BOMBARDIER INC CL-600-2B16Ace Aviation Services
297 lines · 13:06:55.6 – 15:10:47.6 · Naples, FL, 2024-02-09
- 15:10:43.9CAM[sound consistent with stall warbler/stick pusher]
- 15:10:44.3CAM-3brace brace brace brace brace bra—
- 15:10:44.4EGPWSpull up. [electronic voice]
- 15:10:44.4HOT-2all right.
- 15:10:45.9CAM[sounds consistent with touchdown]
- 15:10:46.0CAM[sounds consistent with impact]
- 15:10:46.1EGPWSpull up. [electronic voice] COCKPIT VOICE RECORDER ERA24FA110
- 15:10:46.1GROUPCHAIR'S FACTUAL REPORT PG 36 OF 37 Time and Intra-Aircraft Communication Time and Over-the-Air Communication Source Source
- 15:10:46.5HOT-2ah all right *
- 15:10:47.6EGPWSpull up. [electronic voice]
Crew communication
297 lines readobservations a human-factors reviewer takes from a transcript — the sterile cockpit, the Board's own notations, rhythm, CRM markers. Not emotions, not scores: the affect is in the audio, and the audio is sealedWindow: 12:52:00–15:11:47 · basis: critical phases in the extracted recorder events (approximate). Candidate non-pertinent lines below are a first reading for the investigator, not a finding.
- 14:53:03.8“now this time I don’t want you to change that to that until…”
- 14:53:17.9“I think that's what screwed you up. you had that up.”
- 14:53:24.4“you know I don’t need to watch that I need to watch this.”
- 14:53:54.5“I got a little bit out of practice.”
- 14:53:56.5“sittin' at sittin' at home lately you know. [sound of chuckle]”
- 14:58:07.9“'kay in range uhh recall A-P-U if required start.”
- 15:03:08.1“and you got a straight line comin up here uh…uh...uhhhhh…okay…uh....'kay how's that?”
- 15:10:17.4“okay hey let me take over land in this water.”
Delivery and physiological notes the transcribers added in brackets, plus # expletives. 10 words are marked unintelligible (*).
- sound similar to sniffle14:42:59.8“*. [sound similar to sniffle]”
- sounds consistent with slow engine rpm decrease14:44:34.8“[sounds consistent with slow engine rpm decrease]”
- sound of sniffle14:44:51.0“[sound of sniffle]”
- sound of sniffle14:46:26.9“[sound of sniffle]”
- sound of sniffle14:47:39.2“[sound of sniffle]”
- sound of sniffle14:49:22.9“[sound of sniffle]”
- sound similar to yawn14:51:41.6“[sound similar to yawn] COCKPIT VOICE RECORDER ERA24FA110”
- sound of sniffle14:54:17.2“[sound of sniffle]”
- sound consistent with sniffle14:58:45.8“[sound consistent with sniffle]”
- sounds similar to sigh15:01:16.2“[sounds similar to sigh]”
- sound of sniffle15:01:54.0“[sound of sniffle]”
- sound of sniffle15:02:13.8“[sound of sniffle]”
- sound of sigh15:02:22.8“[sound of sigh]”
- sound similar to decreasing engine RPM15:05:47.8“[sound similar to decreasing engine RPM]”
- sound similar to decreasing engine RPM15:07:31.5“[sound similar to decreasing engine RPM]”
- sound similar to increasing engine RPM15:08:13.8“[sound similar to increasing engine RPM] COCKPIT VOICE RECORDER ERA24FA110”
- sound of sigh15:08:28.6“[sound of sigh]”
- sound similar to decreasing engine RPM15:08:38.1“[sound similar to decreasing engine RPM] COCKPIT VOICE RECORDER ERA24FA110”
- sound similar to decreasing engine RPM15:09:15.4“[sound similar to decreasing engine RPM]”
- sound similar to decreasing engine RPM15:09:23.8“[sound similar to decreasing engine RPM]”
- #15:09:41.0“* the #.”
- #15:09:47.3“# all right.”
- sounds of breathing15:09:51.7“[sounds of breathing]”
- louder voice15:09:57.4“(declare/run) an emergency. [louder voice]”
- +18 more
- 5686 s13:06:55.6 → 14:41:41.4in sterile window
- 139 s14:49:22.9 → 14:51:41.6in sterile window
- 104 s14:47:39.2 → 14:49:22.9in sterile window
- 72 s14:46:26.9 → 14:47:39.2in sterile window
- 69 s14:59:31.8 → 15:00:40.6in sterile window
- 55 s14:56:03.6 → 14:56:58.6in sterile window
- 45 s14:57:07.6 → 14:57:52.7in sterile window
Hedged or questioning lines from one pilot in the critical window, with the other pilot’s next words.
- 14:42:45.4“check. shoulder harnesses will be… pressurization is descending. windshield heat still on high oh should we try low… COCKPIT VOICE RECORDER ERA24FA110”→ 14:42:58.4“yep.”
