# NTSB FTW95FA319: Boeing 737-3A4, N675AA, Dallas, TX, July 28, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: July 28, 1995, 07:37 local (12:37 UTC) - Place: Dallas, TX - Coordinates: 32.830383, -96.850013 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8304&lon=-96.8500&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 99 uninjured - Status: Completed, report November 15, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 19242 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95FA319 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19242/pdf - Page: https://openairdocs.org/ntsb/FTW95FA319 ## Probable cause (aircraft 2) FAILURE OF THE FLIGHTCREWS OF THE BOEING 737, N675AA, AND THE CESSNA 401, N31DB, TO SEE AND AVOID EACH OTHER. FACTORS WERE: THE FAILURE OF 737 FLIGHTCREW TO RESPOND TO THE TRAFFIC ADVISORY GIVEN BY THE GROUND CONTROLLER IDENTIFYING POTENTIALLY CONFLICTING TRAFFIC, AND THE FAILURE OF THE GROUND CONTROLLER TO ISSUE SEQUENCING INSTRUCTIONS TO BOTH AIRCRAFT. ## Probable cause (aircraft 1) FAILURE OF THE FLIGHTCREWS OF THE BOEING 737, N675AA, AND THE CESSNA 401, N31DB, TO SEE AND AVOID EACH OTHER. FACTORS WERE: THE FAILURE OF 737 FLIGHTCREW TO RESPOND TO THE TRAFFIC ADVISORY GIVEN BY THE GROUND CONTROLLER IDENTIFYING POTENTIALLY CONFLICTING TRAFFIC, AND THE FAILURE OF THE GROUND CONTROLLER TO ISSUE SEQUENCING INSTRUCTIONS TO BOTH AIRCRAFT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Collision between aircraft (other than midair), taxi - from landing - traffic advisory - not identified, flightcrew (contributing factor) - instructions,written/verbal - not issued, atc personnel(lcl/gnd/clnc) (contributing factor) - visual lookout - inadequate, flightcrew (cause) - visual lookout - inadequate, pilot of other aircraft (cause) - Collision between aircraft (other than midair), taxi - to takeoff - traffic advisory - not identified, pilot of other aircraft (contributing factor) - instructions,written/verbal - not issued, atc personnel(lcl/gnd/clnc) (contributing factor) - visual lookout - inadequate, flightcrew (cause) - visual lookout - inadequate, pilot of other aircraft (cause) ## Analysis (aircraft 2) THE CESSNA 401, N31DB, HAD BEEN CLEARED TO TAXI FOR TAKEOFF ON RUNWAY 13L, AND REPORTED HAVING THE BOEING 737, N675AA, IN SIGHT. AFTER TURNING NORTHWEST ONTO TAXIWAY BRAVO, THE CESSNA CAPTAIN LOST SIGHT OF THE 737. THE CESSNA FIRST OFFICER WAS OCCUPIED WITH DUTIES INSIDE THE COCKPIT AND DID NOT SEE THE 737 UNTIL IMMEDIATELY BEFORE THE COLLISION. AFTER LANDING ON RUNWAY 13L, THE 737 EXITED THE RUNWAY, RECEIVED AND ACKNOWLEDGED CLEARANCE TO TAXI TO THE GATE, BUT DID NOT ACKNOWLEDGE RECEIVING THE TRAFFIC ADVISORY CONCERNING THE CESSNA TO HIS LEFT. THE 737 PROCEEDED TO TAXI NORTHWEST ON TAXIWAY MIKE. THE COLLISION OCCURRED AS THE 737 MERGED FROM MIKE ONTO BRAVO. THE 737 CREW STATED THEY NEVER SAW THE CESSNA. WITNESSES OBSERVED THE AIRPLANES TAXIING PARALLEL TO ONE ANOTHER WITH THE 737 SLIGHTLY AHEAD OF THE CESSNA AND GRADUALLY CONVERGING UNTIL THE LEFT WING OF THE 737 IMPACTED THE RUDDER OF THE CESSNA. ALTHOUGH THE GROUND CONTROLLER 'ANTICIPATED' THAT THE 737 WOULD FOLLOW THE CESSNA, HE DID NOT ISSUE SPECIFIC SEQUENCING INSTRUCTIONS TO ENSURE THAT THIS TOOK PLACE. ## Analysis (aircraft 1) THE CESSNA 401, N31DB, HAD BEEN CLEARED TO TAXI FOR TAKEOFF ON RUNWAY 13L, AND REPORTED HAVING THE BOEING 737, N675AA, IN SIGHT. AFTER TURNING NORTHWEST ONTO TAXIWAY BRAVO, THE CESSNA CAPTAIN LOST SIGHT OF THE 737. THE CESSNA FIRST OFFICER WAS OCCUPIED WITH DUTIES INSIDE THE COCKPIT AND DID NOT SEE THE 737 UNTIL IMMEDIATELY BEFORE THE COLLISION. AFTER LANDING ON RUNWAY 13L, THE 737 EXITED THE RUNWAY, RECEIVED AND ACKNOWLEDGED