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Cases › DCA11IA015 › The analyst

BOEING 757-223AMERICAN 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.

16
timed facts
8
precedents
106
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

16 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. 09:40:20.0CVR STARTp.8
    “OF RECORDING”
    read in context ↗
  2. 10:59:49.2CVR CAM-2calloutp.9
    “if you * don't like what you see tell me to go around.”
    read in context ↗
  3. 11:00:04.7CVR CAM-2final secondsp.10
    “yeah.”
    read in context ↗
  4. 11:00:06.3CVR CAM-2final secondsp.10
    “right once we get down you know we're slowin' down I'll whenever you either want it or I'll hand it over to ya'.”
    read in context ↗
  5. 11:00:13.3CVR CAM-1final secondsp.10
    “yeah * probably I'll get it just 'cause wanna make sure I'm comfortable with the steering in the turn before I get to the turn...cause it's got that ninety degree turn.”
    read in context ↗
  6. 11:00:13.8CVR CAM-2final secondsp.10
    “*.”
    read in context ↗
  7. 11:00:19.5CVR CAM-2final secondsp.10
    “right okay.”
    read in context ↗
  8. 11:00:23.9CVR CAM-2final secondsp.10
    “right.”
    read in context ↗
  9. 11:00:26.6CVR CAM-2final secondsp.10
    “with those M-Us I almost stop before I turn.”
    read in context ↗
  10. 11:00:30.1CVR CAM-1final secondsp.10
    “yeah well that's it.”
    read in context ↗
  11. 11:37:36 MSTFDRfinal approachp.9
    Start of the 60-second incident landing plot, about 7.5 seconds before touchdown
  12. 11:37:43.5 MSTFDRlandingp.9
    Touchdown: airspeed 132.5 knots, pitch 3.69 degrees, ground speed 145 knots, engine 1 and 2 throttle lever angles 50.2 and 49.9 degrees, speed brake handle about 8 degrees (the Armed position)
  13. 11:37:44.5 MSTFDRlandingp.9
    Weight-on-wheels indicated Air again for 0.5 seconds before returning to Ground; the speed brake handle began retracting to about 2 degrees, just above Down; as WOW returned to Ground both thrust reversers indicated in transit and the handle moved back to 8 degrees
  14. 11:37:45-11:38:02 MSTFDRlandingp.9
    Thrust reversers showed In Transit and Not Deployed for ten seconds, Not In Transit for one second, In Transit for a further six seconds, then Not In Transit and Deployed
  15. 11:38:18 MSTFDRoverrunp.9
    Large downward spike in longitudinal acceleration and minor oscillations began in pitch (overrun into snow)
  16. 11:38:30 MSTFDRoverrunp.10
    Deceleration no longer indicated; ground speed reached one knot and remained there to the end of the recording
Recorder events without a clock time
  • March 31, 2011, first and second landings (SRN)Speed brake handle began moving toward the deployed position (about 80 degrees) less than one second after touchdown
  • March 31, 2011, third and fourth landings (SRN)Speed brake handle began moving toward deployed three to four seconds after touchdown, about when the thrust reversers completed their transition to deployed
  • March 31, 2011 (SFO landing)Auto speed brake system failed to deploy the lever on touchdown; crew extended it manually; airplane ferried to Tulsa where no air/ground sensing anomalies were found and the speed brake mechanism (actuator, no-back clutch, switches, wiring) was replaced
  • January 20, 2011Interview of William T. Satterfield, FAA Supervisory Principal Avionics Inspector for the American Airlines certificate: no direct FDR experience, outdated training, FDR maintenance program inspected every other quarter; found nothing on FDRs in ATOS
  • February 17, 2011Interview of James R. Leeder, FAA B757 Avionics Partial Program Manager: only one ATOS question (EPI 1.3.1) addresses the FDR; inspections check that the operator follows its program, not parameter validity; had never observed a reasonableness audit or functional check; never done an SAI on the 757 FDR program
  • January 25, 2011Interview of Kevin McBride, American Airlines Lead Engineer FOE-Avionics: reasonableness audits use on-the-job training and an AE checklist covering only the 34 mandatory categories; each engineer uses their own judgement; audits routinely find broken parameters; no process to keep FDR documentation aligned with current guidance
  • January 25, 2011Interview of Gerald Shroyer, American Airlines Avionics Engineering recorder engineer for about 3 months: no detailed knowledge of the 757 recorder STC, audit or functional check procedures
  • June 1, 2011FAA revised ATOS EPI/SAI criteria: inspectors must verify the operator maintains an FDR conversion document with an established correlation between recorded and measured values, and added oversight of the filtered-data rule (14 CFR 121.346)
  • December 7, 2011FAA response: all connected parameters, including those beyond the mandatory set, must be inspected and maintained; no FDR-specific inspector training is required (CBI course 25813 is available); requirements for operational checks, reasonableness checks and inspection intervals reside in the TC/STC holder's instructions for continued airworthiness
Flight Data Recorder 10 - Factual Report of Group Chairman · 6 events extracted by claude-fable-5-1 (in-session)Flight Data Recorder 10 - Addendum 1 - Report On Download After San Francisco Event · 3 events extracted by claude-fable-5-1 (in-session)Flight Data Recorder 10 - Summaries of Interviews Conducted by the FDR Group · 4 events extracted by claude-fable-5-1 (in-session)Flight Data Recorder 10 - FAA Response Letter · 2 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 10 of 33 lines shown
How the Board coded the sequence
  1. Landing-flare/touchdown: Flight control sys malf/fail→
  2. Landing-landing roll: Powerplant sys/comp malf/fail→
  3. Landing-landing roll: Runway excursion

