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Cases › DCA13MA133 › The analyst

AIRBUS A300 - F4 622RUNITED PARCEL SERVICE CO

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.

81
timed facts
8
precedents
163
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

81 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. 03:13:39.5CVR CAMp.12
    “[power applied to CVR]”
    read in context ↗
  2. 03:28:21.7CVR EGPWSwarningp.12
    “glideslope. pull up. terrain ahead pull up. [crew initiated EGPWS test]”
    read in context ↗
  3. 03:31:40.8CVR TCASwarningp.12
    “TCAS Test. TCAS Test Pass. [crew initiated TCAS test]”
    read in context ↗
  4. 03:36:27.3CVR CAM-1calloutp.13
    “(** six) takeoff fuel (* four).”
    read in context ↗
  5. 03:36:38.5CVR CAM-1calloutp.14
    “[captain begins takeoff brief] (okay it’s my turn again). (left seat three hundred and three thousand pound take off. flaps fifteen zero). profile.”
    read in context ↗
  6. 03:37:08.5CVR CAM-1calloutp.15
    “and uhhh. **. gonna be runway heading. five thousand. turn on course.”
    read in context ↗
  7. 03:37:15.5CVR CAM-1calloutp.15
    “as far as the reject. eighty knots. call it out loud and clear. ahhh. after v-one ahh. high speed. critical items only. after v-one ** pink page. transition altitude eighteen thousand feet.”
    read in context ↗
  8. 03:58:13.8CVR HOT-1calloutp.26
    “okay left seat. three hundred and two thousand pound take-off. flaps fifteen zero profile up to five thousand. off the right side. pink page [stammering] is going to be reviewed and its complete. unless there's any questions?”
    read in context ↗
  9. 03:58:28.5CVR HOT-2calloutp.26
    “before takeoff checklist flaps.”
    read in context ↗
  10. 03:58:36.6CVR HOT-2calloutp.26
    “set. ignitions. continuous relight. bleeds and packs are set. one's off just for noise. takeoff configuration is normal for takeoff. before takeoff checklist complete.”
    read in context ↗
  11. 04:02:22.0CVR RDO-2calloutp.27
    “fly runway heading runway three five right cleared for takeoff UPS thirteen fifty four heavy.”
    read in context ↗
  12. 04:02:26.7CVR HOT-2calloutp.28
    “cleared to go runway heading.”
    read in context ↗
  13. 04:02:33.6CVR HOT-1calloutp.28
    “set takeoff thrust.”
    read in context ↗
  14. 04:03:05.3CVR HOT-2calloutp.28
    “v-one rotate. v-two.”
    read in context ↗
  15. 04:03:14.0CVR HOT-1calloutp.28
    “gear up.”
    read in context ↗
  16. 04:03:53.2CVR RDO-2calloutp.29
    “(hello) departure UPS thirteen fifty four heavy two point six climbing to five thousand runway heading.”
    read in context ↗
  17. 04:04:08.5CVR HOT-1calloutp.29
    “after takeoff checklist.”
    read in context ↗
  18. 04:04:09.5CVR HOT-2calloutp.29
    “after takeoff checklist.”
    read in context ↗
  19. 04:42:35 CDTFDRapproachp.11
    About 5 minutes before the end of the recording: pressure altitude about 10,000 ft, DME 20.6 NM, computed airspeed about 248 knots, speed brake handle fully extended
  20. 04:42:38.1CVR HOT-1p.45
    “gear down.”
    read in context ↗
  21. 04:42:40.3CVR HOT-2p.46
    “gear down speed checks.”
    read in context ↗
  22. 04:42:55 CDTFDRapproachp.11
    Landing gear discretes indicated all three gear down and locked
  23. 04:42:55.2CVR HOT-1p.46
    “oh I know. I * [chuckling].”
    read in context ↗
  24. 04:42:55.7CVR HOT-2p.46
    “...yeah they were doin' good until...then...”
    read in context ↗
  25. 04:44:18.2CVR HOT-1p.48
    “thirty five for twenty five.”
    read in context ↗
  26. 04:44:19.6CVR HOT-2p.48
    “thirty five for twenty five. final's activated.”
    read in context ↗
  27. 04:44:22 CDTFDRapproachp.11
    Lateral AFCS mode changed to localizer track mode
  28. 04:44:37.5CVR HOT-1p.48
    “slats extend.”