- 14:53:27.3“yeah ninety five percent for four seconds then you have a hundred percent— and you— is that what you're saying? it will be fully up to speed avail at that point right?”→ 14:53:36.7“yeah once…”
- 14:53:46.6“so just start it, wait ‘til it gets to a hundred then switch.”→ 14:53:48.8“okay.”
- 15:09:35.3“what the hell what— oh right engine just quit.”→ 15:09:41.5“it's over temp.”
- 15:09:39.0“looks like. COCKPIT VOICE RECORDER ERA24FA110”→ 15:09:41.5“it's over temp.”
- 15:09:53.3“uh no engines huh?”→ 15:09:57.4“(declare/run) an emergency. [louder voice]”
- 14:42:16.3[sound similar to altitude alert]→ 2.6 s later: 14:42:18.9“one to go.”
- 15:00:40.6[sound similar to altitude alert]→ 1.6 s later: 15:00:42.2“one to go.”
- 15:04:12.9[sound of tone consistent with altitude alert] COCKPIT VOICE RECORDER ERA24FA110→ 1.8 s later: 15:04:14.7“one.”
- 15:04:54.3[sound of chime consistent with master caution]→ 2.2 s later: 15:04:56.5“disregard.”
- 15:09:18.3[sounds similar to cavalry charge tone, consistent with autopilot disconnect]→ 1 s later: 15:09:19.3“landing flaps.”
- 15:09:32.9[sound of triple chime consistent with master warning]→ 2.4 s later: 15:09:35.3“what the hell what— oh right engine just quit.”
- 15:09:38.3[sound of tone consistent with altitude alert]→ 0.7 s later: 15:09:39.0“looks like. COCKPIT VOICE RECORDER ERA24FA110”
- 15:09:39.3[sound of triple chime consistent with master warning]→ 1.7 s later: 15:09:41.0“* the #.”
- 15:10:07.7[sound of tone consistent with altitude alert]→ 1.4 s later: 15:10:09.1“there's water right there.”
- 15:10:21.0[sound consistent with stick shaker]→ 0.9 s later: 15:10:21.9“where?”
- 15:10:26.3sink rate. [electronic voice]→ 0.7 s later: 15:10:27.0“not the runway the # run—”
- 15:10:27.8five hundred. [electronic voice]→ 0.6 s later: 15:10:28.4“no.”
- 15:10:29.1sink rate. [electronic voice]→ 0.1 s later: 15:10:29.2“no the road’s got traffic man.”
- 15:10:34.3too low terrain. [electronic voice] COCKPIT VOICE RECORDER ERA24FA110→ 1.1 s later: 15:10:35.4“land in the grass.”
- 15:10:36.3sink rate. [electronic voice]→ 1.7 s later: 15:10:38.0“a hundred and ten knots.”
- 15:10:37.7sink— terrain terrain. [electronic voice]→ 0.3 s later: 15:10:38.0“a hundred and ten knots.”
- 15:10:39.6pull up. [electronic voice]→ 0.9 s later: 15:10:40.5“this # airplane.”
- 15:10:39.6[sound consistent with stick shaker]→ 0.9 s later: 15:10:40.5“this # airplane.”
- 15:10:41.3pull up. [electronic voice]→ 0.8 s later: 15:10:42.1“land in the grass. COCKPIT VOICE RECORDER ERA24FA110”
- 15:10:42.1[sound consistent with stick shaker]→ 0 s later: 15:10:42.1“land in the grass. COCKPIT VOICE RECORDER ERA24FA110”
- 15:10:42.8[sound of clacking consistent with continuous stick shaker]→ 1.5 s later: 15:10:44.3“brace brace brace brace brace bra—”
- 15:10:43.0pull up. [electronic voice]→ 1.3 s later: 15:10:44.3“brace brace brace brace brace bra—”
- 15:10:43.4[sound of clacking consistent with continuous stick shaker]→ 0.9 s later: 15:10:44.3“brace brace brace brace brace bra—”
- 15:10:44.4pull up. [electronic voice]→ 0 s later: 15:10:44.4“all right.”
- 15:10:46.0[sounds consistent with impact]→ 0.5 s later: 15:10:46.5“ah all right *”
- 15:10:46.1pull up. [electronic voice] COCKPIT VOICE RECORDER ERA24FA110→ 0.4 s later: 15:10:46.5“ah all right *”
- 15:10:47.6pull up. [electronic voice]→ no crew words within 5 s
- 14:53:27.3“yeah ninety five percent for four seconds then you have a hundred percent— and you— is that what you're saying? it will be fully up to speed avail at that point right?”
“Not in transcript” never means “not said”: a line may be unintelligible, or the recording may not cover that phase.
| Speaker | words | questions | hedges | exclamations | expletives | checklists | non-pertinent lines |
|---|---|---|---|---|---|---|---|
| Captain | 304 | 4 | 2 | 2 | 2 | 0 | 3 |
| First officer | 850 | 5 | 6 | 4 | 4 | 0 | 5 |
| Observer / jumpseat | 16 | 1 | 0 | 0 | 0 | 0 | 0 |
Read next to the Board’s coded human-factors findings on the case page. The NTSB cautions that a transcript is not a precise science; these are pointers into it, for a trained reader to weigh.
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