Cases › DCA19MA143 › The analyst
Boeing 737Miami Air International
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.
20
timed facts
8
precedents
218
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
20 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- 19:36:48CVR HOTp.8“[intermittent speech in Spanish].”read in context ↗
- 21:20:43CVR CAMwarningp.10“[sound of altitude alert].”read in context ↗
- 21:31:19CVR CAMwarningp.15“[sound of altitude alert].”read in context ↗
- 21:39:06CVR HOTwarningp.19“[sound of altitude alert].”read in context ↗
- 21:39:45CVR CAM-1calloutp.20“gear down flaps fifteen.”read in context ↗
- 21:40:04CVR HOTwarningp.20“[sound of altitude alert].”read in context ↗
- 21:40:25CVR CAMwarningp.21“[sound of autopilot disconnect warning].”read in context ↗
- 21:40:33CVR CAM-2calloutp.21“* landing checklist. * * ah. * * * * speedbrakes ah armed, landing gear down three green, flaps thirty.”read in context ↗
- 21:41:17CVR HOTcalloutp.21“approaching minimums [electronic voice].”read in context ↗
- 21:41:23CVR HOTcalloutp.21“minimums. [electronic voice].”read in context ↗
- 21:41:35CVR ?warningp.21“sink rate, sink rate, sink rate, sink rate, sink rate HOT [electronic voice].”read in context ↗
- 21:41:42CVR HOTwarningp.22“sink rate [electronic voice].”read in context ↗
- 21:41:44CVR CAMfinal secondsp.22“[sounds consistent with touchdown]”read in context ↗
- 21:41:52CVR HOT-1final secondsp.22“oh.”read in context ↗
- 21:41:52CVR CAM-?final secondsp.22“*.”read in context ↗
- 21:42:00CVR HOT-1final secondsp.22“oh. * *.”read in context ↗
- 21:42:01CVR CAM-?final secondsp.22“* * *.”read in context ↗
- 21:42:04CVR HOT-1final secondsp.22“oh we're going *.”read in context ↗
- 21:42:06CVR HOT-2final secondsp.22“oh.”read in context ↗
- 21:42:10CVR CAMfinal secondsp.22“[sounds consistent with departure from prepared surface]. 2142:19”read in context ↗
Recorder events without a clock time
- 2142 EDTMiami Air International flight 293 departed the end of runway 10 at Jacksonville Naval Air Station, Jacksonville, Florida, and came to rest in shallow water in St. Johns River.
FLIGHT DATA RECORDER FACTUAL REPORT · 1 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER · 20 of 165 lines shown
How the Board coded the sequence
- Landing-landing roll: Other weather encounter→
- Landing-landing roll: Runway excursion→
- Landing-landing roll: Landing area overshoot
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BOEING 737 7L9 · Eastern Airlines Group, Inc.,New York, NY
- ●Personnel issues › Action/decision › Action
Landing area overshootRunway excursion - Embraer EMB145 · Envoy Air Inc.Chicago, IL
- ●Personnel issues › Action/decision › Action
Runway excursion - MCDONNELL DOUGLAS AIRCRAFT CO MD 88 · Delta Air LinesNew York, NY
- ●Aircraft › Aircraft oper/perf/capability › Aircraft capability
Runway excursion - BOEING 737 7H4 · SOUTHWEST AIRLINES COFlushing, NY
- ●Personnel issues › Action/decision › Action
- AEROSPATIALE SA365N-1 D · Maryland State PoliceDistrict Heights, MD
- ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Experience/knowledge › Experience/qualifications
- CESSNA 207A · Sea Port Airlines, IncJuneau, AK
- ●Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip
- ●Organizational issues › Management › Policy/procedure
- BOEING 757 223 · AMERICAN AIRLINES INCMiami, FL
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Experience/knowledge › Experience/qualifications
- CESSNA 210L · SOUTHERN SEAPLANE INCClay, AL
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Experience/knowledge › Experience/qualifications
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
- 6 of 8Personnel issues › Action/decision › Actioncited here too
- 5 of 8Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- 3 of 8Personnel issues › Action/decision › Info processing/decision
- 3 of 8Personnel issues › Task performance › Use of equip/info
- 3 of 8Personnel issues › Experience/knowledge › Experience/qualificationscited here too
- 2 of 8Organizational issues › Support/oversight/monitoring › Training
- 2 of 8Personnel issues › Psychological › Perception/orientation/illusion
- 2 of 8Personnel issues › Task performance › Workload management
- 2 of 8Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precipcited here too
Occurrences it coded
- 3 of 8Runway excursion
- 2 of 8Collision with terr/obj (non-CFIT)