    read in context ↗
  29. 04:44:39.1CVR HOT-2p.48
    “speed checks. slats extend.”
    read in context ↗
  30. 04:44:41 CDTFDRapproachp.11
    Speed brake handle retracted, then moved periodically between retracted and full extension over the next 60 seconds; slats/flaps lever moved from detent 1 (slats/flaps up) to detent 2 (slats 15/flaps 0)
  31. 04:45:08.4CVR HOT-1p.48
    “flaps fifteen.”
    read in context ↗
  32. 04:45:10.2CVR HOT-2p.48
    “speed checks. flaps fifteen.”
    read in context ↗
  33. 04:45:12 CDTFDRapproachp.11
    Longitudinal AFCS mode changed to altitude mode; pressure altitude about 2,500 ft, DME about 9 NM, computed airspeed about 213 knots; selected airspeed changed from 170 to 160 knots
  34. 04:45:15 CDTFDRapproachp.11
    Slats/flaps lever moved to detent 3 (slats 15/flaps 15)
  35. 04:45:28.9CVR RDO-2p.49
    “thirteen fifty four up nineteen nine.”
    read in context ↗
  36. 04:45:32 CDTFDRapproachp.11
    Lateral AFCS mode changed to NAV, to heading at 04:45:34, to localizer capture at 04:45:38, and about 9 seconds later back to localizer track where it remained
  37. 04:45:34.8CVR RDO-2p.49
    “one eight cleared to land thirteen fifty four heavy.”
    read in context ↗
  38. 04:45:38.3CVR HOT-1p.49
    “flaps twenty.”
    read in context ↗
  39. 04:45:39.9CVR HOT-2p.49
    “speed checks flaps twenty.”
    read in context ↗
  40. 04:45:42 CDTFDRapproachp.11
    Slats/flaps lever moved to detent 4 (slats 15/flaps 20)
  41. 04:45:45 CDTFDRapproachp.12
    Speed brake handle returned to 0 and remained there; ground spoilers armed at 04:45:47
  42. 04:45:48 CDTFDRapproachp.12
    Selected airspeed changed to 137 knots and remained there
  43. 04:45:50.9CVR HOT-1p.49
    “flaps forty speed one thirty seven landing check.”
    read in context ↗
  44. 04:45:53.8CVR HOT-2p.49
    “okay...”
    read in context ↗
  45. 04:45:54.7CVR HOT-1p.49
    “set the missed approach altitude.”
    read in context ↗
  46. 04:45:56 CDTFDRapproachp.12
    Slats/flaps lever moved to detent 5 (slats 30/flaps 40)
  47. 04:46:01 CDTFDRapproachp.12
    Longitudinal AFCS mode changed to vertical speed mode; selected vertical speed set to about -700 fpm at 04:46:08
  48. 04:46:05.2CVR HOT-2p.50
    “landing gears down three green pressure check. TRP thrust limit GA.”
    read in context ↗
  49. 04:46:14.2CVR HOT-2p.50
    “speed brakes armed. ignition continuous relight.”
    read in context ↗
  50. 04:46:15 CDTFDRfinal approachp.12
    Computed airspeed converged to the selected 137 knots; pressure altitude decreased below 2,500 ft marking the start of the final descent, DME about 5.75 NM (79 seconds before end of recording)
  51. 04:46:17.4CVR HOT-2p.50
    “landing checklist complete.”
    read in context ↗
  52. 04:46:18.4CVR HOT-1p.50
    “unbelievable kept us high...”
    read in context ↗
  53. 04:46:19.0CVR VEHp.50
    “affirm uhm they're very close to the end right now uh.”
    read in context ↗
  54. 04:46:20 CDTFDRfinal approachp.12
    Selected vertical speed changed to about -1000 fpm, then to about -1500 fpm at 04:46:34
  55. 04:46:33.7CVR HOT-2p.51
    “I'll put your missed approach altitude in there.”
    read in context ↗
  56. 04:46:35.7CVR HOT-1p.51
    “yeah. thank you.”
    read in context ↗
  57. 04:46:38 CDTFDRfinal approachp.12
    Selected altitude changed from about 2,500 ft to about 3,775 ft; no significant change in aircraft state over the next 45 seconds
  58. 04:47:24.5CVR EGPWSwarningp.52
    “sink rate.”
