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Cases › CEN09MA142 › The analyst

AEROSPATIALE ALENIA ATR 42-320Empire Airlines

What the docket says, assembled. No language model is involved, so nothing on this page can be invented — every line traces to a recorder, a report page or the Board's own record.

51
timed facts
8
precedents
181
passages to ask

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Every answer is a passage of the docket with the page it came from, or the words “not in the docket”. Nothing is summarised or reasoned for you — read the source.

One timeline

51 timed factsthe recorder events from the FDR report, with the transcript's warnings, callouts, the words nearest each event and the final seconds — on one clock, as printed in each report
  1. 03:19 CSTFDRclimb/cruisep.7
    Departed Fort Worth Alliance, climbing to 18,000 ft; autopilot engaged at 03:23 through 4,700 ft; airframe de-ice on at 03:31 through 16,300 ft; level at 18,000 ft at 03:36
    see the traces at this moment ↗
  2. 04:02-04:31 CSTFDRdescentp.7
    Descent begun 04:02, level 13,900 ft at 04:08; descent 04:18, de-ice off through 10,000 ft at 04:22; level 5,800 ft at 04:27; descent 04:30 with de-ice selected on; level 4,800 ft at 04:31
    see the traces at this moment ↗
  3. 04:10:52CVR STARTp.7
    “OF RECORDING”
    read in context ↗
  4. 04:25:17CVR HOTwarningp.14
    “[sound similar to altitude alert]”
    read in context ↗
  5. 04:29:48CVR HOTwarningp.17
    “[sound similar to altitude alert]”
    read in context ↗
  6. 04:30:15CVR HOTwarningp.18
    “[sound similar to master caution single chime]”
    read in context ↗
  7. 04:30:36CVR HOTwarningp.18
    “[sound similar to altitude alert]”
    read in context ↗
  8. 04:32:53CVR HOT-1p.19
    “yeah.”
    read in context ↗
  9. 04:33-04:34:20 CSTFDRapproachp.7
    Left turn onto the approach; localizer 0.0-0.5 dots, glideslope about -1.0 dot
    see the traces at this moment ↗
  10. 04:33:04CVR APPp.20
    “Empire eighty two eighty four turn seven miles from the outer marker. turn left heading two one zero. maintain five thousand until established on the localizer. cleared ILS runway one seven right approach.”
    read in context ↗
  11. 04:34:24CVR HOT-2p.21
    “flaps fifteen gear down landing check.”
    read in context ↗
  12. 04:34:25-04:34:26 CSTFDRapproachp.7
    Flap position began increasing from 0 deg; at about 4 deg a flap asymmetry was recorded and a left roll
    see the traces at this moment ↗
  13. 04:34:33CVR HOT-1p.21
    “alright awww landing check. start selector is continuous relight. power management is in takeoff. icing AOA is on landing gear confirmed three green.”
    read in context ↗
  14. 04:34:48CVR HOT-2p.21
    “confirmed.”
    read in context ↗
  15. 04:34:48CVR HOT-1p.21
    “uh let's see we should have glideslope star. CEN09MA142”
    read in context ↗
  16. 04:34:50-04:34:54 CSTFDRfinal approachp.7
    Descent on the glideslope began (localizer 0.0, glideslope 1.0 dot); engine power reduced on both engines
    see the traces at this moment ↗
  17. 04:34:58CVR HOTwarningp.22
    “[sound similar to altitude alert]”
    read in context ↗
  18. 04:35:22CVR TAWSwarningp.22
    “one thousand. CEN09MA142”
    read in context ↗
  19. 04:35:28CVR HOT-1p.23
    “what the hell?”
    read in context ↗
  20. 04:35:29-04:35:30 CSTFDRfinal approachp.7
    Autopilot disengaged and power increased on both engines at 3,990 ft pressure altitude, 125 kts, AOA 11.3 deg; aircraft rolled to about 12 deg right then about 10 deg left
    see the traces at this moment ↗
  21. 04:35:30CVR HOTwarningp.23
    “[sound similar to stall warning and stickshaker lasting 1.1 seconds]”
    read in context ↗
  22. 04:35:31CVR HOT-2p.23
    “aw #.”
    read in context ↗
  23. 04:35:32CVR CAMwarningp.23
    “[sound similar to stall warning lasting 0.3 seconds]”
    read in context ↗
  24. 04:35:40CVR HOT-2calloutp.23
    “should I go around?”
    read in context ↗
  25. 04:35:48CVR HOT-1p.24
    “okay my airplane.”
    read in context ↗
  26. 04:35:49CVR HOT-2p.24
    “your controls.”
    read in context ↗
  27. 04:35:50-04:35:58 CSTFDRfinal approachp.8
    Localizer -1.5 dots, glideslope 2.0 dots (above), radio altitude about 700 ft; momentary autopilot engage selections at 04:35:54 and 04:35:58; power reduced on both engines
    see the traces at this moment ↗
  28. 04:35:53CVR HOTwarningp.24
    “[sound similar to altitude alert]”
    read in context ↗
  29. 04:35:58CVR TAWSwarningp.24
    “five hundred.”
    read in context ↗
  30. 04:36:00-04:36:18 CSTFDRfinal approachp.8
    Glideslope deviation approached 0.0 dots then increased; power increased on both engines at 04:36:18 at about 200 ft radio altitude
    see the traces at this moment ↗
  31. 04:36:00CVR HOT-1p.24
    “aw #.”
    read in context ↗
  32. 04:36:00CVR HOTwarningp.24
    “[sound similar to stall warning and stickshaker lasting 0.9 seconds]”
    read in context ↗
  33. 04:36:00CVR TAWSwarningp.24
    “pull up. pull up.”
    read in context ↗
  34. 04:36:17CVR HOT-1p.24
    “max RPM. CEN09MA142”
    read in context ↗
  35. 04:36:19CVR HOTwarningp.25
    “[sound similar to stall warning and stickshaker lasting 0.5 seconds]”
    read in context ↗
  36. 04:36:20-04:36:27 CSTFDRstall/impactp.8
    Loss of control: roll from 6 deg right varying between 35 deg right and 50 deg left; AOA from 13.6 deg varying -0.2 to 29.3 deg; pitch from 2 deg nose up varying between 11 deg nose up and 6 deg nose down (stall)
    see the traces at this moment ↗
  37. 04:36:20CVR HOTwarningp.25
    “[sound similar to stall warning and stickshaker lasting 5.4 seconds]”
    read in context ↗
  38. 04:36:22CVR HOT-2p.25
    “oh #.”
    read in context ↗
  39. 04:36:25CVR HOT-1p.25
    “#.”
    read in context ↗
  40. 04:36:25CVR HOT-2p.25
    “#. [straining]”
    read in context ↗
  41. 04:36:27 CSTFDRimpactp.8
    Approximate time of ground impact; airspeed, pressure altitude, pitch, roll and TAT/SAT unreliable thereafter
    see the traces at this moment ↗
  42. 04:36:27CVR CAMwarningp.25
    “[sound of impact]”
    read in context ↗
  43. 04:36:29CVR CAMwarningp.25
    “[sound similar to stall warning]”
    read in context ↗
  44. 04:36:48CVR CAMfinal secondsp.26
    “[sound of scraping stops]”
    read in context ↗
  45. 04:36:52CVR CAM-1final secondsp.26
    “go out the— go out the hatch.”
    read in context ↗
  46. 04:37:10CVR CAM-1final secondsp.26
    “there's a fire on the right hand side. go out the left.”
    read in context ↗
  47. 04:37:16CVR CAM-1final secondsp.26
    “no you know what—.”
    read in context ↗
  48. 04:37:17CVR CAM-2final secondsp.26
    “what.”
    read in context ↗
  49. 04:37:17CVR CAM-1final secondsp.26
    “when you get out can you get out—.”
    read in context ↗
  50. 04:37:25CVR CAMfinal secondsp.26
    “[sound similar to door opening]”
    read in context ↗
  51. 04:37:27CVR CAM-1final secondsp.26
    “*.”
    read in context ↗
Flight Data Recorder 10A - Specialist's Factual Report · 10 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 41 of 257 lines shown
How the Board coded the sequence
  1. Approach-IFR final approach: Collision with terr/obj (non-CFIT) →
  2. Approach-IFR initial approach: Aerodynamic stall/spin

