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Cases › DCA09MA021 › The analyst

BOEING 737-524CONTINENTAL AIRLINES 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.

20
timed facts
8
precedents
91
passages to ask

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passages, not paraphrases
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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

20 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. 17:48:33CVR CAM-1p.7
    “cold front.”
    read in context ↗
  2. 17:53:41CVR CAM-1warningp.11
    “MSA's ninety two hundred and engine out runway ah three four.”
    read in context ↗
  3. 17:54:09CVR CAM-2warningp.11
    “engine failure after *.”
    read in context ↗
  4. 17:54:10CVR CAM-2warningp.11
    “standard engine out. 17:54:12 so what have we got here we're fifty three ah”
    read in context ↗
  5. 17:56:03CVR CAM-2calloutp.14
    “takeoff config switch?”
    read in context ↗
  6. 18:14:07CVR HOT-1calloutp.32
    “alright before takeoff checklist”
    read in context ↗
  7. 18:14:14CVR CAM-2calloutp.33
    “want the ice protection on for takeoff?”
    read in context ↗
  8. 18:16:57CVR TWRcalloutp.35
    “two seven turn right heading zero two zero runway three four right cleared for takeoff”
    read in context ↗
  9. 18:17:32-18:18:29 MSTFDRtakeoffp.4
    Entire attempted takeoff covered by four plots: accelerations, ailerons, air/ground, airspeed, brake pressures and brake select, column and wheel, drift angle, elevators, engine N1/TLA/reversers, nose WOW, ground speed, heading, mic keys, master caution, pitch, roll, rudder and pedals, slats, speed brake handle, spoilers 2 and 7, stabilizer, yaw damper
    see the traces at this moment ↗
  10. 18:17:32-18:18:29 MSTFDRtakeoffp.4
    Attempted takeoff covered by the two OQAR plots, aligned with the FDR: engine N1/N2, FCC master lights, flight path accelerations, flight spoilers 2 and 7, EFIS ground speed, heading and total pressure
    see the traces at this moment ↗
  11. 18:17:37CVR CAM-1p.35
    “alright”
    read in context ↗
  12. 18:17:38CVR CAM-1p.35
    “left cross wind twenty ah seven knots”
    read in context ↗
  13. 18:18:13CVR CAM-?final secondsp.36
    “Jesus”
    read in context ↗
  14. 18:18:14CVR CAMfinal secondsp.36
    “sound of snap”
    read in context ↗
  15. 18:18:15CVR CAMfinal secondsp.36
    “sound of snap”
    read in context ↗
  16. 18:18:15CVR HOT-2final secondsp.36
    “oh # # #”
    read in context ↗
  17. 18:18:17CVR CAMfinal secondsp.36
    “sound of increasing background noise”
    read in context ↗
  18. 18:18:21CVR HOT-1final secondsp.36
    “reject”
    read in context ↗
  19. 18:18:22CVR HOT-1final secondsp.36
    “reject”
    read in context ↗
  20. 18:18:22CVR HOT-2final secondsp.36
    “*ject”
    read in context ↗
Flight Data Recorder 10 - Specialist's Factual Report · 1 events extracted by claude-fable-5-1 (in-session)Optical Quick Access Recorder - Specialist's Factual Report · 1 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 18 of 302 lines shown
How the Board coded the sequence
  1. Takeoff: Other weather encounter→
  2. Takeoff: Loss of control on ground→
  3. Takeoff: Runway excursion

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA17IA0202016-10-27no fatalitiesmatch 64
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
    • +1 more shared findings
    Runway excursion
  • DCA13FA1312013-07-22substantialmatch 59
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA15FA0852015-03-05substantialmatch 59
    MCDONNELL DOUGLAS AIRCRAFT CO MD 88 · Delta Air Lines
    New York, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Loss of control on groundRunway excursion
  • WPR18MA0872018-02-115 fatalmatch 58
    EUROCOPTER EC130 · Papillon Airways, Inc.
    Peach Springs, AZ
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Wind
    • ●Personnel issues › Task performance › Use of equip/info
    Other weather encounter
  • ANC19FA0192019-05-202 fatalmatch 57
    De Havilland DHC 2 · Venture Travel, LLC
    Metlakatla, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Wind
    • ●Personnel issues › Task performance › Use of equip/info
    Loss of control on ground
  • DCA26LA1392026-02-26no fatalitiesmatch 56
    BOMBARDIER INC CL-600-2C10 · Endeavor Airlines
    College Park, GA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Wind
    • ●Personnel issues › Task performance › Use of equip/info
  • ERA12FA0072011-10-051 fatalmatch 56
    CESSNA 207A · WATERS AERO-MARINE, INC.
    Matinicus Island, ME
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Task performance › Use of equip/info
    Other weather encounter
  • ERA10LA0412009-10-26no fatalitiesmatch 52
    BOEING 717-200 · Air Tran Airways
    Pleasant Grove, NC
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info

