DCA24LA256

NTSB accident investigation · Boeing 737 · Severn, MD · August 7, 2024

Accident · Serious injuriesClass 4 · LimitedFinal report
Date
August 7, 2024, 14:30 local (18:30 UTC)
Place
Severn, MD · Descent into BWI
Injuries
1 serious, 142 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N226WNBoeing 737
Defining event
Enroute-descent: Turbulence encounter
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Major Investigations Division
Parties
Southwest Airlines, FAA
Case key
194882

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

A passenger’s failure to comply with crew member instructions to remain seated with seatbelt fastened.

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.

ActionPersonnel issues › Action/decision · PassengerBoeing 737-7H4: 3 casesAll aircraft: 111 casesProbable cause
TurbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on personnelBoeing 737-7H4: 1 caseAll aircraft: 92 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

Southwest Airlines Flight 3633 (SWA 3633) encountered turbulence while descending through flight level (FL) 190 to Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland. The flight was a regularly scheduled domestic passenger flight from Manchester-Boston Regional Airport (MHT), Manchester, New Hampshire to BWI. The flight crew illuminated the seat belt sign during descent into BWI. A few minutes following the illumination, a passenger stood up and walked to the back of the cabin. The flight attendant told the passenger to return to her seat, and the passenger responded that she would not return to her seat because she needed to stretch. About a minute later, as the aircraft descended through a cloud, the flight encountered short duration moderate turbulence. The standing passenger lost her balance and fell to the floor, breaking her ankle. Two nurses came to assist the passenger on the floor of the galley where they bandaged and splinted her ankle. The nurses returned to their seats for landing. An off-duty flight attendant sat on the floor of the galley with the injured passenger to secure her during landing. EMTs met the flight at the gate and transported the injured passenger from the airplane to a local hospital. The flight crew reported that the there were no reports of turbulence or radar returns that would have indicated turbulence. A post flight review of weather showed no predicted turbulence or evidence of convection near the location and altitude where the encounter occurred.

Aircraft

Registration
N226WN
Reported as
Boeing 737 (7H4)
Category
Airplane
Serial number
32494
Built
2005
Airframe hours
62,278
Engines
CFM Intl. CFM56-7B24, 24,000 lbs thrust, turbo fanCFM Intl. CFM56-7B24, 24,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Southwest Airlines Co
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 23, 2024
Departed
MHT · Manchester, NH
Destination
BWI · Baltimore, MD
Flight plan
IFR
Equipment
ADS-B, Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Heads up display, Onboard weather, Stall warning system

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 · 6

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
None
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 23, 2024
Seat
Left
Restraint
5-point
Flight hours
30,000 total · 13,000 in this make and model · 25,000 as pilot in command · 245 in the last 90 days · 80 in the last 30 days · 8 in the last 24 hours
Role
Co-pilot
Age
44
Injuries
None
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
March 23, 2024
Seat
Right
Restraint
Lap only
Flight hours
10,000 total · 5,000 in this make and model · 3,000 as pilot in command · 180 in the last 90 days · 60 in the last 30 days · 8 in the last 24 hours
Role
Cabin crew
Injuries
None
Restraint
4-point
Role
Cabin crew
Injuries
None
Restraint
4-point
Role
Cabin crew
Restraint
4-point
Role
Cabin crew
Restraint
Lap only

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 12 knots
Visibility
10 statute miles
Lowest ceiling
9,000 ft broken
Temperature
84 °F, dew point 75 °F
Altimeter
29.98 inHg
Observed at
BWI

Docket · 2

The files NTSB released with the investigation on October 28, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.5 MB in all.

Other investigations on N226WN · 1

Matched to the same aircraft by N-number and date.