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Cases › DCA13MA120 › The analyst

BOEING 777-200ERAsiana 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.

84
timed facts
8
precedents
1,008
passages to ask

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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

84 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. 10:42:27.9CVR CAM-2p.8
    “{I will give you a} approach briefing. {current weather is Juliet, variable is six, visibility is one zero mile cloud few is one thousand three hundred scattered is eighteen hundred, temperature seventeen Celsius, dew point is ten degree, and altimeter is twenty nine eighty two. Runway is twenty eight L, and I set approach with localizer. And I will fly through Point Reyes, Papa Yankee Echo, of Golden Gate Six Arrival and when close to San Francisco I will fly using radial three zero three to San Francisco. and when I receive vector of final turn twenty eight left or right. airport field elevation is thirteen feet and transition is one eight zero MSA. North of airport is five thousand one hundred and approach side is four thousand five hundred. Type of approach is localizer and”
    read in context ↗
  2. 10:47:35.1CVR CAM-2calloutp.10
    “VREF one three two, minimum four six zero.”
    read in context ↗
  3. 10:47:38.4CVR CAM-1calloutp.10
    “VREF one three two, minimum four six zero.”
    read in context ↗
  4. 11:17:29.7CVR HOT-2p.27
    “sir nine thousand flight level change.”
    read in context ↗
  5. 11:17:31.6CVR HOT-1p.27
    “check sir.”
    read in context ↗
  6. 11:17:38 PDTFDRdescentp.7
    Aircraft descended through 10,000 ft at about 210 knots, 10 minutes 12 seconds before impact; flaps up, gear up, gross weight approximately 425,000 lb; autothrottle in Thrust mode, autopilot in Flight Level Change pitch mode
    see the traces at this moment ↗
  7. 11:18:46 PDTFDRdescentp.7
    Autopilot pitch mode changed to Altitude Capture, autothrottle to Speed; aircraft leveled at 9,000 ft (selected altitude)
    see the traces at this moment ↗
  8. 11:18:51.5CVR CAM-1p.28
    “speed alt sir.”
    read in context ↗
  9. 11:18:52.5CVR CAM-2p.28
    “check.”
    read in context ↗
  10. 11:19:25.0CVR APRp.28
    “Asiana two one four heavy descend and maintain six thousand turn left heading one zero zero.”
    read in context ↗
  11. 11:19:28 PDTFDRdescentp.7
    Selected altitude changed to 6,000 ft; about 4 seconds later pitch mode to FLCH, autothrottle to Thrust, and a series of 4 left turns began over the next four and a half minutes onto the final approach heading; thrust lever angles decreased to about 34 degrees over six seconds, then autothrottle mode changed to Hold
    see the traces at this moment ↗
  12. 11:19:29.5CVR RDO-1p.28
    “heading one zero zero descend six thousand Asian two one four.”
    read in context ↗
  13. 11:20:57.0CVR APRp.29
    “Asiana two one four heavy descend and maintain four thousand turn left heading zero three zero.”
    read in context ↗
  14. 11:21:00 PDTFDRdescentp.8
    Selected altitude changed to 4,000 ft; descent continued with pitch mode FLCH and autothrottle Hold
    see the traces at this moment ↗
  15. 11:21:01.0CVR RDO-1p.29
    “heading zero three zero descend four thousand Asiana two one four.”
    read in context ↗
  16. 11:21:03 PDTFDRdescentp.8
    Speed brakes extended for about 54 seconds
    see the traces at this moment ↗
  17. 11:21:04.4CVR HOT-2p.29
    “yes sir zero three zero four thousand.”
    read in context ↗
  18. 11:22:09.0CVR HOT-1p.30
    “yes.”
    read in context ↗
  19. 11:22:11 PDTFDRapproachp.8
    Localizer mode Armed; localizer intercept indicated at 11:22:28; selected altitude to about 3,000 ft at 11:22:48; localizer capture at 11:22:51
    see the traces at this moment ↗
  20. 11:22:12.7CVR HOT-1p.30
    “localizer armed.”
