FlarePath
Cases › DCA26MA024 › The analyst

MCDONNELL DOUGLAS MD-11FUNITED PARCEL SERVICE CO

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.

66
timed facts
8
precedents
98
passages to ask
No probable cause yet

The Board has not determined a cause for this accident. The precedents and the record view below describe the pattern in past cases; they are not a finding about this one, and this page will not offer one.

Ask the docket

passages, not paraphrases
Try

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

66 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
  1. 15:09:17.2CVR STARTp.10
    “OF RECORDING”
    read in context ↗
  2. 16:48:03.1CVR CAM-1calloutp.14
    “make sure…I haven't said anything (to) get our taxi speeds…(and/our) turn coordination and then look at our… airport…location as we're getting ready to takeoff.”
    read in context ↗
  3. 16:48:41.1CVR CAM-1calloutp.15
    “takeoff gross weight is five sixty eight zero.”
    read in context ↗
  4. 16:48:44.4CVR CAM-1calloutp.16
    “takeoff C-G is eighteen seven.”
    read in context ↗
  5. 16:48:50.9CVR CAM-1calloutp.16
    “we are less than…uh on both our…payload and takeoff weight.”
    read in context ↗
  6. 16:48:57.7CVR CAM-1calloutp.16
    “about ten thousand pounds on takeoff weight so that's a little bonus for us on the fuel.”
    read in context ↗
  7. 16:49:12.0CVR CAM-1calloutp.17
    “I got a takeoff gross weight of five sixty eight nothing.”
    read in context ↗
  8. 16:51:58.4CVR CAM-1warningp.21
    “all right mainly for the cockpit voice recorder…uh…just 'cause I haven't flown with either of you guys…it'll be my decision to reject so either of you call out anything you see loud and clear prior to V one…so we can make a decision about stopping or going. after eighty knots it's considered a high speed reject and in that case we'll only reject…for an engine fire engine failure windshear…something that we deem unsafe unfit to take the airplane airborne. uh…we're heavy…so our dump time…”
    read in context ↗
  9. 16:59:14.6CVR HOT-1calloutp.30
    “takeoff is one ninety point zero. COCKPIT VOICE RECORDER DCA26MA024”
    read in context ↗
  10. 17:06:57.7CVR HOT-1p.38
    “clear.”
    read in context ↗
  11. 17:06:59.2CVR HOT-2p.38
    “clear.”
    read in context ↗
  12. 17:07:09FDRPre-taxi/Taxip.10
    The FDR began recording. The aircraft position was at Muhammad Ali International Airport, Louisville, Kentucky Ramp 5. The aircraft was not moving. The aircraft began to taxi to runway 17R at approximately 17:08 EST.
    see the traces at this moment ↗
  13. 17:09:09.4CVR HOT-1calloutp.40
    “how about aaaa….before takeoff checklist.”
    read in context ↗
  14. 17:09:12.7CVR HOT-2calloutp.40
    “before takeoff checklist. flaps.”
    read in context ↗
  15. 17:09:23.3CVR HOT-2calloutp.41
    “before takeoff checklist is complete.”
    read in context ↗
  16. 17:11:17.9CVR TWRcalloutp.42
    “U-P-S twenty nine seventy six heavy Louisville Tower R-NAV to WININ runway one seven right cleared for takeoff winds one two zero at seven.”
    read in context ↗
  17. 17:11:23.2CVR RDO-2calloutp.42
    “cleared for takeoff one seven right R-NAV to WININ U-P-S twenty nine seventy six heavy.”
    read in context ↗
  18. 17:11:38.9CVR HOT-1calloutp.43
    “cleared for takeoff.”
    read in context ↗
  19. 17:11:40.0CVR HOT-2calloutp.43
    “cleared for takeoff.”
    read in context ↗
  20. 17:12:14.7CVR HOT-2p.43
    “I got the airplane…here we go. ready?”
    read in context ↗
  21. 17:12:16FDRTakeoff rollp.10
    All three engine Throttle Resolver Angles (TRA) began to increase, consistent with initiation of takeoff roll. Shortly thereafter, Engine N1 and N1 Cmd increased on all three engines.
    see the traces at this moment ↗
