Cases › DCA20MA002 › The analyst
Saab 2000Peninsula AviationServices 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.
56
timed facts
8
precedents
1,890
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
56 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- 15:36:30.0CVR STARTp.7“OF RECORDING”read in context ↗
- 16:25:05.6CVR HOT-1calloutp.14“yeah so this time we'll see...if we can't make in the front we can't we can't...[therefore] go around the back.”read in context ↗
- 16:25:16.1CVR HOT-1calloutp.14“uh...but...uh...other than that it's a missed approach so we'll do...if we can't do it or go around or whatever we have to do a climbing left turn to twenty three hundred to ROFZU and hold...caution do not exceed ground track of one point five nautical mile...and if we *...try it again or we're gonna...yeah then we're gonna go to Dillingham.”read in context ↗
- 17:22:55.6CVR CAMwarningp.38“[sound similar to altitude alert] Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”read in context ↗
- 17:29:14.2CVR CAMwarningp.44“[sound similar to altitude alert]”read in context ↗
- 17:31:50.8CVR HOT-1calloutp.47“'kay uh gear down.”read in context ↗
- 17:31:53.2CVR HOT-2calloutp.47“gear down.”read in context ↗
- 17:32:28.6CVR CAMwarningp.48“[sound similar to altitude alert] Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”read in context ↗
- 17:33:01.5CVR EGPWSwarningp.50“one thousand. [electronic voice]”read in context ↗
- 17:34:55.9CVR HOT-1calloutp.53“all right...if it gets too sheer-y just say go around we'll go out the back door.”read in context ↗
- 17:34:59.2CVR EGPWSwarningp.53“five hundred. [electronic voice]”read in context ↗
- 17:35:07.6CVR EGPWSwarningp.53“four hundred. [electronic voice]”read in context ↗
- 17:35:18.9CVR EGPWSwarningp.54“three hundred. [electronic voice]”read in context ↗
- 17:35:23.5CVR CAMwarningp.54“[sound similar to altitude alert]”read in context ↗
- 17:35:27.2CVR HOT-2calloutp.54“go around.”read in context ↗
- 17:35:27.9CVR EGPWSwarningp.54“two hundred. [electronic voice] Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”read in context ↗
- 17:35:30.4CVR HOT-1calloutp.55“go around power.”read in context ↗
- 17:35:33.0CVR HOT-1calloutp.55“positive rate...flaps...positive rate...gear up...flaps seven.”read in context ↗
- 17:35:35.7CVR HOT-2calloutp.55“flaps seven. positive rate. gear up.”read in context ↗
- 17:36:05.5CVR CAMwarningp.56“[sound similar to altitude alert]”read in context ↗
- 17:36:41.4CVR CAMwarningp.58“[sound similar to altitude alert]”read in context ↗
- 17:37:23.2CVR HOT-1calloutp.59“gear down. Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”read in context ↗
- 17:37:24.7CVR HOT-2calloutp.60“gear down.”read in context ↗
- 17:37:25.0CVR EGPWSwarningp.60“one thousand. [electronic voice]”read in context ↗
- 17:39:06.0CVR EGPWSwarningp.64“five hundred. [electronic voice]”read in context ↗
- 17:39:16.9CVR EGPWSwarningp.64“four hundred. [electronic voice]”read in context ↗
- 17:39:28.9CVR EGPWSwarningp.65“three hundred. [electronic voice]”read in context ↗
- 17:39:33.1CVR CAMwarningp.65“[sound similar to altitude alert]”read in context ↗
- 17:39:39.0CVR EGPWSwarningp.66“two hundred. [electronic voice]”read in context ↗
- 17:39:44.6CVR EGPWSwarningp.66“sink rate. [electronic voice]”read in context ↗
- 17:39:46.0CVR EGPWSwarningp.66“sink rate. [electronic voice]”read in context ↗
- 17:39:47.5CVR EGPWSwarningp.66“fifty. [electronic voice]”read in context ↗
- 17:39:48.8CVR EGPWSwarningp.66“forty. [electronic voice]”read in context ↗
- 17:39:49.5CVR EGPWSwarningp.67“twenty. [electronic voice]”read in context ↗
- 17:39:50.7CVR EGPWSwarningp.67“ten. [electronic voice]”read in context ↗
- 17:40:01.5CVR CAMwarningp.68“[sound similar to Master Caution]”read in context ↗
- 17:40:06.3CVR CAMwarningp.68“[sound similar to Master Caution]”read in context ↗
- 17:40:11.5CVR CAMwarningp.68“[sound similar to Master Caution]”read in context ↗
- 17:40:16.5CVR CAMwarningp.69“[sound similar to Master Caution]”read in context ↗
- 17:40:21.8CVR HOTwarningp.69“[sound similar to Master Caution]”read in context ↗
- 17:40:26.7CVR HOTwarningp.70“[sound similar to Master Warning]”read in context ↗
- 17:40:31.8CVR HOTwarningp.70“[sound similar to Master Warning]”read in context ↗
- 17:40:36.9CVR HOTwarningp.70“[sound similar to Master Warning]”read in context ↗
- 17:40:37.7CVR HOTwarningp.70“[sound similar to Engine Fire Bell]”read in context ↗
- 17:40:41.9CVR HOTwarningp.70“[sound similar to Master Warning] Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”read in context ↗
- 17:40:46.9CVR HOTwarningp.71“[sound similar to Master Warning]”read in context ↗
- 17:40:51.9CVR HOTwarningp.71“[sound similar to Master Warning]”read in context ↗
- 17:40:56.9CVR HOTwarningp.71“[sound similar to Master Warning]”read in context ↗
- 17:41:25.2CVR HOTfinal secondsp.71“[sound of three switches actuating]”read in context ↗
- 17:41:27.0CVR HOTfinal secondsp.71“[sound similar to DCU Startup/Restart]”read in context ↗
