FlarePath
Cases › DCA16IA200 › The analyst

AIRBUS INDUSTRIE A320 211DELTA AIR LINES INC

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.

73
timed facts
8
precedents
175
passages to ask

Ask the docket

passages, not paraphrases
Try

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

73 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. 19:25 MDTFDRDeparture/Climbp.3
    The aircraft departed MSP at about 19:25 MDT and a climbed to a final cruising altitude of flight level 360
    see the traces at this moment ↗
  2. 19:26:49.8CVR RDO-2p.7
    “right to two three zero. we're switchin' Delta twenty eight forty five.”
    read in context ↗
  3. 19:27:36.2CVR HOT-1calloutp.8
    “after takeoff checklist.”
    read in context ↗
  4. 19:27:41.9CVR HOT-2calloutp.8
    “after takeoff checklist is complete sir.”
    read in context ↗
  5. 19:30:15.6CVR HOT-1calloutp.10
    “autopilot one's on.”
    read in context ↗
  6. 20:25:23.3CVR HOT-1p.63
    “managed descent seventeen. DCA16IA200”
    read in context ↗
  7. 20:25:27.5CVR PA-2p.64
    “ladies and gentlemen from the flight deck we've started our initial ah descent into Rapid City we're showing about seventy five miles out. we should have you on the ground in just about twenty minutes. thanks for flying Delta tonight we do appreciate your business. flight attendants please prepare the cabin for arrival.”
    read in context ↗
  8. 20:25:28 MDTFDRDescentp.3
    The aircraft began a descent when it was about 76 nautical miles (nm) from RAP
    see the traces at this moment ↗
  9. 20:35:51.9CVR HOT-2p.77
    “okay. DCA16IA200”
    read in context ↗
  10. 20:35:52 to 20:36:50 MDTFDRDescent/Level-offp.3
    The aircraft leveled at 10,000 ft as its speed slowed below 250 knots indicated airspeed (KIAS)
    see the traces at this moment ↗
  11. 20:35:52.9CVR HOT-1p.78
    “okay and flight and nav instruments I got R-NAV one four.”
    read in context ↗
  12. 20:36:26.3CVR HOT-1p.78
    “there's the airport.”
    read in context ↗
  13. 20:36:30.1CVR HOT-2p.78
    “there it is.”
    read in context ↗
  14. 20:36:31 MDTFDRDescent/Level-offp.3
    Spoilers were applied during the level-off at 10,000 ft, used until about 20:38:58 MDT (with a retraction for about 15 seconds during this time)
    see the traces at this moment ↗
  15. 20:36:50 MDTFDRApproachp.3
    The aircraft was abeam RCA and about 8.5 nm from RAP and 5.5 nm from RCA
    see the traces at this moment ↗
  16. 20:36:53.0CVR HOT-1p.79
    “we can go ahead and put some drag out here. let's go gear down.”
    read in context ↗
  17. 20:36:55.8CVR HOT-2p.79
    “gear down comin'.”
    read in context ↗
  18. 20:36:58.9CVR HOT-2p.79
    “two below-- two forty all good.”
    read in context ↗
  19. 20:37:03 MDTFDRApproachp.3
    The gear was selected down, when the aircraft was descending through 9,770 ft and was 5.5 nm abeam from RCA
    see the traces at this moment ↗
  20. 20:37:08.5CVR HOT-1p.79
    “flaps one.”
    read in context ↗
  21. 20:37:09.9CVR HOT-2p.79
    “speeds check flaps one.”
    read in context ↗
  22. 20:37:12 MDTFDRApproachp.3
    Flaps 1 were selected
    see the traces at this moment ↗
  23. 20:37:14.5CVR HOT-1p.79
    “this be one of those vertical descents.”
    read in context ↗
  24. 20:37:53.5CVR HOT-1p.80
    “flaps two.”
    read in context ↗
  25. 20:37:54.8CVR HOT-2p.80
    “speeds checkkkk. flaps two.”
    read in context ↗
  26. 20:37:58 MDTFDRApproachp.3
    Flaps 2 were selected, when the aircraft was about 4.8 nm northeast of RCA and 10 nm northeast of RAP
    see the traces at this moment ↗
  27. 20:38:10.3CVR HOT-1p.80
    “flaps three.”
    read in context ↗
  28. 20:38:11.4CVR HOT-2p.80
    “flaps three.”
    read in context ↗
  29. 20:38:14 MDTFDRApproachp.3
    Flaps 3 were selected
    see the traces at this moment ↗
  30. 20:39:41.8CVR HOT-2p.83
    “flaps full landing checklist.”
    read in context ↗
  31. 20:39:46 MDTFDRApproachp.4
    Flaps 4 were selected, as the aircraft was in a left turn towards the RAP RNAV 14 final approach course
    see the traces at this moment ↗
  32. 20:39:49.0CVR HOT-2p.83
    “you did that.”
    read in context ↗
  33. 20:40:43.8CVR HOT-1p.85
    “I'm not happy with it.”
    read in context ↗
  34. 20:40:44 MDTFDRApproachp.4
    The autopilot was turned off, as the aircraft was nearly on the RAP RNAV 14 final approach course
    see the traces at this moment ↗
  35. 20:40:44.4CVR HOT-2p.85
    “...we didn't-we didn't catch the hook. yep.”
    read in context ↗
  36. 20:40:44.5CVR CAMwarningp.85
    “[sound cavalry charge, similar to autopilot disconnect]”
    read in context ↗
  37. 20:40:56.6CVR RDO-2calloutp.85
    “cleared to land runway one four Delta twenty eight forty five. DCA16IA200”
    read in context ↗
  38. 20:41:03.7CVR HOT-1p.86
    “get rid of the autopilot-- of the flight directors.”
    read in context ↗
