Boeing 737 Safety Record

the in-flight separation of the left mid exit door (MED) plug due to Boeing Commercial Airplanes’ failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed from the left MED plug to facilitate rework during the manufacturing process were reinstalled. Contributing to the accident was the Federal Aviation Administration’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process.

An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning. Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments. Contributing to the continuation of an unstabilized approach were 1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and 2) the first officer’s lack of experience.

The gate lead/pushback driver's failure to recognize that the provisioning truck was within the safety zone of the gate during his walkaround due to distractions, which resulted in the subsequent collision between the airplane and the truck. Contributing to the collision was the provisioning truck driver's failure to recognize he was parked in the safety zone of an active gate adjacent to his assigned gate, and the guide agent's improper assumption that the safety zone was properly cleared by the gate lead/pushback driver.

The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.