    read in context ↗
  21. 11:23:02 PDTFDRapproachp.8
    Selected altitude set to about 1,800 ft; flap handle to detent 1 at 11:23:10; selected airspeed reduced from 212 to 172 knots over 35 seconds from 11:23:16; flap handle to detent 5 at 11:23:45
    see the traces at this moment ↗
  22. 11:23:03.1CVR HOT-1p.31
    “{because} clear visual {is given.}”
    read in context ↗
  23. 11:23:04.0CVR HOT-1p.31
    “yes sir.”
    read in context ↗
  24. 11:23:57 PDTFDRapproachp.8
    Autopilot pitch mode changed to Vertical Speed and autothrottle to Speed; airspeed about 195 knots, selected 172 knots; recorded vertical speed about -400 ft/min, selected -1000 ft/min
    see the traces at this moment ↗
  25. 11:23:58.0CVR HOT-1p.32
    “V/S.”
    read in context ↗
  26. 11:23:58.8CVR HOT-2p.32
    “one thousand.”
    read in context ↗
  27. 11:24:50.6CVR HOT-2calloutp.33
    “okay gear down sir.”
    read in context ↗
  28. 11:24:52.0CVR HOT-1p.33
    “gear down.”
    read in context ↗
  29. 11:24:53 PDTFDRapproachp.8
    Gear handle selected down, about 3 minutes before impact
    see the traces at this moment ↗
  30. 11:24:53.1CVR CAM-1p.33
    “{this seems a little high.}”
    read in context ↗
  31. 11:25:43.4CVR HOT-2p.34
    “(missed) approach three thousand * *.”
    read in context ↗
  32. 11:25:45 PDTFDRapproachp.8
    Selected altitude changed from about 1,800 ft to about 3,000 ft; radio altitude about 2,350 ft
    see the traces at this moment ↗
  33. 11:25:50.3CVR CAM-?p.34
    “(down flaps five).”
    read in context ↗
  34. 11:26:04.9CVR CAM-1p.34
    “flaps twenty.”
    read in context ↗
  35. 11:26:05 PDTFDRapproachp.8
    Flap handle set to detent 20
    see the traces at this moment ↗
  36. 11:26:05.9CVR CAM-2p.34
    “yeah.”
    read in context ↗
  37. 11:26:21.2CVR HOT-1p.35
    “{* * speed. speed one three seven.* * one thousand speed. speed one three seven.}”
    read in context ↗
  38. 11:26:25 PDTFDRapproachp.8
    At about 1,600 ft radio altitude, pitch mode changed from Vertical Speed to FLCH and autothrottle from Speed to Thrust; the aircraft began a climb toward the selected 3,000 ft with a slight thrust increase and pitch up
    see the traces at this moment ↗
  39. 11:26:28.3CVR CAM-1p.35
    “flaps thirty.”
    read in context ↗
  40. 11:26:29 PDTFDRapproachp.9
    Autopilot disengaged; flight director began displaying pitch-up commands toward the selected altitude
    see the traces at this moment ↗
  41. 11:26:29.5CVR HOT-2p.35
    “* sir *.”
    read in context ↗
  42. 11:26:30 PDTFDRapproachp.9
    Flap handle set to detent 30; two seconds later autothrottle changed from Thrust to Hold after thrust lever angles returned to about 34 degrees (about 1,475 ft radio altitude)
    see the traces at this moment ↗
  43. 11:26:35.7CVR CAM-1p.35
    “speed.”
    read in context ↗
  44. 11:26:36.8CVR CAM-2p.35
    “target speed one three seven.”
    read in context ↗
  45. 11:26:37 PDTFDRapproachp.9
    At about 1,400 ft radio altitude, airspeed approximately 170 knots; selected airspeed changed to 137 knots
    see the traces at this moment ↗
  46. 11:26:41.3CVR CAM-1p.35
    “okay.”
