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Cases › DCA09MA026 › The analyst

AIRBUS A320US AIRWAYS 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.

51
timed facts
8
precedents
121
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

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. 15:00:32CVR ATISp.15
    “expressway visual runway three one approach in use. depart runway four, bravo four hold line in use. LaGuardia class bravo services avail- able on frequency one two six point zero five. all pilots read back all hold short instructions and assigned altitudes. advise on initial contact you have information papa... LaGuardia airport in- formation papa. one nine five one zulu. winds three four zero at one three, visibility one zero. ceiling three thousand five hundred broken. temperature minus six dewpoint minus one four. altimeter three zero two three. remarks A O two sea level pressure two three four. [ATIS repeats on ch2 until time 15:02:44.]”
    read in context ↗
  2. 15:02:51CVR PA-1calloutp.16
    “a quick hello from the cockpit crew, this is fifteen forty nine bound for Charlotte. its a nice day for flying, be at thirty eight thousand feet mostly smooth about an hour and forty five minutes takeoff to landing, welcome aboard.”
    read in context ↗
  3. 15:05:07CVR HOT-1calloutp.19
    “yeah too bad they aren't still using three one... for takeoff.”
    read in context ↗
  4. 15:05:11CVR HOT-1calloutp.19
    “I was hoping we could land on four and takeoff on three one, but it didn't quite work out that way.”
    read in context ↗
  5. 15:05:29CVR HOT-1warningp.19
    “yeah. and we have to pull up before we can even start on this.”
    read in context ↗
  6. 15:17:30CVR PA-1calloutp.32
    “flight attendants please be seated for takeoff.”
    read in context ↗
  7. 15:18:46CVR HOT-2calloutp.33
    “um. takeoff data verify... one forty, one forty five, one forty nine, TOGA. [Takeoff/Go Around]”
    read in context ↗
  8. 15:19:22CVR PA-2calloutp.34
    “ladies and gentlemen at this time we're number one for takeoff, flight attendants please be seated.”
    read in context ↗
  9. 15:19:27CVR HOT-2calloutp.34
    “takeoff min fuel quantity verify. nineteen thou- sand pounds required we got twenty one point eight on board.”
    read in context ↗
  10. 15:24:54CVR TWRcalloutp.35
    “Cactus fifteen forty nine runway four clear for takeoff.”
    read in context ↗
  11. 15:24:56.7CVR RDO-1calloutp.35
    “Cactus fifteen forty nine clear for takeoff.”
    read in context ↗
  12. 15:25:33CVR HOT-1calloutp.36
    “V one, rotate.”
    read in context ↗
  13. 15:25:39CVR HOT-2calloutp.36
    “gear up please.”
    read in context ↗
  14. 15:25:39CVR HOT-1calloutp.36
    “gear up.”
    read in context ↗
  15. 15:26:52CVR HOT-2calloutp.37
    “flaps up please, after takeoff checklist.”
    read in context ↗
  16. 15:26:54CVR HOT-1p.38
    “flaps up.”
    read in context ↗
  17. about 15:27-15:31 ESTFDRditchingp.8
    Bird ingestion into both engines, loss of thrust and landing in the Hudson River (engine parameters, flight controls, flaps/slats/spoilers, roll/yaw, electrical and smoke parameters presented in plots 1-12; recording ended 5 minutes 49 seconds after takeoff thrust)
  18. 15:27:07CVR HOT-1p.38
    “after takeoff checklist complete.”
    read in context ↗
  19. 15:27:18.5CVR HOT-1p.38
    “ignition, start.”
    read in context ↗
  20. 15:27:18.5CVR CVRp.38
    “Group Chairman’s Factual Report Page”
    read in context ↗
  21. about 15:27:19 ESTFDRclimbp.3
    Second recording discontinuity during the accident flight (annotated on the plots; not long enough to reset the FDIU frame counter)
  22. 15:27:32.9CVR RDO-1warningp.40
    “mayday mayday mayday. uh this is uh Cactus fifteen thirty nine hit birds, we've lost thrust (in/on) both engines we're turning back towards LaGuardia.”
    read in context ↗
  23. about 15:28:30 ESTFDRdescentp.3
    Third recording discontinuity during the accident flight
  24. 15:28:30CVR HOT-2p.42
    “distress message, transmit. we did.”
    read in context ↗
  25. 15:28:31CVR DEPp.42
    “arright Cactus fifteen forty nine its gonna be left traffic for runway three one.”
    read in context ↗
  26. 15:28:36CVR TCASwarningp.42
    “traffic traffic.”
    read in context ↗
  27. 15:28:45CVR PWSwarningp.42
    “go around. windshear ahead.”
    read in context ↗
  28. 15:28:59CVR TCASwarningp.43
    “monitor vertical speed.”
    read in context ↗
  29. 15:29:05CVR TCASwarningp.43
    “clear of conflict.”
    read in context ↗
  30. 15:29:11CVR PA-1warningp.43
    “this is the Captain brace for impact.”
    read in context ↗
  31. 15:29:14.9CVR GPWSwarningp.43
    “one thousand.”
    read in context ↗
  32. 15:29:37CVR GPWSwarningp.45
    “too low. terrain.”
    read in context ↗
  33. 15:29:41CVR GPWSwarningp.45
    “too low. terrain.”
    read in context ↗
  34. 15:29:43CVR GPWSwarningp.45
    “too low. terrain.”
    read in context ↗
  35. 15:29:45CVR EGPWSwarningp.45
    “caution. terrain.”
    read in context ↗
  36. 15:29:48CVR EGPWSwarningp.45
    “caution terrain.”
    read in context ↗
  37. 15:29:49CVR EGPWSwarningp.45
    “terrain terrain. pull up. pull up.”
    read in context ↗
  38. 15:29:55CVR EGPWSwarningp.46
    “pull up. pull up. pull up. pull up. pull up. pull up.”
    read in context ↗
  39. 15:30:04CVR GPWSwarningp.46
    “too low. terrain.”
    read in context ↗
  40. 15:30:06CVR GPWSwarningp.46
    “too low. gear.”
    read in context ↗
  41. 15:30:13CVR EGPWSwarningp.46
    “caution terrain.”
    read in context ↗
  42. 15:30:15CVR EGPWSwarningp.47
    “caution terrain.”
    read in context ↗
  43. 15:30:23CVR EGPWSwarningp.47
    “caution terrain.”
    read in context ↗
  44. 15:30:24CVR EGPWSfinal secondsp.47
    “terrain terrain. pull up. pull up. ["pull up" repeats until the end of the recording]”
    read in context ↗
  45. 15:30:38CVR HOT-1final secondsp.47
    “we're gonna brace.”
    read in context ↗
  46. 15:30:38CVR CVRfinal secondsp.47
    “Group Chairman’s Factual Report Page”
    read in context ↗
  47. 15:30:38CVR HOT-2final secondsp.48
    “* * switch?”
    read in context ↗
  48. 15:30:40CVR HOT-1final secondsp.48
    “yes.”
    read in context ↗
  49. 15:30:41.1CVR GPWSfinal secondsp.48
    “(fifty or thirty)”
    read in context ↗
  50. 15:30:42CVR FWCfinal secondsp.48
    “retard. 15:30:43.7 [End of Recording] 15:30:43.7 [End of Transcript]”
    read in context ↗
  51. 15:30:42CVR CVRfinal secondsp.48
    “Group Chairman’s Factual Report Page 47 of 47”
    read in context ↗
Recorder events without a clock time
  • engine startFirst recording discontinuity after engine 2 spooled up enough for generator 2 to power AC bus 2 and the Flight Data Interface Unit
  • before takeoffFluctuations in indicated airspeed before takeoff indicate the FDIU was not receiving valid airspeed at that time
Flight Data Recorder 10A - Factual Report of Group Chairman · 5 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 48 of 365 lines shown
How the Board coded the sequence
  1. Initial climb: Birdstrike→
  2. Landing: Ditching→
  3. Post-impact: Aircraft structural failure→
  4. Post-impact: Evacuation

