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Cases › DCA17IA020 › The analyst

BOEING 737 7L9Eastern Airlines Group, 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.

53
timed facts
8
precedents
112
passages to ask

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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

53 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. 18:48:06.7CVR HOT-1p.7
    “after twenty three hundred. one sixty at thirteen. gusting to twenty. one mile rain. mist. broken seven hundred. overcast twelve hundred.”
    read in context ↗
  2. 18:55:58.4CVR CAMwarningp.14
    “[sound of c-chord, similar to altitude alert] ATIS-LGA ...braking action advisories in effect. c-p-d-l-c available. LaGuardia Class Bravo services available on frequency one two six point zero five. taxi (lane) Zulu-Alpha between Kilo and Mike is now taxiway Alpha. taxiway Lima is closed between taxiways Alpha and Bravo. runway two two centerline lights out of service. runway status light system out of service. use caution ***. DCA17IA020”
    read in context ↗
  3. 18:59:05.4CVR HOT-1calloutp.18
    “okay information Charlie at twenty two fifty one. one twenty at nine. three miles in rain. nine hundred broken. fifteen hundred overcast. thirteen degrees. three zero one four on the altimeter. i-l-s runway two two. centerline lights. and status lights are out of service.”
    read in context ↗
  4. 19:00:48.2CVR CAM-2calloutp.20
    “okay we'll cross GREKO nineteen hundred. and the minimums are two twelve.”
    read in context ↗
  5. 19:02:21.9CVR CAM-2calloutp.23
    “vref one thirty seven. minimums two twelve.”
    read in context ↗
  6. 19:18:19.7CVR CAMwarningp.24
    “[sound of c-chord, similar to altitude alert]”
    read in context ↗
  7. 19:25:47.2CVR CAMwarningp.32
    “[sound of c-chord, similar to altitude alert]”
    read in context ↗
  8. 19:33:58.4CVR CAMwarningp.42
    “[sound of c-chord, similar to altitude alert]”
    read in context ↗
  9. 19:35:16.9CVR CAMwarningp.44
    “[sound of c-chord, similar to altitude alert]”
    read in context ↗
  10. 19:36:25.0CVR HOT-2calloutp.46
    “yeah so let's say ah. flaps ah. gear down flaps fifteen.”
    read in context ↗
  11. 19:36:30.1CVR HOT-1calloutp.46
    “* gear down flaps fifteen.”
    read in context ↗
  12. 19:38:29.3CVR HOT-2calloutp.49
    “awe she didn't say cleared to land.”
    read in context ↗
  13. 19:38:57.5CVR HOT-2calloutp.51
    “yeah. ask her if we're cleared to land because she didn't say it.”
    read in context ↗
  14. 19:39:01.0CVR TWRcalloutp.51
    “American eight ninety traffic three out for runway two two. wind one one zero at niner. runway one three cleared for takeoff.”
    read in context ↗
  15. 19:39:12.2CVR EGPWSwarningp.51
    “one thousand.”
    read in context ↗
  16. 19:39:16.7CVR RDO-1calloutp.51
    “and confirm Eastern ah thirty four fifty two is cleared to land.”
    read in context ↗
  17. 19:39:19.8CVR TWRcalloutp.51
    “Eastern thirty four fifty two. runway two two cleared to land. wind one one zero at niner. traffic departing will be in position runway one three.”
    read in context ↗
  18. 19:39:26.0CVR RDO-1calloutp.51
    “cleared to land Eastern thirty four fifty two. copy traffic.”
    read in context ↗
  19. 19:39:29.8CVR CAM-2calloutp.51
    “now we're cleared to land. DCA17IA020”
    read in context ↗
  20. 19:39:55.3CVR EGPWSwarningp.52
    “five hundred.”
    read in context ↗
  21. 19:40:12.9CVR AWMwarningp.53
    “[sound of three low to high frequency tones, similar to autopilot disconnect]”
    read in context ↗
  22. 19:40:13.5CVR EGPWSwarningp.53
    “approaching minimums.”
    read in context ↗
  23. 19:40:17.5CVR CAM-1calloutp.53
    “cleared to land.”
    read in context ↗
  24. 19:40:21.1CVR EGPWSwarningp.53
    “minimums.”
    read in context ↗
  25. 19:40:31.6CVR EGPWSwarningp.53
    “one hundred.”
    read in context ↗
  26. 19:40:35.1CVR EGPWSwarningp.53
    “fifty. DCA17IA020”
    read in context ↗
  27. 19:40:37.4CVR TWRcalloutp.54
    “* thirty seven fifty three traffic two and half out for runway two two. runway one three cleared for takeoff.”
    read in context ↗
  28. 19:40:38.2CVR EGPWSwarningp.54
    “thirty.”
    read in context ↗
  29. 19:40:40.3CVR EGPWSwarningp.54
    “twenty.”
    read in context ↗
  30. 19:40:46.0CVR EGPWSwarningp.54
    “ten.”
    read in context ↗
  31. 19:40:52 EDTFDRlandingp.4
    Left and right main landing gear weight on wheels (Gear WOW-R and Gear WOW-L) transitioned from air to ground and remained ground for the rest of the FDR recording
    see the traces at this moment ↗
  32. 19:40:54.5CVR TWRp.54
    “JetBlue sixteen forty runway two two cleared to land. traffic holding position one three.”
    read in context ↗
  33. 19:40:54.6 EDTFDRlanding rollp.4
    Nose landing gear weight on wheels (Gear WOW-N) transitioned from air to ground
    see the traces at this moment ↗
  34. 19:40:55.6 EDT (approx., 1 second later)FDRlanding rollp.4
    Gear WOW-N transitioned back to air
    see the traces at this moment ↗
  35. 19:40:57.3CVR HOT-2p.55
    “manual braking.”
    read in context ↗
  36. 19:40:57.8 EDTFDRlanding rollp.4
    Gear WOW-N transitioned back to ground and remained ground for the rest of the FDR recording; ground speed decreased to 117 kts
    see the traces at this moment ↗
  37. 19:41:00.6CVR CAM-?p.55
    “**.”
    read in context ↗
  38. 19:41:07.4CVR HOT-1p.55
    “errhm [sound of exertion].”
    read in context ↗
  39. 19:41:08 EDT to 19:41:16 EDTFDRlanding roll/stopp.4
