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Cases › DCA16LA100 › The analyst

EMBRAER EMB145TRANS STATES AIRLINES 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.

69
timed facts
8
precedents
44
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One timeline

69 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. 23:04:30.0CVR HOT-2p.8
    “alright. it's gonna be a visual backed up by the I-L-S. one eleven point five. inbound. three oh two.”
    read in context ↗
  2. 23:05:59.6CVR HOT-1p.8
    “be off to ops. DCA16LA100”
    read in context ↗
  3. 23:06:00 CSTFDRDescentp.3
    Descent begins from pressure altitude of about 20,000 ft (start of Figures 2 and 3 data range)
    see the traces at this moment ↗
  4. 23:06:00.6CVR HOT-2p.9
    “roger.”
    read in context ↗
  5. 23:10:56.8CVR HOTwarningp.12
    “[sound of 3 buzzers, similar to altitude alert]”
    read in context ↗
  6. 23:15:29.9CVR HOT-1p.16
    “boom.”
    read in context ↗
  7. 23:15:33 CSTFDRDescentp.3
    Autopilot status transitioned from engaged to not engaged and remained not engaged for the remainder of the flight, while descending through a pressure altitude of approximately 10,500 ft (about 41 minutes after takeoff)
    see the traces at this moment ↗
  8. 23:15:34.7CVR HOT-2p.16
    “I'm flyin'.”
    read in context ↗
  9. 23:18:40.0CVR TWRcalloutp.18
    “Waterski forty six fifteen Saint Louis Tower runway three zero right. cleared to land. the left's available if you want it. the wind zero two zero at two zero gust two five.”
    read in context ↗
  10. 23:18:51.5CVR HOTwarningp.18
    “[sound of 3 buzzers, similar to altitude alert]”
    read in context ↗
  11. 23:18:52.5CVR TWRcalloutp.18
    “Waterski forty six fifteen change to cleared to land runway three zero left. the localizer is ah one one one point five. cleared to land runway three zero left.”
    read in context ↗
  12. 23:19:00.8CVR RDO-1calloutp.19
    “cleared to land thirty left Waterski forty six fifteen.”
    read in context ↗
  13. 23:19:03.2CVR HOT-2calloutp.19
    “gear down.”
    read in context ↗
  14. 23:19:36.1CVR HOT-1p.20
    “yeah it's pretty well a direct crosswind.”
    read in context ↗
  15. 23:19:39 CSTFDRApproachp.3
    While descending through a pressure altitude of approximately 3,387 ft, radio altitude decreased from its maximum value of 2,550 ft to 2,532 ft and continued to decrease
    see the traces at this moment ↗
  16. 23:19:40.9CVR HOT-2p.20
    “and four thousand you can set for miss. uh once I.”
    read in context ↗
  17. 23:19:56.8CVR HOTwarningp.20
    “[sound of 3 buzzers, similar to altitude alert]”
    read in context ↗
  18. 23:20:32.4CVR HOT-2calloutp.20
    “I see gear down. flaps forty five. before landing checklist.”
    read in context ↗
  19. 23:22:15 CSTFDRMissed Approachp.3
    Start of missed approach data window (Figures 4 and 5)
    see the traces at this moment ↗
  20. 23:22:20.3CVR HOT-1p.21
    “lookin' good.”
    read in context ↗
  21. 23:22:22.1CVR AWUp.21
    “two hundred. DCA16LA100”
    read in context ↗
  22. 23:22:51.6CVR HOTwarningp.22
    “[sound of 3 chimes, similar to master warning]”
    read in context ↗
  23. 23:22:52 CSTFDRApproach/Landingp.3
    While at a radio altitude of 4 ft, gear weight on wheels changed from air to ground then switched back to air less than a second later while the master warning changed from off to on
    see the traces at this moment ↗
  24. 23:22:52.9CVR AWUwarningp.22
    “bank angle. bank angle.”
    read in context ↗
  25. 23:22:53.0CVR AWUwarningp.22
    “(takeoff). [simultaneous with prior "bank angle"]”
    read in context ↗
  26. 23:22:55.1CVR AWUwarningp.23
    “bank angle.”
    read in context ↗
  27. 23:22:55.8CVR AWUwarningp.23
    “bank angle.”
    read in context ↗
  28. 23:22:56.3CVR HOTwarningp.23
    “[sound of 3 chimes, similar to master warning]”
    read in context ↗
  29. 23:23:00.1CVR HOTwarningp.23
    “[sound of 3 chimes, similar to master warning]”
    read in context ↗
  30. 23:23:02.3CVR HOT-1p.23
    “(ah go-round). positive climb.”
    read in context ↗
  31. 23:23:03 CSTFDRMissed Approachp.3
    Master warning changed to off
    see the traces at this moment ↗
  32. 23:23:04.7CVR HOT-2p.23
    “gear up. [sound of click, similar to gear handle] DCA16LA100”
    read in context ↗
  33. 23:23:05.7CVR HOTwarningp.24
    “[sound of 3 chimes, similar to master warning]”
    read in context ↗
  34. 23:23:06 CSTFDRMissed Approachp.3
