Cases › DCA21FA174 › The analyst
BOEING 737-275CRHOADES AVIATION 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.
62
timed facts
8
precedents
268
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
62 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- 00:39:14.4CVR CAM-1p.10“*** actuator *** it's not that much *** (we're/he's) going to check the reservoir...top it up...and we'll write it up in the morning. are you okay with that?”read in context ↗
- 00:40:54.9CVR CAMwarningp.11“[sound similar to fire bell]”read in context ↗
- 00:41:28.0CVR CAMwarningp.12“[sound similar to fire bell]”read in context ↗
- 00:42:29.7CVR CAMwarningp.12“[sound similar to fire bell]”read in context ↗
- 01:15:28.3CVR CAM-2warningp.58“uhh standard uhh takeoff procedures (see anything) below eighty knots be your call but we'll probably abort for anything between eighty and vee one again your call we'll probably abort for any fire engine failure loss of directional control windshear otherwise we'll be lookin' to fly...if we lose the engine at vee one we'll climb straight out to five hundred feet one point three D-M-E whichever comes first we'll start a right turn to two twenty up to eight hundred we'll level off we'll accelerate we'll clean up we'll coordinate A-T-C run the checklists as appropriate (if we shut the engine down) *** [unintelligible] fourteen thousand on the fuel...no A-C-Ms...** runway ***...flaps five eight right dry runway...uhh two oh one set speed are (one twenty six one twenty six one thirty two...uhh one forty/twenty seven)...you've got forty over * auto ** (normal/romeo) in the box...five point two (units) ** questions?”read in context ↗
- 01:19:48.4CVR CAM-2warningp.66“on. anti-collision lights.”read in context ↗
- 01:32:00 to 01:45:30 HSTFDRDitchingp.10Aircraft ditches in the ocean, ending the recording (figure 9 range starts prior to runway turn-on and ends at ditching)see the traces at this moment ↗
- 01:33:08 HSTFDRTakeoff rollp.10Engines advanced to takeoff power; both engines stabilized at EPR consistent with takeoff (Engine 1 at 2.00 EPR, Engine 2 at 1.97 EPR)see the traces at this moment ↗
- 01:35:34.7CVR RDO-1warningp.85“okay Rhoades eight ten we've lost an engine...we are on a two twenty heading...maintaining two thousand...declaring emergency how do you read?”read in context ↗
- 01:36:47.4CVR ?warningp.86“and Rhoades express eight ten uhh...when you get a chance TWR-B uhh can I get ya...uh the nature of the emergency I know you said an engine out which one...uhh how many souls onboard and fuel.”read in context ↗
- 01:37:24.2CVR ?warningp.87“eight ten declared emergency. N809TA”read in context ↗
- 01:38:18.3CVR HOT-1warningp.89“yeah we'll stay within fifteen...all right I have controls you run the checklist...let's do the engine failure shutdown checklist.”read in context ↗
- 01:38:57.8CVR HOT-2warningp.90“okay engine failure or shutdown when these occurs engine failure engine flameout or another checklist directs an engine failure.”read in context ↗
- 01:40:11.0CVR CAMwarningp.92“[sounds possibly similar to momentary stick shaker, approximately 1.8 seconds duration]”read in context ↗
- 01:41:58.2CVR EGPWSwarningp.95“five hundred. [electronic voice]”read in context ↗
- 01:41:59.5CVR EGPWSwarningp.95“too low gear. [electronic voice]”read in context ↗
- 01:42:36.1CVR EGPWSwarningp.95“too low gear. [electronic voice]”read in context ↗
- 01:42:37.8CVR EGPWSwarningp.95“too low terrain. [electronic voice]”read in context ↗
- 01:42:40.9CVR EGPWSwarningp.96“too low gear. [electronic voice]”read in context ↗
- 01:42:43.7CVR EGPWSwarningp.96“terrain terrain. [electronic voice]”read in context ↗
- 01:42:45.8CVR EGPWSwarningp.96“pull up. [electronic voice]”read in context ↗
- 01:42:46.3CVR HOT-2warningp.96“pull up we're low. [spoken urgently]”read in context ↗
- 01:42:47.6CVR EGPWSwarningp.96“pull up. [electronic voice]”read in context ↗
- 01:42:48.8CVR EGPWSwarningp.96“pull up. [electronic voice]”read in context ↗
- 01:42:53.1CVR ?warningp.96“and Rhoades Express eight ten low altitude alert... uh low TWR-B altitude alert...are you able to climb at all?”read in context ↗
- 01:43:08.6CVR EGPWSwarningp.97“too low terrain. [electronic voice]”read in context ↗
- 01:43:11.1CVR EGPWSwarningp.97“(three) hundred. [electronic voice]”read in context ↗
- 01:43:12.3CVR EGPWSwarningp.97“too low gear. [electronic voice]”read in context ↗
- 01:43:37.2CVR HOT-2warningp.98“pull back to the stick shaker.”read in context ↗
- 01:43:46.7CVR EGPWSwarningp.99“too low terrain. [electronic voice]”read in context ↗
- 01:43:48.7CVR EGPWSwarningp.99“too low gear. [electronic voice]”read in context ↗
- 01:43:50.6CVR EGPWSwarningp.99“too low gear. [electronic voice]”read in context ↗
- 01:43:55.2CVR EGPWSwarningp.99“too low gear. [electronic voice]”read in context ↗
- 01:44:06.8CVR EGPWSwarningp.99“too low gear. [electronic voice]”read in context ↗
