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Cases › DCA09FA048 › The analyst

BOEING DC-10World Airways

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.

67
timed facts
8
precedents
68
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

67 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. 12:00:23CVR STARTp.7
    “OF RECORDING”
    read in context ↗
  2. 12:40:33CVR TAWSwarningp.7
    “twenty five hundred.”
    read in context ↗
  3. 12:40:41CVR CAMwarningp.7
    “[sound similar to landing gear warning horn]”
    read in context ↗
  4. 12:40:44CVR CAMwarningp.7
    “[sound similar to altitude alerter]”
    read in context ↗
  5. 12:40:56CVR CAMwarningp.8
    “[sound similar to landing gear warning horn]”
    read in context ↗
  6. 12:41:16CVR CAM-1calloutp.8
    “gear down.”
    read in context ↗
  7. 12:41:18CVR CAM-2calloutp.8
    “gear down.”
    read in context ↗
  8. 12:42:24CVR CAMwarningp.9
    “[sound similar to altitude alerter]”
    read in context ↗
  9. 12:42:58CVR CAMwarningp.11
    “[sound similar to altitude alerter]”
    read in context ↗
  10. 12:43:16CVR TWRcalloutp.11
    “World eighty five thirty five heavy Baltimore tower. runway one zero cleared to land. winds calm. traffic will be holding in position runway one five right.”
    read in context ↗
  11. 12:43:23CVR RDO-2calloutp.11
    “cleared to land one zero. World eighty five thirty five heavy.”
    read in context ↗
  12. 12:44:18CVR TAWSwarningp.11
    “five hundred. DCA09FA048”
    read in context ↗
  13. 12:44:40CVR CAM-3calloutp.12
    “minimums. ah you said you're visual. never mind.”
    read in context ↗
  14. 12:44:53CVR TAWSwarningp.12
    “one hundred.”
    read in context ↗
  15. 12:44:56CVR TAWSwarningp.12
    “fifty.”
    read in context ↗
  16. 12:44:57CVR TAWSwarningp.12
    “forty.”
    read in context ↗
  17. 12:44:58CVR TAWSwarningp.12
    “thirty.”
    read in context ↗
  18. 12:44:59CVR TAWSwarningp.12
    “twenty.”
    read in context ↗
  19. 12:44:59CVR TAWSwarningp.12
    “ten.”
    read in context ↗
  20. 12:45:00 EDTFDRlandingp.5
    Initial touchdown at about 6 degrees nose up (time correlated to an airport security camera); vertical acceleration about 1.6 g; the control column then commanded nose down and the aircraft rotated nose down
    see the traces at this moment ↗
  21. 12:45:01CVR CAM-1p.12
    “#.”
    read in context ↗
  22. about 12:45:02 EDTFDRbouncep.5
    Control column began commanding nose up
    see the traces at this moment ↗
  23. 12:45:02CVR CAM-3p.12
    “no spoilers. DCA09FA048”
    read in context ↗
  24. about 12:45:03 EDTFDRbouncep.5
    Second ground contact: column at a local maximum of 8 degrees aft while pitch reached about 2 degrees nose down; vertical acceleration about 3.0 g; first data dropout
    see the traces at this moment ↗
  25. 12:45:03-12:45:05 EDTFDRbouncep.5
    Pitch rebounded to about 10 degrees nose up while the column commanded nose down to about 7-8 degrees forward
    see the traces at this moment ↗
  26. 12:45:04CVR CAM-?p.13
    “**”
    read in context ↗
  27. about 12:45:05 EDTFDRbouncep.5
    Nose began dropping; column returned toward neutral without commanding nose up until just before the third contact
    see the traces at this moment ↗
  28. 12:45:05CVR CAM-?p.13
    “** pull.”
    read in context ↗
  29. 12:45:06CVR CAM-2p.13
    “flare flare.”
    read in context ↗
  30. about 12:45:07 EDTFDRbouncep.5
    Third ground contact at about 1 degree nose down; vertical acceleration about 3.4 g
    see the traces at this moment ↗
  31. about 12:45:08 EDTFDRgo-aroundp.4
    Second and third data dropouts; pitch, roll and heading became invalid for the rest of the flight
    see the traces at this moment ↗
  32. 12:45:08CVR CAM-1p.13
    “what are you doing?”
    read in context ↗
  33. 12:45:09CVR CAM-2p.13
    “it's yours—.”
    read in context ↗
  34. 12:45:10CVR CAM-2calloutp.13
    “go around go around.”