- 17:41:27.9CVR HOTfinal secondsp.71“[sound similar to mic key]”read in context ↗
- 17:41:28.6CVR RDO-1final secondsp.71“and Dutch Harbor Radio we need uh - crash fire rescue...uh...crash fire rescue.”read in context ↗
- 17:41:29.4CVR HOTfinal secondsp.71“[sound similar to Master Warning]”read in context ↗
- 17:41:30.9CVR HOTfinal secondsp.71“[sound similar to Config Warning] Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”read in context ↗
- 17:41:34.4CVR HOTfinal secondsp.72“[sound similar to Master Warning]”read in context ↗
- 17:41:36.9CVR HOTfinal secondsp.72“[sound of switch actuating]”read in context ↗
Recorder events without a clock time
- 1523Flight departed from ANC
- N/AAircraft climbed to a pressure altitude of 30,000 ft and cruised on a southwesterly heading for about 1 hour and 26 minutes
- N/AAircraft descended steadily for about 21 minutes
- 1733:00Autopilot was disconnected and remained disconnected for remainder of flight
- 1733:30Aircraft began a descent from 950 ft AGL
- N/AAt 425 ft AGL the aircraft rolled 30 degrees left, rolling out at 172 ft AGL on a heading of 117 degrees, consistent with final approach to the runway
- 1735:30Maneuvers consistent with a go around were performed
- N/AFollowing the go around, aircraft climbed to 1150 ft AGL and began to descend again while performing a 300 degree left turn
- N/AWhile descending through about 350 ft AGL, the aircraft rolled 30 degrees left, rolling out on the runway heading at about 100 ft AGL
- N/AAs the aircraft rolled out from 100 ft to 50 ft AGL, a Sink Rate warning was recorded from the GPWS
- N/AVertical speed recorded a peak of -1292 fpm during final descent
- N/AAircraft roll angle oscillated +/- 5 degrees as it pitched up consistent with a landing flare
- 1739:54Accelerations consistent with main gear touchdown occurred
- 1739:55Nose gear touchdown
- 1739:561 Hz Gear Weight on Wheels signal became true
- N/ARate of deceleration increased over three seconds following main gear touchdown to a peak of -0.48 g; flaps retracted by 5 degrees and both propellers transitioned to beta mode
- 1739:59Longitudinal deceleration changed from smooth to slightly oscillatory profile; Anti-Skid Inboard Fault Caution became active
- 1740:03Engines transitioned from ground idle beta to max reverse power
- 1740:10Longitudinal deceleration profile became smooth for 5.5 seconds; Anti-Skid Inboard Fault Caution transitioned to inactive
- 1740:16Oscillations in longitudinal acceleration resumed and Anti-Skid Inboard Fault Caution reactivated
- 1740:18Engine PLA began to increase from about 1 degree to about 35 degrees, consistent with idle power, over 3 seconds; engines and propellers transitioned to idle power and beta mode
- 1740:19Changes in pitch, roll, and vertical and longitudinal accelerations were consistent with a departure of the runway surface
- N/AOne second after runway departure, the weight on wheels and left main gear down and locked signals became false, consistent with damage to the left main gear
- N/AAbout one second after that the left engine gas generator speed dropped to 0%, consistent with damage to the left engine
- 1740:31The recording stopped, consistent with a sudden power interruption to the recorder
FLIGHT DATA RECORDER SPECIALIST'S FACTUAL REPORT · 25 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT · 56 of 674 lines shown
How the Board coded the sequence
- Landing-landing roll: Runway excursion
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- Embraer EMB145 · Envoy Air Inc.Chicago, IL
- ●Personnel issues › Action/decision › Info processing/decision
Runway excursion - Learjet LR60 · Global Exec AvaitionColumbia, SC
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Aircraft › Aircraft systems › Landing gear system
- ●Organizational issues › Development › Design
- +1 more shared findings
Runway excursion - GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLCBedford, MA
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Management › Policy/procedure
- ●Organizational issues › Support/oversight/monitoring › Oversight
- +1 more shared findings
Runway excursion - Airbus Industrie A320 · United Air LinesJackson, WY
- ●Aircraft › Aircraft systems › Landing gear system
- ●Personnel issues › Task performance › Maintenance
- Dassault FALCON 50 · Air America Flight Services INCGreenville, SC
- ●Aircraft › Aircraft systems › Landing gear system
- ●Personnel issues › Action/decision › Info processing/decision
Runway excursion - BOEING 717-200 · Delta Air Lines IncCharlotte, NC
- ●Aircraft › Aircraft systems › Landing gear system
- ●Organizational issues › Support/oversight/monitoring › Oversight
- ●Personnel issues › Task performance › Maintenance
- BOEING 757-223 · AMERICAN AIRLINES INCJackson Hole, WYRunway excursion
- TEXTRON AVIATION INC 208B · BERING AIR INCNome, AK
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Management › Policy/procedure
- ●Organizational issues › Support/oversight/monitoring › Oversight
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
