Cases › DCA18IA081 › The analyst
BOMBARDIER INC DHC 8 402HORIZON AIR INDUSTRIES 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.
6
timed facts
8
precedents
11
passages to ask
Ask the docket
passages, not paraphrasesTry
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
6 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- 17:59:00 PSTFDRPre-departure/enroutep.3Start of tabular data for entire flightsee the traces at this moment ↗
- 18:37:40 PSTFDRDescentp.3Start of Figure 2 plot covering final descent from pressure altitude of approximately 4,560 ft through landingsee the traces at this moment ↗
- 18:39:32 PSTFDRLanding approachp.3Start of Figure 1 Google Earth overlay of aircraft's position during landingsee the traces at this moment ↗
- 18:40:07 PSTFDRLandingp.3Aircraft landed at Pullman/Moscow Regional Airport (KPUW), Pullman, Washington (about 40 minutes after takeoff)see the traces at this moment ↗
- 18:40:48 PSTFDRLanding rolloutp.3End of Figure 1 Google Earth overlay of aircraft's position during landingsee the traces at this moment ↗
- 18:40:50 PSTFDRLanding rolloutp.3End of Figure 2 plot and end of tabular data for entire flightsee the traces at this moment ↗
Flight Data Recorder Specialist's Factual Report · 6 events extracted by claude-sonnet-5
How the Board coded the sequence
- Landing-flare/touchdown: Wrong surface or wrong airport
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BOEING 737 · ALASKA AIRLINES INCSeattle, WA
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - Embraer EMB145 · CommutairPresque Isle, ME
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - BOEING 767 · Delta Air Lines, Inc.Atlanta Hartsfield Intl. Apt. (KATL), GA
- ●Environmental issues › Operating environment › Airport facilities/design
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - BOEING 737-9 · UNITED AIRLINES INCPittsburgh, PA
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - BOEING 757-236 · Federal Express CorporationTulsa, OK
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - BOMBARDIER INC CL 600 2B19 · SKYWEST AIRLINES INCSan Francisco, CA
- ●Personnel issues › Action/decision › Info processing/decision
- EMBRAER ERJ190 · Air CanadaDenver, CO
- ●Personnel issues › Action/decision › Info processing/decision
- EMBRAER EMB 145LR · American Eagle AirlinesChicago, IL
- ●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 causeFindings the Board cited in those cases
- 8 of 8Personnel issues › Action/decision › Info processing/decisioncited here too
- 2 of 8Environmental issues › Operating environment › Approach aid coverage/avail
- 2 of 8Personnel issues › Physical › Alertness/Fatigue
Occurrences it coded
- 5 of 8Wrong surface or wrong airport
- 3 of 8Runway incursion veh/AC/person
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Action/decision › Info processing/decision
Cited here, not seen in the precedents
- —
Common in the precedents, not cited here
- Operating environment › Approach aid coverage/avail
- Physical › Alertness/Fatigue
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
- DCA16IA0362015-12-19 · BOEING 737 · ALASKA AIRLINES INC
the flight crew's misidentification of the taxiway as the landing runway.
- DCA19FA0892019-03-04 · Embraer EMB145 · Commutair
The flight crew’s decision, due to confirmation bias, to continue the descent below the decision altitude when the runway had not been positively identified. Contributing to the accident were (1) the first officer’s fatigue, which exacerbated his confirmation bias, and (2) the failure of CommutAir pilots who had observed the localizer misalignment to report it to the company and air traffic before the accident.
- OPS10IA0012009-10-19 · BOEING 767 · Delta Air Lines, Inc.
The flight crew’s failure to identify the correct landing surface due to fatigue. Contributing to the cause of the incident were (1) the flight crew’s decision to accept a late runway change, (2) the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and (3) the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.
- DCA22LA1332022-06-21 · BOEING 737-9 · UNITED AIRLINES INC
The flightcrew’s misidentification of the intended landing runway, which resulted in approach to and landing on the wrong runway. Contributing to the incident was the distraction caused by the dual reset of the flight management computer displays.
- DCA22LA1262022-06-08 · BOEING 757-236 · Federal Express Corporation
The flight crew’s misidentification of the intended landing runway. Contributing to the incident were (1) the flight crew’s failure to perceive and correctly interpret visual and auditory indicators – including electronic guidance – that they were approaching the incorrect runway which was likely the result of a degradation in cognitive function brought on by working within their window of circadian low, increased workload, and fatigue, and (2) the air traffic controller’s failure to monitor the arriving flight af…
What it recommended after them
- A-11-012TO THE FEDERAL AVIATION ADMINISTRATION: Perform a technical review of Airport Surface Detection Equipment–Model X (ASDE-X) to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. · OPS10IA001Closed - Unacceptable Action
- A-11-013tO THE FEDERAL AVIATION ADMINISTRATION: At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment–Model X (A… · OPS10IA001Closed - Unacceptable Action
- A-11-014TO THE FEDERAL AVIATION ADMINISTRATION: Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control pa… · OPS10IA001Closed - Acceptable Action
- A-11-015TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 150/5345-56A, “Specification for L-890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances… · OPS10IA001Closed - Exceeds Recommended 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).