CLEARANCE TO TAXI TO THE GATE, BUT DID NOT ACKNOWLEDGE RECEIVING THE TRAFFIC ADVISORY CONCERNING THE CESSNA TO HIS LEFT. THE 737 PROCEEDED TO TAXI NORTHWEST ON TAXIWAY MIKE. THE COLLISION OCCURRED AS THE 737 MERGED FROM MIKE ONTO BRAVO. THE 737 CREW STATED THEY NEVER SAW THE CESSNA. WITNESSES OBSERVED THE AIRPLANES TAXIING PARALLEL TO ONE ANOTHER WITH THE 737 SLIGHTLY AHEAD OF THE CESSNA AND GRADUALLY CONVERGING UNTIL THE LEFT WING OF THE 737 IMPACTED THE RUDDER OF THE CESSNA. ALTHOUGH THE GROUND CONTROLLER 'ANTICIPATED' THAT THE 737 WOULD FOLLOW THE CESSNA, HE DID NOT ISSUE SPECIFIC SEQUENCING INSTRUCTIONS TO ENSURE THAT THIS TOOK PLACE. ## Factual narrative (aircraft 2) SEE NARRATIVE FOR FTW-95-F-A319A. ## Factual narrative (aircraft 1) HISTORY OF FLIGHT On July 28, 1995, at 0737 central daylight time, a Boeing 737- 3A4, N675AA, collided with a Cessna 401, N31DB, while both airplanes were taxiing at Love Field, Dallas, Texas. The Boeing was operating under Title 14 CFR Part 121 as Southwest Airlines Flight 5, scheduled service from Amarillo, Texas, to Dallas. The Cessna was operating under Title 14 CFR Part 135 as Raven Air 31, a non-scheduled cargo flight from Dallas to Tyler, Texas. The Boeing sustained minor damage and the Cessna was substantially damaged. There were no injuries to Raven Air's commercially rated captain and first officer or to Southwest's five crew members and 92 passengers. Visual meteorological conditions prevailed. At 0736:04, the Cessna received clearance from ground control to taxi from the Dalfort ramp to runway 13L and was advised of "the Boeing clearing that runway." The Cessna acknowledged having the Boeing 737 in sight and taxied from the ramp onto taxiway Bravo. After exiting runway 13L, at 0736:31, the 737 received clearance from ground control to taxi to parking and was advised of "traffic ahead to your left, twin Cessna outbound from Dalfort." The 737 responded with "into parking, Southwest five," and proceeded to taxi northwest on taxiway Mike. There was no further activity on the ground control frequency until 0737:21 when the Cessna transmitted "that 737 just hit us." Witness statements were submitted by six witnesses who observed the collision. Two witnesses (both passengers on the 737) described the Cessna and the 737 as moving in the same direction and at the same speed. Three witnesses reported the two aircraft were merging/converging with the Cessna's right wing tip slightly ahead of the 737's left wing tip. Four witnesses observed the leading edge of the 737's left wing contact the rudder of the Cessna. All six witnesses reported that, immediately following the impact, the Cessna made a sharp left turn of approximately 360 degrees before coming to a stop. They further reported that the 737 continued straight ahead for a "short" distance before coming to a stop. The captain of the Cessna reported in his written statement that, after intercepting taxiway Bravo, he "lost visual contact with the 737 due to my position on the taxiway." During an interview, he recalled observing the 737 while on taxiway Bravo by looking back over his right shoulder through the Cessna's right forward cabin window. The first officer of the Cessna was occupied with duties inside the cockpit during the taxi, and did not see the 737 until immediately prior to the collision. When the captain of the Cessna heard engine noise, he realized he was hearing the 737 and "added power trying to speed up." He felt the collision and applied left rudder, performing a 360 degree turn before coming to a stop. The captain and first officer of the 737 reported that they did not recall hearing any traffic advisories from ground control. Neither recalled