Cases › DCA22LA126 › The analyst
BOEING 757-236Federal Express Corporation
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.
61
timed facts
8
precedents
73
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
61 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- 03:09:39.6CVR CAMp.8“[sound of ACARS chime]”read in context ↗
- 03:23:38.9CVR ?warningp.15“copy that clear to push and pull up agea— abeam gate PUSH sixteen...go ahead and release your brakes.”read in context ↗
- 03:28:19.6CVR HOT-1calloutp.20“all right (we/you) can do the before takeoff checklist.”read in context ↗
- 03:28:50.2CVR CAMcalloutp.21“[ATIS information mike winds 170 at 9 knots gusts to 20 knots, visibility 10 miles, clouds 25,000 feet broken, temperature 27 dewpoint 22 altimeter 29.81 inHg, visual approach runway 16L with various NOTAMs]”read in context ↗
- 03:29:23.1CVR HOT-2calloutp.21“all right before takeoff checklist...flaps...five.”read in context ↗
- 03:32:11.3CVR ?calloutp.23“FedEx eleven seventy Alliance Tower runway one six left. AFW clear for takeoff. wind at one six zero at seven.”read in context ↗
- 03:32:18.6CVR RDO-2calloutp.23“FedEx eleven seventy cleared for takeoff one six left.”read in context ↗
- 03:32:36.8CVR HOT-2calloutp.24“before takeoff checklist complete.”read in context ↗
- 03:33:14.0CVR RAASp.24“on runway one six left. [electronic voice]”read in context ↗
- 03:33:17FDRTakeoffp.4FedEx Flight 1170 began takeoff roll on runway 16L from Fort Worth Alliance Airport (KAFW), Fort Worth, TX.see the traces at this moment ↗
- 03:33:17.3CVR HOT-1p.25“arright set thrust.”read in context ↗
- 03:33:20.4CVR CAMcalloutp.25“[increase in engine pitch consistent with applying takeoff thrust]”read in context ↗
- 03:33:43.6CVR HOT-2calloutp.25“rotate.”read in context ↗
- 03:33:53.3CVR HOT-1calloutp.25“gear up.”read in context ↗
- 03:34:22.5CVR HOT-1calloutp.26“flaps up after takeoff checklist.”read in context ↗
- 03:35:03.3CVR HOT-2calloutp.27“after takeoff checklist complete.”read in context ↗
- 03:36:58.5CVR CAMwarningp.30“[altitude alert]”read in context ↗
- 03:37:46.3CVR HOT-1p.30“autopilot's on.”read in context ↗
- 03:37:47.3CVR HOT-2p.30“see it.”read in context ↗
- 03:37:49FDRClimbp.4The left autopilot was engaged.see the traces at this moment ↗
- 03:48:52.4CVR CAMwarningp.35“[altitude alert]”read in context ↗
- 03:49:11.4CVR HOT-1p.36“yep.”read in context ↗
- 03:49:26FDRCruisep.5The aircraft reached cruising altitude of 31,000 ft pressure altitude, with a computed airspeed of 296 kts (484 kts ground speed) and a magnetic heading of 013 degrees.see the traces at this moment ↗
- 03:51:23.7CVR HOT-2p.37“yeah.”read in context ↗
- 03:51:24FDRDescentp.5The aircraft began a descent for landing.see the traces at this moment ↗
- 03:51:24.4CVR HOT-2p.37“aaaand...we're leaving thirty one.”read in context ↗
- 04:00:00FDRDescentp.5The aircraft began to arrest the descent at 11733 ft pressure altitude at an airspeed of 323 kts (385 kts ground speed), and a magnetic heading of 16 degrees.see the traces at this moment ↗
- 04:00:01.3CVR HOT-1p.41“*.”read in context ↗
- 04:07:22.2CVR CAMwarningp.46“[altitude alert]”read in context ↗
- 04:07:25.0CVR ?calloutp.47“FedEx eleven seventy cleared visual approach runway one TUL eight left runway one eight left cleared to land wind zero five zero at six.”read in context ↗
- 04:08:17FDRApproachp.5The aircraft leveled off at 2546 ft pressure altitude at an airspeed of 230 kts (251 kts ground speed) and a magnetic heading of 000 degrees.see the traces at this moment ↗
- 04:08:24.6CVR HOT-1p.47“set flaps one.”read in context ↗
- 04:08:26.4CVR HOT-2p.47“flaps one.”read in context ↗
- 04:10:15.0CVR HOT-1calloutp.49“landing gear down before landing checklist.”read in context ↗
- 04:10:41.0CVR HOT-1p.49“random autopilot...we'll turn it off.”read in context ↗
- 04:10:42.6CVR HOT-2p.49“all right.”read in context ↗
- 04:10:43FDRApproachp.5The autopilot was disengaged.see the traces at this moment ↗
- 04:11:29.8CVR EGPWSwarningp.51“one thousand. [electronic voice]”read in context ↗
- 04:11:30FDRApproachp.5The aircraft reached a magnetic heading of 174 degrees, a computed airspeed of 132 knots, and a pressure altitude of 1539 feet. The Localizer and Glideslope deviation was -4.10 dots and +0.43 dots, respectively.see the traces at this moment ↗
- 04:11:30.4CVR HOT-2p.51“if I can add five.”read in context ↗
- 04:12:13.6CVR EGPWSwarningp.52“five hundred. [electronic voice]”read in context ↗
- 04:12:14.6CVR HOT-2calloutp.52“you're stable. cleared to land one eight left.”read in context ↗
- 04:12:46.8CVR EGPWSwarningp.53“one hundred. [electronic voice]”read in context ↗
