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Cases › OPS15IA020 › The analyst

AIRBUS INDUSTRIE A320 211Delta Air Lines

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.

9
timed facts
8
precedents
11
passages to ask

Ask the docket

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

9 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. 19:50:04 MDTFDRCruisep.3
    Aircraft position shown at pressure altitude of 33,992 ft (start of Figure 2 depiction)
    see the traces at this moment ↗
  2. 20:02:00 MDTFDRCruisep.3
    Vertical acceleration variations began, ranging between 1.93 g's and -0.03 g's before settling to about 1 g; approximately 3 hours and 17 minutes after takeoff
    see the traces at this moment ↗
  3. 20:02:00 MDT to 20:04:00 MDTFDRCruisep.3
    Pressure altitude started at 33,832 ft and decreased to 31,352 ft during vertical acceleration variations
    see the traces at this moment ↗
  4. 20:02:45 MDTFDRCruisep.3
    Autopilot 2 (AP-2) status transitioned from Engaged to Not Engaged
    see the traces at this moment ↗
  5. 20:02:47 MDTFDRCruisep.3
    Master warning transitioned from No Warn to Warn
    see the traces at this moment ↗
  6. 20:02:50 MDTFDRCruisep.3
    Master warning transitioned back to No Warn (3 seconds after Warn activation)
    see the traces at this moment ↗
  7. 20:04:00 MDTFDRCruisep.3
    Vertical acceleration settled to about 1 g
    see the traces at this moment ↗
  8. About 38 minutes after 20:04:00 MDT (approximately 20:42 MDT)FDRLandingp.3
    The aircraft landed
    see the traces at this moment ↗
  9. 20:50:00 MDTFDRPost-landingp.3
    End of plotted data range; aircraft had landed
    see the traces at this moment ↗
Flight Data Recorder - Specialist’s Factual Report · 9 events extracted by claude-sonnet-5
How the Board coded the sequence
  1. Enroute-cruise: Turbulence encounter→
  2. Enroute-cruise: Other weather encounter

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • OPS10IA1962010-05-21no fatalitiesmatch 68
    AIRBUS INDUSTRIE A319-132 · USAirways Inc
    Anchorage, AK
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • DCA11IA0402011-04-04no fatalitiesmatch 67
    Airbus A320 · United Airlines
    New Orleans, LA
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • OPS16IA0042016-01-29no fatalitiesmatch 67
    AIRBUS A321 231 · Spirit Airlines
    Fort Lauderdale, FL
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • DCA23LA0962022-12-18no fatalitiesmatch 65
    AIRBUS A330-243 · HAWAIIAN AIRLINES INC
    Kahului, HI
    • ●Personnel issues › Action/decision › Info processing/decision
    Turbulence encounter
  • DCA15CA1292015-06-08no fatalitiesmatch 64
    MCDONNELL DOUGLAS DC 9 83(MD-83) · ALLEGIANT AIR LLC
    St Petersburg, FL
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • SEA08LA0612008-01-14substantialmatch 55
    Bombardier, Inc. CL-600-2C10 · United Express
    San Francisco, CA
    • ●Personnel issues › Action/decision › Info processing/decision
    • ●Personnel issues › Task performance › Communication (personnel)
  • OPS14IA0072014-04-29no fatalitiesmatch 54
    BOEING 757 · NA
    Powhatan, VA
    • ●Personnel issues › Task performance › Communication (personnel)
    Turbulence encounter
  • CEN10LA3632010-06-28no fatalitiesmatch 54
    EMBRAER EMB-145LR · AMERICAN EAGLE AIRLINES INC
    Pioneer, LA
    • ●Personnel issues › Task performance › Communication (personnel)
    Turbulence encounter

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
  • 3 of 8Turbulence encounter
  • 2 of 8Air traffic event
  • 2 of 8Fire/smoke (non-impact)
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Action/decision › Info processing/decision
  • Task performance › Communication (personnel)
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Action/decision › Action

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
  • OPS10IA1962010-05-21 · AIRBUS INDUSTRIE A319-132 · USAirways Inc
    The approach controller's delayed transfer of communications on the A319 to the tower controller and failure to account for the aircraft's speed when he directed the crew to turn north. Contributing to the incident was the 747 crew's transfer of radio communications to departure control prior to being directed to do so by the tower controller.
  • DCA11IA0402011-04-04 · Airbus A320 · United Airlines
    the captain's failure to properly recognize and manage the abnormal condition, resulting in it escalating to an in-flight emergency.
  • 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.
  • DCA23LA0962022-12-18 · AIRBUS A330-243 · HAWAIIAN AIRLINES INC
    The flight crew’s decision to fly over an observed storm cell instead of deviating around it despite sufficient meteorological information indicating the potential for severe convective activity.
  • DCA15CA1292015-06-08 · MCDONNELL DOUGLAS DC 9 83(MD-83) · ALLEGIANT AIR LLC
    evacuation of the aircraft due to reported, but unverified, aircraft condition and poor communication between Aircraft Rescue and Firefighting personnel and the flight crew.
What it recommended after them
  • A-12-018TO THE FEDERAL AVIATION ADMINISTRATION: Study the technical feasibility of presenting, through the use of the weather and radar processor system or other means, real-time total lightning data on controller displays at both air route traffic… · CEN10LA363Closed - Unacceptable Action
  • A-12-019TO THE FEDERAL AVIATION ADMINISTRATION: To the extent practicable, incorporate direct center weather service unit briefings on new weather-related air traffic control equipment and information services into controller training. · CEN10LA363Closed - Unacceptable Action
  • A-12-020TO THE FEDERAL AVIATION ADMINISTRATION: Incorporate real-time total lightning data into the products supplied to pilots through the flight information services –broadcast data link. · CEN10LA363Closed - Acceptable 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).