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Cases › DCA19FA089 › The analyst

Embraer EMB145Commutair

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.

55
timed facts
8
precedents
75
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

55 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. 09:29:05.0CVR STARTp.7
    “OF RECORDING”
    read in context ↗
  2. 10:56:09.1CVR HOT-1calloutp.7
    “(that's) six, minimum required five, actual forty four, alright there ya go.”
    read in context ↗
  3. 11:03:43.9CVR HOTwarningp.13
    “[sound similar to altitude alert warning tone].”
    read in context ↗
  4. 11:06:20.0CVR HOT-1calloutp.15
    “so we need to veri-* on the radio that we're cleared to land? DCA19FA089”
    read in context ↗
  5. 11:06:44.8CVR HOT-2calloutp.17
    “alright gear down flaps twenty two.”
    read in context ↗
  6. 11:06:47.3CVR HOT-1calloutp.17
    “gear down, speed checks, flaps twenty two.”
    read in context ↗
  7. 11:06:53.9CVR HOT-1p.17
    “alright your mins will be six seventy eight.”
    read in context ↗
  8. 11:06:58 ESTFDRfirst approachp.3
    The aircraft began its first approach into KPQI (about 1 hour and three minutes after takeoff)
    see the traces at this moment ↗
  9. 11:07:02.0CVR HOT-1p.17
    “* * you're cleared to land.”
    read in context ↗
  10. 11:09:45.5CVR HOTcalloutp.19
    “approaching minimums [sound of electronic voice]. DCA19FA089”
    read in context ↗
  11. 11:09:51.4CVR HOTcalloutp.20
    “minimums, minimums [sound of electronic voice].”
    read in context ↗
  12. 11:10:02.3CVR HOT-1p.20
    “watch your speed yeah watch watch your, go go up, go-up go-up, go-up go-up.”
    read in context ↗
  13. 11:10:04 ESTFDRfirst approach go-aroundp.3
    Aircraft descended to a minimum pressure altitude of 703 ft before it began its ascent and go-around
    see the traces at this moment ↗
  14. 11:10:06.4CVR HOTwarningp.20
    “[sounds similar to stick shaker].”
    read in context ↗
  15. 11:10:06.5CVR HOT-1p.20
    “no no no, yeah yeah, no no, go go go-up.”
    read in context ↗
  16. 11:10:18.4CVR HOTwarningp.21
    “[sound of master caution aural alert].”
    read in context ↗
  17. 11:10:24.6CVR HOT-2calloutp.21
    “gear up.”
    read in context ↗
  18. 11:10:26.2CVR HOTwarningp.21
    “[sound of master warning aural alert].”
    read in context ↗
  19. 11:10:29.6CVR HOTwarningp.22
    “[sound of master warning aural alert].”
    read in context ↗
  20. 11:11:07.5CVR HOTwarningp.23
    “[sound of altitude alerter].”
    read in context ↗
  21. 11:11:41.3CVR HOT-1calloutp.24
    “you got autopilot on? I'm gonna throw that on for ya.”
    read in context ↗
  22. 11:18:35.7CVR HOT-2calloutp.31
    “alright so this time I'll stay on the flight director until, things start screaming minimums-”
    read in context ↗
  23. 11:19:00.3CVR HOT-1calloutp.32
    “yeah, yeah I'll give you the countdown five four three two one, at two, you know, obviously (take) the autopilot on and just stay on the- and that ah, the flight director, okay, yeah, yeah.”
    read in context ↗
  24. 11:25:28.6CVR HOT-2calloutp.38
    “yeah we can do gear down flaps twenty two.”
    read in context ↗
  25. 11:25:30.6CVR HOT-1calloutp.38
    “gear down, flaps twenty two.”
    read in context ↗
  26. 11:25:38.4CVR CTRp.38
    “CommutAir forty nine thirty three roger change to advisory frequency is approved you can cancel with me in the air on this frequency or on the ground on one two one point six.”
    read in context ↗
  27. 11:25:42 ESTFDRfinal approachp.3
    The aircraft started its final descent to KPQI at a pressure altitude of approximately 3,400 ft
    see the traces at this moment ↗
  28. 11:25:45.5CVR RDO-1p.38
    “roger will advise thank you * *.”
    read in context ↗
  29. 11:26:22.9CVR HOT-1calloutp.39
    “flaps forty five landing che- landing gear down three green?”
    read in context ↗
  30. 11:27:58.7CVR HOT-2calloutp.40
    “five hundred cleared to land. I'm inside you're outside.”
    read in context ↗
  31. 11:28:01.1CVR HOT-1calloutp.40
    “cleared to land stay in.”
    read in context ↗
  32. 11:28:09.3CVR HOT-1calloutp.40
    “keep the autopilot on until two okay?”
    read in context ↗
  33. 11:28:21.8CVR HOT-1calloutp.41
    “alright there's two hundred, get the autopilot off.”
    read in context ↗
  34. 11:28:26.3CVR HOT-1calloutp.41
    “ah autopilot off, yeah.”
    read in context ↗
  35. 11:28:29.6CVR HOTcalloutp.41
    “approaching minimums [electronic voice].”
    read in context ↗
  36. 11:28:37.3CVR HOTcalloutp.41
    “minimums, minimums [electronic voice].”
    read in context ↗
  37. 11:28:54.5CVR HOT-1p.42
    “ah.”
    read in context ↗
  38. 11:28:55.3CVR HOTp.42
    “landing gear [electronic voice].”
    read in context ↗
  39. 11:28:56 ESTFDRlandingp.4