    read in context ↗
  35. 12:45:10CVR TWRcalloutp.13
    “World eighty three fifty three climb and maintain two thousand. fly runway heading.”
    read in context ↗
  36. 12:45:10CVR CAM-3calloutp.13
    “go around. go around.”
    read in context ↗
  37. 12:45:12CVR CAWSwarningp.13
    “TCAS test...pass.”
    read in context ↗
  38. 12:45:18CVR CAM-1calloutp.14
    “positive rate. gear up. no. leave the gear down. leave the # gear down.”
    read in context ↗
  39. 12:45:33CVR CAM-1warningp.14
    “let's declare an emergency.”
    read in context ↗
  40. 12:45:38CVR RDO-2warningp.14
    “tower World eighty five thirty five declaring an emergency. we had to go around.”
    read in context ↗
  41. 12:45:40CVR CAM-?calloutp.14
    “** go around. DCA09FA048”
    read in context ↗
  42. 12:45:59CVR RDO-2warningp.15
    “yes sir. ah we had to do ah go around here. need to declare an emergency.”
    read in context ↗
  43. 12:46:38CVR CAMwarningp.16
    “[sound similar to altitude alerter]”
    read in context ↗
  44. 12:47:07CVR PA-3warningp.17
    “ladies and gentlemen ah we've had a bit of a malfunction as you can see. we're going to be returning for unfortunately an emergency landing. ah when we give the command please ah brace for impact. flight attendants please brief the passengers.”
    read in context ↗
  45. 12:47:23CVR TAWSwarningp.17
    “don't sink. don't sink.”
    read in context ↗
  46. 12:47:24CVR RDO-2calloutp.17
    “Potomac approach World eighty five thirty five heavy. ah runway heading.”
    read in context ↗
  47. 12:47:31CVR CAM-1calloutp.18
    “runway heading.”
    read in context ↗
  48. 12:50:27CVR CAM-2calloutp.22
    “you wanna just go around and land on on ah one five right?”
    read in context ↗
  49. 12:55:14CVR APRcalloutp.28
    “World eighty five thirty five heavy cleared to land runway three three left.”
    read in context ↗
  50. 12:55:17CVR RDO-2calloutp.28
    “cleared to land three three left. World eighty five thirty five heavy.”
    read in context ↗
  51. 12:56:54CVR TAWSwarningp.30
    “five hundred.”
    read in context ↗
  52. 12:57:23CVR TAWSwarningp.30
    “one hundred.”
    read in context ↗
  53. 12:57:24CVR TAWSwarningp.30
    “fifty.”
    read in context ↗
  54. 12:57:26CVR TAWSwarningp.30
    “thirty.”
    read in context ↗
  55. 12:57:26CVR TAWSwarningp.30
    “twenty.”
    read in context ↗
  56. 12:57:27CVR TAWSwarningp.30
    “ten. DCA09FA048”
    read in context ↗
  57. 13:02:57CVR CAM-?warningp.37
    “from the impact or **.”
    read in context ↗
  58. 13:03:11CVR CAM-3warningp.37
    “aww I've never been in a plane crash before.”
    read in context ↗
  59. 13:03:16CVR CAM-2warningp.37
    “you weren't involved in a plane crash.”
    read in context ↗
  60. 13:59:06CVR CAM-1final secondsp.52
    “hey...hey is there water back there?”
    read in context ↗
  61. 13:59:31CVR CAMfinal secondsp.52
    “[background conversation in cabin] DCA09FA048”
    read in context ↗
  62. 14:00:23CVR CAM-?final secondsp.53
    “[sound of chuckle] is it?”
    read in context ↗
  63. 14:00:26CVR CAM-3final secondsp.53
    “maybe you should get up and stretch out a little bit ya know.”
    read in context ↗
  64. 14:00:43CVR CAM-3final secondsp.53
    “I couldn't get that bathroom door open man. it took two of us.”
    read in context ↗
  65. 14:01:07CVR CAM-3final secondsp.53
    “I think she did herself in this time.”
    read in context ↗
  66. 14:01:25CVR CAM-1final secondsp.53
    “did you pull that?”
    read in context ↗
  67. 14:01:26CVR CAM-3final secondsp.53
    “aw #. no I never did.”
    read in context ↗
Recorder events without a clock time
  • laterGo-around and landing on runway 33L (plots 3 and 4, without attitude parameters)
Flight Data Recorder 10 - Specialist's Factual Report · 8 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 60 of 603 lines shown
How the Board coded the sequence
  1. Landing-flare/touchdown: Abnormal runway contact