    read in context ↗
  59. 04:47:25 CDTFDRfinal approachp.12
    Three-second EGPWS sink rate warning recorded; vertical speed -1536 fpm, radio altitude 235 ft
  60. 04:47:25.9CVR EGPWSwarningp.52
    “sink rate.”
    read in context ↗
  61. 04:47:26 CDTFDRfinal approachp.12
    Selected vertical speed changed to about -640 fpm, then -448 fpm 3 seconds later; control column began increasing to a final value of about 5 degrees nose up with pitch increasing similarly
  62. 04:47:26.6CVR HOT-2p.52
    “(there it is) [mumbling].”
    read in context ↗
  63. 04:47:29.7CVR HOT-1p.52
    “autopilot's off.”
    read in context ↗
  64. 04:47:29.9CVR HOT-2p.52
    “eh.”
    read in context ↗
  65. 04:47:30 CDTFDRfinal approachp.12
    Slight increase in thrust indicated by engine parameters
  66. 04:47:30.6CVR HOT-2p.53
    “alrighty.”
    read in context ↗
  67. 04:47:32 CDTFDRfinal approachp.12
    Throttle resolver angle indicated an additional request for increased thrust; N1, N2, EGT and fuel flow show the engines responded
  68. 04:47:32.5CVR CAMwarningp.53
    “[sound of rustling, similar to impact, volume increases for about 5.4 seconds]”
    read in context ↗
  69. 04:47:32.9CVR HOT-2p.53
    “ooh.”
    read in context ↗
  70. 04:47:33 CDTFDRimpactp.13
    Last second of recording: left autopilot command changed to disengaged, autopilot off warning indicated, autothrottle changed from speed mode to retard mode; last recorded pitch about 7 degrees nose up, airspeed about 138 knots, radio altitude 14 ft
  71. 04:47:33.4CVR HOT-1p.53
    “oh # #.”
    read in context ↗
  72. 04:47:33.5CVR EGPWSwarningp.53
    “too low terrain [recorded on CAM]”
    read in context ↗
  73. 04:47:34 CDTFDRimpactp.13
    FDR recording ended
  74. 04:47:37.9CVR HOT-2final secondsp.53
    “oh.”
    read in context ↗
  75. 04:47:37.9CVR CAMfinal secondsp.53
    “[cessation in rustling/impact sounds]”
    read in context ↗
  76. 04:47:38.3CVR HOT-1final secondsp.53
    “oh. oh God.”
    read in context ↗
  77. 04:47:38.8CVR CAMfinal secondsp.54
    “[sound of rustling, similar to impact, continues at higher volume until end of recording]”
    read in context ↗
  78. 04:47:39.9CVR HOT-?final secondsp.54
    “[grunting].”
    read in context ↗
  79. 04:47:41.1CVR HOTfinal secondsp.54
    “[static].”
    read in context ↗
  80. 04:47:41.3CVR CAMfinal secondsp.54
    “[end of loudest noise]”
    read in context ↗
  81. 04:47:41.6CVR HOTfinal secondsp.54
    “[end of recording]”
    read in context ↗
Flight Data Recorder 10 - Exhibit A -Group Chairman's Factual Report · 21 events extracted by claude-fable-5-1 (in-session)Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 60 of 443 lines shown
How the Board coded the sequence
  1. Approach-IFR final 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
  • ERA16FA2152016-06-162 fatalmatch 67
    PIPER PA31 · AERONATIONAL INC
    State College, PA
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Task performance › Use of equip/info
    Controlled flight into terr/obj (CFIT)
  • CEN09MA1422009-01-27substantialmatch 66
    AEROSPATIALE ALENIA ATR 42-320 · Empire Airlines
    Lubbock, TX
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Physical › Alertness/Fatigue
    • +2 more shared findings
  • DCA13MA1202013-07-063 fatalmatch 66
    BOEING 777-200ER · Asiana Airlines
    San Francisco, CA
    • ●Personnel issues › Physical › Alertness/Fatigue
    • ●Personnel issues › Psychological › Attention/monitoring
    Controlled flight into terr/obj (CFIT)
  • ERA09FA0392008-11-073 fatalmatch 65
    PARTENAVIA SPA P.68C · Florida Aero Charter Inc.
