DCA18CA074

NTSB accident investigation · Boeing 737 7H4 · Los Angeles, CA · November 19, 2017

Accident · Serious injuriesData collectionFinal report
Date
November 19, 2017, 12:30 local (20:30 UTC)
Place
Los Angeles, CA
Injuries
1 serious, 5 uninjured; on the ground: 1 serious
Damage
No damage
Phase of flight
Prior to flight
Aircraft
N740SWBoeing 737 7H4
Defining event
Prior to flight: Ground handling event
Weather
Visual (VMC) · Day
Status
Completed · report September 5, 2018
Report
Approved by Office Director
NTSB office
Major Investigations Division
Case key
96582

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The provisioning agent's lack of situational awareness while stepping from the airplane to the provisioning van. Contributing to the accident was the provisioning vans failed switch.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Object/animal/substance: ground equipmentEnvironmental issues › Physical environment · Contributed to outcomeBoeing 737-7H4: 2 casesAll aircraft: 52 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · Ground crewBoeing 737-7H4: 2 casesAll aircraft: 226 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

On November 11, 2017, about 1230 Pacific standard time, Southwest Airlines flight 1159, a Boeing 737-700, N740SW, had a provisioning agent fall from the airplane while parked at Gate 13 at Los Angeles International Airport (KLAX), Los Angeles, California . The flight was deplaning and onboard were the captain, first officer, three flight attendants, several passengers, and the provisioning agent. The regularly scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from San Francisco International Airport (KSFO), San Francisco, California, to KLAX. According to the operator, the provisioning vans platform/box assembly malfunctioned and lowered about 2-3 feet. As the provisioning agent was moving from the airplane to the platform he lost situational awareness and fell onto the lowered platform, injuring his shoulder. The agent was transported to the hospital and diagnosed with a fractured right shoulder. The van was removed from service and the left side tape switch was found to have dislodged from its track, resulting in the uncommanded lowering of the platform.

Factual narrative

On November 11, 2017, about 1230 Pacific standard time, Southwest Airlines flight 1159, a Boeing 737-700, N740SW, had a provisioning agent fall from the airplane while parked at Gate 13 at Los Angeles International Airport (KLAX), Los Angeles, California . The flight was deplaning and onboard were the captain, first officer, three flight attendants, several passengers, and the provisioning agent. The regularly scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from San Francisco International Airport (KSFO), San Francisco, California, to KLAX. According to the operator, the provisioning vans platform/box assembly malfunctioned and lowered about 2-3 feet. As the provisioning agent was moving from the airplane to the platform he lost situational awareness and fell onto the lowered platform, injuring his shoulder. The agent was transported to the hospital and diagnosed with a fractured right shoulder. The van was removed from service and the left side tape switch was found to have dislodged from its track, resulting in the uncommanded lowering of the platform.

Aircraft

Registration
N740SW
Reported as
Boeing 737 7H4 (7H4)
Category
Airplane
Serial number
29276
Built
1998
Engines
CFM Intl. CFM56 SERIES, turbo fanCFM Intl. CFM56 SERIES, turbo fan
Damage
No damage
Flight
Part 121
Operator
Southwest Airlines
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Departed
SFO · San Francisco, CA
Destination
LAX · Los Angeles, CA
Airport
LAX · Los Angeles International

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
59
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
October 28, 2017
Seat
Left
Restraint
4-point
Flight hours
15,243 total · 8,500 in this make and model · 8,500 as pilot in command · 207 in the last 90 days · 78 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
47
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 27, 2017
Seat
Right
Restraint
4-point
Flight hours
4,179 total · 1,082 in this make and model · 3,553 as pilot in command · 260 in the last 90 days · 101 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 10 knots
Visibility
10 statute miles
Observed at
LAX

Docket · 2

The files NTSB released with the investigation on August 21, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.2 MB in all.