    Vertical acceleration peaked between 1.68 g's and 0.37 g's and longitudinal acceleration decreased to a maximum of -0.55 g's before both vertical and longitudinal accelerations settled to about 1 g; ground speed decreased from 44 kts to 0 kts
    see the traces at this moment ↗
  40. 19:41:08.3CVR TWRp.55
    “go around. go around. JetBlue sixteen forty.”
    read in context ↗
  41. 19:41:10.8CVR TWRcalloutp.55
    “fly runway heading climb [portion prior to "maintain" had a hum background, similar to simultaneous transmission with JetBlue 1640] maintain two thousand. DCA17IA020”
    read in context ↗
  42. 19:41:24.5CVR HOT-2calloutp.56
    “should have go around.”
    read in context ↗
  43. 19:43:22 EDTFDRpost-eventp.4
    FDR data ended
    see the traces at this moment ↗
  44. 19:43:22.4CVR CAM-1p.59
    “they're-they're shut down.”
    read in context ↗
  45. 19:43:23.1CVR PORTp.59
    “Tower the airport is closed at this time.”
    read in context ↗
  46. 19:47:56.0CVR CAM-1final secondsp.66
    “see unfortunately. I should have gone straight ahead and we would have been fine. when I made the turn is when I screwed up.”
    read in context ↗
  47. 19:48:00.6CVR CAM-2final secondsp.66
    “yeah I was- I was- I was fighting you. because I was trying to stay on the centerline.”
    read in context ↗
  48. 19:48:05.1CVR HOTfinal secondsp.66
    “[sound of siren]”
    read in context ↗
  49. 19:48:06.2CVR CAM-2final secondsp.66
    “I was- I was trying to stay on the centerline and-”
    read in context ↗
  50. 19:48:10.7CVR CAM-1final secondsp.66
    “well.”
    read in context ↗
  51. 19:48:13.7CVR CAM-2final secondsp.66
    “we would have been fine. I- I- *** stay on centerline. you were fighting.”
    read in context ↗
  52. 19:48:22.0CVR CAM-2final secondsp.66
    “we would have broken just a few lights and that's it.”
    read in context ↗
  53. 19:48:22.0CVR ENDfinal secondsp.66
    “OF PART TWO OF TRANSCRIPT”
    read in context ↗
Recorder events without a clock time
  • 1942 EDT (approx.)Eastern Air Lines flight 3452 overran runway 22 during landing roll at LaGuardia Airport
  • N/AF30 approach to Runway 22 at LaGuardia (LGA)
  • N/ATurbulent atmosphere with increasing tailwind as airplane approached runway; tailwind approximately 10 knots at touchdown
  • 300 ft RAAutopilot was disconnected at approximately 300 feet radio altitude
  • 200 ft RAAutothrottle disconnected approximately 7 seconds after autopilot disconnect, at 200 feet radio altitude
  • N/AShortly after autopilot disconnect, glideslope deviation began to increase indicating airplane deviating above glideslope beam
  • N/AAirplane crossed runway threshold at radio altitude of 66 feet with glideslope deviation increasing beyond 4 dots and descent rate of approximately 750 ft/min
  • N/ADescent rate was reduced to near zero by 2500 feet beyond the runway threshold, resulting in the airplane floating down the runway
  • 9127.5Initial touchdown occurred at distance of 4242 feet beyond threshold, airspeed 123 knots (Vref-4), ground speed 130 knots, sink rate 3.3 ft/sec
  • 9127.5Upon main gear touchdown, maximum manual wheel brakes were commanded
  • ~9129.5Nose gear touched down approximately 2 seconds after main gear touchdown, but rebounded back into air due to commanded aft control column
  • ~9132.5Nose gear held off ground until it touched down a second and final time approximately 5 seconds after main gear touchdown
  • ~9132Speedbrakes were manually extended to full approximately 4.5 seconds after main gear touchdown (not armed for automatic extension); airplane had traveled approximately 1250 feet down runway before full extension
  • 9135.5Max reverse thrust was commanded by time 9135.5 seconds (8 seconds after initial touchdown); airplane had traveled approximately 1650 feet down runway from initial touchdown
  • N/AAirplane achieved good deceleration with speedbrake extension, maximum wheel brakes, and maximum reverse thrust, reaching 0.5 g's of deceleration
  • 9133.5Friction-limited braking period began when nose gear touched down at 5520 feet beyond threshold; calculated airplane braking coefficient varied between 0.2 and 0.4 through EMAS entry
  • 9145As airplane decelerated, increasing left control wheel was commanded, reaching 50 degrees of left control wheel by time 9145 seconds, reducing spoiler deflections on right wing per design
  • N/ACalculated in-air crosswind component indicated left crosswind of 7 to 8 knots, reducing to 3 to 5 knots before touchdown; on-ground winds could not be calculated
  • N/ASome left rudder pedal was commanded as airplane rolled down runway, until it was removed and right rudder pedal was commanded at 6650 feet beyond threshold; airplane responded by deviating right of centerline
  • N/AAirplane departed the end of Runway 22 while deviating right of centerline at a ground speed of approximately 40 knots
  • N/AAirplane crossed through right corner of EMAS and came to rest to the right of the EMAS, approximately 7180 feet beyond runway threshold, 114 feet right of centerline
  • N/APreliminary analysis of data indicates all systems were operating as designed; automatic speedbrake functionality could not be verified as system was not armed for landing and was reportedly on MEL as inoperative
Flight Data Recorder - Specialist’s Factual Report · 7 events extracted by claude-sonnet-5Boeing FDR Analysis · 21 events extracted by claude-sonnet-5Cockpit Voice Recorder - Factual Report of Group Chairman · 47 of 647 lines shown
How the Board coded the sequence
  1. Landing-flare/touchdown: Landing area overshoot→
  2. Landing-landing roll: Runway excursion