  39. 20:41:05 MDTFDRApproachp.4
    The flight directors were turned off, as the aircraft deviated left of the RAP RNAV 14 final approach course, was aligned with the runway 13 extended centerline at RCA, and was about 2.8 nm from the approach end of RCA runway 13
    see the traces at this moment ↗
  40. 20:41:05.7CVR HOT-2p.86
    “yep. there we go.”
    read in context ↗
  41. 20:41:25.4CVR HOT-2calloutp.86
    “okay. one thousand. cleared to land. all green. we're a little steep for v-v-i intentionally. all energy is good.”
    read in context ↗
  42. 20:42:39.3CVR HOT-1p.89
    “ah man that's not a good thing.”
    read in context ↗
  43. 20:42:42 MDTFDRLandingp.4
    The aircraft landed at RCA
    see the traces at this moment ↗
  44. 20:42:46.5CVR HOT-1p.89
    “we need Ellsworth Tower.”
    read in context ↗
  45. 20:42:54.4CVR PA-1calloutp.89
    “well ladies and gentlemen you're not gonna believe this. (It was my leg) and Ellsworth and Rapid City are directly in line. and I just landed at Ellsworth. so we're gonna have to get off the runway come back around and takeoff and go over to Rapid City. first time in my career to do that.”
    read in context ↗
  46. 20:52:03.2CVR CAMwarningp.103
    “[sound of single chime, similar to master caution]”
    read in context ↗
  47. 23:02:14.1CVR CAMwarningp.107
    “[sound of single chime, similar to master caution]”
    read in context ↗
  48. 23:02:50.4CVR CAMwarningp.108
    “[sound of single chime, similar to master caution]”
    read in context ↗
  49. 23:03:35.4CVR HOT-2calloutp.110
    “one one and one. takeoff speeds.”
    read in context ↗
  50. 23:07:51.5CVR HOT-1calloutp.114
    “I got twenty five eighty five in the ah...radio number two to activate the lights as soon as we takeoff.”
    read in context ↗
  51. 23:08:08.4CVR HOT-1calloutp.114
    “I'll activate the lights as soon as we take off.”
    read in context ↗
  52. 23:08:11.0CVR INT-3calloutp.114
    “(@) cabin's ready for takeoff. DCA16IA200”
    read in context ↗
  53. 23:10:20.2CVR HOT-2calloutp.119
    “it's gonna be vectors departure. do what they tell us to. initially it's gonna be runway heading.”
    read in context ↗
  54. 23:10:46.3CVR HOT-1calloutp.120
    “slowly go around I'll make all those necessary radio calls.”
    read in context ↗
  55. 23:11:02.1CVR HOT-1calloutp.120
    “I think we're close enough. sure before takeoff checklist.”
    read in context ↗
  56. 23:11:04.4CVR HOT-2calloutp.120
    “before takeoff checklist. runway position.”
    read in context ↗
  57. 23:11:20.6CVR HOT-2calloutp.121
    “one and one. takeoff memo.”
    read in context ↗
  58. 23:11:33.0CVR HOT-2calloutp.121
    “before takeoff checklist is complete.”
    read in context ↗
  59. 23:12:15.7CVR RDO-2calloutp.122
    “and tower our fuel imbalance is ah fixed Delta twenty eight forty five ready to takeoff for runway one three.”
    read in context ↗
  60. 23:12:25.8CVR RDO-2calloutp.123
    “line up and wait runway one three I'm assuming it will be ah runway heading initially for Delta twenty eight forty five.”
    read in context ↗
  61. 23:12:57.7CVR RDO-2calloutp.123
    “fly runway heading up to six thousand Delta twenty eight forty five.”
    read in context ↗
  62. 23:13:07.9CVR RDO-2calloutp.123
    “cleared takeoff ah Delta twenty eight forty five runway one three.”
    read in context ↗
  63. 23:13:20.3CVR HOT-1calloutp.124
    “okay runway heading six thousand.”
    read in context ↗
  64. 23:13:37.4CVR HOT-1calloutp.124
    “we've been cleared for takeoff.”
    read in context ↗
  65. 23:25:26.8CVR CAMwarningp.142
    “[sound of cavalry charge, similar to autopilot disconnect]”
    read in context ↗
  66. 23:34:03.6CVR HOT-1final secondsp.153
    “and we'll have do the ah securing checklist but we won't do that--”
    read in context ↗
  67. 23:34:05.8CVR HOT-2final secondsp.153
    “yep. I'll do that as s-soon as I get back.”
    read in context ↗
  68. 23:34:17.4CVR CAMfinal secondsp.153
    “[sound of unintelligible chatter from cabin]”
    read in context ↗
  69. 23:34:59.5CVR HOTfinal secondsp.153
    “[sound of beep]”
    read in context ↗
  70. 23:35:06.5CVR CAMfinal secondsp.153
    “[sound of unintelligible chatter from cabin]”
    read in context ↗
  71. 23:37:09.1CVR CAMfinal secondsp.153
    “[sound of chime]”
    read in context ↗
  72. 23:37:14.8CVR CAMfinal secondsp.153
    “[sound of discontinuity in recording, similar to CVR power cycle]”
    read in context ↗
  73. 23:37:20.6CVR CAMfinal secondsp.153
    “[sound of unintelligible voices]”
    read in context ↗
FLIGHT DATA RECORDER - SPECIALIST'S FACTUAL REPORT · 13 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT · 60 of 1,369 lines shownRAP LC AUDIO DAL2845 · 13 min· not yet aligned to a clock
How the Board coded the sequence
  1. Landing: Wrong surface or wrong airport→
  2. Landing: Runway incursion veh/AC/person