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA13MA1332013-08-142 fatalmatch 66
    AIRBUS A300 - F4 622R · UNITED PARCEL SERVICE CO
    Birmingham, AL
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Physical › Alertness/Fatigue
    • +2 more shared findings
  • ERA16FA2152016-06-162 fatalmatch 59
    PIPER PA31 · AERONATIONAL INC
    State College, PA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Action/decision › Info processing/decision
    • +1 more shared findings
  • CEN19MA3122019-09-112 fatalmatch 59
    Convair 440 · Ferreteria E Implementos San Francisco
    Monclova, OH
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Task performance › Use of equip/info
    Collision with terr/obj (non-CFIT)
  • MIA08MA2032008-09-284 fatalmatch 58
    AEROSPATIALE SA365N-1 D · Maryland State Police
    District Heights, MD
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Action/decision › Action
    • +1 more shared findings
  • DCA12IA1412012-09-05no fatalitiesmatch 58
    DE HAVILLAND DHC8 · ERA AVIATION INC
    Soldotna, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Aerodynamic stall/spin
  • DCA08MA0852008-07-318 fatalmatch 57
    Raytheon Corporate Jets BAE 125-800A · East Coast Jets Inc.,
    Owatonna, MN
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Physical › Alertness/Fatigue
    • ●Personnel issues › Task performance › Communication (personnel)
    • +1 more shared findings
  • ERA13MA1392013-02-215 fatalmatch 57
    BEECH 390 · Richard Z. Trammell
    Thomson, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Physical › Alertness/Fatigue
    • +1 more shared findings
    Collision with terr/obj (non-CFIT)
  • CEN24MA1112024-02-106 fatalmatch 57
    AIRBUS HELICOPTERS EC 130 · ORBIC AIR LLC
    Halloran Springs, CA
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
    Collision with terr/obj (non-CFIT)

