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Cases › DCA11IA040 › The analyst

Airbus A320United Airlines

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.

41
timed facts
8
precedents
45
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

41 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. 06:53:41-06:53:47 CDTFDRpre-flightp.4
    FDR began recording on the ground; the avionics smoke warning from the flight warning computer was already active and remained so continuously until the last data point; no master warning or other faults recorded (master caution not a recorded parameter)
    see the traces at this moment ↗
  2. 06:53:45.8CVR STARTp.9
    “OF RECORDING”
    read in context ↗
  3. 06:53:45.8CVR STARTp.9
    “OF TRANSCRIPT”
    read in context ↗
  4. 06:58:37.4CVR INT-4p.14
    “and pre departure check is complete. **.”
    read in context ↗
  5. 06:58:42.1CVR INT-1p.14
    “okay roger that. would you like the brakes and we'll call—. [POWER INTERRUPTION LASTING FROM 6:58:44 TO 7:01:19.7]”
    read in context ↗
  6. 06:58:44-07:01:20 CDTFDRengine startp.4
    FDR stopped after the 5-minute ground timer with no engine running and resumed when the left engine was started (2 minutes 35 seconds gap inserted in the plots)
    see the traces at this moment ↗
  7. 07:05:46.8CVR PA-2calloutp.19
    “flight attendants prepare for takeoff please.”
    read in context ↗
  8. 07:07:28.0CVR TWRcalloutp.20
    “United four ninety seven runway one niner. fly the runway heading. cleared for takeoff.”
    read in context ↗
  9. 07:07:32.3CVR RDO-2calloutp.20
    “runway heading. cleared for takeoff. runway one nine. thanks very much United four nine seven.”
    read in context ↗
  10. 07:07:36.4CVR HOT-2calloutp.20
    “final items. cabin notification complete. transponder traffic. takeoff memo's green. before takeoff checklist complete.”
    read in context ↗
  11. 07:08:36 CDTFDRtakeoffp.4
    Takeoff with autothrust engaged and active; climb at EPR 1.4 with throttles around 42 degrees in autopilot climb mode
    see the traces at this moment ↗
  12. 07:08:36.2CVR HOT-2p.21
    “positive climb. gear up.”
    read in context ↗
  13. 07:08:42.4CVR HOT-2p.21
    “pull for heading please.”
    read in context ↗
  14. 07:08:59.8CVR RDO-2p.21
    “and four ninety seven departure. good day.”
    read in context ↗
  15. 07:09:01 CDTFDRclimbp.4
    Throttles reduced over 3 seconds to 22 degrees, EPR 1.3, climb continued
    see the traces at this moment ↗
  16. 07:09:04.2CVR HOT-2p.21
    “let's go flaps one please.”
    read in context ↗
  17. 07:09:45.9CVR HOT-2calloutp.22
    “and flaps up please. after takeoff checklist at your leisure.”
    read in context ↗
  18. 07:10:20 CDTFDRclimbp.4
    ECAM page select recorded 'elec' (electrical page displayed); previous 4-second sample had recorded 'cruise'
    see the traces at this moment ↗
  19. 07:10:25.7CVR HOT-1p.22
    “okay ECAM I got the uh— uh you got the jet. I got this.”
    read in context ↗
  20. 07:10:30.2CVR HOT-2p.22
    “I got the jet.”
    read in context ↗
  21. 07:10:34.8CVR HOT-1p.22
    “mask on. we don't have that.”
    read in context ↗
  22. 07:10:36 CDTFDRclimbp.4
    Throttle reduction, returning to the previous position at 07:10:44
    see the traces at this moment ↗
  23. 07:10:36.2CVR HOT-1p.22
    “cabin fans off. DCA11IA040”
    read in context ↗
  24. 07:10:51.4CVR HOT-1p.23
    “auto— autopilot won't *.”
    read in context ↗
  25. 07:10:52 CDTFDRclimbp.4
    Autothrust changed from active/engaged to not active/not engaged, with a throttle reduction shortly after
    see the traces at this moment ↗
  26. 07:10:54.5CVR HOT-1p.23
    “we— we got a no # uh deal. blower off.”
    read in context ↗
  27. 07:11:40.2CVR HOT-2p.24
    “you want me to start getting vectors back?”
    read in context ↗
  28. 07:11:41.4CVR HOT-1p.24
    “yeah uh gen two off. [POWER INTERRUPTION LASTING FROM 7:11:43.5 to 7:11:49.2]”
    read in context ↗
  29. 07:11:42 CDTFDRclimbp.4
    Last valid FDR data point: climbing through 5,224 ft at 252 knots on a heading of 251 degrees; no data for the remainder of the flight (loss of power to the FDR)
    see the traces at this moment ↗
  30. 07:13:02.6CVR RDO-2warningp.26
    “alright pilot's discretion to two thousand for United four ninety seven. we are declaring an emergency. and please roll the equipment for our landing please. DCA11IA040”
    read in context ↗
  31. 07:13:10.6CVR HOTwarningp.27
    “[sound similar to altitude alert]”
    read in context ↗
  32. 07:15:11.5CVR HOTwarningp.30
    “[sound similar to altitude alert]”
    read in context ↗
  33. 07:15:50.9CVR HOT-2final secondsp.31
    “okay I have no way to put that in so it's gonna be a visual.”
    read in context ↗
  34. 07:15:52.4CVR HOTfinal secondsp.31
    “[sound of continuous repetitive chime until end of recording]”
    read in context ↗
  35. 07:15:52.8CVR HOT-1final secondsp.31
    “yeah.”
    read in context ↗
  36. 07:15:56.3CVR HOT-1final secondsp.31
    “select gear down.”
    read in context ↗
  37. 07:15:57.8CVR HOT-2final secondsp.31
    “gear down?”
    read in context ↗
  38. 07:15:58.5CVR HOT-1final secondsp.31
    “yeah. let's go to the emergency...”
    read in context ↗
  39. 07:16:00.0CVR CAMfinal secondsp.31
    “[sound similar to landing gear deployment]”
    read in context ↗
  40. 07:16:02.9CVR HOT-1final secondsp.31
    “right one four—.”
    read in context ↗
  41. April 2, 2011, SRN 117290 (20:01:39 GMT)FDRprevious flightp.17
    Two days earlier, on the ground between flights, an avionics smoke warning was recorded for about 18 minutes until SRN 118385 when parameters became invalid (possible power interruption); at SRN 118481 the parameter was valid again with no warning and the aircraft took off shortly after
Flight Data Recorder 10 - Specialist's Factual Report · 9 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 32 of 258 lines shown
How the Board coded the sequence
  1. Initial climb: Electrical system malf/failure→
  2. Enroute-climb to cruise: Fire/smoke (non-impact)→
  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
  • DCA15CA1292015-06-08no fatalitiesmatch 70
    MCDONNELL DOUGLAS DC 9 83(MD-83) · ALLEGIANT AIR LLC
    St Petersburg, FL
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
    Fire/smoke (non-impact)
  • OPS16IA0042016-01-29no fatalitiesmatch 70
    AIRBUS A321 231 · Spirit Airlines
    Fort Lauderdale, FL
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • OPS15IA0202015-08-08no fatalitiesmatch 67
    AIRBUS INDUSTRIE A320 211 · Delta Air Lines
    Max, NE
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • OPS10IA1962010-05-21no fatalitiesmatch 64
    AIRBUS INDUSTRIE A319-132 · USAirways Inc
    Anchorage, AK
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • SEA08LA0612008-01-14substantialmatch 52
    Bombardier, Inc. CL-600-2C10 · United Express
    San Francisco, CA
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • OPS14IA0052014-04-24no fatalitiesmatch 51
    EMBRAER EMB 145XR · NOT SPECIFIED
    Newark, NJ
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • CEN12FA1002011-12-094 fatalmatch 49
    CESSNA 421C · Quest Aviation Inc.
    Sioux Falls, SD
    • ●Personnel issues › Action/decision › Info processing/decision
    Fire/smoke (non-impact)
  • SEA08IA0962008-03-26no fatalitiesmatch 48
    Raytheon Aircraft Company 1900D · Great Lakes Aviation
    Page, AZ
    • ●Personnel issues › Action/decision › Info processing/decision

