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Cases › DCA13MA081 › The analyst

BOEING 747-400 BCFNational Air Cargo

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.

32
timed facts
8
precedents
71
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

32 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. 07:50 GMT (previous flight)FDRprevious flightp.4
    FDR began recording for the previous flight from Camp Bastion; aircraft took off at 08:04 from runway 19 with maximum pitch after rotation of 17 degrees; cruise at around 29,000 ft reached at 08:30 with descent about 20 minutes later; vertical acceleration perturbations of +0.62 g to +1.36 g in the descent; landed at Bagram runway 03 at 09:09 with minimum longitudinal acceleration -0.27 g; last fuel 46,200 lb, gross weight 617,280 lb; FDR stopped at 09:19:28
    see the traces at this moment ↗
  2. 09:57:33CVR CAM-2p.11
    “there’s your trouble Brad.”
    read in context ↗
  3. 10:41:21CVR CAMp.17
    “[break in transcript]”
    read in context ↗
  4. 10:41:21CVR HOT-1p.17
    “ok. starting four and three [engines 4 and 3]”
    read in context ↗
  5. 10:41:23 GMTFDRpre-flightp.4
    FDR began recording for the accident flight; total fuel 106,000 lb, gross weight 677,120 lb
    see the traces at this moment ↗
  6. 10:44 GMTFDRtaxip.4
    Flaps lowered to 10 degrees, leading edge flaps extended, flight control check performed
    see the traces at this moment ↗
  7. 10:45:32CVR GNDcalloutp.18
    “nine five alpha quebec, cleared direct SIBLO via diverse vectors. on departure fly runway heading until thee DME then turn left heading two one zero. climb and maintain two eight zero, squawk zero four seven three, departure frequency one two four point eight.”
    read in context ↗
  8. 10:45:48CVR RDO-2calloutp.18
    “ok understand cleared to diverse vectors to SIBLO on takeoff runway heading to three DME, then right turn two one zero up to flight level two eight zero, squawk zero four seven three, on one two four decimal eight for departure ISAF nine five alpha quebec.”
    read in context ↗
  9. 10:48:17CVR HOT-2calloutp.20
    “all right. for our takeoff departure review, be uh...I got one six seven, V1 one forty, runway heading is zero two seven up to flight level two eight zero,”
    read in context ↗
  10. 10:48:17CVR TOGAcalloutp.20
    “TOGA, VNAV, uh when I get up to three DME, have you put me on uh runway heading... actually before that, I'll have you- * right autopilot on command.”
    read in context ↗
  11. 10:48:59CVR HOT-1calloutp.20
    “kay uh, let’s go before takeoff checklist, to the line.”
    read in context ↗
  12. 10:49:02CVR HOT-2calloutp.21
    “before takeoff checklist....... flaps?”
    read in context ↗
  13. 10:49:12CVR HOT-2calloutp.21
    “takeoff departure review is complete, before takeoff checklist is complete to the line.”
    read in context ↗
  14. 10:54:55CVR HOT-2calloutp.27
    “verified runway three. before takeoff checklist complete.”
    read in context ↗
  15. 10:55:44CVR HOT-1calloutp.28
    “cleared for takeoff.”
    read in context ↗
  16. 10:55:45CVR HOT-2p.28
    “clear for takeoff runway three.”
    read in context ↗
  17. 10:55:47 GMTFDRtakeoffp.4
    Last radio call before takeoff after taxiing and lining up on runway 03
    see the traces at this moment ↗
  18. 10:55:47CVR RDO-2p.28
    “clear for takeoff runway three, ISAF nine five alpha quebec.”
    read in context ↗
  19. 10:55:52CVR HOT-1p.28
    “got it.”
    read in context ↗
  20. 10:55:54 GMTFDRtakeoffp.4
    N1 for all four engines began to increase, reaching full power at 10:56:11
    see the traces at this moment ↗
  21. 10:56:22CVR HOT-2final secondsp.29
    “checks.”
    read in context ↗
  22. 10:56:33 GMTFDRtakeoffp.4
    At 137 knots the pitch parameter began to increase (rotation)
    see the traces at this moment ↗
  23. 10:56:34CVR HOT-1final secondsp.29
    “V1.”
    read in context ↗
  24. 10:56:35CVR AWSfinal secondsp.29
    “V1. [from the Aural Voice Annunciation system]”
    read in context ↗
  25. 10:56:38CVR HOT-1final secondsp.29
    “rotate.”
    read in context ↗
  26. 10:56:40 GMTFDRtakeoffp.4
    Slight right roll of +2 degrees recorded
    see the traces at this moment ↗
  27. 10:56:42 GMTFDRlift-offp.4
    One sample of the air/ground sensor transitioning from ground to air at 163 knots; the sensor toggled between air and ground over the next 1.5 seconds
    see the traces at this moment ↗
  28. 10:56:44CVR HOT-1final secondsp.29
    “positive climb.”
    read in context ↗
  29. 10:56:45 GMTFDRinitial climbp.4
    Last recorded data point: airspeed 171 knots, pitch 13 degrees, roll +4 degrees right, radio altitude 33 ft, gross weight 675,200 lb; the CVR ceased at approximately the same moment; other sources indicate the flight continued past this time
    see the traces at this moment ↗
  30. 10:56:45CVR HOT-2final secondsp.29
    “gear up.”
    read in context ↗
  31. 10:56:46CVR HOT-1final secondsp.29
    “keep on that (wing/weight/wait).”
    read in context ↗
  32. 10:56:47CVR CAMfinal secondsp.29
    “[End of Recording, End of Transcript] E”
    read in context ↗
Recorder events without a clock time
  • takeoff roll (SRN 6220-6276.3)Aircraft configured for a flaps 10 takeoff with a recorded stabilizer setting of approximately -0.85 degrees (3.85 units); recorded gross weight approximately 676,000 lb (Boeing Weights Engineering calculated ~685,000 lb accounting for pallets and tie-downs); maximum takeoff thrust with N1 = 108 percent; slight left rudder on average to hold centerline
  • takeoff rollFluctuations in computed airspeed consistent with gusty wind conditions; last valid wind data about 12 knots from 040 degrees true (right crosswind on runway magnetic heading 027), differing in direction from METARs
  • SRN 6268.5Rotation initiated with a nose-up column input, approximately 4,700 ft beyond the runway threshold just after Taxiway E; aircraft rotated to a normal takeoff pitch attitude
  • SRN ~6274.5Lift-off, approximately 6,400 ft beyond the threshold; the air/ground discrete momentarily changed to air twice before lift-off
  • SRN ~6276.3Valid data end about 2 seconds after lift-off, around 6,860 ft beyond the threshold: 33 ft radio altitude, 171 knots computed airspeed (V2+4), pitch approximately 13 degrees, bank approximately 4 degrees right, elevators around 5-6 degrees trailing edge up
  • after data endDash-cam video shows the airplane at low altitude with an extremely high pitch attitude, motion consistent with an aerodynamic stall, then a roll/yaw right and nose-down ground impact near the end of the runway about 600 ft right of the centerline; body and nose gear extended, wing gear raised at impact
  • simulation (SRN 6272)Boeing simulation with a CG shift from 31.7 to 34.9 percent ramped over 3 seconds (aft-most MRAP moving to the stabilizer jackscrew) matched pitch, longitudinal acceleration and radio altitude better than the baseline; an incremental nose-up stabilizer deflection of 5 units or more could have produced the observed motion
Flight Data Recorder (FDR) Group Chairman's Factual Report · 9 events extracted by claude-fable-5-1 (in-session)FDR Data Study · 7 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder Group Chairman's Factual Report · 23 of 233 lines shown
How the Board coded the sequence
  1. Prior to flight: Aircraft loading event→
  2. Initial climb: Loss of control in flight→
  3. Uncontrolled descent: Flight control sys malf/fail