    The air to ground switch (Air/Ground Switch) changed from Air to Ground (Grnd)
    see the traces at this moment ↗
  40. 11:28:57 ESTFDRlandingp.4
    The vertical acceleration (Accel Vert) peaked at a maximum value of 3.35 g's
    see the traces at this moment ↗
  41. 11:28:57.4CVR HOTwarningp.42
    “[sound of master warning].”
    read in context ↗
  42. 11:28:58.8CVR HOTp.42
    “takeoff [electronic voice].”
    read in context ↗
  43. 11:29:03.7CVR HOTwarningp.42
    “[sound of master warning].”
    read in context ↗
  44. 11:29:08.2CVR HOTwarningp.43
    “[repeated aural configuration warnings].”
    read in context ↗
  45. 11:29:14 ESTFDRlanding rolloutp.4
    The ground speed (Ground Spd) decreased to 0 knots (kts) when the aircraft came to a complete rest
    see the traces at this moment ↗
  46. 11:29:14.0CVR CAM-1p.43
    “what the #.”
    read in context ↗
  47. 11:29:17.6CVR PA-1p.43
    “remain seated, remain seated, remain seated.”
    read in context ↗
  48. 11:29:20.6CVR CAM-3final secondsp.43
    “-remain seated, remain seated-”
    read in context ↗
  49. 11:29:23.6CVR CAM-1final secondsp.43
    “run the checklist [repeated seven times].”
    read in context ↗
  50. 11:29:33.8CVR CAM-2final secondsp.43
    “*.”
    read in context ↗
  51. 11:29:39.1CVR CAM-1final secondsp.43
    “remain seated, remain seated.”
    read in context ↗
  52. 11:29:45.5CVR CAM-2final secondsp.43
    “what checklist do you want me to run @ .”
    read in context ↗
  53. 11:29:49.4CVR CAM-1final secondsp.43
    “(let's run the) shutdown check. shutdown. DCA19FA089”
    read in context ↗
  54. 11:29:52.9CVR CAMfinal secondsp.44
    “[sounds consistent with checklist usage and aircraft evacuation].”
    read in context ↗
  55. 11:29:52.9CVR CAMfinal secondsp.44
    “[sound of interphone chime].”
    read in context ↗
FLIGHT DATA RECORDER - SPECIALISTA��S FACTUAL REPORT · 6 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT · 49 of 430 lines shown
How the Board coded the sequence
  1. Landing: 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
  • DCA25LA1632025-03-20no fatalitiesmatch 69
    BOEING 737-8H4 · SOUTHWEST AIRLINES CO
    Orlando, FL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport
  • OPS10IA0012009-10-19no fatalitiesmatch 61
    BOEING 767 · Delta Air Lines, Inc.
    Atlanta Hartsfield Intl. Apt. (KATL), GA
    • ●Environmental issues › Operating environment › Approach aid coverage/avail
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport
  • DCA11FA0502011-01-03substantialmatch 60
    BOEING 737-823 · American Airlines
    Los Angeles, CA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA20LA0132019-11-11substantialmatch 60
    Embraer EMB145 · Envoy Air Inc.
    Chicago, IL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA14IA0372014-01-13no fatalitiesmatch 59
    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 58
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA19CA0662018-12-31substantialmatch 57
    Boeing 757 · American Airlines
    Charlotte, NC
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA16IA2002016-07-08no fatalitiesmatch 56
    AIRBUS INDUSTRIE A320 211 · DELTA AIR LINES INC
    Rapid City, SD
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport

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
  • 4 of 8Wrong surface or wrong airport
  • 2 of 8Tailstrike
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
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
  • DCA25LA1632025-03-20 · BOEING 737-8H4 · SOUTHWEST AIRLINES CO
    The captain’s failure to recognize that the airplane’s location did not agree with the assigned departure runway as required per the Southwest Airlines Airplane Operating Manual, and the captain’s plan continuation error when he missed several cues that would have informed him that he was not on the assigned departure runway when he initiated takeoff.
  • 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.
  • 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.
  • DCA20LA0132019-11-11 · Embraer EMB145 · Envoy Air Inc.
    The flight crew’s inability to maintain the airplane on the runway centerline after touchdown due to the reduced braking action resulting from the deteriorating weather conditions, which caused the airplane’s departure from the runway surface. Contributing to the accident were the delay in performing the runway assessment for undetermined reasons and failure to close the runway. Also contributing to the accident was the controller’s failure to advise the accident flight crew that braking action was no longer cons…
  • 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.
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
  • 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).