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Cases › DCA07FA037 › The analyst

Bombardier CL-600-2B19PINNACLE AIR INC

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.

49
timed facts
8
precedents
212
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

49 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. 03:31:54.1CVR HOT-1p.9
    “ah what kinda winds are we poppin' I can't even remember any more. they're not light (weight) either I can't find a sock with a light on it. ahh there's one.”
    read in context ↗
  2. 03:33:26.3CVR TWRcalloutp.12
    “and forty seven twelve caution wake turbulence have a DC eight departed off of runway four two minutes ago wind three six zero at one two runway three zero right heading of three one zero cleared for takeoff.”
    read in context ↗
  3. 03:33:36.7CVR RDO-2calloutp.12
    “alright three one zero cleared for takeoff Flagship ah forty seven twelve.”
    read in context ↗
  4. 03:34:01.1CVR HOT-2calloutp.13
    “V one, rotate.”
    read in context ↗
  5. 03:34:07.2CVR HOT-1calloutp.13
    “gear up.”
    read in context ↗
  6. 03:37:06.0CVR HOT-1calloutp.19
    “you haven't done non-flying but like two times. (in the airplane). from takeoff, you know.”
    read in context ↗
  7. 03:41:19.1CVR HOT-1calloutp.25
    “(let's) say what vertical speed autopilot on.”
    read in context ↗
  8. 03:41:21.8CVR HOT-2calloutp.26
    “"kay vertical speed. autopilot on.”
    read in context ↗
  9. 03:41:23.8CVR HOT-2calloutp.26
    “autopilot on.”
    read in context ↗
  10. 03:41:30.6CVR HOT-2calloutp.26
    “* autopilot on your side alright.”
    read in context ↗
  11. 03:41:33.8CVR HOT-1calloutp.26
    “most guys *. alright if I keep it in speed mode and say autopilot on it'd say two ninety five right now [sound of chuckle] 'cause I'm not on speed. know what I mean?”
    read in context ↗
  12. 03:47:44.4CVR HOT-1calloutp.37
    “gives you the gate, flags yes or no, and you’re good to takeoff * * *. so *. those are the three things your doing and actually four if you count the book. takeoff landing ID.”
    read in context ↗
  13. 03:50:34.2CVR CAMwarningp.43
    “[sound of altitude warning tone].”
    read in context ↗
  14. 04:01:50.1CVR HOT-1calloutp.63
    “alright ah good, ILS two eight (ten) seven almost set twice. set twice. two seventy nine's inbound twenty five forty nine over GWENN. you wanna pop that in there also? twenty five forty nine over GWENN. eight twenty is decision height ah eight seventeen sorry eight twenty in the window.”
    read in context ↗
  15. 04:02:15.4CVR HOT-1calloutp.63
    “if we have to go missed its climb to eleven hundred before we turn then we turn left to three thousand direct to the VOR so that's cake. alright it'll be white needles auto tune you know what I mean? so heading sync heading mode * to four hundred feet autopilot on.”
    read in context ↗
  16. 04:08:50.0CVR HOT-1calloutp.76
    “* * would take this # out. and it was gate two forty seven max landing flaps eight go around.”
    read in context ↗
  17. 04:10:56.2CVR HOT-1calloutp.80
    “okay couple things that are different about this airport, nobody's gonna tell you cleared to land.”
    read in context ↗
  18. 04:13:45.3CVR HOT-1calloutp.84
    “so I don't know that's why I'm puttin' in if he can vector us and ha- we don't get below his minimum vectoring altitude then he can give us the clearance, ya know?”
    read in context ↗
  19. 04:28:15.7CVR HOT-1calloutp.107
    “Ahh I don't wanna be stuck (in this) go around just 'cause there's equipment on the runway, ya know?”
    read in context ↗
  20. 04:28:32.9CVR CAMwarningp.108
    “[sound similar to altitude alert chime].”
    read in context ↗
  21. 04:40:00.8CVR HOT-1calloutp.128
    “so lets put thirty two nine on two and we'll put twenty four two on one I got you cleared to land lights.”
    read in context ↗
  22. 04:40:18.7CVR HOT-1calloutp.128
    “eh gear down flaps thirty bug one sixty.”
    read in context ↗
  23. 04:40:19.4CVR HOT-2calloutp.129
    “gear down.”
    read in context ↗
  24. 04:40:23.6CVR HOTwarningp.129
    “[sound similar to flap overspeed clacker].”
    read in context ↗
  25. 04:41:14.8CVR HOT-2p.130
    “all right landing gear down three green?”
    read in context ↗
  26. 04:41:15-04:43:50 GMT (revised)FDRapproach/landingp.1
    Plots 1, 3 and 5 re-issued on the revised 155-second time scale covering the approach and landing
    see the traces at this moment ↗
  27. 04:41:16.1CVR HOT-1p.130
    “down three green.”
    read in context ↗
  28. 04:41:41.2CVR HOT-1calloutp.132
