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Cases › DCA14FA058 › The analyst

EMBRAER EMB145 - EPTrans States Airlines, LLC

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.

66
timed facts
8
precedents
96
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

66 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. 00:00:10.3CVR AWUwarningp.27
    “[sound of three buzzers, similar to altitude alert]”
    read in context ↗
  2. 00:01:19 CSTFDRapproachp.3
    Aircraft descended to about 2,000 ft and held that altitude for 11 minutes 19 seconds before descending consistent with landing
  3. 00:02:55.5CVR HOT-1calloutp.28
    “if this doesn't pick (up) and we have to go around again we're goin' to Little Rock.”
    read in context ↗
  4. 00:07:57.3CVR RDO-1calloutp.35
    “three six right. cleared to land. Waterski thirty three ninety five.”
    read in context ↗
  5. 00:08:36.6CVR RDO-1warningp.36
    “ah the visibility's too low.”
    read in context ↗
  6. 00:09:16.1CVR HOT-1calloutp.37
    “yeah if we go around we're goin' straight to Little Rock.”
    read in context ↗
  7. 00:10:15.9CVR RDO-1p.38
    “one seventy till MCGHE cleared for the ILS three six right. Waterski thirty three ninety five.”
    read in context ↗
  8. 00:10:18 CSTFDRapproachp.3
    Lateral flight director mode changed to localizer
  9. 00:10:19.6CVR HOT-2p.38
    “alright [exhaling]. DCA14FA058”
    read in context ↗
  10. 00:10:21.5CVR HOT-1calloutp.39
    “cleared to land.”
    read in context ↗
  11. 00:10:22.5CVR HOT-2calloutp.39
    “cleared to land. cleared for the approach. now let's see if George can figure it out.”
    read in context ↗
  12. 00:12:21.7CVR HOT-2calloutp.41
    “alright. gear down.”
    read in context ↗
  13. 00:12:28.1CVR HOT-1calloutp.41
    “gear down. twenty two selected.”
    read in context ↗
  14. 00:14:34.9CVR AWUp.43
    “autopilot.”
    read in context ↗
  15. 00:14:35 CSTFDRapproachp.3
    Autopilot became disengaged (dashed line on figure 4)
  16. 00:14:35.3CVR HOT-2p.43
    “auto's off.”
    read in context ↗
  17. 00:15:01.1CVR AWUwarningp.45
    “bank angle. bank angle.”
    read in context ↗
  18. 00:15:01.5CVR HOT-2p.45
    “#.”
    read in context ↗
  19. 00:15:02 CSTFDRlandingp.3
    One second before weight on wheels, the stick shaker became active at a recorded angle of attack of 15 degrees
  20. 00:15:03 CSTFDRlandingp.3
    Weight on wheels became active; a peak vertical acceleration of 2.6 g was recorded at this time (hard landing on runway 36R); rollout continued uneventfully
  21. 00:15:03.2CVR AWUwarningp.45
    “[sound of three chimes, similar to master warning]”
    read in context ↗
  22. 00:15:04.7CVR HOT-1p.45
    “* the #.”
    read in context ↗
  23. 00:15:04.7CVR AWUcalloutp.45
    “takeoff...”
    read in context ↗
  24. 00:15:08.0CVR AWUwarningp.45
    “[sound of three chimes, similar to master warning]”
    read in context ↗
  25. 00:15:12.9CVR HOTwarningp.46
    “[sound of three chimes, similar to master warning]”
    read in context ↗
  26. 00:15:38.8CVR AWUwarningp.47
    “[sound of single chime, similar to master caution]”
    read in context ↗
  27. 00:22:29.4CVR HOTwarningp.59
    “[sound of single chime, similar to master caution]”
    read in context ↗
  28. 00:33:39.5CVR HOT-2final secondsp.60
    “***we come in for the first approach. can't get a localizer. have to go missed. *** come back around. try and get it again. (it's not really holding). the the airplane's having a hard time. (so we descend on in). we're in ice. our icing stuff never worked. never came on. and then about fifty feet (before) the (ground) (or landing) (or less) our rudder. we had what's called a rudder hardover. where the rudder went one way and it took the whole plane with it. *** and the plane went from like this to I mean it *** (I don't know how much you felt ** (could) see back there). *** so he jammed on the other rudder to get the system to turn off *** and we were able to ** runway ** hard landing *** so ***.”
    read in context ↗
  29. 00:35:13.1CVR HOT-2final secondsp.60
    “I'm afraid to go look at the plane. I really am.”
    read in context ↗
  30. 00:35:20.5CVR HOT-2final secondsp.60
    “did the overhead bins pop open?”
    read in context ↗
  31. 00:35:23.4CVR HOT-4final secondsp.60
    “***walk around did yeah?***”
    read in context ↗
  32. 00:35:37.2CVR HOT-4final secondsp.60
    “*** shattered the glass. you got a hole in the tip of the wing. right above where ***.”