- 04:12:48.3CVR EGPWSwarningp.53“fifty. [electronic voice]”read in context ↗
- 04:12:48.9CVR EGPWSwarningp.53“forty. [electronic voice]”read in context ↗
- 04:12:49.8CVR EGPWSwarningp.53“thirty. [electronic voice]”read in context ↗
- 04:12:50.7CVR EGPWSwarningp.53“twenty. [electronic voice]”read in context ↗
- 04:12:51.7CVR EGPWSwarningp.53“ten. [electronic voice]”read in context ↗
- 04:12:53FDRLandingp.5The aircraft touched down on runway 18R and began landing rollout (36.203040 deg N, 95.899654 deg W).see the traces at this moment ↗
- 04:13:20.7CVR HOT-1p.54“we landed on the right runway.”read in context ↗
- 04:13:22FDRLanding rolloutp.5The aircraft slowed below 15 knots ground speed approximately 638 feet from the end of runway 18R at Tulsa International Airport (KTUL).see the traces at this moment ↗
- 04:13:23.5CVR HOT-1p.54“God # @. [captain]”read in context ↗
- 04:17:36.8CVR HOT-2warningp.58“terrain terrain. * brakes.”read in context ↗
- 04:19:41.8CVR HOT-2final secondsp.60“[sigh]”read in context ↗
- 04:20:02.2CVR HOT-1final secondsp.60“those cans look like they are all right.”read in context ↗
- 04:20:04.5CVR HOT-2final secondsp.60“yup. they are on the other side of the line-foul line. got wands up.”read in context ↗
- 04:20:18.1CVR HOT-2final secondsp.60“you're clear on the right.”read in context ↗
- 04:21:16.8CVR HOT-1final secondsp.60“all right. parking brake is set and holding. ice is off. right engine is coming down.”read in context ↗
- 04:21:23.8CVR HOT-2final secondsp.60“[sound of mumbling sigh]”read in context ↗
- 04:21:50.8CVR CAMfinal secondsp.60“[sound of quad beeper]”read in context ↗
- 04:21:52.2CVR HOT-1final secondsp.60“power selected on. ice is off. left engine is coming down. 0421:52.2”read in context ↗
FLIGHT DATA RECORDER - SPECIALIST'S FACTUAL REPORT · 10 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - FACTUAL REPORT OF GROUP CHAIR · 51 of 551 lines shown
How the Board coded the sequence
- Approach: Wrong surface or wrong airport
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BOEING 737-9 · UNITED AIRLINES INCPittsburgh, PA
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - EMBRAER ERJ 170-100 LR · Envoy Air Inc.Chicago, IL
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - BOEING 737-79P · SOUTHWEST AIRLINES COAustin, TX
- ●Personnel issues › Action/decision › Info processing/decision
- ●Personnel issues › Psychological › Attention/monitoring
- ●Personnel issues › Task performance › Communication (personnel)
- BOEING 767 · Delta Air Lines, Inc.Atlanta Hartsfield Intl. Apt. (KATL), GA
- ●Personnel issues › Action/decision › Info processing/decision
- ●Personnel issues › Physical › Alertness/Fatigue
Wrong surface or wrong airport - BOEING 737 7H4 · SOUTHWEST AIRLINES COBranson, MO
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - Embraer EMB145 · CommutairPresque Isle, ME
- ●Personnel issues › Action/decision › Info processing/decision
Wrong surface or wrong airport - Boeing 737-700 · AirTransSeattle, WA
- ●Personnel issues › Psychological › Attention/monitoring
- ●Personnel issues › Task performance › Communication (personnel)
- BOEING 777-200ER · Asiana AirlinesSan Francisco, CA
- ●Personnel issues › Action/decision › Info processing/decision
- ●Personnel issues › Physical › Alertness/Fatigue
- ●Personnel issues › Psychological › Attention/monitoring
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 › Info processing/decisioncited here too
- 3 of 8Personnel issues › Psychological › Attention/monitoringcited here too
- 3 of 8Personnel issues › Action/decision › Action
- 2 of 8Personnel issues › Task performance › Use of equip/info
- 2 of 8Personnel issues › Task performance › Communication (personnel)cited here too
- 2 of 8Environmental issues › Operating environment › Approach aid coverage/avail
- 2 of 8Personnel issues › Physical › Alertness/Fatiguecited here too
Occurrences it coded
- 5 of 8Wrong surface or wrong airport
- 2 of 8Airport occurrence
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Action/decision › Info processing/decision
- Physical › Alertness/Fatigue
- Psychological › Attention/monitoring
- Task performance › Communication (personnel)
Cited here, not seen in the precedents
- Management › Policy/procedure
Common in the precedents, not cited here
- Operating environment › Approach aid coverage/avail
- 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
- DCA22LA1332022-06-21 · BOEING 737-9 · UNITED AIRLINES INC
The flightcrew’s misidentification of the intended landing runway, which resulted in approach to and landing on the wrong runway. Contributing to the incident was the distraction caused by the dual reset of the flight management computer displays.
