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Cases › DCA15MA029 › The analyst

EMBRAER EMB-500SAGE AVIATION 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.

35
timed facts
8
precedents
181
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

35 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. 09:39:51.3CVR CAMp.54
    “[change in background sound, similar to engine start sequence]”
    read in context ↗
  2. 09:39:54.6CVR CAMp.55
    “[increase in background sound, similar to engine start and spool up (about 37 seconds)]”
    read in context ↗
  3. 09:39:56 ESTFDRPre-flight/Groundp.5
    Engine 2 Start
    see the traces at this moment ↗
  4. 09:47:32.4CVR AWUwarningp.59
    “autopilot. [similar to autopilot disconnect]”
    read in context ↗
  5. 09:54:51.9CVR HOTwarningp.62
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  6. 09:58:35.5CVR HOTwarningp.64
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  7. 09:59:51.2CVR HOT-1p.66
    “oh. oh.”
    read in context ↗
  8. 09:59:53.1CVR HOT-1p.66
    “yeah. it's supposed to be rainin' when we're leaving.”
    read in context ↗
  9. 10:00 to 10:04 ESTFDRCruisep.7
    De-icing systems were active for approximately 3 minutes while the aircraft was at 23,000 feet
    see the traces at this moment ↗
  10. 10:15:15.4CVR HOTwarningp.73
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  11. 10:23:24.1CVR HOTwarningp.78
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  12. 10:29:02.0CVR HOTwarningp.80
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  13. 10:30:22.0CVR HOTwarningp.81
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  14. 10:38:33.8CVR HOTwarningp.85
    “[sound of c-chord, similar to altitude alerter] [sound of c- chord, similar to altitude alerter]”
    read in context ↗
  15. 10:41:46.7CVR AWUfinal secondsp.93
    “stall. stall.”
    read in context ↗
  16. 10:41:49.4CVR AWUfinal secondsp.93
    “stall. stall.”
    read in context ↗
  17. 10:41:51.1CVR HOT-?final secondsp.93
    “[loud inhale and exhale]”
    read in context ↗
  18. 10:41:52.1CVR AWUfinal secondsp.93
    “stall. stall.”
    read in context ↗
  19. 10:41:54 ESTFDRImpact/Post-impactp.5
    End of Recording
    see the traces at this moment ↗
  20. 10:41:54.0CVR CAM-?final secondsp.93
    “[unintelligible exclamation]”
    read in context ↗
  21. 10:41:54.8CVR AWUfinal secondsp.93
    “stall.”
    read in context ↗
  22. 10:41:55.2CVR CAM-?final secondsp.94
    “[unintelligible exclamation]”
    read in context ↗
  23. 10:41:55.4CVR CAMfinal secondsp.94
    “[sound of loud noise, similar to impact]”
    read in context ↗
  24. 14:32:42.9CVR HOT-4p.8
    “inaccurate to that. that doesn't.”
    read in context ↗
  25. 14:36:57.8CVR HOTwarningp.11
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  26. 14:42:47.2CVR HOTwarningp.13
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  27. 15:10:16.7CVR HOTwarningp.31
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  28. 15:17:18.9CVR HOTwarningp.36
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  29. 15:18:08.3CVR HOTwarningp.38
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  30. 15:21:29.3CVR HOTwarningp.40
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  31. 15:24:06.7CVR HOTwarningp.43
    “[sound of c-chord, similar to altitude alerter]”
    read in context ↗
  32. 15:24:28.7CVR AWUwarningp.45
    “autopilot. [similar to autopilot disconnect]”
    read in context ↗
  33. 15:24:42.5CVR HOTwarningp.45
    “[sound of c-chord, similar to altitude alerter][sound of c-chord, similar to altitude alerter]”
    read in context ↗
  34. 15:26:02.8CVR AWUwarningp.47
    “sink rate.”
    read in context ↗
  35. 15:26:08.0CVR AWUwarningp.48
    “sink rate.”
    read in context ↗
Recorder events without a clock time
  • Last 1 minute of flightStall warning related parameters recorded; auto pilot disengaged prior to indication that quick disconnect switch was being pressed
  • 1041 EST (approximate)Aircraft impacted terrain and houses about 0.75 miles short of runway 14 while on approach to GAI
  • 1041 ESTAirplane impacted terrain and houses about 0.75 miles short of runway 14 while on approach to Montgomery County Airpark (GAI)
Flight Data Recorder - Specialist's Factual Report · 5 events extracted by claude-sonnet-5Flight Data Recorder Addendum - Additional Parameters · 1 events extracted by claude-sonnet-5Cockpit Voice Recorder - Group Chairman's Factual Report · 32 of 650 lines shown
How the Board coded the sequence
  1. Enroute-descent: Structural icing→
  2. Approach-IFR final approach: Loss of control in flight→
  3. Approach-IFR final approach: 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
  • DCA14FA0582014-02-05substantialmatch 52
    EMBRAER EMB145 - EP · Trans States Airlines, LLC
    Memphis, TN
    • ●Aircraft › Aircraft systems › Ice/rain protection system
    Structural icing
  • CHI08FA2822008-09-123 fatalmatch 49
    Cirrus Design Corporation SR22
    Woodruff, WI
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    Collision with terr/obj (non-CFIT) Loss of control in flight
  • WPR09MA1592009-03-2214 fatalmatch 47
    PILATUS PC-12/45 · Eagle Cap Leasing, Inc.
    Butte, MT
    • ●Personnel issues › Action/decision › Action
    Loss of control in flight
  • CEN09MA1422009-01-27substantialmatch 47
    AEROSPATIALE ALENIA ATR 42-320 · Empire Airlines
    Lubbock, TX
    • ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
    • ●Personnel issues › Action/decision › Action
    Collision with terr/obj (non-CFIT)
  • DCA09MA0272009-02-1349 fatalmatch 46
    BOMBARDIER INC DHC-8-402 · COLGAN AIR INC
    Clarence Center, NY
    • ●Personnel issues › Action/decision › Action
    Loss of control in flight
  • ERA14FA1202014-02-152 fatalmatch 46
    CESSNA 210L · SOUTHERN SEAPLANE INC
    Clay, AL
    • ●Personnel issues › Action/decision › Action
    Collision with terr/obj (non-CFIT) Loss of control in flight
  • DCA19FA0892019-03-04substantialmatch 45
    Embraer EMB145 · Commutair
    Presque Isle, ME
    • ●Personnel issues › Action/decision › Action
  • CEN10MA0882010-01-052 fatalmatch 45
    GATES LEARJET CORP. 35A · ROYAL AIR FREIGHT INC
    Prospect Heights, IL
    Collision with terr/obj (non-CFIT) Loss of control in flight

