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Cases › DCA18LA285 › The analyst

Boeing 757American Airlines

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.

61
timed facts
8
precedents
67
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

61 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. 09:25:00FDRPre-departurep.3
    Full incident flight FDR data range begins
    see the traces at this moment ↗
  2. 09:28:24FDRDeparture/Climbp.4
    Aircraft departed EGPH and climbed to a cruising altitude of 36,000 feet
    see the traces at this moment ↗
  3. 15:56:06.2CVR STARTp.7
    “OF RECORDING”
    read in context ↗
  4. 16:31:50FDRDescentp.4
    Initial descent to 24,000 feet into KJFK began
    see the traces at this moment ↗
  5. 16:37:49FDRDescentp.4
    Aircraft reached 24,000 feet and held for about a minute
    see the traces at this moment ↗
  6. 16:38:00FDRDescentp.3
    Descent time range begins (24,000 feet)
    see the traces at this moment ↗
  7. 16:39:04FDRDescentp.4
    12,000 feet dialed into the mode control panel (MCP) and another descent began
    see the traces at this moment ↗
  8. 16:39:04.1CVR RDO-2p.7
    “Calverton at twelve and two fifty speed. American two seven nine.”
    read in context ↗
  9. 16:39:10.9CVR CAM-2p.7
    “twelve at Calverton.”
    read in context ↗
  10. 16:45:30.6CVR APPp.12
    “American two seventy nine New York Approach expect the”
    read in context ↗
  11. 16:45:38.1CVR RDO-2p.12
    “after ROBER heading uh two eight zero American uh two seven nine and we have india.”
    read in context ↗
  12. 16:45:39FDRDescentp.4
    As aircraft neared 12,000 feet, Altitude Hold mode engaged
    see the traces at this moment ↗
  13. 16:45:51 to 16:45:55FDRDescentp.4
    Recorded altimeter setting changed from 29.92 inHg to 30.13 inHg (input change may have occurred any time in this window; altimeter setting recorded only once every four seconds)
    see the traces at this moment ↗
  14. 16:45:55FDRDescentp.4
    Flight change (FLCH) button activated on MCP; auto throttle system immediately transitioned to FLCH descent mode; MCP speed window switched to display current airspeed, slightly above desired 250 knots; MCP speed then manually dialed down to 250 knots; engine throttle lever angle began to decrease and airplane decelerated
    see the traces at this moment ↗
  15. unspecified (after 16:45:55)FDRDescentp.5
    Once throttles reached the aft stop, auto throttle system entered Throttle Hold mode
    see the traces at this moment ↗
  16. 16:45:55.0CVR CAM-1p.12
    “wonder why it kicked out like that? thirty thirteen...thirty thirteen and thirty thirteen.”
    read in context ↗
  17. 16:46:00 to 16:49:00FDREventp.3
    Event time range covering three minutes surrounding the event
    see the traces at this moment ↗
  18. 16:47:31FDRDescentp.5
    Airspeed had degraded to 186.5 knots and pitch attitude was approximately 6 deg nose up
    see the traces at this moment ↗
  19. 16:47:31.1CVR CAM-1p.14
    “oh #.”
    read in context ↗
  20. 16:47:32.2CVR CAM-3p.14
    “speed.”
    read in context ↗
  21. 16:47:34FDRDescentp.5
    At an airspeed of 185.5 knots, throttle lever angles increased rapidly, and the auto throttle system exited Throttle Hold mode; N1 on both engines began to increase
    see the traces at this moment ↗
  22. 16:47:40.1CVR CAM-3p.14
    “push. push it over. get the autopilot off. push it over. [loud]”
    read in context ↗
  23. 16:47:42FDREventp.5
    Autopilot and auto throttle systems were disengaged; throttle lever angles began to decrease; airspeed was 195 knots and increasing
    see the traces at this moment ↗
  24. 16:47:42.7CVR CAMwarningp.14
    “[sound of autopilot disconnect]”
    read in context ↗
  25. 16:47:44FDREventp.5
    Aircraft pitch attitude was approximately 10 degrees nose up and control column position moved quickly forward (to command nose down attitude)
    see the traces at this moment ↗
  26. 16:47:44 to 16:47:55FDREventp.5
    Vertical acceleration varied between 1.476 g and -0.156 g and pitch attitude varied between 10 degrees nose up and 3 degrees nose down
    see the traces at this moment ↗
  27. 16:47:45FDREventp.3
    Approximate time of the event during descent
    see the traces at this moment ↗
  28. 16:47:52.0CVR CAM-1p.14
    “#.”
    read in context ↗
  29. 16:47:55.2CVR CAM-1p.14
    “flight level.”
    read in context ↗
  30. 16:48:00.2CVR CAM-1p.14
    “I wonder why that kicked off?”
    read in context ↗
  31. 16:48:01FDRPost-eventp.5
    Auto throttle system briefly engaged again