- 01:44:08.5CVR EGPWSwarningp.99“too low terrain. [electronic voice]”read in context ↗
- 01:44:28.0CVR CAMwarningp.100“[sound similar to stick shaker, approximately 1.7 seconds duration]”read in context ↗
- 01:44:33.9CVR EGPWSwarningp.100“too low gear. [electronic voice]”read in context ↗
- 01:44:35.9CVR EGPWSwarningp.100“too low gear. [electronic voice]”read in context ↗
- 01:44:37.8CVR EGPWSwarningp.101“too low gear. [electronic voice]”read in context ↗
- 01:44:39.6CVR EGPWSwarningp.101“too low gear. [electronic voice]”read in context ↗
- 01:44:39.8CVR CAMwarningp.101“[sound similar to stick shaker, approximately 1.6 seconds duration]”read in context ↗
- 01:44:41.6CVR EGPWSwarningp.101“terrain terrain. [electronic voice]”read in context ↗
- 01:44:43.1CVR EGPWSwarningp.101“pull up. [electronic voice]”read in context ↗
- 01:44:44.7CVR EGPWSwarningp.101“pull up. [electronic voice]”read in context ↗
- 01:44:46.2CVR EGPWSwarningp.101“pull up. [electronic voice]”read in context ↗
- 01:44:47.8CVR EGPWSwarningp.101“pull up. [electronic voice]”read in context ↗
- 01:44:49.3CVR EGPWSwarningp.101“pull up. [electronic voice]”read in context ↗
- 01:44:50.8CVR EGPWSwarningp.102“pull up. [electronic voice]”read in context ↗
- 01:44:52.3CVR EGPWSwarningp.102“pull up. [electronic voice]”read in context ↗
- 01:44:54.0CVR EGPWSwarningp.102“pull up. [electronic voice]”read in context ↗
- 01:44:55.3CVR CAMwarningp.102“[sound similar to stick shaker, approximately 2.6 seconds duration]”read in context ↗
- 01:44:55.4CVR EGPWSwarningp.102“pull up. [electronic voice]”read in context ↗
- 01:44:57.2CVR EGPWSwarningp.102“pull up. [electronic voice]”read in context ↗
- 01:44:58.4CVR EGPWSwarningp.102“pull up. [electronic voice]”read in context ↗
- 01:45:11.4CVR HOT-1final secondsp.103“oh man we're in the water we're in the water we can't go...”read in context ↗
- 01:45:12.0CVR CAMfinal secondsp.104“[sound similar to stick shaker, remained active throughout the duration of the recording]”read in context ↗
- 01:45:12.4CVR EGPWSfinal secondsp.104“terrain terrain. [electronic voice]”read in context ↗
- 01:45:13.7CVR EGPWSfinal secondsp.104“pull up. [electronic voice]”read in context ↗
- 01:45:14.9CVR EGPWSfinal secondsp.104“pull up. [electronic voice]”read in context ↗
- 01:45:15.9CVR HOT-1final secondsp.104“#.”read in context ↗
- 01:45:16.3CVR EGPWSfinal secondsp.104“pull up. [electronic voice]”read in context ↗
- 01:45:17.0CVR CAMfinal secondsp.104“[sounds consistent with impact] 0145:17.3”read in context ↗
Recorder events without a clock time
- N/A (during takeoff roll)Longitudinal acceleration peaked at 0.2055 g during the takeoff roll
- N/A (during takeoff)Aircraft rotated at about 140 knots and took off on a heading of 80 degrees
- N/AAs the aircraft passed through about 390 ft at 155 knots, engine 2 EPR suddenly dropped to 1.43, while engine 1 remained at its previously set takeoff power
- N/A (immediately after EPR drop)Rudder pedal moved to about 5.5 degrees of left rudder, consistent with a command to counteract adverse yaw of losing thrust on right engine
- N/AClimb paused at 1,000 feet for 25 seconds, then continued to 2,000 ft
- N/A (at 2,000 feet)Engine 1 EPR reduced to a value of 1.051, consistent with idle power in previous flights; stayed at this value for remainder of flight
- N/A (at 2,000 feet)Engine 2 EPR also reduced, but continued to be advanced and reduced several times until end of flight
- N/A (over next 9 minutes)Altitude and airspeed decreased over the next 9 minutes until the end of the recording
- N/A (end of recording)At end of recording, engine 2 EPR was 1.462 and engine 1 EPR was still consistent with previous flight idle settings at 1.052
FLIGHT DATA RECORDER SPECIALIST'S FACTUAL REPORT · 11 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - GROUP CHAIR'S FACTUAL REPORT · 60 of 836 lines shown
How the Board coded the sequence
- Initial climb: Loss of engine power (partial)→
- Enroute: Ditching
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- SWEARINGEN SA226 · CASTLE AVIATION INCBedford, NH
- ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Action/decision › Info processing/decision
Loss of engine power (partial) - Convair C131 · Conquest Air IncAtlantic Ocean, AO
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Action/decision › Info processing/decision
DitchingLoss of engine power (partial) - BOEING 737-932ER · Delta Air LinesAtlanta, GA
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Action/decision › Info processing/decision
- BOEING 767 · AMERICAN AIRLINES INCChicago, IL
- ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › Communication (personnel)
- BOEING 777 · UNITED AIRLINES INCKahului, HI
- ●Personnel issues › Action/decision › Info processing/decision
- MCDONNELL DOUGLAS MD11 · FEDERAL EXPRESS CORPDenver, CO
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Action/decision › Info processing/decision
- Bombardier, Inc. CL-600-2C10 · United ExpressSan Francisco, CA