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA23LA3842023-07-29substantialmatch 67
    BOEING 767-322 · UNITED AIRLINES INC
    Houston, TX
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
  • DCA16LA1002016-02-24substantialmatch 63
    EMBRAER EMB145 · TRANS STATES AIRLINES INC
    St Louis, MO
    • ●Personnel issues › Action/decision › Action
    Abnormal runway contact
  • DCA17IA0202016-10-27no fatalitiesmatch 59
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
  • DCA14FA1222014-06-20substantialmatch 56
    BOEING 767 36N · OMNI AIR INTERNATIONAL INC
    Kabul, AF
    Abnormal runway contact
  • DCA14MA0812014-03-13substantialmatch 55
    AIRBUS A320 - 214 · US AIRWAYS INC
    Philadelphia, PA
    • ●Personnel issues › Action/decision › Action
    Abnormal runway contact
  • ERA10LA0412009-10-26no fatalitiesmatch 54
    BOEING 717-200 · Air Tran Airways
    Pleasant Grove, NC
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
  • OPS10IA0012009-10-19no fatalitiesmatch 54
    BOEING 767 · Delta Air Lines, Inc.
    Atlanta Hartsfield Intl. Apt. (KATL), GA
    • ●Personnel issues › Physical › Alertness/Fatigue
    • ●Personnel issues › Physical › Impairment/incapacitation
  • DCA13FA1312013-07-22substantialmatch 54
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Personnel issues › Action/decision › Action

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
  • 3 of 8Abnormal runway contact
  • 2 of 8Hard landing
  • 2 of 8Landing gear collapse
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Support/oversight/monitoring › Training
  • Action/decision › Action
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters
  • Action/decision › Info processing/decision
  • Task performance › Use of equip/info

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
  • DCA23LA3842023-07-29 · BOEING 767-322 · UNITED AIRLINES INC
    The first officer’s improper control inputs after the airplane touched down. Contributing to the severity of the damage was the flight crew’s lack of recognition that the speedbrakes were not armed, which led to their delayed deployment.
  • DCA16LA1002016-02-24 · EMBRAER EMB145 · TRANS STATES AIRLINES INC
    the flight crews' failure to consider all available runways for landing to minimize the gusty crosswind component. Contributing to the accident was the captain's reduction of the engine thrust for about 1 second at low altitude immediately after the first officer applied maximum thrust to conduct a go-around.
  • DCA17IA0202016-10-27 · BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    The first officer's failure to attain the proper touchdown point and the flight crew's failure to call for a go-around, which resulted in the airplane landing more than halfway down the runway. Contributing to the incident were, the first officer's initiation of the landing flare at a relatively high altitude and his delay in reducing the throttles to idle, the captain's delay in manually deploying the speed brakes after touchdown, the captain's lack of command authority, and a lack of robust training provided by t…
  • DCA14FA1222014-06-20 · BOEING 767 36N · OMNI AIR INTERNATIONAL INC
    the early reduction of engine thrust that resulted in an excessive sink rate and nose high pitch attitude during the landing flare. Contributing to the accident was a significant change in the vertical and horizontal wind components just prior to touchdown.
  • DCA14MA0812014-03-13 · AIRBUS A320 - 214 · US AIRWAYS INC
    the captain's decision to reject the takeoff after the airplane had rotated. Contributing to the accident was the flight crew's failure to follow standard operating procedures by not verifying that the airplane's flight management computer was properly configured for takeoff and the captain's failure to perform the correct action in response to the electronic centralized aircraft monitoring alert.
What it recommended after them
  • A-11-012TO THE FEDERAL AVIATION ADMINISTRATION: Perform a technical review of Airport Surface Detection Equipment–Model X (ASDE-X) to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. · OPS10IA001Closed - Unacceptable Action
  • A-11-013tO THE FEDERAL AVIATION ADMINISTRATION: At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment–Model X (A… · OPS10IA001Closed - Unacceptable Action
  • A-11-014TO THE FEDERAL AVIATION ADMINISTRATION: Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control pa… · OPS10IA001Closed - Acceptable Action
  • A-11-015TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 150/5345-56A, “Specification for L-890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances… · OPS10IA001Closed - Exceeds Recommended 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).