    see the traces at this moment ↗
  32. 16:48:08FDRPost-eventp.5
    Auto throttle system disengaged
    see the traces at this moment ↗
  33. unspecified (around 16:48:08-16:48:16)FDRPost-eventp.5
    Aircraft continued to gain airspeed; pressure altitude was 11149 feet and decreasing
    see the traces at this moment ↗
  34. 16:48:11.9CVR CAM-1p.14
    “left autopilot's engaged.”
    read in context ↗
  35. 16:48:16FDRPost-eventp.5
    Autopilot reengaged with a target altitude of 7,000 feet
    see the traces at this moment ↗
  36. 16:48:25.5CVR CAM-1p.14
    “we'll talk about that on the ground guys.”
    read in context ↗
  37. 16:49:26.4CVR CAM-2p.15
    “now do you—”
    read in context ↗
  38. 16:49:30.2CVR INT-1p.15
    “hey @. Captain @ here. uh good time to make our final P-A?”
    read in context ↗
  39. 16:49:31FDRPost-eventp.5
    Auto throttle system reengaged (had remained disengaged since 16:48:08)
    see the traces at this moment ↗
  40. 16:49:58.5CVR CAM-1p.15
    “somebody I think the flight attendant went down in the back.”
    read in context ↗
  41. 16:50:00FDRPost-eventp.3
    End of descent time range (two minutes fifteen seconds after the event)
    see the traces at this moment ↗
  42. 16:50:01.7CVR CAM-2p.15
    “she alright? DCA18LA285 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  43. 16:56:21.5CVR CAM-1calloutp.22
    “gear down please. DCA18LA285 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  44. 16:57:43.6CVR CAMwarningp.25
    “[sound of configuration warning]”
    read in context ↗
  45. 16:58:32.0CVR TWRcalloutp.26
    “American two seventy nine Kennedy Tower roger. runway two two left cleared to land.”
    read in context ↗
  46. 16:58:46.9CVR CAM-2calloutp.27
    “cleared for the approach. cleared to land.”
    read in context ↗
  47. 17:00:30.1CVR CAMp.28
    “ten. [automated voice]”
    read in context ↗
  48. 17:00:35FDRLandingp.5
    Aircraft landed on runway 22L at KJFK, approximately 13 minutes following the event
    see the traces at this moment ↗
  49. 17:00:35.8CVR CAM-2p.28
    “deployed. DCA18LA285 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  50. 17:01:20FDRLandingp.3
    Approximate arrival at KJFK; end of full incident flight time range
    see the traces at this moment ↗
  51. 17:01:33.5CVR RDO-2p.29
    “American two seven nine is with you on juliet.”
    read in context ↗
  52. 17:06:26.2CVR CAM-1calloutp.34
    “so you— I— just to let you know I'm trying to figure out how we got slow when we had everything set up up here and the autopilot on. that's why it's a surprise to me. DCA18LA285 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  53. 17:12:30.3CVR CAM-2warningp.40
    “red anti-collision light?”
    read in context ↗
  54. 17:43:31.1CVR CAMfinal secondsp.49
    “[sound of unintelligible background conversation]”
    read in context ↗
  55. 17:45:09.4CVR CAMfinal secondsp.49
    “[sound of unintelligible background conversation]”
    read in context ↗
  56. 17:50:12.7CVR CAM-1final secondsp.49
    “tell me exactly **. @? ***.”
    read in context ↗
  57. 17:50:37.0CVR CAM-1final secondsp.49
    “**.”
    read in context ↗
  58. 17:50:59.0CVR CAM-1final secondsp.49
    “okay. I've got the guys coming down. we're gonna pull the circuit breaker. ** I thought it was so obvious but I'm not * right now. ** hold on. do me a favor. where's the C-V-R? where's the— the tape? I looked up there I didn't see anything. I don't have my glasses. so I thought it was collared too . I thought it was white also. okay after we do that what else do you want? okay now here's a question on— and— oh okay I see what you're talking about. I thought you meant about the event. okay so we write that up and then—”
    read in context ↗
  59. 17:51:16.2CVR CAM-2final secondsp.49
    “*. DCA18LA285 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  60. 17:51:34.6CVR CAMfinal secondsp.50
    “[sound of unintelligible background conversation]”
    read in context ↗
  61. 17:51:39.5CVR CAMfinal secondsp.50
    “[sound similar to circuit breaker being pulled and power interruption]”
    read in context ↗
Recorder events without a clock time
  • unspecifiedWith autopilot in FLCH mode targeting 12,000 feet and auto throttles in Throttle Hold mode, aircraft pitch attitude began to increase to attempt to hold 12,000 feet and airspeed started to decay below 250 knots
FLIGHT DATA RECORDER - SPECIALIST'S FACTUAL REPORT · 26 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT · 36 of 453 lines shown
How the Board coded the sequence
  1. Enroute-descent: Abrupt maneuver