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DFW08MA0762008-03-045 fatalmatch 49
    CESSNA 500 · Interstate Helicopters Inc
    Oklahoma City, OK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Physical environment › Object/animal/substance
    Birdstrike
  • CEN10IA0532009-11-15no fatalitiesmatch 48
    AIRBUS A319-111 · Frontier Airlines
    Kansas City, MO
    • ●Environmental issues › Physical environment › Object/animal/substance
    Birdstrike
  • CEN18FA2152018-06-091 fatalmatch 46
    ROBINSON HELICOPTER R44 · MF HELICOPTERS LLC
    Oshkosh, WI
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Physical environment › Object/animal/substance
  • DCA15FA0852015-03-05substantialmatch 45
    MCDONNELL DOUGLAS AIRCRAFT CO MD 88 · Delta Air Lines
    New York, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
  • CEN19MA3122019-09-112 fatalmatch 45
    Convair 440 · Ferreteria E Implementos San Francisco
    Monclova, OH
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
  • ANC23FA0742023-09-131 fatalmatch 44
    PIPER PA-18-150 · NEITZ AVIATION INC
    St. Mary's, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
  • ERA14MA2712014-06-017 fatalmatch 44
    GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLC
    Bedford, MA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Physical environment › Object/animal/substance
    • ●Organizational issues › Development › Selection/certification/testing
  • DCA12IA1412012-09-05no fatalitiesmatch 44
    DE HAVILLAND DHC8 · ERA AVIATION INC
    Soldotna, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters

