FlarePath
Cases › ERA24FA110 › The analyst

BOMBARDIER INC CL-600-2B16Ace Aviation Services

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.

75
timed facts
8
precedents
72
passages to ask

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

75 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. 12:54 ESTFDRPre-departure/Engine startp.6
    Engine 2 was started for the accident flight. Peak ITT was 605 degrees C.
  2. 12:55 ESTFDRPre-departure/Engine startp.6
    Engine 1 was started for the accident flight. Peak ITT was 603 degrees C. Both engines had similar start characteristics, idle N2 was 62.9% on both engines, idle fuel flow varied from 340-380 pph on both engines.
  3. 13:02 ESTFDRDeparturep.6
    The aircraft departed Ohio State University Airport (OSU), Columbus Ohio, with about 4,300 lbs of fuel in each tank.
  4. 13:06:55.6CVR STARTp.8
    “OF TRANSCRIPT”
    read in context ↗
  5. 14:42:16.3CVR CAMwarningp.9
    “[sound similar to altitude alert]”
    read in context ↗
  6. 15:00:40.6CVR CAMwarningp.19
    “[sound similar to altitude alert]”
    read in context ↗
  7. 15:04:12.9CVR CAMwarningp.22
    “[sound of tone consistent with altitude alert] COCKPIT VOICE RECORDER ERA24FA110”
    read in context ↗
  8. 15:04:54.3CVR CAMwarningp.23
    “[sound of chime consistent with master caution]”
    read in context ↗
  9. 15:07:14.0CVR HOT-2p.25
    “thats what he said okay. COCKPIT VOICE RECORDER ERA24FA110”
    read in context ↗
  10. 15:07:14.0CVR GROUPp.25
    “CHAIR'S FACTUAL REPORT PG 25 OF 37 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  11. 15:07:25 ESTFDRApproachp.6
    The aircraft leveled at about 1785 ft pressure altitude and 200 knots with the left side autopilot engaged.
  12. 15:07:30 ESTFDRApproachp.6
    The selected airspeed reduced to 180 knots. Engine power reduced in both engines in response to the command and the aircraft began to decelerate.
  13. 15:07:42.5CVR RDO-2p.26
    “all right we'll slow back to final Hopajet eight twenty three.”
    read in context ↗
  14. 15:07:48 ESTFDRApproachp.6
    The selected airspeed reduced to 168 knots. Engine power for both engines reduced in response to the command and the aircraft continued to decelerate.
  15. 15:07:50.5CVR RDO-2p.26
    “uh okay Hopajet eight twenty three lookin'.”
    read in context ↗
  16. 15:08:00 ESTFDRApproachp.6
    The selected airspeed was reduced to 160 knots.
  17. 15:08:01.2CVR HOT-1p.26
    “flaps thirty gear down before landing.”
    read in context ↗
  18. 15:08:04 ESTFDRApproachp.6
    Flaps were selected to 30 degrees.
  19. 15:08:05.4CVR CAMp.26
    “[increase in ambient noise, consistent with landing dear deployment]”
    read in context ↗
  20. 15:08:06 ESTFDRApproachp.6
    Gear was selected down (two seconds after flaps to 30). Engine power increased as the 160-knot airspeed target was captured. All engine ignitors transitioned from 'not active' to 'active' after gear was selected down.
  21. approx after 15:08:06FDRApproachp.7
    The aircraft entered a left turn followed by a right turn. Engine power for both engines stayed steady until the aircraft rolled out of the turn and began to accelerate; power decreased as aircraft speed increased above the 160-knot target.
  22. 15:09:13.5CVR HOT-2p.28
    “we want to play it or…oh it's already done, you got it going? COCKPIT VOICE RECORDER ERA24FA110”
    read in context ↗
  23. 15:09:13.5CVR GROUPp.28
    “CHAIR'S FACTUAL REPORT PG 28 OF 37 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  24. 15:09:14 ESTFDRApproachp.7
    Both engines began a decrease in power similar in rate to the previous power decreases.
  25. 15:09:17.5CVR HOT-2p.29
    “'kay.”
    read in context ↗
  26. 15:09:18 ESTFDRApproachp.7
    The autopilot was disengaged. Both engines were still decelerating to idle power.
  27. 15:09:18.3CVR CAMwarningp.29
    “[sounds similar to cavalry charge tone, consistent with autopilot disconnect]”
    read in context ↗
  28. 15:09:19.3CVR HOT-1p.29
    “landing flaps.”
    read in context ↗
  29. 15:09:21 ESTFDRApproachp.7
    Both engines reached the lowest N2 point in their commanded decelerations of 62.8%/63.3% (engine 1/engine 2). During the deceleration, fuel flow briefly dropped below idle rates; manufacturer confirmed this is normal transient behavior consistent with commanding and capturing idle power.
  30. 15:09:22 ESTFDRApproachp.7
    N2 increased to 65.0%/64.6% consistent with the throttle command increasing.
  31. 15:09:22.7CVR HOT-2p.29
    “all right.”
    read in context ↗
  32. 15:09:23 ESTFDRApproach/Engine anomalyp.7
    N2 rolled back on both engines and decreased to a sub-idle state, and ITT increased for the rest of the recording. This behavior is consistent with both engine compressors operating in an unrecoverable rotating stall. The airplane began to decelerate immediately as engine power was lost. Flaps were selected to 45 and the selected airspeed changed to 140 knots.
  33. 15:09:23.6CVR HOT-1p.29
    “landing flaps.”
    read in context ↗
  34. 15:09:31.7CVR HOT-2p.30
    “three green(?)”
    read in context ↗
  35. 15:09:32.9CVR CAMwarningp.30
    “[sound of triple chime consistent with master warning]”
    read in context ↗
  36. 15:09:33 ESTFDREngine anomalyp.7