- DCA24LA3182024-09-25 · EMBRAER ERJ 170-100 LR · Envoy Air Inc.
The flight crew’s misidentification of the intended landing runway, which resulted in an approach to and landing on the wrong runway due to their planned continuation bias. Contributing to the incident was the flight crew’s decision to continue the approach without the correct ILS frequency in the FMS. Also contributing was air traffic control’s failure to notify the flight crew that the were lined up with the incorrect runway contrary to FAA directives.
- DCA23FA1492023-02-04 · BOEING 737-79P · SOUTHWEST AIRLINES CO
the local controller’s incorrect assumption that the Southwest Airlines (SWA) airplane would depart from the runway before the Federal Express airplane arrived on the same runway, which resulted in a loss of separation between both airplanes. Contributing to the controller’s incorrect assumption were his expectation bias regarding the SWA airplane’s departure, his lack of situational awareness regarding the SWA airplane’s position when the flight crew requested takeoff clearance, and the air traffic control tower’s…
- OPS10IA0012009-10-19 · BOEING 767 · Delta Air Lines, Inc.
The flight crew’s failure to identify the correct landing surface due to fatigue. Contributing to the cause of the incident were (1) the flight crew’s decision to accept a late runway change, (2) the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and (3) the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.
- DCA14IA0372014-01-13 · BOEING 737 7H4 · SOUTHWEST AIRLINES CO
The Flight crew's failure to properly identify the airport and runway of intended landing. Contributing to the incident was the flight crew's failure to comply with procedures for use of navigation information and visual cues to verify the airport and runway of intended landing and the air traffic controller's issuance of erroneous airport geographic information without including the location of proximate airports.
What it recommended after them
- A-24-010TO THE FEDERAL AVIATION ADMINISTRATION: For airports that are certificated under Title 14 Code of Federal Regulations Part 139 and are currently not equipped with airport surface detection equipment, model X (ASDE-X) or airport surface surv… · DCA23FA149Open - Acceptable Response
- A-24-011TO THE FEDERAL AVIATION ADMINISTRATION: Require air traffic controllers to • advise pilots, through direct communication and automatic terminal information system broadcasts, when visual contact with aircraft operating on taxiways and run… · DCA23FA149Open - Unacceptable Response
- A-24-012TO THE FEDERAL AVIATION ADMINISTRATION: Brief all air traffic controllers about the circumstances of this incident, emphasizing the effect that certain conditions might have on a pilot’s ability to begin a takeoff in a timely manner, includ… · DCA23FA149Open - Acceptable Response
- A-24-013TO THE FEDERAL AVIATION ADMINISTRATION: Amend the Aeronautical Information Manual so that it instructs pilots to inform controllers, before entering an active runway with the intent to depart, when they need time on the runway for any reaso… · DCA23FA149Open - Acceptable Response
- A-24-014TO THE FEDERAL AVIATION ADMINISTRATION: Require all airports with a Surface Movement Guidance and Control System plan to ensure that their plans and the associated letters of agreement correspond with each other and the stakeholder duties a… · DCA23FA149Open - Unacceptable Response
- A-24-015TO THE FEDERAL AVIATION ADMINISTRATION: Direct training administrators at airports with a Surface Movement Guidance and Control System plan to require initial and annual refresher training for all stakeholders, including air traffic control… · DCA23FA149Open - Unacceptable Response
- A-24-016TO THE FEDERAL AVIATION ADMINISTRATION: Require training administrators at all operating air traffic control towers to conduct annual refresher training on low-visibility operations. · DCA23FA149Open - Unacceptable Response
- A-11-012TO THE FEDERAL AVIATION ADMINISTRATION: Perform a technical review of Airport Surface Detection Equipment–Model X (ASDE-X) to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. · OPS10IA001Closed - Unacceptable 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).