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 8Collision with terr/obj (non-CFIT)
  • 2 of 8Runway excursion
  • 2 of 8Loss of control on ground
  • 2 of 8Loss of control in flight
  • 2 of 8Other weather encounter
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 › Wind
  • Support/oversight/monitoring › Training
  • Action/decision › Action
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • Management › Communication (organizational)
Common in the precedents, not cited here
  • Support/oversight/monitoring › Documentation/record keeping
  • Action/decision › Info processing/decision

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
  • 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…
  • DCA13FA1312013-07-22 · BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    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.
  • DCA15FA0852015-03-05 · MCDONNELL DOUGLAS AIRCRAFT CO MD 88 · Delta Air Lines
    the captain's inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the airplane's heading. Contributing to the accident were the captain's (1) situational stress resulting from his concerns about stopping performance and (2) attentional limitations due to the high workload during the landing, which prevented him from immediately recognizing the use of excessive reverse thrust.
  • WPR18MA0872018-02-11 · EUROCOPTER EC130 · Papillon Airways, Inc.
    A loss of tail rotor effectiveness, the pilot’s subsequent loss of helicopter control, and collision with terrain during an approach to land in gusting, tailwind conditions in an area of potential downdrafts and turbulence.
  • ANC19FA0192019-05-20 · De Havilland DHC 2 · Venture Travel, LLC
    The pilot’s inadequate compensation for a quartering tailwind during a water landing, which resulted in a loss of control and subsequent nose-over. Contributing to the accident was the company’s inadequate operational control of the flight release process, which resulted in assignment of an inexperienced pilot to a commuter seaplane flight.
What it recommended after them
  • A-16-020TO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with Boeing and US operators of MD-80 series airplanes to (1) conduct a study to examine reverse thrust engine pressure ratio (EPR)-related operational data, procedures, and training and (… · DCA15FA085Closed - Acceptable Action
  • A-16-021TO THE FEDERAL AVIATION ADMINISTRATION: Encourage US operators of MD-80 series airplanes to (1) implement the best practices identified in Safety Recommendation A-16-20 and (2) participate in an industry-wide monitoring program to verify th… · DCA15FA085Closed--No Longer Applicable
  • A-16-022TO THE FEDERAL AVIATION ADMINISTRATION: Require operators of MD-80 series airplanes to revise operational procedures to include a callout when reverse thrust power exceeds 1.3 engine pressure ratio during landings on a contaminated runway. · DCA15FA085Closed--No Longer Applicable
  • A-16-023TO THE FEDERAL AVIATION ADMINISTRATION: Continue to work with industry to develop the technology to outfit transport-category airplanes with equipment and procedures to routinely calculate, record, and convey the airplane braking ability re… · DCA15FA085Closed - Acceptable Action
  • A-16-024TO THE FEDERAL AVIATION ADMINISTRATION: If the systems described in Safety Recommendation A-16-23 are shown to be technically and operationally feasible, work with operators and the system manufacturers to develop procedures that ensure tha… · DCA15FA085Open - Acceptable Response
  • A-16-025TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 operators to provide (1) guidance that instructs flight attendants to remain at their assigned exits and actively monitor exit availability in all non-n… · DCA15FA085Closed - Unacceptable Action
  • A-16-026TO THE FEDERAL AVIATION ADMINISTRATION: Develop best practices related to evacuation communication, coordination, and decision-making during emergencies through the establishment of an industry working group and then issue guidance for 14 C… · DCA15FA085Closed - Unacceptable Action
  • A-16-027TO THE FEDERAL AVIATION ADMINISTRATION: Clarify guidance to all 14 Code of Federal Regulations Part 121 air carriers to reinforce the importance of (1) having precise information about the number of passengers aboard an airplane, including… · DCA15FA085Closed - Acceptable Alternate 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).