seeing any general aviation aircraft that might be a hazard to their taxiing. Just after turning left off taxiway Mike to join Bravo, the captain of the 737 felt a "push" on his airplane. Seconds later he heard a radio transmission stating "the 737 just hit us." Realizing that the communication referred to his aircraft, the 737 captain stopped his aircraft. After ground personnel examined the 737 and found no damage or leaking fluids, the 737 contacted ground control, received clearance and taxied to the gate. After the 737 was parked at the gate, a passenger came forward and identified himself to the crew as a witness. In his description of the event as recorded on the cockpit voice recorder (transcript attached), the passenger described the 737 as "overtaking" the Cessna and stated that the leaded edge of the 737 "clipped" the Cessna. COMMUNICATIONS A transcript is attached of the transmissions on the Love Field Air Traffic Control Tower local and ground control frequencies during the time periods pertinent to the accident. On August 3, 1995, the controller who was working the ground control position at the time of the accident was interviewed by the investigator- in-charge. Representatives of all parties to the investigation were also present at the interview. In response to questions, the controller provided the following information. He came on duty at 0630. He was acting as the controller- in-charge. Approximately 0727, he relieved the ground controller. Also present in the tower and working their respective positions were three other controllers: local, radar, and clearance delivery. He considered the traffic to be minimal. Prior to the accident, airport operations personnel were in the process of closing runway 13R. He was coordinating the closure with FAA maintenance and airport operations. The local controller was coordinating on the land-line concerning arrivals being handled by regional approach. Approximately 0736, Raven 31 called to request taxi instructions from the Dalfort FBO. He instructed the pilot to taxi to runway 13L and issued traffic advisories about a Boeing 737 (Southwest 5) clearing runway 13L and a Baron taxiing in the opposite direction on the inboard taxiway (taxiway B.) Raven 31 reported both aircraft in sight and acknowledged the taxi instructions. He then issued a traffic advisory to the Baron about the opposite direction twin Cessna (Raven 31) and received an acknowledgment. Southwest 5 called for taxi instructions to gate 4C. He advised Southwest about the twin Cessna traffic outbound from Dalfort and instructed the pilot to taxi into parking. Southwest 5 acknowledged. Once he heard verbal acknowledgment from both aircraft he had "anticipation of separation." There was a large separation between the airplanes and he anticipated they would stay separated. In his mind, Raven was first and Southwest was following. He did not observe the actual taxiing of the two aircraft after issuing the taxi clearances. He diverted his attention to another duty, logging the closure of runway 13R in the facility log. While he was typing, he heard the pilots of both aircraft call ground control. Approximately 0738, he requested a transmission repeat. The pilot of Raven 31 stated that the 737 had just hit him. He saw the collision damage to Raven 31 and asked Southwest if they required any assistance. He then requested position relief and made the initial accident notification calls. AIRPORT INFORMATION Love Field has three runways, two of which are parallel, runway 13L/31R and runway 13R/31L. Taxiway Bravo is the main taxiway on the southwest side of runway 13L/31R. The Dalfort Aviation ramp is located southwest of runway 