  22. 17:12:16.6CVR HOT-1p.43
    “ready.”
    read in context ↗
  23. 17:12:28FDRTakeoff rollp.10
    Autothrottles 1 and 2 were ENGAGED. Ground speed was 17 kts.
    see the traces at this moment ↗
  24. 17:12:28.5CVR HOT-2p.43
    “set takeoff thrust.”
    read in context ↗
  25. 17:12:29.4CVR HOT-1p.43
    “set takeoff thrust. COCKPIT VOICE RECORDER DCA26MA024”
    read in context ↗
  26. 17:12:31.0CVR CAMcalloutp.44
    “[increase in ambient noise, consistent with application of takeoff thrust]”
    read in context ↗
  27. 17:13:02.7CVR HOT-1calloutp.44
    “rotate.”
    read in context ↗
  28. 17:13:04.8CVR HOT-1p.44
    “V two.”
    read in context ↗
  29. 17:13:05FDRRotation/Liftoffp.10
    Computed airspeed was 174 kts (173 kts ground speed). The nose landing gear weight on wheels left and right parameters changed from ON GROUND to IN FLIGHT.
    see the traces at this moment ↗
  30. 17:13:05.5CVR CAMp.44
    “[high pitch ringing sound, approximately 6350 Hz continued with varying amplitude throughout the remainder of the recording]3”
    read in context ↗
  31. 17:13:09FDRInitial climbp.10
    Longitudinal acceleration decreased at a radio altitude of 5 feet (ft). Engine 1 parameters were no longer reliable after this point.
    see the traces at this moment ↗
  32. 17:13:09.5CVR CAMp.44
    “[low frequency thump sound] 3 Significant efforts were undertaken to identify this sound, both within and outside the group process. However, due to the poor quality of the CAM, the sound could not be positively identified. For more information, see the CVR Sound Spectrum Specialist’s Study, in the docket. COCKPIT VOICE RECORDER DCA26MA024”
    read in context ↗
  33. 17:13:09.5CVR GROUPp.44
    “CHAIR'S FACTUAL REPORT PG 43 OF 46 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  34. 17:13:10FDRInitial climbp.10
    The Rudder Pedal input was sustained in the airplane nose right direction for the remainder of the recording. The Control Wheel Position input was predominantly in the right wing down direction for the majority of the remainder of the recording.
    see the traces at this moment ↗
  35. 17:13:10.5CVR HOT-1p.45
    “# # #.”
    read in context ↗
  36. 17:13:11FDRInitial climbp.10
    Slat-L4 position changed from EXTENDED to IN TRANSIT (Near Ret). Slat Disagree changed from AGREE to DISAGREE. The Stick Shaker-2 state changed to ACTIVE and remained ACTIVE throughout the remainder of the flight. The Stick Shaker-1 state changed to ACTIVE and remained ACTIVE throughout the remainder of the flight except at data points recorded at 17:13:16 and 17:13:27.
    see the traces at this moment ↗
  37. 17:13:11FDRInitial climbp.7
    The Engine 1 Fire Switch changed from NO FIRE to FIRE.
    see the traces at this moment ↗
  38. 17:13:11.1CVR HOT-2p.45
    “what's the— what's the problem?”
    read in context ↗
  39. 17:13:12FDRInitial climbp.10
    Hydraulic Pressure-1 reduced from 3096 psi to 16 psi. One second later, Hydraulic Pressure Low-1 changed from NORMAL to LOW. Hydraulic Quantity 1 and 3 began to decrease. Engine 2 and 3 TRA increased from 74.18 deg and 73.48 deg to 79.45 deg and 80.86 deg, respectively.
    see the traces at this moment ↗
  40. 17:13:12.1CVR GPWSwarningp.45
    “bank angle. bank angle. [electronic voice]”
    read in context ↗
  41. 17:13:12.2CVR HOT-1p.45
    “lower the nose.”
    read in context ↗
  42. 17:13:12.8CVR HOT-1p.45
    “lower the nose.”
    read in context ↗
  43. 17:13:13FDRInitial climbp.11
    Engine 2 N1 reduced from 108.00 %RPM to 101.13 %RPM at a commanded Engine N1 of 110.25 %RPM. Engine 2 N1 returned to 111.75 %RPM two seconds later with a command of 111.25 %RPM.
    see the traces at this moment ↗
  44. 17:13:13.5CVR HOT-1p.45
