Cases › DCA23LA133 › The analyst
BOEING 777-222UNITED 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.
3
timed facts
8
precedents
20
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
3 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- 09:38:38 HSTFDRDeparturep.6Aircraft departed Denver International Airport, Denver, Coloradosee the traces at this moment ↗
- 16:09:16 HSTFDRLandingp.6Aircraft landed on runway 04R at Daniel K. Inouye International Airport, Honolulu, Hawaiisee the traces at this moment ↗
- 16:09:16 HST (approx.)FDRLanding rollout/taxip.6Aircraft exited runway 04R onto taxiway K at a groundspeed of about 46 knotssee the traces at this moment ↗
Recorder events without a clock time
- after runway exitAircraft crossed runway 4L without stopping and continued to parking
FLIGHT DATA RECORDER - SPECIALIST'S FACTUAL REPORT · 4 events extracted by claude-sonnet-5AIR TRAFFIC CONTROL - ATTACHMENT 2 LOCAL CONTROL 1 (LC1) AUDIO · 43 min· not yet aligned to a clockAIR TRAFFIC CONTROL - ATTACHMENT 3 GROUND CONTROL (GC) AUDIO · 41 min· not yet aligned to a clockAIR TRAFFIC CONTROL - ATTACHMENT 4 CAB COORDINATOR (CS) AUDIO · 32 min· not yet aligned to a clockAIR TRAFFIC CONTROL - ATTACHMENT 5 OPERATIONS MANAGER IN CHARGE (OMIC) AUDIO · 97 min· not yet aligned to a clockAIR TRAFFIC CONTROL - ATTACHMENT 6 RADAR CONTROLLER (V) AUDIO · 34 min· not yet aligned to a clockAIR TRAFFIC CONTROL - ATTACHMENT 7 RADAR CONTROLLER (H) AUDIO · 50 min· not yet aligned to a clockAIR TRAFFIC CONTROL - ATTACHMENT 8 ATIS RECORDING · 81 min· not yet aligned to a clock
How the Board coded the sequence
- Taxi-from runway: Runway incursion veh/AC/person→
- Landing: Runway incursion veh/AC/person
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- BOMBARDIER INC CL-600-2D24 · MESA AIRLINES INCBurbank, CA
- ●Personnel issues › Action/decision › Action
Runway incursion veh/AC/person - BOEING 737-900ER · Delta Air LinesQueens, NY
- ●Personnel issues › Action/decision › Action
Runway incursion veh/AC/person - AIRBUS A321 231 · Spirit AirlinesFort Lauderdale, FLRunway incursion veh/AC/person
- BOEING 737 7H4 · SOUTHWEST AIRLINES COBranson, MO
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › (general)
- BOEING 757-232 · Delta AirlinesATLANTA, GA
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › (general)
- BOEING 737-932ER · Delta Air LinesAtlanta, GA
- ●Personnel issues › Action/decision › Action
- BOEING 737-7H4 · SOUTHWEST AIRLINES COPhiladelphia, PA
- ●Personnel issues › Action/decision › Action
- ●Personnel issues › Task performance › (general)
- BOEING 747 - 409LCF · Atlas Air , Inc.Wichita, KS
- ●Personnel issues › Action/decision › Action
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
- 3 of 8Personnel issues › Action/decision › Info processing/decision
- 3 of 8Personnel issues › Task performance › (general)cited here too
- 2 of 8Personnel issues › Task performance › Use of equip/info
Occurrences it coded
- 3 of 8Runway incursion veh/AC/person
- 2 of 8Air traffic event
- 2 of 8Navigation error
- 2 of 8Wrong surface or wrong airport
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Action/decision › Action
- Task performance › (general)
Cited here, not seen in the precedents
- Development › Design
Common in the precedents, not cited here
- Action/decision › Info processing/decision
- 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
- DCA23LA1852023-02-23 · BOMBARDIER INC CL-600-2D24 · MESA AIRLINES INC
The interruption of the local controller’s workflow due to the necessitated management of a go-around of a third airplane that was approaching a different runway. Contributing to the incident was: 1) the controller’s decision to continue the landing of ASH5826, likely without a re-assessment of its distance from the departing SKW5326, after the interruption, and 2) the lack of surface detection equipment at the Bob Hope Airport to aid the controller with traffic management.
- DCA23LA1252023-01-14 · BOEING 737-900ER · Delta Air Lines
The American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the ru…
- OPS16IA0042016-01-29 · AIRBUS A321 231 · Spirit Airlines
The air traffic controller's failure to ensure the runway surface area was clear of vehicles before clearing an aircraft for takeoff. Also causal was the flight crew's decision to initiate a takeoff while the Runway Status Lights (RWSL) Takeoff Hold Lights (THLs) were activated. Contributing to the incident was the lack of a standard procedure for vehicle operators to request runway clearances and resultant "hear back/read back" error between the vehicle operator and the air traffic controller.
- 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.
- OPS11IA4102011-03-11 · BOEING 757-232 · Delta Airlines
The air traffic controllers’ failure to adhere to required radar identification procedures, which resulted in loss of separation between the departing Boeing 757 and three other airplanes. Contributing to the incident was the pilots’ inadequate preflight checks, which resulted in the airplane departing with an inoperative transponder.
What it recommended after them
- A-24-002TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 91K, 135, and 121 operators to incorporate into their standard operating procedures a procedural crosscheck that requires flight crews to verbalize… · DCA23LA125Open - Unacceptable Response
- A-24-003TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent t… · DCA23LA125Open Acceptable Alternate Response
- A-24-004TO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on… · DCA23LA125Open - Unacceptable Response
- A-24-005TO THE FEDERAL AVIATION ADMINISTRATION: Require that the technology developed in response to Safety Recommendation A-24-4 be installed in all newly certificated transport-category airplanes. (Supersedes A-00-66) · DCA23LA125Open - Unacceptable Response
- A-24-006TO THE FEDERAL AVIATION ADMINISTRATION: Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A-24-4. (Supersedes A-00-66) · DCA23LA125Open - Unacceptable Response
- A-24-007TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the effectiveness of the activation logic for the runway status light system considering the circumstances of this incident. · DCA23LA125Open - Acceptable Response
- A-24-008TO THE FEDERAL AVIATION ADMINISTRATION: Using the findings of the evaluation conducted in response to Safety Recommendation A-24-7, update the runway status light system activation logic as necessary to improve system effectiveness. · DCA23LA125Open - Acceptable Response
- A-24-009TO THE FEDERAL AVIATION ADMINISTRATION: Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (Supersedes A… · DCA23LA125Open - Unacceptable 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).