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA13FA1312013-07-22substantialmatch 72
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA18IA0262017-11-29no fatalitiesmatch 69
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA11IA0472011-04-26no fatalitiesmatch 68
    BOEING 737-7Q8 · SOUTHWEST AIRLINES CO
    Chicago, IL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
    Landing area overshoot
  • DCA19MA1432019-05-04substantialmatch 66
    Boeing 737 · Miami Air International
    Jacksonville, FL
    • ●Personnel issues › Action/decision › Action
    Landing area overshootRunway excursion
  • DCA09MA0212008-12-21substantialmatch 64
    BOEING 737-524 · CONTINENTAL AIRLINES INC
    Denver, CO
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
    • +1 more shared findings
    Runway excursion
  • ERA10LA0412009-10-26no fatalitiesmatch 63
    BOEING 717-200 · Air Tran Airways
    Pleasant Grove, NC
    • ●Organizational issues › Support/oversight/monitoring › Training
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • +1 more shared findings
  • DCA14FA0022013-10-23substantialmatch 62
    BEECH 1900C · ERA AVIATION INC
    Homer, AK
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA23LA1722022-12-19no fatalitiesmatch 61
    BOEING 777 · UNITED AIRLINES INC
    Kahului, HI
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info

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
  • 2 of 8Landing gear collapse
  • 2 of 8Landing area overshoot
  • 2 of 8Other weather encounter
  • 2 of 8Runway excursion
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Support/oversight/monitoring › Training
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • —

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
  • DCA13FA1312013-07-22 · BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.
  • 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…
  • DCA11IA0472011-04-26 · BOEING 737-7Q8 · SOUTHWEST AIRLINES CO
    The flight crew's delayed deployment of the speedbrakes and thrust reversers, resulting in insufficient runway remaining to bring the airplane to a stop. Contributing to the delay in deployment of these stopping devices was the flight crew's inadequate monitoring of the airplane's configuration after touchdown, likely as a result of being distracted by a perceived lack of wheel braking effectiveness. Contributing to the incident was the flight crew's omission of the Before Landing checklist, which includes an…
  • DCA19MA1432019-05-04 · Boeing 737 · Miami Air International
    An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning. Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments. Contributing to the continuation of an unstabilized approach were 1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and 2) the first officer’s lack of…
  • 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…
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).