    read in context ↗
  47. 11:26:44.0CVR CAM-1p.35
    “{it's high.}”
    read in context ↗
  48. 11:26:45 PDTFDRapproachp.9
    At about 1,240 ft radio altitude the captain's flight director switch was selected off while the first officer's remained on, and they stayed so to the end; the AFDS mode did not change again
    see the traces at this moment ↗
  49. 11:26:52.2CVR CAM-1p.35
    “one thousand.”
    read in context ↗
  50. 11:26:54.2CVR CAM-2p.35
    “check.”
    read in context ↗
  51. 11:26:55 PDTFDRfinal approachp.9
    At about 1,000 ft radio altitude, airspeed approximately 149 knots
    see the traces at this moment ↗
  52. 11:26:58.6CVR CAM-3warningp.36
    “sink rate sir.”
    read in context ↗
  53. 11:27:05 PDTFDRfinal approachp.9
    Descent rate momentarily -1776 ft/min, the highest in the last 2.5 minutes; from here it gradually decreased to -608 ft/min at impact while pitch attitude increased until stick shaker activation
    see the traces at this moment ↗
  54. 11:27:05.1CVR CAM-3warningp.36
    “sink rate sir.”
    read in context ↗
  55. 11:27:06.1CVR HOT-1p.36
    “cleared to land {?}”
    read in context ↗
  56. 11:27:07.3CVR CAM-?warningp.36
    “{(sink rate.)}”
    read in context ↗
  57. 11:27:07.5CVR TWRcalloutp.36
    “Asiana two one four heavy San Francisco tower runway two eight left cleared to land.”
    read in context ↗
  58. 11:27:10.8CVR RDO-2calloutp.36
    “cleared to land two eight left Asiana two one four.”
    read in context ↗
  59. 11:27:14.3CVR CAM-1p.36
    “okay.”
    read in context ↗
  60. 11:27:15 PDTFDRfinal approachp.9
    At about 500 ft radio altitude, airspeed approximately 134 knots, 3 knots below the selected airspeed
    see the traces at this moment ↗
  61. 11:27:15.5CVR CAMp.36
    “five hundred. [electronic voice]”
    read in context ↗
  62. 11:27:16.8CVR CAMcalloutp.36
    “minimums, minimums. [electronic voice]”
    read in context ↗
  63. 11:27:17.5CVR CAM-1calloutp.36
    “landing checklist complete cleared to land.”
    read in context ↗
  64. 11:27:31 PDTFDRfinal approachp.9
    Stall protection function activated, reaching a peak value about 15 seconds later
    see the traces at this moment ↗
  65. 11:27:32.3CVR CAMp.37
    “two hundred. [electronic voice]”
    read in context ↗
  66. 11:27:33.6CVR CAM-1p.37
    “{it's low.}”
    read in context ↗
  67. 11:27:42.8CVR CAM-1p.37
    “speed.”
    read in context ↗
  68. 11:27:43 PDTFDRfinal approachp.9
    Seven seconds before impact, thrust levers moved forward and autothrottle changed from Hold to Thrust; radio altitude about 125 ft, airspeed approximately 112 knots
    see the traces at this moment ↗
  69. 11:27:44.0CVR CAM-?p.37
    “speed * *.”
    read in context ↗
  70. 11:27:46.4CVR CAMwarningp.37
    “[sound similar to stick shaker lasting for approximately 2.24 seconds]”
    read in context ↗
  71. 11:27:46.6CVR CAMp.37
    “forty. [electronic voice]”
    read in context ↗
  72. 11:27:47 PDTFDRfinal approachp.9
    About 3 seconds before impact: lowest airspeed of the approach, approximately 103 knots; stick shaker activated; N1 increasing through 50%; pitch about 12 degrees, the highest of the last 2.5 minutes
    see the traces at this moment ↗
  73. 11:27:47.3CVR CAMp.37
    “thirty. [electronic voice]”
    read in context ↗
  74. 11:27:49.6CVR CAMp.38
    “ten. [electronic voice]”
    read in context ↗
  75. 11:27:50 PDTFDRimpactp.10
    All three acceleration parameters spiked, indicating initial impact; both engines N1 approximately 92% and increasing; airspeed approximately 106 knots
    see the traces at this moment ↗
  76. 11:27:50.3CVR HOT-?final secondsp.38
    “oh.”
