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Cases › DCA20LA013 › The analyst

Embraer EMB145Envoy Air 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.

44
timed facts
8
precedents
28
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

44 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. 05:20:00FDRpre-departurep.3
    FDR data begins, aircraft on the ground at KGSO
    see the traces at this moment ↗
  2. 05:26:18FDRtakeoffp.3
    Gear weight-on-wheels (WOW) indication switched from ground to air, indicating the aircraft had departed KGSO
    see the traces at this moment ↗
  3. 06:00:35.0CVR STARTp.8
    “OF RECORDING”
    read in context ↗
  4. 06:11:00FDRdescentp.3
    Aircraft began a descent to KORD
    see the traces at this moment ↗
  5. 07:12:00FDRapproachp.3
    Aircraft was configured for an approach to runway 10L at KORD
    see the traces at this moment ↗
  6. 07:15:43FDRgo-aroundp.3
    Engine 1 and 2 N1 increased rapidly from 40% to 85% and the aircraft began to climb, indicative of a go-around
    see the traces at this moment ↗
  7. 07:31:43.1CVR HOT-1calloutp.8
    “alright - well - if we go around this time we're going to Cincy.”
    read in context ↗
  8. 07:32:41.1CVR HOT-2calloutp.9
    “same thing as before if we have to go around? Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  9. 07:39:05.1CVR HOT-1calloutp.13
    “let's go gear down.”
    read in context ↗
  10. 07:39:23.1CVR HOT-2calloutp.14
    “speed brake - closed - thrust rating T O one [T O for take off] - flaps set twenty two - before landing checklist complete.”
    read in context ↗
  11. 07:41:10FDRapproachp.3
    Data begins for second final approach to runway 10L at KORD; radio altitude 518 ft AGL, autopilot engaged, indicated airspeed approximately 146 knots
    see the traces at this moment ↗
  12. 07:41:11.0CVR HOT-1p.16
    “roger.”
    read in context ↗
  13. 07:41:11.1CVR HOT-2p.16
    “sinking nine hundred v ref plus thirteen.”
    read in context ↗
  14. 07:41:30FDRapproachp.4
    Autopilot was disengaged; vertical and lateral guidance remained on flight director until touchdown
    see the traces at this moment ↗
  15. 07:41:30.1CVR CAMp.16
    “approaching minimums - autopilot - autopilot.”
    read in context ↗
  16. 07:41:32.2CVR HOT-2p.16
    “runway in sight.”
    read in context ↗
  17. 07:41:37.2CVR CAMcalloutp.16
    “minimums - minimums.”
    read in context ↗
  18. 07:41:48.6CVR CAMwarningp.17
    “[sound similar with master caution]”
    read in context ↗
  19. 07:41:52.8CVR HOT-2p.17
    “yaw damp off.”
    read in context ↗
  20. 07:41:54.4CVR HOT-1p.17
    “roger.”
    read in context ↗
  21. 07:41:57FDRlandingp.3
    First gear WOW indication (touchdown); all four spoiler panels commanded open
    see the traces at this moment ↗
  22. 07:42:00FDRlanding rollp.3
    Three seconds after touchdown, inboard and outboard wheel brake pressure began to increase
    see the traces at this moment ↗
  23. 07:42:01.7CVR HOT-2p.17
    “stay on that centerline.”
    read in context ↗
  24. 07:42:02FDRlanding rollp.3
    All four thrust reverser halves indicated deployed; ground speed was 127 knots
    see the traces at this moment ↗
  25. 07:42:02.5CVR HOT-1p.17
    “yep #.”
    read in context ↗
  26. 07:42:06.4CVR HOT-1p.17
    “#.”
    read in context ↗
  27. 07:42:15FDRlanding rollp.3
    Aircraft began to turn to the left, with thrust reversers still deployed, inboard wheel brake pressure at approximately 340 psi, and outboard wheel brake pressure at 90 psi
    see the traces at this moment ↗
  28. 07:42:16.7CVR HOT-1final secondsp.17
    “aww #.”
    read in context ↗
  29. 07:42:21.5CVR CAMfinal secondsp.17
    “[sound similar to thrust levers being moved] Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  30. 07:42:23FDRlanding rollp.3
    As the aircraft slowed to 39 knots, the thrust reversers indicated stowed; left and right inboard spoiler panels stowed; inboard and outboard wheel brake pressure increased, and the aircraft continued to turn to the left
    see the traces at this moment ↗
  31. 07:42:24.6CVR HOT-1final secondsp.18
    “# - ugh.”
    read in context ↗
  32. 07:42:26.9CVR CAMfinal secondsp.18
    “[increase in background noise]”
    read in context ↗
  33. 07:42:27FDRlanding rollp.3
    Left and right outboard spoiler panels stowed
    see the traces at this moment ↗
  34. 07:42:27 to 07:42:30FDRrunway excursionp.3
    Right roll increased from approximately 2.5 deg right to 12 deg right, likely due to the aircraft departing the paved surface and the right wing impacting the ground
    see the traces at this moment ↗
  35. 07:42:29FDRrunway excursionp.3
    Spike in vertical acceleration of 1.64 g and lateral acceleration of -0.85 g was recorded
    see the traces at this moment ↗
  36. 07:42:29.7CVR CAMfinal secondsp.18
    “[sound of triple chime - master warning] landing gear [master warning continues until the end of the recording]”
    read in context ↗
  37. 07:42:30FDRrunway excursionp.4
    A master warning indication was recorded, 32 seconds after touchdown
    see the traces at this moment ↗
  38. 07:42:31FDRrunway excursionp.4
    Gear WOW switched from ground to air
    see the traces at this moment ↗
  39. 07:42:32FDRrunway excursionp.4
    A master caution indication was also recorded
    see the traces at this moment ↗
  40. 07:42:32.0CVR CAMfinal secondsp.18
    “[sound similar to stick shaker]”
    read in context ↗
  41. 07:42:34.1CVR RDO-2final secondsp.18
    “* * need assistance Envoy forty one twenty five.”
    read in context ↗
  42. 07:42:38.5CVR HOT-2final secondsp.18
    “thanks.”
    read in context ↗
  43. 07:42:40FDRend of eventp.3
    Plot ends after the ground speed indicated zero and the aircraft was at rest
    see the traces at this moment ↗
  44. 07:42:41FDRrunway excursionp.3
    Gear WOW indication switched from ground to air; ground speed was 12 knots
    see the traces at this moment ↗
FLIGHT DATA RECORDER - SPECIALISTA��S FACTUAL REPORT · 20 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT AND TRANSCRIPT OF INVESTIGATION · 24 of 115 lines shownAIRPORT SPECIALIST'S FACTUAL REPORT ATTACHMENT 1 - ATCT RECORDING · 114 min· not yet aligned to a clock
How the Board coded the sequence
  1. Landing: Runway excursion

