing 737-2H4](https://openairdocs.org/model/boeing-737-2h4) (registry code 138448C) (OpenAirDocs) - Category: Airplane - Serial number: 21534 - Airframe hours: 58873 - Engines: P&W JT8D-9 14500 lbs thrust turbo fan - Damage: Minor damage - Fire: On-Ground - Flight: Part 121 - Registered owner: Southwest Airlines - Airworthiness certificate: Standard, Transport - Departed: BNA - Destination: MDW, CHICAGO, IL - Flight plan: IFR - Airport: BNA, Nashville International, runway 20C, 8,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 6,000 total, 4,400 in this make and model, 1,633 as pilot in command, 180 in the last 90 days, 110 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 220° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 900 ft broken - Temperature: 73 °F, dew point 70 °F - Altimeter: 29.00 inHg - Observed at: BNA, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19960708019899A](https://openairdocs.org/incident/19960708019899A), Jul 8, 1996: Boeing 7372H4, Nashville, TN, Minor damage. Narrative: on July 8, 1996, southwest 436, a B-737-2H4 (N53SW) aborted takeoff on RW20C at Nashville, TN (bna), after ingesting a bird in the left engine at… ## Other investigations on N53SW (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB FTW94IA070](https://openairdocs.org/ntsb/FTW94IA070), Jan 19, 1994: Boeing 737-2H4 (N53SW), Little Rock, AR, incident, minor damage. Probable cause: WAS THE LANDING GEAR SEPARATION DUE TO AN UNDETERMINED CAUSE. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.