    read in context ↗
  77. 11:27:50.3CVR CAMfinal secondsp.38
    “[sound similar to impact]”
    read in context ↗
  78. 11:27:51.9CVR HOTfinal secondsp.38
    “[sound similar to telephone dial tone]”
    read in context ↗
  79. 11:27:54.3CVR CAMfinal secondsp.38
    “[sound of quadruple chime]”
    read in context ↗
  80. 11:27:55.4CVR INT-?final secondsp.38
    “ah what's happening over there?”
    read in context ↗
  81. 11:27:55.9CVR CAMfinal secondsp.38
    “[sound of quadruple chime]”
    read in context ↗
  82. 11:27:57.8CVR CAMfinal secondsp.38
    “[sound of quadruple chime]”
    read in context ↗
  83. 11:28:00.2CVR CAMfinal secondsp.38
    “{sound of quadruple chime] End of Transcript 11:28:01.9 [end of recording]”
    read in context ↗
  84. 11:28:01 PDTFDRimpactp.10
    Recording continued for approximately 11 seconds after impact, ending about 11:28:01
    see the traces at this moment ↗
FLIGHT DATA RECORDER 10-EXHIBIT A-FACTUAL REPORT OF GROUP CHAIRMAN · 24 events extracted by claude-fable-5-1 (in-session)COCKPIT VOICE RECORDER 12-EXHIBIT 12A-FACTUAL REPORT OF GROUP CHAIRMAN · 60 of 412 lines shownAUDIO FILE-CAUTION TONE FROM IIC OPENER PRESENTATION · 0 min· not yet aligned to a clock
How the Board coded the sequence
  1. Approach: Controlled flight into terr/obj (CFIT)

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA13MA1332013-08-142 fatalmatch 66
    AIRBUS A300 - F4 622R · UNITED PARCEL SERVICE CO
    Birmingham, AL
    • ●Personnel issues › Physical › Alertness/Fatigue
    • ●Personnel issues › Psychological › Attention/monitoring
    Controlled flight into terr/obj (CFIT)
  • ANC15FA0492015-07-171 fatalmatch 59
    CESSNA 207A · Sea Port Airlines, Inc
    Juneau, AK
    • ●Personnel issues › Action/decision › Info processing/decision
    Controlled flight into terr/obj (CFIT)
  • ANC13FA0302013-03-082 fatalmatch 58
    BEECH 1900C · ALASKA CENTRAL EXPRESS INC
    Aleknagik, AK
    • ●Personnel issues › Action/decision › Info processing/decision
    Controlled flight into terr/obj (CFIT)
  • ANC14MA0082013-11-305 fatalmatch 57
    CESSNA 208B · Hageland Aviation
    Saint Marys, AK
    • ●Personnel issues › Action/decision › Info processing/decision
    Controlled flight into terr/obj (CFIT)
  • CEN17FA1002017-02-071 fatalmatch 57
    BELL 206B · Republic Helicopters, Inc.