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
  • 5 of 8Loss of control in flight
  • 4 of 8Collision with terr/obj (non-CFIT)
  • 3 of 8Aerodynamic stall/spin
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Conditions/weather/phenomena › Ceiling/visibility/precip
  • Action/decision › Action
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters
  • Management › Policy/procedure
  • Action/decision › Info processing/decision
  • Experience/knowledge › Experience/qualifications
  • Psychological › Attention/monitoring
  • Task performance › Communication (personnel)

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
  • DCA14FA0582014-02-05 · EMBRAER EMB145 - EP · Trans States Airlines, LLC
    the failure of the flight crew to adequately monitor the system for proper operation and manually activate the system during the flight in icing conditions. Contributing to the accident was the crew's limited training on the manual operation of the anti-ice system and the nonactivation of the automatic ice detection system for reasons that could not be determined.
  • CHI08FA2822008-09-12 · Cirrus Design Corporation SR22
    The pilot’s failure to maintain airspeed during a missed approach leading to the inadvertent stall. Contributing to the accident were the pilot’s lack of experience in the type of operation conducted, the certificate holder’s loss of operational control, and the lack of adequate oversight of the operation by the Federal Aviation Administration.
  • WPR09MA1592009-03-22 · PILATUS PC-12/45 · Eagle Cap Leasing, Inc.
    (1) the pilot's failure to ensure that a fuel system icing inhibitor was added to the fuel before the flights on the day of the accident; (2) his failure to take appropriate remedial actions after a low fuel pressure state (resulting from icing within the fuel system) and a lateral fuel imbalance developed, including diverting to a suitable airport before the fuel imbalance became extreme; and (3) a loss of control while the pilot was maneuvering the left wing-heavy airplane near the approach end of the runway.
  • 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…
  • 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…
What it recommended after them
  • A-10-121TO THE FEDERAL AVIATION ADMINISTRATION: Amend 14 Code of Federal Regulations Part 91 to require separate seats and restraints for every occupant. · WPR09MA159Closed - Unacceptable Action
  • A-10-122TO THE FEDERAL AVIATION ADMINISTRATION: Amend 14 Code of Federal Regulations Part 91 to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff… · WPR09MA159Closed - Unacceptable Action
  • A-10-123TO THE FEDERAL AVIATION ADMINISTRATION: Amend 14 Code of Federal Regulations Parts 121 and 135 to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system duri… · WPR09MA159Closed - Unacceptable Action
  • A-11-070TO THE FEDERAL AVIATION ADMINISTRATION: Amend certification requirements for aircraft requiring fuel additives, including fuel system icing inhibitors, so that those limitations are highlighted by a warning in the limitations section of the… · WPR09MA159Closed - Unacceptable Action
  • A-11-071TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing certificated aircraft (both newly manufactured and in-service aircraft) that require fuel additives, including fuel system icing inhibitors, to have those limitations highlighted… · WPR09MA159Closed - Unacceptable Action
  • A-11-072TO THE FEDERAL AVIATION ADMINISTRATION: Amend aircraft certification fuel placarding requirements so that aircraft requiring fuel additives, including fuel system icing inhibitors, have a fuel filler placard that notes this limitation and r… · WPR09MA159Closed - Unacceptable Action
  • A-11-073TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing certificated aircraft (both newly manufactured and in-service aircraft) that require fuel additives, including fuel system icing inhibitors, to have a fuel filler placard that not… · WPR09MA159Closed - Unacceptable Action
  • A-11-074TO THE FEDERAL AVIATION ADMINISTRATION: Issue guidance on fuel system icing prevention that (1) includes pilot precautions and procedures to avoid fuel system icing problems aboard turbine engine-powered aircraft and (2) describes the possi… · WPR09MA159Closed - Acceptable Alternate 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).