    Gainesville, FL
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Task performance › Use of equip/info
    Controlled flight into terr/obj (CFIT)
  • WPR12MA0462011-11-246 fatalmatch 64
    ROCKWELL 690 · Ponderosa Aviation
    Apache Junction, AZ
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Aircraft › Aircraft systems › Navigation system
    • ●Personnel issues › Task performance › Use of equip/info
    Controlled flight into terr/obj (CFIT)
  • ANC15FA0492015-07-171 fatalmatch 62
    CESSNA 207A · Sea Port Airlines, Inc
    Juneau, AK
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    Controlled flight into terr/obj (CFIT)
  • SEA08FA0622008-01-141 fatalmatch 61
    Hawker Beechcraft Corporation 1900C · Alpine Air
    Lihue, HI
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Controlled flight into terr/obj (CFIT)
  • ANC11FA1072011-09-241 fatalmatch 60
    DEHAVILLAND DHC-3T · PAKLOOK AIR INC
    Kodiak, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Task performance › Use of equip/info
    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
  • 7 of 8Controlled flight into terr/obj (CFIT)
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Conditions/weather/phenomena › Ceiling/visibility/precip
  • Physical › Alertness/Fatigue
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • Task performance › (general)
Common in the precedents, not cited here
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Psychological › Perception/orientation/illusion
  • Psychological › Personality/attitude

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
  • ERA16FA2152016-06-16 · PIPER PA31 · AERONATIONAL INC
    The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.
  • 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…
  • DCA13MA1202013-07-06 · BOEING 777-200ER · Asiana Airlines
    The flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems tha…
  • ERA09FA0392008-11-07 · PARTENAVIA SPA P.68C · Florida Aero Charter Inc.
    The pilot's failure to maintain the proper glidepath during an instrument-landing-system (ILS) approach. Contributing to the accident were the pilot's decision to initiate the ILS approach with weather below the published minimums, and the pilot's self-induced pressure to expeditiously transport an organ recipient to a hospital.
  • WPR12MA0462011-11-24 · ROCKWELL 690 · Ponderosa Aviation
    The pilot's failure to maintain a safe ground track and altitude combination for the moonless night visual flight rules flight, which resulted in controlled flight into terrain. Contributing to the accident were the pilot's complacency and lack of situational awareness and his failure to use air traffic control visual flight rules flight following or minimum safe altitude warning services. Also contributing to the accident was the airplane's lack of onboard terrain awareness and warning system equipment. Member…
What it recommended after them
  • A-11-039TO THE FEDERAL AVIATION ADMINISTRATION: Require that role-playing or simulator-based exercises that teach first officers to assertively voice their concerns and that teach captains to develop a leadership style that supports first officer a… · CEN09MA142Closed - Unacceptable Action
  • A-11-040TO THE FEDERAL AVIATION ADMINISTRATION: Prohibit all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators of pneumatic deice boot-equipped airplanes from dispatching or deliberately operating these airplanes in known fre… · CEN09MA142Closed - Unacceptable Action
  • A-11-041TO THE FEDERAL AVIATION ADMINISTRATION: Review the approved pilot, dispatcher, and flight follower training programs and procedures for all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and require revisions to th… · CEN09MA142Closed - Unacceptable Action
  • A-11-042TO THE FEDERAL AVIATION ADMINISTRATION: Develop a method to quickly communicate information regarding the number of persons on board and the presence of hazardous materials to emergency responders when airport emergency response or search a… · CEN09MA142Closed - Unacceptable Action
  • A-11-043TO THE FEDERAL AVIATION ADMINISTRATION: Amend Advisory Circular 150/5200-30C to include guidance on monitoring and ensuring the operability of emergency response and mutual aid gates during winter operations. · CEN09MA142Closed - Acceptable Action
  • A-11-044TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of Avions de Transport Régional Aerospatiale Alenia ATR 42- and ATR 72-series airplanes to retrofit the airplanes with an aircraft performance monitoring system if they are not a… · CEN09MA142Closed - Unacceptable Action
  • A-11-045TO THE FEDERAL AVIATION ADMINISTRATION: Require all Avions de Transport Régional Aerospatiale Alenia ATR 42-series airplanes to be equipped with a flap asymmetry annunciator light if they are not already so equipped. · CEN09MA142Closed - Unacceptable Action
  • A-11-046TO THE FEDERAL AVIATION ADMINISTRATION: Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradat… · CEN09MA142Closed - 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).