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
  • 2 of 8Fire/smoke (non-impact)
  • 2 of 8Air traffic event
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Action/decision › Info processing/decision
  • Task performance › Communication (personnel)
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Action/decision › Action

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
  • DCA15CA1292015-06-08 · MCDONNELL DOUGLAS DC 9 83(MD-83) · ALLEGIANT AIR LLC
    evacuation of the aircraft due to reported, but unverified, aircraft condition and poor communication between Aircraft Rescue and Firefighting personnel and the flight crew.
  • OPS16IA0042016-01-29 · AIRBUS A321 231 · Spirit Airlines
    The air traffic controller's failure to ensure the runway surface area was clear of vehicles before clearing an aircraft for takeoff. Also causal was the flight crew's decision to initiate a takeoff while the Runway Status Lights (RWSL) Takeoff Hold Lights (THLs) were activated. Contributing to the incident was the lack of a standard procedure for vehicle operators to request runway clearances and resultant "hear back/read back" error between the vehicle operator and the air traffic controller.
  • OPS15IA0202015-08-08 · AIRBUS INDUSTRIE A320 211 · Delta Air Lines
    The flight crew's continued flight into a closing gap between areas of thunderstorm activity and their failure to maintain the required lateral separation from the thunderstorms, which resulted in the airplane's encounter with hail and subsequent airplane damage. Contributing to the incident were the company flight dispatcher's failure to provide complete and timely weather information to the flight crew and the Denver air route traffic controller's failure to provide significant pilot weather report information…
  • OPS10IA1962010-05-21 · AIRBUS INDUSTRIE A319-132 · USAirways Inc
    The approach controller's delayed transfer of communications on the A319 to the tower controller and failure to account for the aircraft's speed when he directed the crew to turn north. Contributing to the incident was the 747 crew's transfer of radio communications to departure control prior to being directed to do so by the tower controller.
  • SEA08LA0612008-01-14 · Bombardier, Inc. CL-600-2C10 · United Express
    The company tug operator's failure to maintain clearance with another aircraft during the pushback process. Also causal was the ground controller's failure to alert the pilot of the other aircraft and tug operator of this airplane of the simultaneous pushback occurring from adjacent gates. Contributing to the accident was the company's pushback operation without the use of wing/tail walkers.

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).