    “lower the nose.”
    read in context ↗
  45. 17:13:16.9CVR CAM-3p.46
    “#.”
    read in context ↗
  46. 17:13:18FDRInitial climbp.11
    Hydraulic Quantity-1 reduced to 0 gallons (gal) and Hydraulic Quantity-3 started to decrease.
    see the traces at this moment ↗
  47. 17:13:18.0CVR HOT-1p.46
    “hold (up/on) hold (up/on) hold (up/on).”
    read in context ↗
  48. 17:13:19FDRInitial climbp.11
    Engine 2 N1 reduced from 109.88 %RPM to 98.88 %RPM at a commanded Engine N1 of 110.00 %RPM. Engine 2 N1 returned to 110.00 %RPM one second later with a command of 110.25 %RPM.
    see the traces at this moment ↗
  49. 17:13:19.4CVR HOT-1p.46
    “right there pause it pause it.”
    read in context ↗
  50. 17:13:20.7CVR HOT-1p.46
    “freeze it.”
    read in context ↗
  51. 17:13:21FDRInitial climbp.11
    The aircraft reached a maximum radio altitude of 29 ft.
    see the traces at this moment ↗
  52. 17:13:21.5CVR HOT-1p.46
    “freeze it.”
    read in context ↗
  53. 17:13:22FDRInitial climbp.11
    Engine 2 and 3 TRA increased from 80.86 deg and 81.21 deg to 84.38 deg and 84.73 deg, respectively.
    see the traces at this moment ↗
  54. 17:13:22.2CVR HOT-1p.46
    “firewall it.”
    read in context ↗
  55. 17:13:24.1CVR HOT-1final secondsp.46
    “[sounds of breathing]”
    read in context ↗
  56. 17:13:24.6CVR CAM-3final secondsp.46
    “God d—”
    read in context ↗
  57. 17:13:24.8CVR CAMfinal secondsp.46
    “[loud thumping sounds] COCKPIT VOICE RECORDER DCA26MA024”
    read in context ↗
  58. 17:13:24.8CVR GROUPfinal secondsp.46
    “CHAIR'S FACTUAL REPORT PG 45 OF 46 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  59. 17:13:25FDRInitial climb/Loss of controlp.11
    The aircraft began an increasing left roll throughout the remainder of the recording.
    see the traces at this moment ↗
  60. 17:13:25.9CVR CAM-3final secondsp.47
    “[unintelligible exclamation]”
    read in context ↗
  61. 17:13:26FDRLoss of controlp.11
    Engine 2 N1 and N2 decreased through the remainder of the recording.
    see the traces at this moment ↗
  62. 17:13:27.2CVR CAMfinal secondsp.47
    “[sound of aural warning level 3 tritone]”
    read in context ↗
  63. 17:13:27.6CVR CAMfinal secondsp.47
    “[loud crashing sounds, continued throughout the remainder of the recording]”
    read in context ↗
  64. 17:13:28FDRLoss of controlp.11
    Hydraulic Quantity-3 was 3.25 gal.
    see the traces at this moment ↗
  65. 17:13:29.0CVR HOT-1final secondsp.47
    “ah #. [exclamation]”
    read in context ↗
  66. 17:13:30.004FDREnd of recordingp.11
    End of recorded data.
    see the traces at this moment ↗
10A - FLIGHT DATA RECORDER GROUP CHAIRMAN'S FACTUAL REPORT · 18 events extracted by claude-sonnet-512A - COCKPIT VOICE RECORDER - GROUP CHAIRMAN'S FACTUAL REPORT · 48 of 420 lines shown3C - ATC SPECIALIST'S FACTUAL REPORT ATTACHMENT 2 - SDF ATC AUDIO RECORDING (TOWER CONTROLLER IN CHARGE POSITION) · 34 min· not yet aligned to a clock3D - ATC SPECIALIST'S FACTUAL REPORT ATTACHMENT 3 - SDF ATC AUDIO RECORDING (TRACON CONTROLLER IN CHARGE POSITION) · 34 min· not yet aligned to a clock3E - ATC SPECIALIST'S FACTUAL REPORT ATTACHMENT 4 - SDF ATC AUDIO RECORDING (LOCAL CONTROL EAST POSITION) · 34 min· not yet aligned to a clock3F - ATC SPECIALIST'S FACTUAL REPORT ATTACHMENT 5 - SDF ATC AUDIO RECORDING (GROUND CONTROL POSITION) · 34 min· not yet aligned to a clock3G - ATC SPECIALIST'S FACTUAL REPORT ATTACHMENT 6 - SDF ATC AUDIO RECORDING (GROUND CONTROL EAST POSITION) · 287 min· not yet aligned to a clock3H - ATC SPECIALIST'S FACTUAL REPORT ATTACHMENT 7 - SDF ATIS RECORDING · 10 min· not yet aligned to a clock
How the Board coded the sequence
  1. Takeoff: Part(s) separation from AC→
  2. Takeoff: Collision during takeoff/land

