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Cases › DCA22LA133 › The analyst

BOEING 737-9UNITED AIRLINES 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.

0
timed facts
8
precedents
13
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

0 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

No timed facts: this docket has no extracted recorder sequence and no transcript.

Recorder events without a clock time
  • 0845:00Flight departed Chicago
  • 0850:47Autopilot was engaged
  • 0918:50Initial descent into Pittsburgh began
  • 0940:13Data loss condition likely began based on sampling rate of affected parameters
  • 0940:17Parameters sourced from the FMC began to show an error pattern consistent with the recorder not receiving data from their FMC ARINC data bus words, while on descent into Pittsburgh at an altitude of about 3,950 ft
  • ~0940:30Error pattern transitioned to a No Computed Data (NCD) error pattern, consistent with the system transmitting data on its ARINC label which is not reliable
  • 0940:36Valid data was again received by the FDR
  • 0942:07Autopilot was disconnected at about 2,650 ft; aircraft was turning onto final approach course
  • 0944:42Aircraft touched down on runway 28L
FLIGHT DATA RECORDER SPECIALIST'S FACTUAL REPORT · 9 events extracted by claude-sonnet-5AIR TRAFFIC CONTROL PIT APPROACH CONTROL AUDIO · 18 min· not yet aligned to a clockAIR TRAFFIC CONTROL PIT ATIS RECORDING · 49 min· not yet aligned to a clockAIR TRAFFIC CONTROL PIT LOCAL CONTROL AUDIO · 16 min· not yet aligned to a clock
How the Board coded the sequence
  1. Landing: 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
  • DCA22LA1262022-06-08no fatalitiesmatch 67
    BOEING 757-236 · Federal Express Corporation
    Tulsa, OK
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport
  • DCA24LA3182024-09-25no fatalitiesmatch 66
    EMBRAER ERJ 170-100 LR · Envoy Air Inc.
    Chicago, IL
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport
  • DCA14IA0372014-01-13no fatalitiesmatch 64
    BOEING 737 7H4 · SOUTHWEST AIRLINES CO
    Branson, MO
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
    Wrong surface or wrong airport
  • DCA18IA0262017-11-29no fatalitiesmatch 61
    BOEING 737-932ER · Delta Air Lines
    Atlanta, GA
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • DCA23LA1722022-12-19no fatalitiesmatch 61
    BOEING 777 · UNITED AIRLINES INC
    Kahului, HI
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
  • OPS17IA0142017-02-16no fatalitiesmatch 60
    EMBRAER S A ERJ 170-200 LR · Compass Airlines
    San Francisco, CA
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Use of equip/info
    Wrong surface or wrong airport
  • DCA18IA0812017-12-30no fatalitiesmatch 60
    BOMBARDIER INC DHC 8 402 · HORIZON AIR INDUSTRIES INC
    Pullman, WA
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport
  • DCA19FA0892019-03-04substantialmatch 59
    Embraer EMB145 · Commutair
    Presque Isle, ME
    • ●Personnel issues › Action/decision › Info processing/decision
    Wrong surface or wrong airport

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
  • 6 of 8Wrong surface or wrong airport
  • 2 of 8Air traffic event
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Action/decision › Info processing/decision
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • Aircraft systems › Navigation system
Common in the precedents, not cited here
  • Action/decision › Action
  • Task performance › Communication (personnel)

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
  • DCA22LA1262022-06-08 · BOEING 757-236 · Federal Express Corporation
    The flight crew’s misidentification of the intended landing runway. Contributing to the incident were (1) the flight crew’s failure to perceive and correctly interpret visual and auditory indicators – including electronic guidance – that they were approaching the incorrect runway which was likely the result of a degradation in cognitive function brought on by working within their window of circadian low, increased workload, and fatigue, and (2) the air traffic controller’s failure to monitor the arriving flight af…
  • 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.
  • 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.
  • 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…
  • 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-15-009TO THE FEDERAL AVIATION ADMINISTRATION: Amend air traffic control procedures so that controllers withhold landing clearance until the aircraft has passed all other airports that may be confused with the destination airport. · DCA14IA037Open Acceptable Alternate Response
  • A-15-010TO THE FEDERAL AVIATION ADMINISTRATION: Modify the minimum safe altitude warning (MSAW) software to apply the MSAW parameters for the flight plan destination airport to touchdown, rather than automatically reassigning the flight to another… · DCA14IA037Open Acceptable Alternate Response

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).