Cases › DCA19MA086 › The analyst
Boeing 767Atlas Air
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.
51
timed facts
8
precedents
104
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
51 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- 10:33FDRtakeoff/climbp.5Aircraft departed and climbed for about 20 minutes to a cruise altitude of 40,000 ft; center autopilot and autothrottle engaged shortly after takeoff and remained engaged for the remainder of the flightsee the traces at this moment ↗
- 11:57:59.1CVR RDO-1p.12“Houston good afternoon Giant thirty-five ninety-one heavy four zero zero.”read in context ↗
- 12:08:26.6CVR CAM-1calloutp.23“uhhh let's see. minimums.”read in context ↗
- 12:08:28.8CVR CAM-2calloutp.23“minimums are gunna be three- four ninety-six I guess.”read in context ↗
- 12:14:02.0CVR HOT-2calloutp.30“and umm as far as my uhh technique in landing this plane- umm a thousand feet- I’ll take the autopilot off- roughly. at five hundred feet or below ill probably take the auto throttles off when I come in I pretty much keep my power in until around thirty feet or so- and that's when I start leveling off- then coming back slowly on the power so- um you can expect that. um other than that- if we have to go missed it's gunna be go around- flaps twenty- positive climb. go gear up. um at a thousand feet eh you know we go uh speed- select speed.”read in context ↗
- 12:24:54.2CVR RDO-1p.35“and Giant thirty-five ninety-one three four zero's beginning our descent.”read in context ↗
- 12:24:58.1CVR CTRp.35“Giant thirty-five ninety-one roger.”read in context ↗
- 12:25FDRdescentp.5Initial descent out of 34,000 ft began; autoflight systems in LNAV/VNAV modessee the traces at this moment ↗
- 12:26:29.4CVR HOT-2warningp.36“– overspeeding- so-”read in context ↗
- 12:36:19.3CVR HOT-1calloutp.46“alright we can go around it- alright my controls.”read in context ↗
- 12:36:21.4CVR RDO-2p.46“Giant uh thirty-five uh six- sorry thirty-five and ninety-one we will go on the west side.”read in context ↗
- 12:36:27FDRdescentp.5Autopilot lateral mode changed from LNAV to Heading Select; immediately before reaching 10,000 ft the captain's radio mic was keyedsee the traces at this moment ↗
- 12:36:28.9CVR APPp.47“alright the only problem we have with that right now there's a bunch of departures departin' out right at ya so we're gunna do–”read in context ↗
- 12:36:34.0CVR APPp.47“all the way down.”read in context ↗
- 12:36:34.9CVR RDO-2p.47“okay then we'll go on the east side then that's fine just go ahead and direct us.”read in context ↗
- 12:36:35FDRdescentp.5Aircraft reached 10,000 ftsee the traces at this moment ↗
- 12:36:55.2CVR CAM-1p.47“three thousand set.”read in context ↗
- about 12:37:00FDRdescentp.5Autopilot vertical mode changed from VNAV to Flight Level Change; MCP altitude selection changed from 7,000 ft to 3,000 ft; speedbrake handle extended and rate of descent increasedsee the traces at this moment ↗
- 12:37:00.4CVR HOT-2p.47“okay so one second. okay so we gunna hold off on that checklist. right?”read in context ↗
- 12:38:02.2CVR HOT-2p.49“'kay flaps one.”read in context ↗
- 12:38:04FDRapproachp.5Flaps selected from up to position 1; autoflight go-around modes armed as flaps began to movesee the traces at this moment ↗
- 12:38:05.1CVR HOT-2p.50“thank you.”read in context ↗
- 12:38:17.9CVR HOT-2p.50“yeah.”read in context ↗
- 12:38:26FDRapproachp.5At about 6,500 ft, triaxial acceleration magnitudes increased, consistent with entering light to moderate turbulencesee the traces at this moment ↗
- 12:38:31FDRapproachp.5Autoflight system entered go-around mode; engines began advancing to go-around thrust; control column moved slightly aft, elevator deflected up, pitch began to increase, altitude stopped descending and began to climbsee the traces at this moment ↗
- 12:38:35.1CVR APPp.50“Giant thirty-five ninety-one in about another eighteen miles or so we'll cut you due north(bound) for a base leg. 2 The group was reconvened on November 14, 2019. This sound was not initially heard during the first transcription sitting of the group on March 5, 2019. After the generation of the Sound Spectrum Study, which can be found in the public docket for this accident, all members of the group were able to detect this sound when directed to the area of interest on the recording.”read in context ↗
- 12:38:37FDRapproachp.5Speedbrake handle retracted; engines approached commanded go-around power settingssee the traces at this moment ↗
- 12:38:40FDRupsetp.5Master Caution and Autopilot Caution recorded; control column had moved to be deflected forward, pitch decreasing, airspeed accelerating rapidly from 240 knots; autoflight remained in go-around modes; shallow climb briefly then rapid descent; column remained forward for the next 10 secondssee the traces at this moment ↗