    read in context ↗
  33. 00:54:16.7CVR HOT-2final secondsp.60
    “[mentions Director of Operations name]”
    read in context ↗
  34. 01:04:55.0CVR HOT-2final secondsp.60
    “**everything's good on this side** alright. DCA14FA058”
    read in context ↗
  35. 01:04:59.4CVR HOTfinal secondsp.61
    “[power cycle to CVR]”
    read in context ↗
  36. 22:30:00 CSTFDRcruisep.3
    Start of plotted overview of the accident event (figures 1 and 3 cover 22:30:00 through 00:20:00 CST; times before midnight reference February 4, 2014)
    see the traces at this moment ↗
  37. 23:40:00 CSTFDRapproachp.3
    Data non-eventful until the approach phase began at a pressure altitude of about 8,000 ft
    see the traces at this moment ↗
  38. 23:45:00 CSTFDRapproachp.3
    Aircraft continued to descend and prepared for an attempted landing from about 4,000 ft
    see the traces at this moment ↗
  39. 23:48:24.6CVR HOT-1p.9
    “so what did he say. FREAZ.”
    read in context ↗
  40. 23:49:36.8CVR RDO-1calloutp.11
    “three six left ah cleared to land Waterski thirty three ninety five.”
    read in context ↗
  41. 23:50:01.0CVR HOT-1calloutp.11
    “follow it down. if we don't have anything by...CADUS we'll go around and then we'll...we'll ask for the center I guess. DCA14FA058”
    read in context ↗
  42. 23:50:25.4CVR AWUwarningp.12
    “[sound of triple buzzer, similar to altitude alerter]”
    read in context ↗
  43. 23:50:31.6CVR HOT-1calloutp.12
    “go around?”
    read in context ↗
  44. 23:51:00.8CVR HOT-2p.13
    “ahh your's went away too.”
    read in context ↗
  45. 23:51:04.4CVR HOT-1p.13
    “alright hit it. DCA14FA058”
    read in context ↗
  46. 23:51:05 CSTFDRapproachp.3
    Lateral flight director mode changed to localizer
    see the traces at this moment ↗
  47. 23:51:56.1CVR HOT-2p.14
    “you want me to take it off autopilot?”
    read in context ↗
  48. 23:51:59 CSTFDRapproachp.3
    Autopilot disengaged
    see the traces at this moment ↗
  49. 23:51:59.4CVR HOT-1p.14
    “yeah.”
    read in context ↗
  50. 23:52:24.4CVR HOT-2calloutp.15
    “gear down.”
    read in context ↗
  51. 23:52:28.1CVR HOT-1calloutp.16
    “gear down twenty two selected.”
    read in context ↗
  52. 23:52:48.4CVR HOT-1calloutp.16
    “oh there it goes. let's. let's go around.”
    read in context ↗
  53. 23:52:50.7CVR HOT-2calloutp.16
    “you want to go around?”
    read in context ↗
  54. 23:52:51.7CVR HOT-2p.16
    “alright.”
    read in context ↗
  55. 23:52:52.8CVR HOT-2p.16
    “go around. set max thrust. flaps nine.”
    read in context ↗
  56. 23:52:54 CSTFDRgo-aroundp.3
    Localizer flight director mode changed to heading hold and the aircraft began a climb as airspeed and altitude increased
    see the traces at this moment ↗
  57. 23:53:00.4CVR HOT-2calloutp.16
    “gear up.”
    read in context ↗
  58. 23:53:03.1CVR RDO-1warningp.17
    “Tower Waterski thirty three ninety five we are going around. [sound of three buzzers, similar to altitude alert] runway three six left. we don’t have a very good signal on the localizer. it's taking us everywhere goin' in and out.”
    read in context ↗
  59. 23:53:39.9CVR RDO-1p.17
    “did you want us to stay with you or go over to ah someone else? DCA14FA058”
    read in context ↗
  60. 23:53:48.2CVR RDO-1p.18
    “two six point seven Waterski thirty three ninety (five).”
    read in context ↗
  61. 23:53:54 CSTFDRgo-aroundp.3
    Aircraft leveled off at about 3,000 ft and maintained that altitude for about 6 minutes 30 seconds
    see the traces at this moment ↗
  62. 23:55:20.5CVR HOT-1calloutp.19
    “(you wanna’) do an after take-off.”
    read in context ↗
  63. 23:55:21.6CVR HOT-2calloutp.19
    “yeah. I see up and zero. after takeoff checklist.”
    read in context ↗
  64. 23:56:09.1CVR HOT-2p.20
    “that's exactly what's wrong. alright it's goin' back on autopilot.”
    read in context ↗
  65. 23:56:10 CSTFDRgo-aroundp.3
    Autopilot re-engaged
    see the traces at this moment ↗
  66. 23:56:12.6CVR HOT-1p.20
    “okay. DCA14FA058”
    read in context ↗
FLIGHT DATA RECORDER SPECIALIST'S FACTUAL REPORT · 13 events extracted by claude-fable-5-1 (in-session)COCKPIT VOICE RECORDER - GROUP CHAIRMANA��S FACTUAL REPORT · 53 of 461 lines shown
How the Board coded the sequence
  1. Approach-IFR missed approach: Structural icing→
  2. Landing-flare/touchdown: Aerodynamic stall/spin→
  3. Landing-flare/touchdown: Hard landing