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • CEN17MA1832017-05-152 fatalmatch 58
    LEARJET 35A · Trans-Pacific Jets
    Teterboro, NJ
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Management › Policy/procedure
    • ●Organizational issues › Support/oversight/monitoring › Oversight
    • +1 more shared findings
    Loss of control in flight
  • ANC25MA0182025-02-0610 fatalmatch 54
    TEXTRON AVIATION INC 208B · BERING AIR INC
    Nome, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Management › Policy/procedure
    • ●Organizational issues › Support/oversight/monitoring › Oversight
    Loss of control in flight
  • DCA19MA0862019-02-233 fatalmatch 53
    Boeing 767 · Atlas Air
    Trinity Bay, TX
    • ●Personnel issues › Action/decision › Action
    Loss of control in flight
  • CEN16MA0362015-11-109 fatalmatch 52
    BRITISH AEROSPACE HS 125 700A · Execuflight
    Akron, OH
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Management › Policy/procedure
    • ●Organizational issues › Support/oversight/monitoring › Oversight
    • +1 more shared findings
  • ERA14MA2712014-06-017 fatalmatch 50
    GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLC
    Bedford, MA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Organizational issues › Management › Policy/procedure
    • +2 more shared findings
  • ERA22FA0042021-10-052 fatalmatch 49
    DASSAULT Falcon 20 · Pak West Airlines Inc.
    Thomson, GA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Personnel issues › Action/decision › Action
  • DCA11IA0152010-12-29no fatalitiesmatch 49
    BOEING 757-223 · AMERICAN AIRLINES INC
    Jackson Hole, WY
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Personnel issues › Action/decision › Action
    Flight control sys malf/fail
  • DCA09MA0212008-12-21substantialmatch 48
    BOEING 737-524 · CONTINENTAL AIRLINES INC
    Denver, CO
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action