- 12:38:41.4CVR RDO-1p.51“sounds good uh Giant thirty-five ninety-one.”read in context ↗
- 12:38:43.6CVR APPp.51“it is severe clear on the other side of this stuff so you'll have no problem gettin' the airport *(either).”read in context ↗
- 12:38:45.0CVR CAM-2p.51“woah. [Spoken in elevated voice.]”read in context ↗
- 12:38:45.9CVR CAM-2p.51“(where's) my speed my speed [Spoken in elevated voice.]”read in context ↗
- 12:38:46FDRupsetp.5Throttles brought to idle for about 2 seconds then re-advanced to previous power setting; pitch rapidly decreasing; vertical g negative for nearly 11 secondssee the traces at this moment ↗
- 12:38:47FDRupsetp.5Split between left and right elevators noted, 2 to 7 degrees, until 12:38:57see the traces at this moment ↗
- 12:38:47.3CVR RDO-1p.51“okay.”read in context ↗
- 12:38:48.0CVR HOT-2p.52“we're stalling. [Spoken in elevated voice.]”read in context ↗
- 12:38:55FDRupsetp.6Overspeed and Master Warning alerts recorded with airspeed increasing beyond 350 knotssee the traces at this moment ↗
- 12:38:55.1CVR HOT-2p.52“@Capt. [Spoken in elevated voice.]”read in context ↗
- 12:38:55.7CVR HOT-1p.52“what's goin' on?”read in context ↗
- 12:38:56.6CVR CAM-3p.53“what's goin' on? [Spoken in an elevated voice.]”read in context ↗
- 12:38:56.8CVR HOT-?final secondsp.53“[Sound of rapid breathing.]”read in context ↗
- 12:38:57FDRupsetp.6Altitude crossed through 3,000 ft; autothrottle switched out of go-around mode and engine TRA began to decreasesee the traces at this moment ↗
- 12:38:57.4CVR HOT-2final secondsp.53“@Capt-”read in context ↗
- 12:38:58FDRupsetp.6At about 2,000 ft the control column moved to the aft stop until the end of the recording; pitch about 50 degrees nose downsee the traces at this moment ↗
- 12:38:58.1CVR CAMfinal secondsp.53“[Sound of quick series of four beeps at 1200 Hz.] 5”read in context ↗
- 12:38:58.9CVR CAMfinal secondsp.53“[Sound of longer duration pulse tone about 1000 Hz, similar to Siren. Group could not determine if audible sounds lasted until end of recording.] 6”read in context ↗
- 12:38:59.4CVR CAM-3final secondsp.53“* pull up. [Shouted.]”read in context ↗
- 12:39:00.9CVR HOT-2final secondsp.53“[Unintelligible shout.]”read in context ↗
- 12:39:02.0CVR HOT-?final secondsp.53“(oh God). [Shouted.]”read in context ↗
- 12:39:02.0CVR HOT-2final secondsp.53“Lord * * you have my soul. [Shouted.]”read in context ↗
- 12:39:03FDRimpactp.6End of recording; vertical acceleration went from 0 g to 4.2 g; pitch increased rapidly to final recorded position of 16 degrees nose downsee the traces at this moment ↗
FLIGHT DATA RECORDER ANCILLARY SPECIALIST'S FACTUAL REPORT · 3 events extracted by claude-sonnet-5FLIGHT DATA RECORDER SPECIALIST'S FACTUAL REPORT · 16 events extracted by claude-fable-5-1 (manual, phase 1)COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT · 35 of 481 lines shownAIR TRAFFIC CONTROL ATTACHMENT 4 – ATC AUDIO RECORDING · 64 min· not yet aligned to a clockAIR TRAFFIC CONTROL ATTACHMENT 7 – ATIS RECORDING · 45 min· not yet aligned to a clock
How the Board coded the sequence
- Enroute-descent: Loss of control in flight
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BOEING 717-200 · Air Tran AirwaysPleasant Grove, NC
- ●Organizational issues › Support/oversight/monitoring › Documentation/record keeping
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 737 7L9 · Eastern Airlines Group, Inc.,New York, NY
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 737-932ER · Delta Air LinesAtlanta, GA
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 767 34AF · UNITED PARCEL SERVICE COAlbuquerque, NM
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 737 7H4 · SOUTHWEST AIRLINES COFlushing, NY
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › Use of equip/info
- BOEING 747-400 BCF · National Air CargoBagram, AF
- ●Personnel issues › Action/decision › Action
Loss of control in flight - CESSNA 210L · SOUTHERN SEAPLANE INCClay, AL
- ●Organizational issues › Support/oversight/monitoring › Documentation/record keeping
- ●Personnel issues › Action/decision › Action
Loss of control in flight - BOEING 757-223 · AMERICAN AIRLINES INCJackson Hole, WY
- ●Personnel issues › Action/decision › Action
- ●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 causeFindings the Board cited in those cases
- 8 of 8Personnel issues › Action/decision › Actioncited here too
- 6 of 8Personnel issues › Task performance › Use of equip/infocited here too
- 4 of 8Personnel issues › Action/decision › Info processing/decision
