# NTSB DCA18CA074: Boeing 737 7H4, N740SW, Los Angeles, CA, November 19, 2017 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: November 19, 2017, 12:30 local (20:30 UTC) - Place: Los Angeles, CA - Coordinates: 33.944999, -118.408058 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.9450&lon=-118.4081&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Ground handling event](https://openairdocs.org/ntsb-events/080) - Highest injury: Serious injuries - Injuries: 1 serious, 5 uninjured; on the ground: 1 serious - Status: Completed, report September 5, 2018 - Report: Approved by Office Director - NTSB office: Major Investigations Division - NTSB case key (mKey): 96582 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA18CA074 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96582/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96582 - Page: https://openairdocs.org/ntsb/DCA18CA074 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Object/animal/substance: ground equipment](https://openairdocs.org/ntsb-findings/03022050): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Boeing 737-7H4, 2 cases](https://openairdocs.org/ntsb-findings/03022050/cases.md?model=1384404), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/03022050/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Ground crew (probable cause); cases with it: [Boeing 737-7H4, 2 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=1384404), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Ground handling event](https://openairdocs.org/ntsb-events/080) (defining event); cases with it: [Boeing 737-7H4, 4 cases](https://openairdocs.org/ntsb-events/080/sequence.md?model=1384404), [All aircraft, 108 cases](https://openairdocs.org/ntsb-events/080/sequence.md) ## 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](https://openairdocs.org/deregistered/N740SW-2020-04-02), registration cancelled 2020-04-02, S/N 29276, built 1998 (OpenAirDocs) - Reported make and model: BOEING 737 7H4 (7H4) - Registry model: [Boeing 737-7H4](https://openairdocs.org/model/boeing-737-7h4) (registry code 1384404) (OpenAirDocs) - Registry engine: [CFM International CFM56 series](https://openairdocs.org/engine/cfm-international-cfm56-series) (registry code 13802, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 29276 - Year built: 1998 - Engines: CFM INTL. CFM56 SERIES turbo fan; CFM 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: none; 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 - Co-pilot; age 47; injuries: none; 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 files) The files NTSB released with the investigation on August 21, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96582. 1.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465912&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Employee Statements (item 2, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465913&FileExtension=.PDF&FileName=Employee%20Statements-Master.PDF 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.