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA15MA0292014-12-083 fatalmatch 52
    EMBRAER EMB-500 · SAGE AVIATION LLC
    Gaithersburg, MD
    • ●Aircraft › Aircraft systems › Ice/rain protection system
    Structural icing
  • DCA09MA0272009-02-1349 fatalmatch 51
    BOMBARDIER INC DHC-8-402 · COLGAN AIR INC
    Clarence Center, NY
    • ●Organizational issues › Management › Policy/procedure
    • ●Personnel issues › Psychological › Attention/monitoring
    Aerodynamic stall/spin
  • DCA12IA1412012-09-05no fatalitiesmatch 49
    DE HAVILLAND DHC8 · ERA AVIATION INC
    Soldotna, AK
    • ●Personnel issues › Psychological › Attention/monitoring
    Aerodynamic stall/spin
  • ERA09MA4472009-08-089 fatalmatch 47
    PIPER PA-32R-300 · STEVEN M ALTMAN
    Hoboken, NJ
    • ●Organizational issues › Management › Policy/procedure
    • ●Personnel issues › Psychological › Attention/monitoring
  • DEN03IA0542003-03-17no fatalitiesmatch 46
    Embraer EMB-120ER · Skywest Airlines
    Cedar City, UT
    matched on what happened, as the Board wrote it · same aircraft family
  • NYC05MA0832005-05-13no fatalitiesmatch 46
    BOEING 717-200 · Midwest Airlines
    Union Star, MO
    matched on what happened, as the Board wrote it
  • LAX06IA0762006-01-02no fatalitiesmatch 45
    Saab-Scania AB (Saab) SF340B+ · American Eagle Airlines, Inc.
    Santa Maria, CA
    matched on what happened, as the Board wrote it
  • ANC20LA0742020-07-317 fatalmatch 45
    De Havilland DHC-2 · High Adventure Air Charter
    Soldotna, AK
    • ●Organizational issues › Management › Policy/procedure
    • ●Personnel issues › Psychological › Attention/monitoring

What the record says

a pattern, not a findingacross the 8 closest cases · 5 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 2 of 8Loss of control in flight
  • 2 of 8Aerodynamic stall/spin
  • 2 of 8Midair collision
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Management › Policy/procedure
  • Psychological › Attention/monitoring
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
  • DCA15MA0292014-12-08 · EMBRAER EMB-500 · SAGE AVIATION LLC
    the pilot's conduct of an approach in structural icing conditions without turning on the airplane's wing and horizontal stabilizer deice system, leading to ice accumulation on those surfaces, and without using the appropriate landing performance speeds for the weather conditions and airplane weight, as indicated in the airplane's standard operating procedures, which together resulted in an aerodynamic stall at an altitude at which a recovery was not possible.
  • 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…
  • DCA12IA1412012-09-05 · DE HAVILLAND DHC8 · ERA AVIATION INC
    an in-flight loss of control due to the flight crew's inattention to airspeed, pitch attitude, and engine power during the climb leading to an aerodynamic stall. Contributing to the incident was the flight crew's failure to recognize and properly recover from an aerodynamic stall in a timely manner.
  • ERA09MA4472009-08-08 · PIPER PA-32R-300 · STEVEN M ALTMAN
    (1) the inherent limitations of the see-and-avoid concept, which made it difficult for the airplane pilot to see the helicopter until the final seconds before the collision, and (2) the Teterboro Airport local controller’s nonpertinent telephone conversation, which distracted him from his air traffic control (ATC) duties, including correcting the airplane pilot’s read back of the Newark Liberty International Airport (EWR) tower frequency and the timely transfer of communications for the accident airplane to the EWR…
  • DEN03IA0542003-03-17 · Embraer EMB-120ER · Skywest Airlines
    the captain's failure to maintain directional control during takeoff. Factors contributing to the accident were the crew's diverted attention, the snow and slush-covered runway, the fog, and the runway marker.
What it recommended after them
  • A-16-012TO THE FEDERAL AVIATION ADMINISTRATION: Work with the General Aviation Manufacturers Association to develop a system that can automatically alert pilots when the ice protection systems should be activated on turbofan airplanes that require… · DCA15MA029Closed - Acceptable Action
  • A-16-013TO THE GENERAL AVIATION MANUFACTURERS ASSOCIATION: Work with the Federal Aviation Administration to develop a system that can automatically alert pilots when the ice protection systems should be activated on turbofan airplanes that require… · DCA15MA029Open - Acceptable Response
  • A-16-014TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with your members that are manufacturers and training providers of turbofan airplanes that require a type rating and are certified for single-pilot operations and flight in icing condition… · DCA15MA029Closed - Acceptable Action
  • 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

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).