    Master warning changed back to on, 3 seconds after previous change
    see the traces at this moment ↗
  35. 23:23:06.3CVR HOT-?p.24
    “*.”
    read in context ↗
  36. 23:23:07.2CVR AWUp.24
    “landing gear.”
    read in context ↗
  37. 23:23:10 CSTFDRMissed Approachp.3
    Master warning changed back to off and remained off for the remainder of the flight; radio altitude had increased to 210 ft
    see the traces at this moment ↗
  38. 23:23:27.0CVR HOT-1p.25
    “** come back **.”
    read in context ↗
  39. 23:23:30 CSTFDRMissed Approachp.3
    End of missed approach data window (Figures 4 and 5)
    see the traces at this moment ↗
  40. 23:23:30.5CVR TWRp.25
    “Waterski forty six fifteen ah make left traffic for runway three zero left.”
    read in context ↗
  41. 23:23:41.0CVR HOTwarningp.25
    “[sound of 3 buzzers, similar to altitude alert]”
    read in context ↗
  42. 23:24:15.9CVR HOT-2p.26
    “takeoff checklist complete.”
    read in context ↗
  43. 23:24:16 CSTFDRGo-around/Climbp.3
    Radio altitude had increased to approximately 2,400 ft
    see the traces at this moment ↗
  44. 23:24:17.4CVR HOT-1p.26
    “alright thanks.”
    read in context ↗
  45. 23:25:21.0CVR TWRcalloutp.28
    “Waterski forty six fifteen runway three zero left. cleared to land. the wind now zero two zero at two one gust two six.”
    read in context ↗
  46. 23:25:28.1CVR RDO-2calloutp.28
    “alright three zero left cleared to land. Waterski forty six fifteen.”
    read in context ↗
  47. 23:27:13 CSTFDRFinal Approachp.4
    The aircraft began its final descent
    see the traces at this moment ↗
  48. 23:27:14.0CVR HOT-1p.30
    “yeah. just set me approach mode (on the ah).”
    read in context ↗
  49. 23:27:18.2CVR HOTwarningp.30
    “[sound of 3 buzzers, similar to altitude alert]”
    read in context ↗
  50. 23:27:19.8CVR HOT-2p.30
    “flaps--”
    read in context ↗
  51. 23:27:40.1CVR HOT-1calloutp.30
    “and gear down.”
    read in context ↗
  52. 23:28:10.1CVR HOT-2calloutp.30
    “flight attendant notified. landing gear down. flaps forty five. speed brake closed. crossfeed off. before landing checklist complete.”
    read in context ↗
  53. 23:28:26.6CVR RDO-2calloutp.31
    “and ah confirm forty six fifteen's cleared to land three zero left.”
    read in context ↗
  54. 23:28:30.3CVR TWRcalloutp.31
    “Waterski forty six fifteen affirmative runway three zero left cleared to land. the wind zero one zero at two zero gust two six.”
    read in context ↗
  55. 23:28:37.4CVR RDO-2calloutp.31
    “alright cleared to land three zero left. forty six fifteen.”
    read in context ↗
  56. 23:29:34.6CVR TWRcalloutp.31
    “[runway 30R cleared to land. wind 010 at 23 gust 30. runway 30L available if you like it.]”
    read in context ↗
  57. 23:30:24.5CVR HOT-2p.32
    “twenty feet.”
    read in context ↗
  58. 23:30:25.0CVR HOT-1p.32
    “[low volume] okay.”
    read in context ↗
  59. 23:30:32 CSTFDRLandingp.4
    Gear weight on wheels transitioned to ground
    see the traces at this moment ↗
  60. 23:30:44.5CVR HOT-2final secondsp.32
    “fifty knots. my tops.”
    read in context ↗
  61. 23:30:46.5CVR HOT-1final secondsp.32
    “okay. your tops.”
    read in context ↗
  62. 23:30:58.1CVR TWRfinal secondsp.32
    “Waterski forty six fifteen turn left at quebec and taxi via quebec charlie to the ramp. remain this frequency.”
    read in context ↗
  63. 23:31:04.3CVR RDO-2final secondsp.32
    “quebec charlie to the ramp with you forty six fifteen.”
    read in context ↗
  64. 23:31:08.5CVR PA-3final secondsp.32
    “[unintelligible flight attendant announcement]”
    read in context ↗
  65. 23:31:20.4CVR HOT-1final secondsp.32
    “clear left.”
    read in context ↗
  66. 23:31:21.9CVR HOT-2final secondsp.32
    “clear right. DCA16LA100”
    read in context ↗
  67. 23:31:28.8CVR TWRfinal secondsp.33
    “and Waterski forty six fifteen when you get a chance give me a call on the phone if you don't mind. company will have the number or I can give it to you.”
    read in context ↗
  68. 23:32:00 CSTFDRLanding Rollp.3
    End of data range for Figures 2 and 3, about 1 minute and 28 seconds after final touchdown
    see the traces at this moment ↗
  69. 23:34:24 CSTFDRPost-landingp.3
    End of the event flight data
    see the traces at this moment ↗
FLIGHT DATA RECORDER - SPECIALISTA��S FACTUAL REPORT · 14 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIRMANA��S FACTUAL REPORT · 55 of 268 lines shown
How the Board coded the sequence
  1. Landing: Abnormal runway contact