13L/31R, adjacent to taxiway Bravo. To the north of the Dalfort ramp, the centerline of taxiway Bravo curves towards runway 13L/31R to maintain clearance from a gate structure. (See attached diagram.) Taxiway Mike is the inner taxiway on the southwest side of runway 13L/31R. It runs parallel to runway 13L/31R and extends from taxiway Bravo 1 to Bravo 3. At Bravo 3, an aircraft proceeding northwest on the taxiway centerlines would turn 90 degrees left off Mike onto Bravo 3, and then turn 90 degrees right off Bravo 3 onto Bravo. Tower personnel reported aircraft heading northwest on Mike seldom follow these markings onto Bravo. The majority of aircraft take the same path as that used by the accident 737 and "cut the corner," turning left approximately 20 degrees from Mike directly onto Bravo. FLIGHT RECORDERS The Cessna 401 was not equipped with a cockpit voice recorder (CVR) or flight data recorder (FDR), nor was it required to be so equipped under current Federal Aviation Regulations. ## Aircraft 1 - Registration: [N675AA](https://openairdocs.org/deregistered/N675AA-2015-05-19), registration cancelled 2015-05-19, S/N 23253, built 1985 (OpenAirDocs) - Reported make and model: BOEING 737-3A4 - Registry model: [Boeing 737-3A4](https://openairdocs.org/model/boeing-737-3a4) (registry code 138447H) (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: 23253 - Airframe hours: 29223 - Engines: Cfm CFM56-3 20000 lbs thrust turbo fan - Damage: Minor damage - Flight: Part 121 - Operator: Southwest Airlines Co., doing business as Southwest - Registered owner: First Security Bank Of Utah Na - Airworthiness certificate: Standard, Transport - Departed: AMA, AMARILLO, TX - Destination: DAL - Flight plan: IFR - Airport: DAL, Love Field, runway 13L, 7,753 × 150 ft, concrete ## Aircraft 2 - Registration: [N31DB](https://openairdocs.org/deregistered/N31DB-2023-09-30), registration cancelled 2023-09-30, S/N 401-0202, built 1968 (OpenAirDocs) - Reported make and model: CESSNA 401 - Registry model: [Cessna 401](https://openairdocs.org/model/cessna-401) (registry code 207590C) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 401-0202 - Airframe hours: 6172 - Engines: CONTINENTAL TSIO-520E 300 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Registered owner: Qualiflight Training, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 23, 1995, 47 hours before - Departed: DAL - Destination: TYR, TYLER, TX - Flight plan: IFR - Airport: DAL, Love Field, runway 13L, 7,753 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N675AA; age 51; airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 20,000 total, 14,000 in this make and model, 18,500 as pilot in command, 250 in the last 90 days, 90 in the last 30 days, 7 in the last 24 hours - Pilot, aircraft N31DB; age 20; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; flight hours: 1,588 total, 40 in this make and model, 1,044 as pilot in command, 63 in the last 90 days, 41 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 5 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 70 °F - Altimeter: 29.00 inHg - Observed at: DAL ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19950728047751A](https://openairdocs.org/incident/19950728047751A), Jul 28, 1995: Boeing 7373A4, Dallas, TX, Minor damage. Taxiing to gate left wing hit tail of aircraft that was taxiing out. Failed see plane. Tower failed note proximity. - [Accident 19950728019982A](https://openairdocs.org/incident/19950728019982A), Jul 28, 1995: Cessna 401, Dallas, TX, Substantial damage. Taxiing for takeoff collided with inbound plane on taxiways. Tail hit by wing of other plane. ATC failed advise. 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.