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DE HAVILLAND DHC8ERA AVIATION 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.

0
timed facts
8
precedents
43
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

0 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

No timed facts: this docket has no extracted recorder sequence and no transcript.

Recorder events without a clock time
  • SRN 95,100Start of plotted flight data (figures 1-3 cover the flight to SRN 97,020)
  • about 12 minutes after takeoffAutopilot transitioned from engaged to not engaged; pressure altitude increasing through 12,192 ft, indicated airspeed decreasing through 88 knots, pitch increasing through 20 degrees nose up, roll increasing through 22 degrees left wing down
  • next 36 secondsPressure altitude decreased to 7,072 ft, indicated airspeed increased to 217 knots, pitch decreased to a maximum of 37 degrees nose down then increased to 2 degrees nose up; roll primarily left wing down reaching a maximum of 55 degrees, ending at 6 degrees right wing down
  • next 52 secondsPressure altitude increased to 8,128 ft, airspeed settled to about 199 knots, pitch to about 1 degree nose up; roll reached a maximum of 60 degrees right wing down then fluctuated before settling at 16 degrees left wing down
  • about 10 seconds laterAircraft began its descent; landed approximately 14 minutes later
Flight Data Recorder 10 - Specialist's Factual Report · 5 events extracted by claude-fable-5-1 (in-session)
How the Board coded the sequence
  1. Enroute-climb to cruise: Aerodynamic stall/spin

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA13IA0582013-02-07no fatalitiesmatch 89
    BOMBARDIER INC CL-600-2B19 · PSA Airlines, Inc.
    Bowman, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Psychological › Attention/monitoring
    Aerodynamic stall/spin
  • CEN22FA0312021-11-134 fatalmatch 64
    BRITTEN-NORMAN BN-2A · MCPHILLIPS FLYING SERVICE INC
    Beaver Island, MI
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Aerodynamic stall/spin
  • ANC16FA0172016-04-083 fatalmatch 60
    CESSNA 206 · SUNRISE AVIATION
    Angoon, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Info processing/decision
    Aerodynamic stall/spin
  • DCA09MA0272009-02-1349 fatalmatch 59
    BOMBARDIER INC DHC-8-402 · COLGAN AIR INC
    Clarence Center, NY
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Psychological › Attention/monitoring
    Aerodynamic stall/spin
  • CEN09MA1422009-01-27substantialmatch 58
    AEROSPATIALE ALENIA ATR 42-320 · Empire Airlines
    Lubbock, TX
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Aerodynamic stall/spin
  • NYC08MA0902008-02-016 fatalmatch 58
    RAYTHEON AIRCRAFT COMPANY C90A · BLUE SKY AIRWAYS INC
    Mount Airy, NC
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Info processing/decision
    Aerodynamic stall/spin
  • ANC18FA0552018-07-191 fatalmatch 57
    De Havilland DHC-2 · Alaska Skyways, Inc.
    Willow, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Info processing/decision
    Aerodynamic stall/spin
  • CEN18FA2152018-06-091 fatalmatch 56
    ROBINSON HELICOPTER R44 · MF HELICOPTERS LLC
    Oshkosh, WI
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Psychological › Attention/monitoring

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
  • 7 of 8Aerodynamic stall/spin
  • 4 of 8Collision with terr/obj (non-CFIT)
  • 2 of 8Loss of control in flight
  • 2 of 8Stall warn/stick-shaker/pusher
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Psychological › Attention/monitoring
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Task performance › Communication (personnel)
  • 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
  • DCA13IA0582013-02-07 · BOMBARDIER INC CL-600-2B19 · PSA Airlines, Inc.
    the captain's inappropriate climb speed, his failure to monitor airspeed during the level off, and his inappropriate response to multiple stall warnings.
  • CEN22FA0312021-11-13 · BRITTEN-NORMAN BN-2A · MCPHILLIPS FLYING SERVICE INC
    The pilot's exceedance of the airplane's critical angle of attack during final approach, which resulted in an aerodynamic stall and loss of control at an altitude too low to recover.
  • ANC16FA0172016-04-08 · CESSNA 206 · SUNRISE AVIATION
    The pilot's inadvertent turn toward terrain that was higher-than-expected while trying to avoid poor visibility conditions and his subsequent attempt to clear terrain, which reduced the airspeed and led to the exceedance of the airplane's critical angle of attack and an aerodynamic stall and spin.
  • DCA09MA0272009-02-13 · BOMBARDIER INC DHC-8-402 · COLGAN AIR INC
    The captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew's failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches…
  • CEN09MA1422009-01-27 · AEROSPATIALE ALENIA ATR 42-320 · Empire Airlines
    The flight crew's failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were 1) the flight crew's failure to follow published standard operating procedures in response to a flap anomaly, 2) the captain's decision to continue with the unstabilized approach, 3) the flight crew's poor crew resource management, and 4) fatigue due to the time of day in which the accident occu…
What it recommended after them
  • A-10-010TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques desc… · DCA09MA027Closed - Unacceptable Action
  • A-10-011TO THE FEDERAL AVIATION ADMINISTRATION: Require that airspeed indicator display systems on all aircraft certified under 14 Code of Federal Regulations Part 25 and equipped with electronic flight instrument systems depict a yellow/amber caut… · DCA09MA027Closed - Acceptable Action
  • A-10-012TO THE FEDERAL AVIATION ADMINISTRATION: For all airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121, 135, and 91K, require the installation of low-airspeed alert systems that provide pilots with redunda… · DCA09MA027Open - Unacceptable Response
  • A-10-013TO THE FEDERAL AVIATION ADMINISTRATION: Issue an advisory circular with guidance on leadership training for upgrading captains at 14 Code of Federal Regulations Part 121, 135, and 91K operators, including methods and techniques for effectiv… · DCA09MA027Closed - Acceptable Alternate Action
  • A-10-014TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide a specific course on leadership training to their upgrading captains that is consistent with the advisory circula… · DCA09MA027Closed - Unacceptable Action
  • A-10-015TO THE FEDERAL AVIATION ADMINISTRATION: Develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile coc… · DCA09MA027Closed - Unacceptable Action
  • A-10-016TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to address fatigue risks associated with commuting, including identifying pilots who commute, establishing policy and guidan… · DCA09MA027Closed - Unacceptable Action
  • A-10-017TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to document and retain electronic and/or paper records of pilot training and checking events in sufficient detail so that the ca… · DCA09MA027Closed - 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).