- 2 of 8Controlled flight into terr/obj (CFIT)
- 2 of 8Preflight or dispatch event
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Conditions/weather/phenomena › Ceiling/visibility/precip
- Action/decision › Action
- Experience/knowledge › Experience/qualifications
Cited here, not seen in the precedents
- Physical environment › Runway/land/takeoff/taxi surface
- Psychological › Cognitive limitation
Common in the precedents, not cited here
- Aircraft oper/perf/capability › Performance/control parameters
- Support/oversight/monitoring › Training
- Action/decision › Info processing/decision
- Psychological › Perception/orientation/illusion
- Task performance › Use of equip/info
- Task performance › Workload management
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
- 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…
- 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…
- DCA15FA0852015-03-05 · MCDONNELL DOUGLAS AIRCRAFT CO MD 88 · Delta Air Lines
the captain's inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the airplane's heading. Contributing to the accident were the captain's (1) situational stress resulting from his concerns about stopping performance and (2) attentional limitations due to the high workload during the landing, which prevented him from immediately recognizing the use of excessive reverse thrust.
- 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.
- MIA08MA2032008-09-28 · AEROSPATIALE SA365N-1 D · Maryland State Police
The pilot's attempt to regain visual conditions by performing a rapid descent and his failure to arrest the descent at the minimum descent altitude during a nonprecision approach. Contributing to the accident were (1) the pilot’s limited recent instrument flight experience, (2) the lack of adherence to effective risk management procedures by the Maryland State Police, (3) the pilot’s inadequate assessment of the weather, which led to his decision to accept the flight,, (4) the failure of the Potomac Consolidated Te…
What it recommended after them
- A-16-020TO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with Boeing and US operators of MD-80 series airplanes to (1) conduct a study to examine reverse thrust engine pressure ratio (EPR)-related operational data, procedures, and training and (… · DCA15FA085Closed - Acceptable Action
- A-16-021TO THE FEDERAL AVIATION ADMINISTRATION: Encourage US operators of MD-80 series airplanes to (1) implement the best practices identified in Safety Recommendation A-16-20 and (2) participate in an industry-wide monitoring program to verify th… · DCA15FA085Closed--No Longer Applicable
- A-16-022TO THE FEDERAL AVIATION ADMINISTRATION: Require operators of MD-80 series airplanes to revise operational procedures to include a callout when reverse thrust power exceeds 1.3 engine pressure ratio during landings on a contaminated runway. · DCA15FA085Closed--No Longer Applicable
- A-16-023TO THE FEDERAL AVIATION ADMINISTRATION: Continue to work with industry to develop the technology to outfit transport-category airplanes with equipment and procedures to routinely calculate, record, and convey the airplane braking ability re… · DCA15FA085Closed - Acceptable Action
- A-16-024TO THE FEDERAL AVIATION ADMINISTRATION: If the systems described in Safety Recommendation A-16-23 are shown to be technically and operationally feasible, work with operators and the system manufacturers to develop procedures that ensure tha… · DCA15FA085Open - Acceptable Response
- A-16-025TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 operators to provide (1) guidance that instructs flight attendants to remain at their assigned exits and actively monitor exit availability in all non-n… · DCA15FA085Closed - Unacceptable Action
- A-16-026TO THE FEDERAL AVIATION ADMINISTRATION: Develop best practices related to evacuation communication, coordination, and decision-making during emergencies through the establishment of an industry working group and then issue guidance for 14 C… · DCA15FA085Closed - Unacceptable Action
- A-16-027TO THE FEDERAL AVIATION ADMINISTRATION: Clarify guidance to all 14 Code of Federal Regulations Part 121 air carriers to reinforce the importance of (1) having precise information about the number of passengers aboard an airplane, including… · DCA15FA085Closed - Acceptable Alternate 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).