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA14IA0372014-01-13no fatalitiesmatch 63
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Branson, MO
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport
  • DCA18IA0262017-11-29no fatalitiesmatch 61
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • OPS21LA0022021-04-29no fatalitiesmatch 59
    AIRBUS A319-112 · Allegiant Air
    St Petersburg-Clearwater, FL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Planning/preparation
  • DCA16LA1002016-02-24substantialmatch 58
    EMBRAER EMB145 · TRANS STATES AIRLINES INC
    St Louis, MO
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Planning/preparation
  • DCA11FA0502011-01-03substantialmatch 57
    BOEING 737-823 · American Airlines
    Los Angeles, CA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA16CA1132016-03-05substantialmatch 54
    BOEING 767 34AF · UNITED PARCEL SERVICE CO
    Albuquerque, NM
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA14IA0162013-11-22no fatalitiesmatch 54
    BOEING 747 - 409LCF · Atlas Air , Inc.
    Wichita, KS
    • ●Personnel issues › Action/decision › Action
    Wrong surface or wrong airport
  • DCA19CA0662018-12-31substantialmatch 54
    Boeing 757 · American Airlines
    Charlotte, NC
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision

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 8Tailstrike
  • 2 of 8Air traffic event
  • 2 of 8Navigation error
  • 2 of 8Wrong surface or wrong airport
  • 2 of 8Near midair/TCAS alert/loss of separation
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
  • Task performance › Planning/preparation
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • 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
  • DCA14IA0372014-01-13 · BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    The Flight crew's failure to properly identify the airport and runway of intended landing. Contributing to the incident was the flight crew's failure to comply with procedures for use of navigation information and visual cues to verify the airport and runway of intended landing and the air traffic controller's issuance of erroneous airport geographic information without including the location of proximate airports.
  • DCA18IA0262017-11-29 · BOEING 737-932ER · Delta Air Lines
    The flight crewmembers’ failure to properly monitor the airplane’s flightpath, which caused the approach to become unstabilized and resulted in the airplane’s descent below the decision altitude while misaligned with the localizer course. Contributing to the incident were the first officer’s delay in setting go-around thrust after the captain called for the go-around and the captain’s failure to take control of the airplane after go-around thrust was not immediately set, both of which caused the airplane to come wi…
  • OPS21LA0022021-04-29 · AIRBUS A319-112 · Allegiant Air
    The air traffic controller’s failure to properly scan the runway and local area, and their general loss of situational awareness, resulting in a near midair collision. Contributing to the incident was the Cessna 337 pilot's poor decision making when he failed to fly the standard downwind leg distance from the runway and to maintain the standard traffic pattern altitude.
  • DCA16LA1002016-02-24 · EMBRAER EMB145 · TRANS STATES AIRLINES INC
    the flight crews' failure to consider all available runways for landing to minimize the gusty crosswind component. Contributing to the accident was the captain's reduction of the engine thrust for about 1 second at low altitude immediately after the first officer applied maximum thrust to conduct a go-around.
  • DCA11FA0502011-01-03 · BOEING 737-823 · American Airlines
    the early rotation of the airplane to an angle at which the fuselage contacted the runway. Contributing to early rotation was the Captain’s reaction to the erroneous V1 automated callout, likely assuming that the airplane was at or close to the correct Vr at the same time. The erroneous automated callout was likely due to a keystroke entry error by the FO when manually entering takeoff data for a newly assigned departure runway.
What it recommended after them
  • A-15-009TO THE FEDERAL AVIATION ADMINISTRATION: Amend air traffic control procedures so that controllers withhold landing clearance until the aircraft has passed all other airports that may be confused with the destination airport. · DCA14IA037Open Acceptable Alternate Response
  • A-15-010TO THE FEDERAL AVIATION ADMINISTRATION: Modify the minimum safe altitude warning (MSAW) software to apply the MSAW parameters for the flight plan destination airport to touchdown, rather than automatically reassigning the flight to another… · DCA14IA037Open 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).