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Action/decision › Info processing/decision
- ●Personnel issues › Task performance › Communication (personnel)
- BOEING 737-823 · American AirlinesLos Angeles, CA
- ●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 causeFindings the Board cited in those cases
- 7 of 8Personnel issues › Action/decision › Actioncited here too
- 7 of 8Personnel issues › Action/decision › Info processing/decisioncited here too
- 3 of 8Personnel issues › Task performance › Use of equip/info
- 2 of 8Aircraft › Aircraft power plant › Engine (turbine/turboprop)cited here too
- 2 of 8Personnel issues › Task performance › Communication (personnel)cited here too
Occurrences it coded
- 2 of 8Loss of engine power (partial)
- 2 of 8Tailstrike
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Aircraft power plant › Engine (turbine/turboprop)
- Action/decision › Action
- Action/decision › Info processing/decision
- Task performance › Communication (personnel)
Cited here, not seen in the precedents
- Task performance › Workload management
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
- ERA22FA0862021-12-11 · SWEARINGEN SA226 · CASTLE AVIATION INC
The pilot’s failure to secure and feather the left engine and increase power on the right engine after a perceived loss of engine power in the left engine, which resulted in a loss of control and impact with terrain just short of the runway. Contributing to the accident was a reduction in engine power from the left engine due to a 1st stage turbine blade midspan separation and material loss in the 2nd stage stator that were the result of engine operation at high temperatures for an extended period of time.
- ERA19LA0962019-02-08 · Convair C131 · Conquest Air Inc
The captain's decision to continue with the flight with a malfunctioning left engine propeller control and the subsequent loss of engine power on both engines for undetermined reasons, which resulted in ditching into the ocean. Contributing to the accident was the first officer's failure to challenge the captain's decision to continue with the flight.
- 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…
- DCA17FA0212016-10-28 · BOEING 767 · AMERICAN AIRLINES INC
The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contribu…
- DCA23LA1722022-12-19 · BOEING 777 · UNITED AIRLINES INC
The flight crew’s failure to manage the airplane’s vertical flightpath, airspeed, and pitch attitude following a miscommunication about the captain’s desired flap setting during the initial climb.
What it recommended after them
- A-18-003TO THE FEDERAL AVIATION ADMINISTRATION: Establish and lead an industry group that evaluates current and enhanced inspection technologies regarding their appropriateness and effectiveness for applications using nickel alloys, and use the res… · DCA17FA021Open - Acceptable Response
- A-18-004TO THE FEDERAL AVIATION ADMINISTRATION: Require subsurface in-service inspection techniques, such as ultrasonic inspections, for critical high-energy, life-limited rotating parts for all engines. · DCA17FA021Open - Acceptable Response
- A-18-005TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular (AC) 20-128A, “Design Considerations for Minimizing Hazards Caused by Uncontained Turbine Engine and Auxiliary Power Unit Rotor Failure,” based on an analysis of uncontained e… · DCA17FA021Open - Acceptable Response
- A-18-006TO THE FEDERAL AVIATION ADMINISTRATION: When approving the operating procedures of a 14 Code of Federal Regulations Part 121 air carrier, require operators to develop and/or revise emergency checklist procedures for an engine fire on the gr… · DCA17FA021Closed - Unacceptable Action
- A-18-007TO THE FEDERAL AVIATION ADMINISTRATION: Develop and issue guidance to all air carriers that conduct passenger-carrying operations under 14 Code of Federal Regulations Part 121 regarding (1) discussing this accident during recurrent flight a… · DCA17FA021Closed - Unacceptable Action
- A-18-008TO THE FEDERAL AVIATION ADMINISTRATION: Review the training programs of all 14 Code of Federal Regulations Part 121 operators and make changes as necessary to ensure that the programs provide flight attendants and flight crews with training… · DCA17FA021Closed - Unacceptable Action
- A-18-009TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research to (1) measure and evaluate the effects of carry-on baggage on passenger deplaning times and safety during an emergency evacuation and (2) identify effective countermeasures to reduce… · DCA17FA021Open - Acceptable Response
- A-18-010TO THE BOEING COMPANY: Work with operators as required to develop and/or revise emergency checklist procedures for an engine fire on the ground to expeditiously address the fire hazard without unnecessarily delaying an evacuation. · DCA17FA021Closed - Acceptable 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).