    Galveston, TX
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Controlled flight into terr/obj (CFIT)
  • DCA22LA1262022-06-08no fatalitiesmatch 55
    BOEING 757-236 · Federal Express Corporation
    Tulsa, OK
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Physical › Alertness/Fatigue
    • ●Personnel issues › Psychological › Attention/monitoring
  • DCA11IA0472011-04-26no fatalitiesmatch 55
    BOEING 737-7Q8 · SOUTHWEST AIRLINES CO
    Chicago, IL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Psychological › Attention/monitoring
  • SEA08FA0622008-01-141 fatalmatch 54
    Hawker Beechcraft Corporation 1900C · Alpine Air
    Lihue, HI
    Controlled flight into terr/obj (CFIT)

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
  • 6 of 8Controlled flight into terr/obj (CFIT)
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Physical › Alertness/Fatigue
  • Psychological › Attention/monitoring
Cited here, not seen in the precedents
  • Aircraft systems › Auto flight system
  • Experience/knowledge › Training
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters
  • Conditions/weather/phenomena › Ceiling/visibility/precip
  • Management › Policy/procedure
  • Support/oversight/monitoring › Oversight
  • Support/oversight/monitoring › Training
  • Psychological › Perception/orientation/illusion
  • 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
  • DCA13MA1332013-08-14 · AIRBUS A300 - F4 622R · UNITED PARCEL SERVICE CO
    the flight crew's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain. Contributing to the accident were (1) the flight crew's failure to properly configure and verify the flight management computer for the profile approach; (2) the captain's failure to communicate his intentions to the first officer once it became apparent the vertical profile was not…
  • ANC15FA0492015-07-17 · CESSNA 207A · Sea Port Airlines, Inc
    The pilot's decision to initiate and continue visual flight into instrument meteorological conditions, which resulted in a loss of situational awareness and controlled flight into terrain. Contributing to the accident were the company's failure to follow its operational control and flight release procedures and its inadequate training and oversight of operational control personnel.
  • ANC13FA0302013-03-08 · BEECH 1900C · ALASKA CENTRAL EXPRESS INC
    The flight crew's failure to maintain terrain clearance, which resulted in controlled flight into terrain in instrument meteorological conditions. Contributing to the accident were the flight crew's failure to correctly read back and interpret clearance altitudes issued by the air traffic controller, their failure to adhere to minimum altitudes depicted on the published instrument approach chart, and their failure to adhere to company checklists. Also contributing to the accident were the air traffic control…
  • ANC14MA0082013-11-30 · CESSNA 208B · Hageland Aviation
    The pilot's decision to initiate a visual flight rules approach into an area of instrument meteorological conditions at night and the flight coordinators' release of the flight without discussing the risks with the pilot, which resulted in the pilot experiencing a loss of situational awareness and subsequent controlled flight into terrain. Contributing to the accident were the operator's inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control…
  • CEN17FA1002017-02-07 · BELL 206B · Republic Helicopters, Inc.
    The pilot's failure to recognize the flight had encountered instrument meteorological conditions at night, which resulted in an unrecognized descent and collision with water.
What it recommended after them
  • A-14-072TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to ensure that operators with flight crews performing 14 Code of Federal Regulations Part 121, 135, and 91 subpart K overnight operations brief the threat of fa… · DCA13MA133Closed - Unacceptable Action
  • A-14-073TO THE FEDERAL AVIATION ADMINISTRATION: Require operators to develop an annual recurrent dispatcher resource management module for dispatchers that includes participation of pilots to reinforce the need for open communication. · DCA13MA133Closed - Unacceptable Action
  • A-14-074TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to work with operators to ensure that their operating procedures explicitly state that any changes to an approach after the completion of the approach briefing… · DCA13MA133Closed - Acceptable Action
  • A-14-075TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to ensure consistency among their operators’ training documents, their operators’ Federal Aviation Administration-approved and -accepted documents, such as the… · DCA13MA133Closed - Acceptable Action
  • A-14-076TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that Federal Aviation Administration-approved nonprecision instrument appr… · DCA13MA133Closed - Unacceptable Action
  • A-14-077TO THE FEDERAL AVIATION ADMINISTRATION: Require that the remarks section of meteorological aerodrome reports be provided to all dispatchers and pilots in flight dispatcher papers and through the aircraft communication addressing and reporti… · DCA13MA133Closed - Acceptable Action
  • A-14-078TO THE FEDERAL AVIATION ADMINISTRATION: Expand the current guidance available in Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to further define meteorological aerodrome report pertinent remarks. · DCA13MA133Closed - Acceptable Alternate Action
  • A-14-079TO THE FEDERAL AVIATION ADMINISTRATION: Issue a safety advisory bulletin to air traffic controllers providing examples of the types of meteorological aerodrome report remarks information considered pertinent and reminding them of the requir… · DCA13MA133Closed - 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).