- 5 of 8Personnel issues › Task performance › Use of equip/info
- 4 of 8Personnel issues › Action/decision › Action
- 4 of 8Aircraft › Aircraft systems › Landing gear systemcited here too
- 4 of 8Organizational issues › Support/oversight/monitoring › Oversightcited here too
- 3 of 8Personnel issues › Action/decision › Info processing/decisioncited here too
- 3 of 8Aircraft › Aircraft oper/perf/capability › Performance/control parameterscited here too
- 2 of 8Aircraft › Aircraft power plant › Engine exhaust
- 2 of 8Organizational issues › Development › Selection/certification/testing
- 2 of 8Aircraft › Aircraft systems › Flight control system
- 2 of 8Organizational issues › Management › Policy/procedurecited here too
- 2 of 8Personnel issues › Task performance › Maintenancecited here too
Occurrences it coded
- 5 of 8Runway excursion
- 4 of 8Sys/Comp malf/fail (non-power)
- 2 of 8Fire/smoke (post-impact)
- 2 of 8Collision with terr/obj (non-CFIT)
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Aircraft oper/perf/capability › Performance/control parameters
- Aircraft systems › Landing gear system
- Management › Policy/procedure
- Support/oversight/monitoring › Oversight
- Action/decision › Info processing/decision
- Task performance › Maintenance
Cited here, not seen in the precedents
- Conditions/weather/phenomena › Wind
- Operating environment › Airport facilities/design
Common in the precedents, not cited here
- Aircraft power plant › Engine exhaust
- Aircraft systems › Flight control system
- Development › Selection/certification/testing
- Action/decision › Action
- 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
- 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…
- DCA08MA0982008-09-20 · Learjet LR60 · Global Exec Avaition
The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of criti…
- ERA14MA2712014-06-01 · GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLC
The flight crewmembers' failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew's habitual noncompliance with checklists, Gulfstream Aerospace Corporation's failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and th…
- DCA08IA0442008-02-26 · Airbus Industrie A320 · United Air Lines
the loss of braking action on the left main landing gear due to the cross connection of the wheel speed tachometer wires that was caused by inadequate maintenance performed on the airplane during the installation of the main landing gear.
- ERA18FA2642018-09-27 · Dassault FALCON 50 · Air America Flight Services INC
The operator's decision to allow a flight in an airplane with known, unresolved maintenance discrepancies, and the flight crew's failure to properly configure the airplane in a way that would have allowed the emergency or parking brake systems to stop the airplane during landing.
What it recommended after them
- A-09-055TO THE FEDERAL AVIATION ADMINISTRATION: Require Learjet to change the design of the Learjet 60 thrust lever system in future-manufactured airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverse… · DCA08MA098Closed - Unacceptable Action
- A-09-056TO THE FEDERAL AVIATION ADMINISTRATION: Once design changes are developed per Safety Recommendation A-09-55, require Learjet 60 operators to retrofit existing airplanes so that the reverse lever positions in the cockpit match the positions… · DCA08MA098Closed - Unacceptable Action
- A-09-057TO THE FEDERAL AVIATION ADMINISTRATION: Require Learjet to develop and install improved aural or visual cues on future-manufactured Learjet 60 airplanes that would allow pilots to recognize an inadvertent thrust reverser stowage in a timely… · DCA08MA098Closed--No Longer Applicable
- A-09-058TO THE FEDERAL AVIATION ADMINISTRATION: Once improved aural or visual cues are developed per Safety Recommendation A-09-57, require Learjet 60 operators to install those cues on existing Learjet 60 airplanes. · DCA08MA098Closed - Acceptable Action
- A-09-059TO THE FEDERAL AVIATION ADMINISTRATION: Require that all Learjet 60 pilots receive training, for takeoff as well as landing phases of flight, on recognizing an inadvertent thrust reverser stowage, including the possibility that the stowage… · DCA08MA098Closed - Acceptable Alternate Action
- A-09-060TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the design of the thrust reverser controls and indications in Raytheon Hawker 1000 business jets for potential thrust reverser failure modes that are similar to those identified in Learjet 60… · DCA08MA098Closed - Acceptable Action
- A-10-046TO THE FEDERAL AVIATION ADMINISTRATION: Provide pilots and maintenance personnel with information that (1) transport-category aircraft tires can lose up to 5 percent pressure per day, (2) it may take only a few days for such tires to reach… · DCA08MA098Closed - Acceptable Action
- A-10-047TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators perform tire pressure checks at a frequency that will ensure that the tires remain inflated to within aircraft… · DCA08MA098Closed - Reconsidered
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).