- 4 of 8Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- 2 of 8Organizational issues › Support/oversight/monitoring › Documentation/record keepingcited here too
- 2 of 8Organizational issues › Support/oversight/monitoring › Training
- 2 of 8Aircraft › Aircraft systems › Flight control system
Occurrences it coded
- 2 of 8Runway excursion
- 2 of 8Flight control sys malf/fail
- 2 of 8Loss of control in flight
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Support/oversight/monitoring › Documentation/record keeping
- Action/decision › Action
- Task performance › Use of equip/info
Cited here, not seen in the precedents
- Aircraft systems › Auto flight system
Common in the precedents, not cited here
- Aircraft oper/perf/capability › Performance/control parameters
- Aircraft systems › Flight control system
- Support/oversight/monitoring › Training
- 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
- ERA10LA0412009-10-26 · BOEING 717-200 · Air Tran Airways
The captain's excessive maneuver in response to a traffic alert and collision avoidance system (TCAS) alert, which resulted in a serious injury to a flight attendant. Contributing to the accident was the operator's inadequate TCAS training and guidance.
- DCA17IA0202016-10-27 · BOEING 737 7L9 · Eastern Airlines Group, Inc.,
The first officer's failure to attain the proper touchdown point and the flight crew's failure to call for a go-around, which resulted in the airplane landing more than halfway down the runway. Contributing to the incident were, the first officer's initiation of the landing flare at a relatively high altitude and his delay in reducing the throttles to idle, the captain's delay in manually deploying the speed brakes after touchdown, the captain's lack of command authority, and a lack of robust training provided by t…
- 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…
- DCA16CA1132016-03-05 · BOEING 767 34AF · UNITED PARCEL SERVICE CO
the pilot flying's failure to maintain airspeed and correct pitch attitude. Contributing to the accident was the pilot's failure to maintain appropriate thrust after disconnecting the autothrottles. Also contributing was the first officer's failure to monitor the decaying airspeed and increasing pitch.
- 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.
What it recommended after them
- A-15-013TO THE FEDERAL AVIATION ADMINISTRATION: Revise the guidance material in Advisory Circular (AC) 120-85, “Air Cargo Operations,” chapter 201(a)(4), to specify that an operator should seek Federal Aviation Administration (FAA)-approved data fo… · DCA13MA081Closed - Reconsidered
- A-15-014TO THE FEDERAL AVIATION ADMINISTRATION: Create a certification for personnel responsible for the loading, restraint, and documentation of special cargo loads on transport-category airplanes, and ensure that the certification includes proced… · DCA13MA081Closed - Unacceptable Action
- A-15-015TO THE FEDERAL AVIATION ADMINISTRATION: Add a special emphasis item to Federal Aviation Administration (FAA) Order 1800.56O, “National Flight Standards Work Program Guidelines,” for inspectors of 14 Code of Federal Regulations Part 121 carg… · DCA13MA081Closed - Unacceptable Action
- A-15-016TO THE FEDERAL AVIATION ADMINISTRATION: Include specific guidance in the Federal Aviation Administration inspector handbook that defines responsibilities for principal inspectors for the oversight of an operator’s loading, restraint, and do… · DCA13MA081Closed - Acceptable Action
- A-15-017TO THE FEDERAL AVIATION ADMINISTRATION: Provide initial and recurrent training for all principal inspectors who have oversight responsibilities for air carrier cargo handling operations that specifically addresses operator cargo procedures,… · DCA13MA081Closed - Acceptable Action
- A-15-018TO THE FEDERAL AVIATION ADMINISTRATION: Implement temporary risk-reduction methods any time that required surveillance items for 14 Code of Federal Regulations Part 121 and 135 operators are deferred, and establish appropriate limitations o… · DCA13MA081Closed - Unacceptable Action
- A-12-044TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of existing speedbrake-equipped transport-category airplanes to develop and incorporate training to specifically address recognition of a situation in which the speedbrakes do no… · DCA11IA015Closed - Acceptable Action
- A-12-045TO THE FEDERAL AVIATION ADMINISTRATION: Require all newly type-certificated 14 Code of Federal Regulations Part 25 airplanes to have a clearly distinguishable and intelligible alert that warns pilots when the speedbrakes have not deployed d… · DCA11IA015Open 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).