What the record says

a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 4 of 8Controlled flight into terr/obj (CFIT)
  • 3 of 8Collision with terr/obj (non-CFIT)
  • 2 of 8VFR encounter with IMC
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Conditions/weather/phenomena › Ceiling/visibility/precip
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Physical › Alertness/Fatigue
  • Task performance › Communication (personnel)
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Psychological › Attention/monitoring

A teaching device, not a verdict: what the record would have looked at, next to what the Board found.

In the Board’s words — the closest cases
  • DCA13MA1332013-08-14 · AIRBUS A300 - F4 622R · UNITED PARCEL SERVICE CO
    the flight crew's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain. Contributing to the accident were (1) the flight crew's failure to properly configure and verify the flight management computer for the profile approach; (2) the captain's failure to communicate his intentions to the first officer once it became apparent the vertical profile was not…
  • ERA16FA2152016-06-16 · PIPER PA31 · AERONATIONAL INC
    The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.
  • CEN19MA3122019-09-11 · Convair 440 · Ferreteria E Implementos San Francisco
    The flight crew’s failure to maintain the proper airspeed on final approach, which resulted in an inadvertent aerodynamic stall and impact with trees, and terrain. Contributing to the accident was the flight crew’s fatigue due to the overnight flight schedule.
  • MIA08MA2032008-09-28 · AEROSPATIALE SA365N-1 D · Maryland State Police
    The pilot's attempt to regain visual conditions by performing a rapid descent and his failure to arrest the descent at the minimum descent altitude during a nonprecision approach. Contributing to the accident were (1) the pilot’s limited recent instrument flight experience, (2) the lack of adherence to effective risk management procedures by the Maryland State Police, (3) the pilot’s inadequate assessment of the weather, which led to his decision to accept the flight,, (4) the failure of the Potomac Consolidated Te…
  • DCA12IA1412012-09-05 · DE HAVILLAND DHC8 · ERA AVIATION INC
    an in-flight loss of control due to the flight crew's inattention to airspeed, pitch attitude, and engine power during the climb leading to an aerodynamic stall. Contributing to the incident was the flight crew's failure to recognize and properly recover from an aerodynamic stall in a timely manner.
What it recommended after them
  • A-14-072TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to ensure that operators with flight crews performing 14 Code of Federal Regulations Part 121, 135, and 91 subpart K overnight operations brief the threat of fa… · DCA13MA133Closed - Unacceptable Action
  • A-14-073TO THE FEDERAL AVIATION ADMINISTRATION: Require operators to develop an annual recurrent dispatcher resource management module for dispatchers that includes participation of pilots to reinforce the need for open communication. · DCA13MA133Closed - Unacceptable Action
  • A-14-074TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to work with operators to ensure that their operating procedures explicitly state that any changes to an approach after the completion of the approach briefing… · DCA13MA133Closed - Acceptable Action
  • A-14-075TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to ensure consistency among their operators’ training documents, their operators’ Federal Aviation Administration-approved and -accepted documents, such as the… · DCA13MA133Closed - Acceptable Action
  • A-14-076TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that Federal Aviation Administration-approved nonprecision instrument appr… · DCA13MA133Closed - Unacceptable Action
  • A-14-077TO THE FEDERAL AVIATION ADMINISTRATION: Require that the remarks section of meteorological aerodrome reports be provided to all dispatchers and pilots in flight dispatcher papers and through the aircraft communication addressing and reporti… · DCA13MA133Closed - Acceptable Action
  • A-14-078TO THE FEDERAL AVIATION ADMINISTRATION: Expand the current guidance available in Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to further define meteorological aerodrome report pertinent remarks. · DCA13MA133Closed - Acceptable Alternate Action
  • A-14-079TO THE FEDERAL AVIATION ADMINISTRATION: Issue a safety advisory bulletin to air traffic controllers providing examples of the types of meteorological aerodrome report remarks information considered pertinent and reminding them of the requir… · DCA13MA133Closed - Acceptable Action

This is the pattern in the NTSB’s own record across similar accidents — which findings it cited, what it coded, what it recommended. It is drawn from the record, not written about this case, and it never assigns blame: investigations exist to prevent the next accident (ICAO Annex 13).