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 8Collision with terr/obj (non-CFIT)
  • 2 of 8Birdstrike
  • 2 of 8Runway excursion
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Physical environment › Object/animal/substance
Cited here, not seen in the precedents
  • Task environment › Pressures/demands
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Aircraft capability
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Psychological › Attention/monitoring
  • 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
  • DFW08MA0762008-03-04 · CESSNA 500 · Interstate Helicopters Inc
    Airplane wing-structure damage sustained during impact with one or more large birds (American white pelicans), which resulted in a loss of control of the airplane.
  • CEN10IA0532009-11-15 · AIRBUS A319-111 · Frontier Airlines
    The in-flight engine ingestion of one or more Lesser Snow Geese (Chen caerulescens caerulescens).
  • CEN18FA2152018-06-09 · ROBINSON HELICOPTER R44 · MF HELICOPTERS LLC
    The pilot's decision to fly over the river at a low altitude and his failure to maintain clearance with wires during low-level flight.
  • 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.
  • 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.
What it recommended after them
  • A-09-072TO THE FEDERAL AVIATION ADMINISTRATION: Revise the bird-strike certification requirements for 14 Code of Federal Regulations Part 25 airplanes so that protection from in-flight impact with birds is consistent across all airframe structures.… · DFW08MA076Closed - Unacceptable Action
  • A-09-073TO THE FEDERAL AVIATION ADMINISTRATION: Verify that all federally obligated general aviation airports that are located near woodlands, water, wetlands, or other wildlife attractants are complying with the requirements to perform wildlife ha… · DFW08MA076Closed - Acceptable Alternate Action
  • A-09-074TO THE FEDERAL AVIATION ADMINISTRATION: Require aircraft manufacturers to develop aircraft-specific guidance information that will assist pilots in devising precautionary aircraft operational strategies for minimizing the severity of aircra… · DFW08MA076Closed - Reconsidered
  • A-09-075TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations (CFR) Part 139 airports and 14 CFR Part 121, Part 135, and Part 91 Subpart K aircraft operators to report all wildlife strikes, including, if possible, speci… · DFW08MA076Closed - Acceptable Alternate Action
  • A-09-076TO THE FEDERAL AVIATION ADMINISTRATION: Revise 14 Code of Federal Regulations 91.23 truth-in-leasing regulations to include all turbine-powered airplanes. · DFW08MA076Closed - Unacceptable Action
  • A-09-077TO THE FEDERAL AVIATION ADMINISTRATION: Require that Federal Aviation Administration flight plans include a block for the pilot to identify the operator and a block to specify the operating rules under which the flight is being conducted. · DFW08MA076Closed - Unacceptable Action
  • A-09-078TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 135 on-demand operators to provide their customers with a written document, correspondence, or ticket that expressly describes the terms of carriage, includ… · DFW08MA076Closed - Unacceptable Action
  • A-09-079TO THE FEDERAL AVIATION ADMINISTRATION: Update and keep current the aircraft charter guide on the Federal Aviation Administration’s website to include reliable information on the certification status of on-demand commercial operators and t… · DFW08MA076Closed - 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).