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA19IA0362018-12-06no fatalitiesmatch 71
    Boeing 737 · Southwest Airlines
    Burbank, CA
    • ●Personnel issues › Action/decision › Action
    Runway excursion
  • DCA11FA0502011-01-03substantialmatch 65
    BOEING 737-823 · American Airlines
    Los Angeles, CA
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA13CA0432013-01-25substantialmatch 62
    MCDONNELL DOUGLAS MD11 · FEDERAL EXPRESS CORP
    Denver, CO
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA25LA1632025-03-20no fatalitiesmatch 62
    BOEING 737-8H4 · SOUTHWEST AIRLINES CO
    Orlando, FL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA17IA0202016-10-27no fatalitiesmatch 61
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    Runway excursion
  • DCA22LA2012022-09-11no fatalitiesmatch 60
    BOEING 737-7H4 · SOUTHWEST AIRLINES CO
    Chicago, IL
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA19CA0662018-12-31substantialmatch 60
    Boeing 757 · American Airlines
    Charlotte, NC
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
  • DCA18IA0262017-11-29no fatalitiesmatch 60
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Action
    • ●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 cause
Findings the Board cited in those cases
Occurrences it coded
  • 3 of 8Tailstrike
  • 2 of 8Runway excursion
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
  • Conditions/weather/phenomena › (general)
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
  • DCA19IA0362018-12-06 · Boeing 737 · Southwest Airlines
    (1) The flight crewmembers’ decision, due to plan continuation bias, to continue the approach despite indications of windshear and a higher-than-expected tailwind and (2) the flight crew’s misperception of the airplane’s touchdown point, which was farther down the runway than the crew assumed because of the faster-than-expected groundspeed. Contributing to the accident was Southwest Airlines’ lack of guidance to prompt flight crews to reassess operator-provided landing data when arrival weather conditions differ fr…
  • 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.
  • DCA13CA0432013-01-25 · MCDONNELL DOUGLAS MD11 · FEDERAL EXPRESS CORP
    the flight crews failure to perform a takeoff performance data briefing following the final entries into the Flight Management System, which would have alerted them to the incorrect weight entry and resulting incorrect landing speeds. Contributing to the accident was the failure of the flight crew to recognize and respond to various visual cues indicating the airplane's airspeed was too slow, resulting in a higher than normal pitch during landing and the tail of the airplane striking the runway.
  • 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.
  • 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…

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).