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Cases › DCA15FA085 › The analyst

MCDONNELL DOUGLAS AIRCRAFT CO MD 88Delta Air Lines

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.

58
timed facts
8
precedents
146
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

58 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. 09:00:47.4CVR STARTp.7
    “OF RECORDING”
    read in context ↗
  2. 9:11:30 to 9:14:59FDRCruisep.7
    FDAU parameters (pitch trim, rudder, aileron, control wheel, EPR) invalid
  3. 9:16:54 to 10:05:39FDRCruisep.7
    FDAU parameters invalid (second stretch)
  4. 9:24 am (approx)FDRTakeoff/climbp.6
    Aircraft took off and climbed to an altitude of 33,000 ft
  5. 10:06:10.5CVR HOT-2p.10
    “and— again I can misread anything @ so by— by all means show me.”
    read in context ↗
  6. 10:06:23 to 10:13:12FDRCruise/descentp.7
    FDAU parameters invalid (third stretch)
  7. 10:06:31.7CVR RDO-2p.10
    “direct to Patuxent Delta ten eighty six.”
    read in context ↗
  8. 10:14:34.2CVR HOT-1calloutp.17
    “and— and you are going to ILS minimums. so how much runway do we actually have available?”
    read in context ↗
  9. 10:26:15.8CVR CAMwarningp.32
    “[sound similar to altitude alert]”
    read in context ↗
  10. 10:26:35.4CVR HOTwarningp.33
    “[sound similar to altitude alert] altitude. [automated voice] [sound similar to altitude alert]”
    read in context ↗
  11. 10:26:39.9CVR HOTwarningp.33
    “[sound similar to altitude alert] altitude. [automated voice] [sound similar to altitude alert] altitude. [automated voice] [sound similar to altitude alert] altitude. [automated voice]”
    read in context ↗
  12. 10:35:26.8CVR HOT-2calloutp.42
    “why is she asking me if we can do ILS to one three? runway end identifier lights are out of service.”
    read in context ↗
  13. 10:42:12.0CVR CAMwarningp.47
    “[sound similar to altitude alert]”
    read in context ↗
  14. 10:46:16.3CVR HOT-2calloutp.52
    “thirty thirteen is crosschecked. minimums?”
    read in context ↗
  15. 10:50:39.0CVR CAMwarningp.57
    “[sound similar to altitude alert]”
    read in context ↗
  16. 10:53:38.4CVR CAMwarningp.59
    “[sound similar to altitude alert]”
    read in context ↗
  17. 10:59:09.4CVR HOT-1calloutp.65
    “let's go gear down.”
    read in context ↗
  18. 10:59:34.0CVR LGAcalloutp.66
    “and Delta ten eighty six LaGuardia Tower. uh winds zero three zero at niner. runway one three cleared to land. braking action reported good by an Airbus and then a regional jet. there will be a departure on runway four prior to your arrival. runway one three RVR touchdown greater than six thousand. rollout three thousand five hundred.”
    read in context ↗
  19. 10:59:51.7CVR RDO-2calloutp.66
    “copy all. cleared to land on runway one three. Delta ten eighty six.”
    read in context ↗
  20. 11:01:04.3CVR HOT-2calloutp.68
    “cleared to land. missed approach altitude is set.”
    read in context ↗
  21. 11:01:59.3CVR HOT-2calloutp.69
    “approaching minimums. roger.”
    read in context ↗
  22. 11:02:15.0CVR CAMp.70
    “ten. [automated voice]”
    read in context ↗
  23. 11:02:16.8FDRLandingp.6
    Vertical acceleration peak consistent with main gear making initial contact with the runway
  24. 11:02:17.9CVR CAWSwarningp.70
    “[sound of beep] [CAWS configuration warning]”
    read in context ↗
  25. 11:02:18.3CVR CAWSwarningp.70
    “[sound of beep] [CAWS configuration warning]”
    read in context ↗
  26. 11:02:18.5CVR HOT-2p.70
    “spoilers up.”
    read in context ↗
  27. 11:02:18.6FDRLandingp.6
    Final main gear touchdown
  28. 11:02:18.9CVR CAWSwarningp.70
    “speedbrakes.[automated voice. CAWS configuration warning]”
    read in context ↗
  29. 11:02:20.0FDRLandingp.6
    Nose gear touchdown; weight on wheels sensor detected aircraft on ground