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA11IA0472011-04-26no fatalitiesmatch 71
    BOEING 737-7Q8 · SOUTHWEST AIRLINES CO
    Chicago, IL
    • ●Aircraft › Aircraft power plant › Engine exhaust
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Personnel issues › Action/decision › Action
    • +2 more shared findings
  • DCA17FA0212016-10-28substantialmatch 54
    BOEING 767 · AMERICAN AIRLINES INC
    Chicago, IL
    • ●Organizational issues › Development › Manufacture/production
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA08MA0982008-09-204 fatalmatch 53
    Learjet LR60 · Global Exec Avaition
    Columbia, SC
    • ●Aircraft › Aircraft power plant › Engine exhaust
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
    Runway excursion
  • DCA15FA0852015-03-05substantialmatch 50
    MCDONNELL DOUGLAS AIRCRAFT CO MD 88 · Delta Air Lines
    New York, NY
    Runway excursion
  • DCA21FA1742021-07-02destroyedmatch 50
    BOEING 737-275C · RHOADES AVIATION INC
    Honolulu, HI
    • ●Personnel issues › Action/decision › Action
  • DCA24FA1202024-03-08substantialmatch 50
    BOEING 737-8 · UNITED AIRLINES INC
    Houston, TX
    • ●Personnel issues › Action/decision › Action
  • DCA09MA0212008-12-21substantialmatch 49
    BOEING 737-524 · CONTINENTAL AIRLINES INC
    Denver, CO
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
    Runway excursion
  • DCA13MA0812013-04-297 fatalmatch 49
    BOEING 747-400 BCF · National Air Cargo
    Bagram, AF
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Personnel issues › Action/decision › Action
    Flight control sys malf/fail

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 8Runway excursion
  • 3 of 8Loss of control on ground
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft power plant › Engine exhaust
  • Aircraft systems › Flight control system
  • Action/decision › Action
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters
  • Aircraft power plant › Engine (turbine/turboprop)
  • Development › Design
  • Support/oversight/monitoring › Oversight
  • Action/decision › Info processing/decision
  • Task performance › Communication (personnel)
  • Task performance › Workload management

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
  • DCA11IA0472011-04-26 · BOEING 737-7Q8 · SOUTHWEST AIRLINES CO
    The flight crew's delayed deployment of the speedbrakes and thrust reversers, resulting in insufficient runway remaining to bring the airplane to a stop. Contributing to the delay in deployment of these stopping devices was the flight crew's inadequate monitoring of the airplane's configuration after touchdown, likely as a result of being distracted by a perceived lack of wheel braking effectiveness. Contributing to the incident was the flight crew's omission of the Before Landing checklist, which includes an…
  • DCA17FA0212016-10-28 · BOEING 767 · AMERICAN AIRLINES INC
    The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contribu…
  • DCA08MA0982008-09-20 · Learjet LR60 · Global Exec Avaition
    The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of criti…
  • 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.
  • DCA21FA1742021-07-02 · BOEING 737-275C · RHOADES AVIATION INC
    The flight crewmembers’ misidentification of the damaged engine (after leveling off the airplane and reducing thrust) and their use of only the damaged engine for thrust during the remainder of the flight, resulting in an unintentional descent and forced ditching in the Pacific Ocean. Contributing to the accident were the flight crew’s ineffective crew resource management, high workload, and stress.
What it recommended after them
  • A-18-003TO THE FEDERAL AVIATION ADMINISTRATION: Establish and lead an industry group that evaluates current and enhanced inspection technologies regarding their appropriateness and effectiveness for applications using nickel alloys, and use the res… · DCA17FA021Open - Acceptable Response
  • A-18-004TO THE FEDERAL AVIATION ADMINISTRATION: Require subsurface in-service inspection techniques, such as ultrasonic inspections, for critical high-energy, life-limited rotating parts for all engines. · DCA17FA021Open - Acceptable Response
  • A-18-005TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular (AC) 20-128A, “Design Considerations for Minimizing Hazards Caused by Uncontained Turbine Engine and Auxiliary Power Unit Rotor Failure,” based on an analysis of uncontained e… · DCA17FA021Open - Acceptable Response
  • A-18-006TO THE FEDERAL AVIATION ADMINISTRATION: When approving the operating procedures of a 14 Code of Federal Regulations Part 121 air carrier, require operators to develop and/or revise emergency checklist procedures for an engine fire on the gr… · DCA17FA021Closed - Unacceptable Action
  • A-18-007TO THE FEDERAL AVIATION ADMINISTRATION: Develop and issue guidance to all air carriers that conduct passenger-carrying operations under 14 Code of Federal Regulations Part 121 regarding (1) discussing this accident during recurrent flight a… · DCA17FA021Closed - Unacceptable Action
  • A-18-008TO THE FEDERAL AVIATION ADMINISTRATION: Review the training programs of all 14 Code of Federal Regulations Part 121 operators and make changes as necessary to ensure that the programs provide flight attendants and flight crews with training… · DCA17FA021Closed - Unacceptable Action
  • A-18-009TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research to (1) measure and evaluate the effects of carry-on baggage on passenger deplaning times and safety during an emergency evacuation and (2) identify effective countermeasures to reduce… · DCA17FA021Open - Acceptable Response
  • A-18-010TO THE BOEING COMPANY: Work with operators as required to develop and/or revise emergency checklist procedures for an engine fire on the ground to expeditiously address the fire hazard without unnecessarily delaying an evacuation. · DCA17FA021Closed - 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).