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA16CA1132016-03-05substantialmatch 59
    BOEING 767 34AF · UNITED PARCEL SERVICE CO
    Albuquerque, NM
    matched on what happened, as the Board wrote it · same aircraft family
  • DCA04MA0112003-12-18destroyedmatch 53
    McDonnell Douglas MD-10-10F
    Memphis, TN
    matched on what happened, as the Board wrote it · same aircraft family
  • DCA07MA3102007-09-28substantialmatch 51
    MCDONNELL DOUGLAS DC-9-82 (MD-82) · American Airlines
    St. Louis, MO
    matched on what happened, as the Board wrote it · same aircraft family
  • DCA13MA0812013-04-297 fatalmatch 50
    BOEING 747-400 BCF · National Air Cargo
    Bagram, AF
    matched on what happened, as the Board wrote it · same aircraft family
  • ERA20MA0012019-10-027 fatalmatch 50
    Boeing B17 · Collings Foundation
    Windsor Locks, CT
    matched on what happened, as the Board wrote it · same aircraft family
  • FTW03MA1602003-05-25substantialmatch 49
    Boeing 737-300
    Amarillo, TX
    matched on what happened, as the Board wrote it · same aircraft family
  • CHI01FA2922001-08-25substantialmatch 49
    Boeing 737-3G7
    Kansas City, MO
    matched on what happened, as the Board wrote it · same aircraft family
  • DCA16CA2112016-08-10substantialmatch 49
    BOEING 737 832 · Delta Air Lines
    New York, NY
    matched on what happened, as the Board wrote it · same aircraft family