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA21LA0822021-02-08no fatalitiesmatch 90
    AIRBUS A320 · Spirit Airlines
    Fort Lauderdale, FL
    • ●Personnel issues › Task performance › Use of equip/info
    Abrupt maneuver
  • DCA23LA0602022-11-03no fatalitiesmatch 80
    AIRBUS A319 · SPIRIT AIRLINES INC
    New Orleans, LA
    • ●Personnel issues › Task performance › Use of equip/info
    Abrupt maneuver
  • WPR10LA1342010-02-13no fatalitiesmatch 63
    BOEING 737-7H4 · SOUTHWEST AIRLINES CO
    Santa Clarita, CA
    • ●Personnel issues › Task performance › Use of equip/info
    Abrupt maneuver
  • DCA23LA1722022-12-19no fatalitiesmatch 61
    BOEING 777 · UNITED AIRLINES INC
    Kahului, HI
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA18IA0262017-11-29no fatalitiesmatch 59
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA13FA1312013-07-22substantialmatch 56
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Flushing, NY
    • ●Personnel issues › Task performance › Use of equip/info
  • ERA10LA0412009-10-26no fatalitiesmatch 54
    BOEING 717-200 · Air Tran Airways
    Pleasant Grove, NC
    • ●Personnel issues › Task performance › Use of equip/info
    Abrupt maneuver
  • ANC13FA0542013-06-041 fatalmatch 54
    DEHAVILLAND BEAVER DHC-2 MK.1 · Pacific Wings LLC
    Petersburg, AK
    • ●Personnel issues › Task performance › Use of equip/info
    Abrupt maneuver

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 8Abrupt maneuver
  • 2 of 8Collision avoidance alert
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft oper/perf/capability › Performance/control parameters
  • Action/decision › Action
  • Action/decision › Info processing/decision

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
  • DCA21LA0822021-02-08 · AIRBUS A320 · Spirit Airlines
    An abrupt flight control input by the flight crew during descent that caused a flight attendant to fall and fracture their ankle.
  • DCA23LA0602022-11-03 · AIRBUS A319 · SPIRIT AIRLINES INC
    The captain’s pitch up input to avoid an overspeed condition, which resulted in a flight attendant falling and fracturing her ankle. Contributing was the airplane’s excessive airspeed during the transition to the automation-managed descent profile.
  • WPR10LA1342010-02-13 · BOEING 737-7H4 · SOUTHWEST AIRLINES CO
    The pilot’s abrupt airplane pitch change maneuver. Contributing to the accident was the flight crew’s failure to maintain the heading specified by the air traffic controller, which would have avoided the near collision course with an unidentified airplane that triggered the traffic alert and collision avoidance system resolution advisory.
  • DCA23LA1722022-12-19 · BOEING 777 · UNITED AIRLINES INC
    The flight crew’s failure to manage the airplane’s vertical flightpath, airspeed, and pitch attitude following a miscommunication about the captain’s desired flap setting during the initial climb.
  • 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).