    The number one engine oil pressure warning was recorded.
  37. 15:09:34 ESTFDREngine anomaly/Descentp.7
    The number two engine oil pressure warning was recorded. Airspeed had reduced to less than 130 kts. Pitch was commanded down, and the aircraft began to descend at a rate more than 1,500 fpm.
  38. 15:09:35.3CVR HOT-2p.30
    “what the hell what— oh right engine just quit.”
    read in context ↗
  39. 15:09:38.3CVR CAMwarningp.30
    “[sound of tone consistent with altitude alert]”
    read in context ↗
  40. 15:09:39.0CVR HOT-2p.30
    “looks like. COCKPIT VOICE RECORDER ERA24FA110”
    read in context ↗
  41. 15:09:39.0CVR GROUPp.30
    “CHAIR'S FACTUAL REPORT PG 30 OF 37 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  42. 15:09:39.3CVR CAMwarningp.31
    “[sound of triple chime consistent with master warning]”
    read in context ↗
  43. 15:09:40 ESTFDREngine anomalyp.7
    An engine warning was recorded, consistent with engine ITT exceeding the redline of 889 degrees C.
  44. 15:09:47.3CVR HOT-2p.31
    “# all right.”
    read in context ↗
  45. 15:09:50 ESTFDREngine anomalyp.7
    Starting at this time, engine fuel flow recorded values for both engines became intermittent. The engine manufacturer reported that the flowmeter does not report fuel flow values less than 200 pph.
  46. 15:09:51.1CVR HOT-2p.31
    “all right.”
    read in context ↗
  47. 15:10:03.1CVR RDO-2warningp.32
    “…lost both engines. emergency… (I'm/um) making an emergency landing.”
    read in context ↗
  48. 15:10:07.7CVR CAMwarningp.32
    “[sound of tone consistent with altitude alert]”
    read in context ↗
  49. 15:10:15.7CVR HOT-1warningp.33
    “brace for impact.”
    read in context ↗
  50. 15:10:20.4CVR HOT-1p.33
    “negative I'm landing right here.”
    read in context ↗
  51. 15:10:21 ESTFDRFinal approachp.8
    Stick shaker activation was recorded for two seconds, at an altitude and airspeed of 490 feet and 112.5 kts. The aircraft's pitch reduced following the stick shaker activation.
  52. 15:10:21.0CVR CAMwarningp.33
    “[sound consistent with stick shaker]”
    read in context ↗
  53. 15:10:21.9CVR HOT-2p.33
    “where?”
    read in context ↗
  54. 15:10:26.3CVR EGPWSwarningp.34
    “sink rate. [electronic voice]”
    read in context ↗
  55. 15:10:27.8CVR EGPWSwarningp.34
    “five hundred. [electronic voice]”
    read in context ↗
  56. 15:10:29.1CVR EGPWSwarningp.34
    “sink rate. [electronic voice]”
    read in context ↗
  57. 15:10:34.3CVR EGPWSwarningp.34
    “too low terrain. [electronic voice] COCKPIT VOICE RECORDER ERA24FA110”
    read in context ↗
  58. 15:10:36.3CVR EGPWSwarningp.35
    “sink rate. [electronic voice]”
    read in context ↗
  59. 15:10:37.7CVR EGPWSwarningp.35
    “sink— terrain terrain. [electronic voice]”
    read in context ↗
  60. 15:10:39.6CVR EGPWSwarningp.35
    “pull up. [electronic voice]”
    read in context ↗
  61. 15:10:39.6CVR CAMwarningp.35
    “[sound consistent with stick shaker]”
    read in context ↗
  62. 15:10:41.3CVR EGPWSwarningp.35
    “pull up. [electronic voice]”
    read in context ↗
  63. 15:10:42.1CVR CAMwarningp.35
    “[sound consistent with stick shaker]”
    read in context ↗
  64. 15:10:42.8CVR CAMwarningp.36
    “[sound of clacking consistent with continuous stick shaker]”
    read in context ↗
  65. 15:10:43.0CVR EGPWSwarningp.36
    “pull up. [electronic voice]”
    read in context ↗
  66. 15:10:43.4CVR CAMwarningp.36
    “[sound of clacking consistent with continuous stick shaker]”
    read in context ↗
  67. 15:10:44.4CVR EGPWSfinal secondsp.36
    “pull up. [electronic voice]”
    read in context ↗
  68. 15:10:44.4CVR HOT-2final secondsp.36
    “all right.”
    read in context ↗
  69. 15:10:45.9CVR CAMfinal secondsp.36
    “[sounds consistent with touchdown]”
    read in context ↗
  70. 15:10:46.0CVR CAMfinal secondsp.36
    “[sounds consistent with impact]”
    read in context ↗
  71. 15:10:46.1CVR EGPWSfinal secondsp.36
    “pull up. [electronic voice] COCKPIT VOICE RECORDER ERA24FA110”
    read in context ↗
  72. 15:10:46.1CVR GROUPfinal secondsp.36
    “CHAIR'S FACTUAL REPORT PG 36 OF 37 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source”
    read in context ↗
  73. 15:10:46.5CVR HOT-2final secondsp.37
    “ah all right *”
    read in context ↗
  74. 15:10:47 ESTFDRLandingp.8
    The aircraft touched down at about 110 kts in a 15-degree left bank and with about 1.5 degrees of nose up pitch.
  75. 15:10:47.6CVR EGPWSfinal secondsp.37
    “pull up. [electronic voice]”
    read in context ↗
Recorder events without a clock time
  • cruise (~1 hour)Flight proceeded south and cruised at FL400 and then FL390 for about an hour; engine steady-state and transient behavior of the two engines were well matched during descent.
FLIGHT DATA RECORDER GROUP CHAIRMAN'S FACTUAL REPORT · 22 events extracted by claude-sonnet-5COCKPIT VOICE RECORDER - FACTUAL REPORT OF GROUP CHAIR · 54 of 297 lines shown
How the Board coded the sequence
  1. Prior to flight: Aircraft maintenance event→
  2. Approach-VFR pattern base: Powerplant sys/comp malf/fail→
  3. Approach-VFR pattern base: Loss of engine power (partial)→
  4. Emergency descent: Off-field or emergency landing→
  5. Post-impact: Fire/smoke (post-impact)