  30. ~11:02:20.8 (2 sec after main gear touchdown)FDRLanding rollp.6
    Thrust reversers deployed and engines began advancing in power
  31. 11:02:20.9CVR HOT-2p.70
    “two in reverse.”
    read in context ↗
  32. ~11:02:21.1 (2.5 sec after main gear touchdown)FDRLanding rollp.6
    Spoilers fully deployed
  33. ~11:02:21.4 (2.8 sec after main gear touchdown)FDRLanding rollp.6
    Brake pressure began to rise consistent with autobrake application
  34. 11:02:22.2CVR HOT-2p.70
    “one ten.”
    read in context ↗
  35. 11:02:24.5CVR HOT-2p.71
    “come out of reverse.”
    read in context ↗
  36. ~11:02:24.6 (6 sec after main gear touchdown)FDRLanding roll/excursionp.6
    Aircraft heading began to deviate to the left from 131 degrees
  37. 11:02:25.2CVR HOT-2p.71
    “come out of reverse. [louder]”
    read in context ↗
  38. 11:02:26FDRAccident sequencep.6
    Left spoiler position became invalid
  39. 11:02:27.2CVR HOT-1p.71
    “#.”
    read in context ↗
  40. 11:02:27.5CVR HOT-2p.71
    “#.”
    read in context ↗
  41. ~11:02:27.6 (6 sec after heading deviation started, 12 sec after touchdown)FDRLanding roll/excursionp.6
    Heading reached 114 degrees (left turn continued)
  42. 11:02:27.6FDRLanding rollp.6
    Thrust reversers stowed (9 sec after main gear initial touchdown)
  43. 11:02:27.8CVR CAMp.71
    “[rumbling noise increases]”
    read in context ↗
  44. 11:02:28.6CVR HOT-1p.71
    “#.”
    read in context ↗
  45. ~11:02:29 (8 sec after initial brake pressure rise)FDRLanding rollp.6
    Left brake pressure dropped off, consistent with autobrakes disengaged
  46. ~11:02:31.6 (4 sec later)FDRLanding roll/excursionp.6
    Heading turned back to the right, reaching 125 degrees
  47. 11:02:32FDRAccident sequencep.6
    Heading recording became invalid; right spoiler position became invalid
  48. 11:02:33FDRAccident sequencep.7
    Both brake pressure readings became invalid
  49. 11:02:33.1CVR CAWSwarningp.71
    “[sound of CAWS landing gear configuration warning horn lasts until end of recording]”
    read in context ↗
  50. 11:02:43.2CVR CAMfinal secondsp.71
    “[sound of louder scraping lasting 8.3 seconds]”
    read in context ↗
  51. 11:02:45.1CVR LGAfinal secondsp.71
    “Delta ten eighty six? DCA15FA085 Time and Time and Source Source”
    read in context ↗
  52. 11:02:47.6CVR CAM-?final secondsp.72
    “#.”
    read in context ↗
  53. 11:02:48.0CVR CAM-?final secondsp.72
    “#.”
    read in context ↗
  54. 11:02:49.4CVR CAM-?final secondsp.72
    “#.”
    read in context ↗
  55. 11:02:51.6CVR CAMfinal secondsp.72
    “[sound of scraping noise ends]”
    read in context ↗
  56. 11:02:51.8CVR LGAfinal secondsp.72
    “Delta ten eighty six?”
    read in context ↗
  57. 11:02:53FDRAccident sequencep.7
    Engine 2 N2 went sub-idle, indicative of engine shutdown
  58. 11:02:53.5CVR CAM-?final secondsp.72
    “#.”
    read in context ↗
Recorder events without a clock time
  • ~1000 ft AGLAutopilot engaged; heading, pitch, roll, descent rate stable; control surfaces followed commanded inputs
  • ~220 ft AGLAutopilot disengaged
  • after touchdown, prior to recorder power lossAll parameters except engine speed and pressure altitude became invalid due to damage to aircraft electronics bay as aircraft departed runway and impacted terrain
Flight Data Recorder - Group Chairman's Factual Report · 22 events extracted by claude-sonnet-5Flight Data Recorder - Addendum 1 to Group Chairman's Factual Report · 3 events extracted by claude-sonnet-5Cockpit Voice Recorder - Group Chairman's Factual Report · 39 of 648 lines shown
How the Board coded the sequence
  1. Landing-landing roll: Loss of control on ground→
  2. Landing-landing roll: Runway excursion→
  3. Landing-landing roll: Collision with terr/obj (non-CFIT)