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)
  • 3 of 8Aerodynamic stall/spin
  • 3 of 8Loss of control in flight
  • 3 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
  • Aircraft systems › Flight control system
  • Management › Policy/procedure
  • Support/oversight/monitoring › Oversight
  • Action/decision › Action
Cited here, not seen in the precedents
  • Aircraft systems › Hydraulic power system
Common in the precedents, not cited here
  • Development › Selection/certification/testing
  • 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
  • CEN17MA1832017-05-15 · LEARJET 35A · Trans-Pacific Jets
    The pilot-in-command's (PIC) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude. Contributing to the accident was the PIC's decision to allow an unapproved second-in-command to act as pilot flying, the PIC's inadequate and incomplete preflight planning, and the flight crew's lack of an approach briefing. Also contributing to the accident were Trans-Pacific Jets' lack of safety programs that would have enabled the company to identify and correct patterns of poo…
  • ANC25MA0182025-02-06 · TEXTRON AVIATION INC 208B · BERING AIR INC
    The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s inadequate airspeed management due to workload and degraded situation awareness and his improper inputs leading up to and during the aerodynamic stall, which increased the airplane’s angle of attack. Also causal was operation of the airplane above maximum gross weight, which reduced the airplane’s stall margin. Contributing to the accident were the operator’s inadequate safety management, which allowed the r…
  • DCA19MA0862019-02-23 · Boeing 767 · Atlas Air
    The inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain's failure to adequately monitor the airplane's flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry's selec…
  • CEN16MA0362015-11-10 · BRITISH AEROSPACE HS 125 700A · Execuflight
    The flight crew's mismanagement of the approach and multiple deviations from company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach, a descent below minimum descent altitude without visual contact with the runway environment, and an aerodynamic stall. Contributing to the accident were Execuflight's casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company's lack of…
  • ERA14MA2712014-06-01 · GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLC
    The flight crewmembers' failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew's habitual noncompliance with checklists, Gulfstream Aerospace Corporation's failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and th…
What it recommended after them
  • A-19-007TO THE FEDERAL AVIATION ADMINISTRATION: Require all Title 14 Code of Federal Regulations Part 135 operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures during training… · CEN17MA183Closed - Acceptable Action
  • A-19-008TO THE FEDERAL AVIATION ADMINISTRATION: Develop guidance for Title 14 Code of Federal Regulations Part 135 operators to help them create and implement effective crew resource management training programs. · CEN17MA183Open - Unacceptable Response
  • A-19-009TO THE FEDERAL AVIATION ADMINISTRATION: Review operators’ Learjet 35A operations manuals to determine whether they contain manufacturer-recommended approach speed wind additives and encourage those operators without that information to add… · CEN17MA183Closed - Exceeds Recommended Action
  • A-26-064TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 135 and 91K operators, except single-pilot and single-pilot-in-command operators, to incorporate upset prevention and recovery training, whether in a si… · ANC25MA018Open - Await Response
  • A-26-065TO THE FEDERAL AVIATION ADMINISTRATION: Develop explicit surveillance criteria for 14 Code of Federal Regulations Part 135 and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents,… · ANC25MA018Open - Await Response
  • A-20-033TO THE FEDERAL AVIATION ADMINISTRATION: Inform Title 14 Code of Federal Regulations Part 119 certificate holders, air tour operators, fractional ownership programs, corporate flight departments, and governmental entities conducting public a… · DCA19MA086Closed - Acceptable Action
  • A-20-034TO THE FEDERAL AVIATION ADMINISTRATION: Implement the pilot records database and ensure that it includes all industry records for all training started by a pilot as part of the employment process for any Title 14 Code of Federal Regulations… · DCA19MA086Closed - Acceptable Action
  • A-20-035TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that industry records maintained in the pilot records database are searchable by a pilot’s certificate number to enable a hiring operator to obtain all background records for a pilot reported b… · DCA19MA086Closed - Unacceptable 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).