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • ERA11FA2742011-05-021 fatalmatch 55
    BEECH E18S · AIRCAP MANAGEMENT CO INC
    Miami Gardens, FL
    • ●Personnel issues › Task performance › Maintenance
    Loss of engine power (partial)
  • WPR13LA0452012-11-181 fatalmatch 53
    PIPER PA-32 · Star Marianas Air, Inc
    Obyan, USA
    • ●Organizational issues › Management › Policy/procedure
    Loss of engine power (partial)Off-field or emergency landing
  • ERA22FA0862021-12-111 fatalmatch 53
    SWEARINGEN SA226 · CASTLE AVIATION INC
    Bedford, NH
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Loss of engine power (partial)
  • CEN13FA0492012-11-061 fatalmatch 53
    CESSNA 208B · Baron Aviation Services, Incorporated
    Wichita, KS
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Off-field or emergency landingPowerplant sys/comp malf/fail
  • WPR13IA1442013-03-05no fatalitiesmatch 52
    BOMBARDIER DHC-8-402 · Horizon Air
    Danville, CA
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Off-field or emergency landing
  • WPR17FA0242016-11-194 fatalmatch 52
    PIPER PA 31T · AMERICAN MEDFLIGHT INC
    Elko, NV
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Loss of engine power (partial)
  • WPR14FA0682013-12-121 fatalmatch 52
    CESSNA 208B · Makani Kai Air
    Kalaupapa, HI
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
  • DCA21FA1742021-07-02destroyedmatch 51
    BOEING 737-275C · RHOADES AVIATION INC
    Honolulu, HI
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Loss of engine power (partial)