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA09FA0482009-05-06substantialmatch 63
    BOEING DC-10 · World Airways
    Baltimore, MD
    • ●Personnel issues › Action/decision › Action
    Abnormal runway contact
  • DCA26LA1392026-02-26no fatalitiesmatch 61
    BOMBARDIER INC CL-600-2C10 · Endeavor Airlines
    College Park, GA
    Abnormal runway contact
  • 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
  • DCA16IA2002016-07-08no fatalitiesmatch 58
    AIRBUS INDUSTRIE A320 211 · DELTA AIR LINES INC
    Rapid City, SD
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Planning/preparation
  • DCA18IA0262017-11-29no fatalitiesmatch 57
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
  • DCA14MA0812014-03-13substantialmatch 57
    AIRBUS A320 - 214 · US AIRWAYS INC
    Philadelphia, PA
    • ●Personnel issues › Action/decision › Action
    Abnormal runway contact
  • OPS24LA0042023-10-27no fatalitiesmatch 56
    AIRBUS A321-271N · HAWAIIAN AIRLINES INC
    Long Beach, CA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Planning/preparation
  • OPS11IA4102011-03-11no fatalitiesmatch 55
    BOEING 757-232 · Delta Airlines
    ATLANTA, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Planning/preparation

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 8Abnormal runway contact
  • 3 of 8Air traffic event
  • 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
  • Task performance › Planning/preparation
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Action/decision › Info processing/decision
  • 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
  • DCA09FA0482009-05-06 · BOEING DC-10 · World Airways
    the captain’s inappropriate control inputs following a firm landing, resulting in two hard nose-gear impacts before executing a go-around. Contributing to the inappropriate control inputs was the captain’s fatigue and physical discomfort; and a possible lack of practical consolidation of skills and experience due to a protracted and fragmented training period.
  • DCA26LA1392026-02-26 · BOMBARDIER INC CL-600-2C10 · Endeavor Airlines
    The captain’s inadequate compensation for gusting crosswind wind conditions while attempting to land and a subsequent go-around.
  • 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.
  • DCA16IA2002016-07-08 · AIRBUS INDUSTRIE A320 211 · DELTA AIR LINES INC
    The flight crew's misidentification of the desired landing runway due to excess altitude requiring an extended downwind, and failure to use all available navigation information.
  • 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…

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).