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA09MA0212008-12-21substantialmatch 59
    BOEING 737-524 · CONTINENTAL AIRLINES INC
    Denver, CO
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Loss of control on groundRunway excursion
  • CEN19MA3122019-09-112 fatalmatch 56
    Convair 440 · Ferreteria E Implementos San Francisco
    Monclova, OH
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Collision with terr/obj (non-CFIT)
  • CEN13FA1352013-01-161 fatalmatch 56
    CESSNA 208B · Martinaire Aviation, L.L.C.
    Pellston, MI
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Psychological › Perception/orientation/illusion
    Collision with terr/obj (non-CFIT)
  • ERA11FA2192011-03-302 fatalmatch 55
    BEECH 58 · Jet Logistics, Inc
    Greensboro, NC
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Psychological › Perception/orientation/illusion
  • ANC19LA0452019-08-01substantialmatch 55
    DOUGLAS C 118A · Tatonduk Outfitters Limited
    Buckland, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Runway excursion
  • DCA13FA1312013-07-22substantialmatch 55
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
  • CEN17FA1682017-04-293 fatalmatch 54
    PILATUS AIRCRAFT LTD PC 12 · RICO AVIATION LLC
    Amarillo, TX
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Psychological › Perception/orientation/illusion
  • ERA17FA1952017-06-031 fatalmatch 54
    PIPER PA23 · AIR AMERICA INC
    San Juan, PR
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    Collision with terr/obj (non-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
  • 3 of 8Collision with terr/obj (non-CFIT)
  • 2 of 8Runway excursion
  • 2 of 8Loss of visual reference
  • 2 of 8Landing gear collapse
  • 2 of 8Loss of control in flight
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Psychological › Perception/orientation/illusion
Cited here, not seen in the precedents
  • Aircraft oper/perf/capability › Aircraft capability
  • Task performance › Workload management
Common in the precedents, not cited here
  • Conditions/weather/phenomena › Light condition
  • Action/decision › Action
  • 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
  • DCA09MA0212008-12-21 · BOEING 737-524 · CONTINENTAL AIRLINES INC
    The captain’s cessation of right rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the excursion, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience. Contributing to the accident were the following factors: 1) an air traffic control system that did not require or facilitate the dissemination of key, available wind information to the air traffic controllers and pilots; and 2) inadequate crosswind training…
  • CEN19MA3122019-09-11 · Convair 440 · Ferreteria E Implementos San Francisco
    The flight crew’s failure to maintain the proper airspeed on final approach, which resulted in an inadvertent aerodynamic stall and impact with trees, and terrain. Contributing to the accident was the flight crew’s fatigue due to the overnight flight schedule.
  • CEN13FA1352013-01-16 · CESSNA 208B · Martinaire Aviation, L.L.C.
    The pilot's inadvertent controlled descent into terrain due to spatial disorientation. Contributing to the accident was lack of visual reference due to night conditions.
  • ERA11FA2192011-03-30 · BEECH 58 · Jet Logistics, Inc
    The pilot’s spatial disorientation due to a somatogravic illusion while conducting a missed approach in instrument meteorological conditions, which resulted in the airplane’s descent into objects and terrain.
  • ANC19LA0452019-08-01 · DOUGLAS C 118A · Tatonduk Outfitters Limited
    The pilot's failure to maintain an adequate glidepath during the approach, which resulted in the airplane impacting rocks and dirt at the runway threshold, a separation of the right main landing gear, and a loss of directional control.
What it recommended after them
  • A-10-105TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research into and document the effects of mountain wave and downslope conditions at airports, such as Denver International Airport, that are located downwind of mountainous terrain (including,… · DCA09MA021Closed - Acceptable Action
  • A-10-106TO THE FEDERAL AVIATION ADMINISTRATION: Archive all low-level windshear alert system (LLWAS) data obtained from Denver International Airport and other airports that experience similar wind conditions and make these data available for additi… · DCA09MA021Closed - Acceptable Action
  • A-10-107TO THE FEDERAL AVIATION ADMINISTRATION: Modify Federal Aviation Administration Order 7110.65 to require air traffic controllers at airports with multiple sources of wind information to provide pilots with the maximum wind component, includi… · DCA09MA021Closed - Unacceptable Action
  • A-10-108TO THE FEDERAL AVIATION ADMINISTRATION: Review the required documentation for all low-level windshear alert system (LLWAS)-equipped air traffic control towers to ensure that a letter to airmen has been published and is easily accessible des… · DCA09MA021Closed - Acceptable Action
  • A-10-109TO THE FEDERAL AVIATION ADMINISTRATION: Require air traffic control towers to locally develop and implement written runway selection programs that proactively consider current and developing wind conditions and include clearly defined cross… · DCA09MA021Closed - Acceptable Alternate Action
  • A-10-110TO THE FEDERAL AVIATION ADMINISTRATION: Gather data on surface winds at a sample of major U.S. airports (including Denver International Airport) when high wind conditions and significant gusts are present and use these data to develop reali… · DCA09MA021Closed - Acceptable Alternate Action
  • A-10-111TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate the realistic, gusty crosswind profiles developed as a result of Safety Recommendation A-10-110 into their pilot… · DCA09MA021Closed - Acceptable Alternate Action
  • A-10-112TO THE FEDERAL AVIATION ADMINISTRATION: Once realistic, gusty crosswind profiles as asked for in Safety Recommendation A-10-110 are developed, develop a standard methodology, including pilot-in-the-loop testing, for transport-category airpl… · DCA09MA021Open Acceptable Alternate Response

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).