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
  • 5 of 8Loss of engine power (partial)
  • 4 of 8Collision with terr/obj (non-CFIT)
  • 3 of 8Off-field or emergency landing
  • 3 of 8Loss of engine power (total)
  • 2 of 8Loss of control in flight
  • 2 of 8Ditching
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft power plant › Engine (turbine/turboprop)
Cited here, not seen in the precedents
  • Aircraft power plant › Power plant
Common in the precedents, not cited here
  • Not determined › (general)
  • Action/decision › Action
  • 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
  • ERA11FA2742011-05-02 · BEECH E18S · AIRCAP MANAGEMENT CO INC
    The pilot’s improper response to a loss of power in the No. 2 engine and his failure to ensure that the airplane was airworthy. Contributing to the accident was the inadequate engine maintenance by the operator's maintenance personnel.
  • WPR13LA0452012-11-18 · PIPER PA-32 · Star Marianas Air, Inc
    A partial loss of engine power shortly after takeoff for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation and the pilot’s failure to maintain airplane control during the unsuccessful attempt to return for landing on the airport. Contributing to the accident was the pilot’s decision to conduct his second takeoff using less than the full runway length available and the airline’s lack of guidance regarding how to respond to en…
  • 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.
  • CEN13FA0492012-11-06 · CESSNA 208B · Baron Aviation Services, Incorporated
    The total loss of engine power as a result of a fractured compressor turbine blade due to high-cycle fatigue.
  • WPR13IA1442013-03-05 · BOMBARDIER DHC-8-402 · Horizon Air
    The failure and separation of a section of the No. 2 engine's combustion chamber's small exit duct (SED), which created an airflow disruption that led to an engine surge and subsequent fire. Contributing to the accident was the insufficient weld penetration that remained totally contained within the SED outer dome and did not penetrate through to the inner duct as required by the manufacturing specifications.

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).