The National Transportation Safety Board (NTSB) has released its final report on the United Airlines Boeing 777 altitude deviation incident that occurred on December 18, 2022, near Kahului, Hawaii. The incident involved United flight 1722, which experienced a loss of altitude just one minute after departure. The airplane descended from 2,100 feet to approximately 748 feet above the water before the crew managed to recover. Fortunately, there were no injuries reported, and the aircraft was undamaged. The NTSB’s investigation revealed that the incident was caused by a miscommunication between the flight crew regarding the desired flap setting during the initial climb. This incident highlights the importance of effective communication and flight path management in ensuring the safety of air travel.
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Overview
The National Transportation Safety Board (NTSB) has released its final report on the United Airlines Boeing 777 altitude deviation incident that occurred near Kahului, Hawaii on December 18, 2022. The incident involved a loss of altitude during the initial climb, but the crew was able to recover before any damage or injuries occurred. The NTSB has also opened the public docket for this investigation, providing detailed information and analysis of the incident.
Analysis
The incident took place near Kahului, Hawaii on December 18, 2022, at 14:51 local time. The aircraft involved was a Boeing 777, and the specific issue was an altitude deviation during the flight. This incident falls under Part 121 of the Code of Federal Regulations, which pertains to air carrier operations.
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Incident Details
The incident is identified by the incident number DCA23LA172, and the aircraft involved had the registration N212UA. Thankfully, there was no damage to the aircraft, and no injuries were reported among the 281 passengers onboard.
Aviation Investigation Final Report
According to the final report, United flight 1722 experienced a loss of altitude approximately one minute after departure while in instrument meteorological conditions. The aircraft descended from 2,100 feet to about 748 feet above the water before the crew was able to recover. The incident was not originally reported to the NTSB, but they learned about it two months later and chose to open an investigation.
The investigation relied on flight crew statements and other records as sources of information. The Captain, who was the pilot flying, reported that the initial plan was for a flaps-20 takeoff with reduced-thrust setting. However, due to low-level windshear advisories, the Captain decided to switch to a flaps-20 maximum thrust takeoff. During the takeoff, the aircraft encountered turbulence, and the airspeed fluctuated.
Miscommunication occurred between the Captain and the First Officer regarding the desired flap setting. The Captain called for flaps 5, but the First Officer thought he heard flaps 15 and selected that setting. The resulting confusion led to further airspeed and pitch issues. The Captain manually reduced engine thrust to avoid flap overspeed and attempted to diagnose the flap condition.
Both pilots observed warnings from the ground proximity warning system (GPWS), and the First Officer called for a pull-up as the descent continued. The Captain responded by pulling back on the control column to recover from the controlled flight into terrain (CFIT) situation. The descent was reversed at approximately 748 feet above the water.
After ensuring a positive rate of climb, the Captain leveled the aircraft, retracted the flaps and speed brakes, and engaged the autopilot. The remainder of the flight was uneventful.
Probable Cause and Findings
The NTSB determined that the probable cause of this incident was the flight crew’s failure to manage the aircraft’s vertical flightpath, airspeed, and pitch attitude following a miscommunication about the desired flap setting during the initial climb.
The findings of the investigation also highlighted personnel issues related to aircraft control and identification/recognition on the part of the pilots.
Factual Information
The history of this flight includes an enroute-climb to cruise altitude deviation. The Captain, a 55-year-old male flight instructor, held an airline transport certificate and had extensive flight experience. The First Officer, another male pilot, also held an airline transport certificate and had a significant amount of flight time.
The aircraft involved was a Boeing 777 with the registration N212UA. It was manufactured in 2000 and had over 74,000 hours of airframe total time at the time of the incident. The aircraft was operated by United Airlines, a flag carrier under Part 121 of the operating certificate.
Meteorological information indicated that the incident occurred in instrument meteorological conditions with heavy rain. The visibility was approximately 3 miles, and the lowest cloud condition was broken at 900 feet above ground level. The wind speed was 10 knots, and there was no reported turbulence.
The investigation determined that there was no damage to the aircraft from the incident, and none of the 281 passengers onboard suffered any injuries.
Administrative Information
The investigation was conducted by investigator-in-charge Douglass Brazy. The original publish date of the final report was August 10, 2023. The NTSB did not visit the scene of the incident, but the investigation relied on various records and interviews for information. The complete investigation docket is available on the NTSB’s website for further reference.
In conclusion, the NTSB’s final report on the United Airlines Boeing 777 altitude deviation incident near Kahului, Hawaii provides a comprehensive analysis of the incident. The report emphasizes the importance of effective communication and proper management of the aircraft’s flightpath, airspeed, and pitch attitude. It also highlights the actions taken by the crew to recover from the incident and the subsequent improvements made by United Airlines in their operations training modules.