The airplane was descending toward the destination airport with the autopilot and autothrottle systems engaged. As the airplane was approaching 12,000 ft, and the autopilot was capturing the altitude, the captain adjusted the altimeter resulting in a displayed altitude of 12,100 ft. The captain (the pilot flying) selected flight level change mode on the autopilot to recapture the altitude and set the speed at 250 knots to slow from about 255 knots. As a result, the autothrottles went to Throttle Hold mode when the throttle levers reached the aft stop. As the captain was briefing the approach, the airplane slowed and pitched up as it tried to maintain altitude with a reduced throttle setting. An international relief officer who was in the cockpit at the time commented on the airplane’s decreasing speed three times when the airplane’s airspeed was about 186 knots before stating that the captain should push the nose over. The captain disengaged the autopilot and auto throttles, aggressively pitched down, and increased the throttles. These aggressive maneuvers caused the flight attendants in the aft galley to be thrown against the ceiling. One flight attendant sustained a compound arm fracture; two other flight attendants sustained minor injuries. The crew subsequently landed the airplane without further incident.
The flight crew’s failure to adequately monitor the airplane’s airspeed, which led to the captain’s aggressive control inputs to increase airspeed; these aggressive inputs resulted in injuries to three cabin crewmembers.
Boeing 757-200 · N173AN — 2,539,495 samples, 97 parameters, 09:25:00.0 to 17:01:20.0.
| Parameter | Max | at | Min | at | Final | at |
|---|---|---|---|---|---|---|
| Pressure altitude ft | 36,051.0 | 11:28:11.1 | -162.0 | 17:00:39.1 | -138.0 | 17:01:19.1 |
| Computed airspeed kts | 384.0 | 09:25:02.4 | 0.0 | 09:25:00.4 | 32.0 | 17:01:19.4 |
| Vertical acceleration g | 1.5 | 16:47:43.9 | -0.2 | 16:47:45.3 | 1.0 | 17:01:19.9 |
| Engine 1 N1 %RPM | 101.1 | 16:47:43.0 | 21.1 | 17:01:03.0 | 22.5 | 17:01:19.0 |
| Engine 2 N1 %RPM | 101.4 | 09:51:37.5 | 19.8 | 17:01:03.5 | 21.1 | 17:01:19.5 |
| Time | Event | Page |
|---|---|---|
| 09:25:00 | Full incident flight FDR data range begins | 3 |
| 09:28:24 | Aircraft departed EGPH and climbed to a cruising altitude of 36,000 feet | 4 |
| 16:31:50 | Initial descent to 24,000 feet into KJFK began | 4 |
| 16:37:49 | Aircraft reached 24,000 feet and held for about a minute | 4 |
| 16:38:00 | Descent time range begins (24,000 feet) | 3 |
| 16:39:04 | 12,000 feet dialed into the mode control panel (MCP) and another descent began | 4 |
| 16:45:39 | As aircraft neared 12,000 feet, Altitude Hold mode engaged | 4 |
| 16:45:51 to 16:45:55 | Recorded altimeter setting changed from 29.92 inHg to 30.13 inHg (input change may have occurred any time in this window; altimeter setting recorded only once every four seconds) | 4 |
| 16:45:55 | Flight change (FLCH) button activated on MCP; auto throttle system immediately transitioned to FLCH descent mode; MCP speed window switched to display current airspeed, slightly above desired 250 knots; MCP speed then manually dialed down to 250 knots; engine throttle lever angle began to decrease and airplane decelerated | 4 |
| unspecified (after 16:45:55) | Once throttles reached the aft stop, auto throttle system entered Throttle Hold mode | 5 |
| unspecified | With autopilot in FLCH mode targeting 12,000 feet and auto throttles in Throttle Hold mode, aircraft pitch attitude began to increase to attempt to hold 12,000 feet and airspeed started to decay below 250 knots | 5 |
| 16:47:31 | Airspeed had degraded to 186.5 knots and pitch attitude was approximately 6 deg nose up | 5 |
| 16:47:34 | At an airspeed of 185.5 knots, throttle lever angles increased rapidly, and the auto throttle system exited Throttle Hold mode; N1 on both engines began to increase | 5 |
| 16:47:42 | Autopilot and auto throttle systems were disengaged; throttle lever angles began to decrease; airspeed was 195 knots and increasing | 5 |
| 16:47:44 | Aircraft pitch attitude was approximately 10 degrees nose up and control column position moved quickly forward (to command nose down attitude) | 5 |
| 16:46:00 to 16:49:00 | Event time range covering three minutes surrounding the event | 3 |
| 16:47:44 to 16:47:55 | Vertical acceleration varied between 1.476 g and -0.156 g and pitch attitude varied between 10 degrees nose up and 3 degrees nose down | 5 |
| 16:47:45 | Approximate time of the event during descent | 3 |
| 16:48:01 | Auto throttle system briefly engaged again | 5 |
| 16:48:08 | Auto throttle system disengaged | 5 |
| unspecified (around 16:48:08-16:48:16) | Aircraft continued to gain airspeed; pressure altitude was 11149 feet and decreasing | 5 |
| 16:48:16 | Autopilot reengaged with a target altitude of 7,000 feet | 5 |
| 16:49:31 | Auto throttle system reengaged (had remained disengaged since 16:48:08) | 5 |
| 16:50:00 | End of descent time range (two minutes fifteen seconds after the event) | 3 |
| 17:00:35 | Aircraft landed on runway 22L at KJFK, approximately 13 minutes following the event | 5 |
| 17:01:20 | Approximate arrival at KJFK; end of full incident flight time range | 3 |
453 transcribed utterances from 15:56:06.2 to 17:51:39.5, 20 sources. Final entries:
| 17:50:37.0 | CAM-1 | **. |
| 17:50:59.0 | CAM-1 | okay. I've got the guys coming down. we're gonna pull the circuit breaker. ** I thought it was so obvious but I'm not * right now. ** hold on. do me a favor. where's the C-V-R? where's the— the tape? I looked up there I didn't see anything. I don't have my glasses. so I thought it was collared too . I thought it was white also. okay after we do that what else do you want? okay now here's a question on— and— oh okay I see what you're talking about. I thought you meant about the event. okay so we write that up and then— |
| 17:51:16.2 | CAM-2 | *. DCA18LA285 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source |
| 17:51:34.6 | CAM | [sound of unintelligible background conversation] |
| 17:51:39.5 | CAM | [sound similar to circuit breaker being pulled and power interruption] |
Docket: data.ntsb.gov/Docket/?NTSBNumber=DCA18LA285. This brief is an analytical aid assembled from public records; it is not an investigative finding.