What the record says

a pattern, not a findingacross the 8 closest cases · 4 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
In the Board’s words — the closest cases
  • DCA16CA1132016-03-05 · BOEING 767 34AF · UNITED PARCEL SERVICE CO
    the pilot flying's failure to maintain airspeed and correct pitch attitude. Contributing to the accident was the pilot's failure to maintain appropriate thrust after disconnecting the autothrottles. Also contributing was the first officer's failure to monitor the decaying airspeed and increasing pitch.
  • DCA04MA0112003-12-18 · McDonnell Douglas MD-10-10F
    1) the first officer's failure to properly apply crosswind landing techniques to align the airplane with the runway centerline and to properly arrest the airplane's descent rate (flare) before the airplane touched down; and 2) the captain's failure to adequately monitor the first officer's performance and command or initiate corrective action during the final approach and landing.
  • DCA07MA3102007-09-28 · MCDONNELL DOUGLAS DC-9-82 (MD-82) · American Airlines
    American Airlines’ maintenance personnel’s use of an inappropriate manual engine start procedure, which led to the uncommanded opening of the left engine air turbine starter valve, and a subsequent left engine fire, which was prolonged by the flight crew’s interruption of an emergency checklist to perform nonessential tasks. Contributing to the accident were deficiencies in American Airlines’ Continuing Analysis and Surveillance System program.
  • DCA13MA0812013-04-29 · BOEING 747-400 BCF · National Air Cargo
    National Airlines' inadequate procedures for restraining special cargo loads, which resulted in the loadmaster's improper restraint of the cargo, which moved aft and damaged hydraulic systems Nos. 1 and 2 and horizontal stabilizer drive mechanism components, rendering the airplane uncontrollable. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of National Airlines' handling of special cargo loads.
  • ERA20MA0012019-10-02 · Boeing B17 · Collings Foundation
    The pilot’s failure to properly manage the airplane’s configuration and airspeed after he shut down the No. 4 engine following its partial loss of power during the initial climb. Contributing to the accident was the pilot/maintenance director’s inadequate maintenance while the airplane was on tour, which resulted in the partial loss of power to the Nos. 3 and 4 engines; the Collings Foundation’s ineffective safety management system (SMS), which failed to identify and mitigate safety risks; and the Federal Aviation…
What it recommended after them
  • A-05-014TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the tr… · DCA04MA011Closed - Acceptable Action
  • A-05-015TO THE FEDERAL AVIATION ADMINISTRATION: Amend the emergency exit training information contained in the flight crew and cabin crew sections in Federal Aviation Administration Order 8400.10, Air Transportation Aviation Inspectors Handbook,… · DCA04MA011Closed - Acceptable Action
  • A-05-016TO THE FEDERAL AVIATION ADMINISTRATION: Verify that all 14 Code of Federal Regulations (CFR) Part 121 operators emergency door/slide trainers are configured to accurately represent the actual airplane exit door/slide and that their flight… · DCA04MA011Closed - Acceptable Action
  • A-05-017TO THE FEDERAL AVIATION ADMINISTRATION: Inform all air traffic control tower controllers of the circumstances of this accident, including the need to ensure that aircraft rescue and firefighting (ARFF) vehicles are not delayed without good… · DCA04MA011Closed - Acceptable Action
  • A-05-018TO THE FEDERAL AVIATION ADMINISTRATION: In cooperation with the Memphis/Shelby County Airport Authority and Memphis Fire Department, modify the November 1, 2001, letter of agreement, titled, Airport Emergency .Procedures, to fully describe… · DCA04MA011Closed - Acceptable Action
  • A-09-021TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the history of uncommanded air turbine starter valve (ATSV)-Open events in the MD-80 fleet and the effectiveness of coupling the ATSV-Open light to the Master Caution system to determine wh… · DCA07MA310Closed - Acceptable Action
  • A-09-022TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to review their operators’ pilot guidance and training on task allocation and workload management during emergency situations to verify that they state that, to… · DCA07MA310Closed - Acceptable Action
  • A-09-023TO THE FEDERAL AVIATION ADMINISTRATION: Require MD-80 series airplane operators to incorporate information about the relationship between the pneumatic crossfeed valve and the engine fire handle into their training programs and written guid… · DCA07MA310Closed - Acceptable Alternate 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).