    “* we're allowed three inches. alright. and set my missed please three thousand we might need it if it looks ugly when we're comin' in I'll go around. (you know what I mean). made this mistake before. as long as there's no shovel you know marks and # half inch is nothin'. alright our decision height's eight twenty call me at nine twenty a hundred above.”
    read in context ↗
  29. 04:42:05.2CVR HOT-1calloutp.133
    “if we go around just listen to what I'm sayin' what I'm callin' for 'cause there's a hill right off the twelve o'clock nose see that?”
    read in context ↗
  30. 04:42:12.8CVR HOT-1calloutp.133
    “alright kinda a little hilly around here so don't forget to call my positive rate don't forget to get my gear up when I call for it flaps will go to eight not flaps twenty.”
    read in context ↗
  31. 04:42:42.9CVR HOTwarningp.134
    “[sound of autopilot disconnect cavalry charge] minimums [electronic voice].”
    read in context ↗
  32. 04:42:57.4CVR HOTp.135
    “ten [electronic voice].”
    read in context ↗
  33. 04:43:00-04:43:37 GMT (revised)FDRlanding roll/overrunp.1
    Plots 2, 4 and 6 re-issued on the revised 37-second scale around touchdown and the overrun
    see the traces at this moment ↗
  34. 04:43:04.4CVR HOT-1p.135
    “#. [sotto voce].”
    read in context ↗
  35. 04:43:27.6CVR HOT-1p.136
    “ahh we're goin' off.”
    read in context ↗
  36. 04:43:27.7CVR OPSp.136
    “* * he's off the runway guys holy # he's off.”
    read in context ↗
  37. 04:43:30-04:46:05 GMT (original correlation)FDRapproach/landing rollp.4
    Approach and landing plotted over 155 seconds (plots 1, 3, 5) with a 37-second detail from 04:45:15 to 04:45:42 GMT (plots 2, 4, 6): accelerations, control positions, brake pressures and pedal applications, anti-skid status, ground spoilers, thrust reverser discretes, flaps, WOW and ILS deviations
    see the traces at this moment ↗
  38. 04:45:45.5CVR CAM-1p.139
    “okay I don't want shut all this off to be honest with you. so.”
    read in context ↗
  39. 04:45:47.93 GMTFDRoverrunp.4
    Near the end of the data, left main gear WOW transitioned from ground to air, followed 0.25 s later (04:45:48.18) by the nose gear WOW; these occurred during and after the large acceleration excursions
    see the traces at this moment ↗
  40. 04:45:49.43 GMTFDRoverrunp.4
    Left main WOW cycled between ground and air a few times before remaining at ground; nose gear WOW remained at air for the rest of the data, consistent with the gear damage sustained
    see the traces at this moment ↗
  41. 04:52:30.3CVR CAM-1calloutp.144
    “hello oh yeah, yeah, yeah it's, it's, and ** (left) one of the mains is off the ground it's by it's right wheel er a right wing and ah we've got the air stairs we got a lot of operations out here to help us there's no injuries to the passengers, ahm I'm just trying to ah manage gettin' everybody off the aircraft right now. yeah I mean we're at a a pretty good we're about a now at twenty degree angle to the end to the runway heading off the end of the runway. ah yeah but I'm gonna have to get goin' here a second to keep assisting with this. thank you.”
    read in context ↗
  42. 04:54:46.2CVR CAM-1final secondsp.146
    “I get 'em out it's snowing like crazy it's cold but I don't know the condition of the aircraft as far as from the outside, ya know what I mean? we have the door open I've kinda done a walkaround it appears to be safe.”
    read in context ↗
  43. 04:55:00.9CVR CAM-1final secondsp.146
    “doesn't appear to be but like I said you know we're off the runway so and the main's not (on) the aircraft.”
    read in context ↗
  44. 04:55:15.6CVR CAM-1final secondsp.146
    “okay hey I gotta go I gotta go alright alright.”
    read in context ↗
  45. 04:55:20.6CVR CAM-?final secondsp.147
    “*** still got five thousand pounds of fuel on (on board).”
    read in context ↗
  46. 04:55:25.5CVR CAM-1final secondsp.147
    “okay, alright.”
    read in context ↗
  47. 04:55:28.0CVR CAM-?final secondsp.147
    “* want me to power down * * *?”
    read in context ↗
  48. 04:55:31.9CVR CAMfinal secondsp.147
    “[sound similar to clanking].”
    read in context ↗
  49. 04:55:43.7CVR CAMfinal secondsp.147
    “[sound of single chime]. End of Transcript”
    read in context ↗
Flight Data Recorder 10 - Specialist's Factual Report · 3 events extracted by claude-fable-5-1 (in-session)Flight Data Recorder 10 - Errata 1 (Time correlation changed from original report) · 2 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 44 of 1,208 lines shown

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • CHI03IA0702003-02-15no fatalitiesmatch 74
    Canadair CRJ-600 · ATLANTIC COAST AIRLINES
    Bloomington, IL
    matched on what happened, as the Board wrote it · same aircraft family
  • DCA19IA0362018-12-06no fatalitiesmatch 74
    Boeing 737 · Southwest Airlines
    Burbank, CA
    matched on what happened, as the Board wrote it
  • DCA20LA0132019-11-11substantialmatch 74
    Embraer EMB145 · Envoy Air Inc.
    Chicago, IL
    matched on what happened, as the Board wrote it
  • ANC15FA0492015-07-171 fatalmatch 73
    CESSNA 207A · Sea Port Airlines, Inc
    Juneau, AK
    matched on what happened, as the Board wrote it
  • DCA08MA0852008-07-318 fatalmatch 73
    Raytheon Corporate Jets BAE 125-800A · East Coast Jets Inc.,
    Owatonna, MN
    matched on what happened, as the Board wrote it
  • ERA14FA1202014-02-152 fatalmatch 73
    CESSNA 210L · SOUTHERN SEAPLANE INC
    Clay, AL
    matched on what happened, as the Board wrote it
  • CHI05FA0772005-03-12substantialmatch 73
    Bombardier CL-600-2B19 · Pinnacle Airlines
    Milwaukee, WI
    matched on what happened, as the Board wrote it · same aircraft family
  • DEN05MA0292004-11-283 fatalmatch 72
    Canadair CL-600-2A12 · Air Castle Corporation
    Montrose, CO
    matched on what happened, as the Board wrote it · same aircraft family

What the record says

a pattern, not a findingacross the 8 closest cases · 5 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 2 of 8Runway excursion
In the Board’s words — the closest cases
  • CHI03IA0702003-02-15 · Canadair CRJ-600 · ATLANTIC COAST AIRLINES
    The pilot's improper in-flight decision to land on a runway with a tailwind component that exceeded the airplane's tailwind limitation and his failure to perform a go-around which resulted in the proper touchdown point not being attained and the airplane landing long. Also causal was the inadequate snow removal procedures used by the airport personnel and the airport personnel failed to issue NOTAMS in accordance with existing regulations, resulting in the landing gear to fail in overload as a result of hitting a…
  • DCA19IA0362018-12-06 · Boeing 737 · Southwest Airlines
    (1) The flight crewmembers’ decision, due to plan continuation bias, to continue the approach despite indications of windshear and a higher-than-expected tailwind and (2) the flight crew’s misperception of the airplane’s touchdown point, which was farther down the runway than the crew assumed because of the faster-than-expected groundspeed. Contributing to the accident was Southwest Airlines’ lack of guidance to prompt flight crews to reassess operator-provided landing data when arrival weather conditions differ fr…
  • DCA20LA0132019-11-11 · Embraer EMB145 · Envoy Air Inc.
    The flight crew’s inability to maintain the airplane on the runway centerline after touchdown due to the reduced braking action resulting from the deteriorating weather conditions, which caused the airplane’s departure from the runway surface. Contributing to the accident were the delay in performing the runway assessment for undetermined reasons and failure to close the runway. Also contributing to the accident was the controller’s failure to advise the accident flight crew that braking action was no longer cons…
  • ANC15FA0492015-07-17 · CESSNA 207A · Sea Port Airlines, Inc
    The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel.
  • DCA08MA0852008-07-31 · Raytheon Corporate Jets BAE 125-800A · East Coast Jets Inc.,
    The captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots’ poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots’ performance; and (3) the failure of the Federal Aviation Administration to require crew resource management training and standard operating procedures for Part 135 operators.
What it recommended after them
  • A-11-018TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in t… · DCA08MA085Closed - Reconsidered
  • A-11-019TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and Part 142 training schools to incorporate the information from the revised manufacturers’ Aircraft Flight Manuals as… · DCA08MA085Closed - Acceptable Alternate Action
  • A-11-020TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, standard operating procedures. · DCA08MA085Closed - Unacceptable Action
  • A-11-021TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors of 14 Code of Federal Regulations Part 135 and 91 subpart K operators to ensure that pilots use the same checklists in operations that they used during training… · DCA08MA085Closed - Acceptable Alternate Action
  • A-11-022TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers and 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to design new, or revise existing, checklists to require pilots to clearly call out and respond with… · DCA08MA085Closed - Acceptable Action
  • A-11-023TO THE FEDERAL AVIATION ADMINISTRATION: Work with the National Weather Service to revise Advisory Circular 00-24B, “Thunderstorms,” by including explanations of the terms used to describe severe thunderstorms, such as “bow echo,” “derecho,”… · DCA08MA085Closed - Acceptable Action
  • A-11-024TO THE FEDERAL AVIATION ADMINISTRATION: Revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia. · DCA08MA085Closed - Unacceptable Action
  • A-11-025TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 135 and 91 subpart K pilots to receive initial and recurrent education and training on factors that create fatigue in flight operations, fatigue signs and s… · DCA08MA085Closed - Unacceptable 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).