DCA23LA172

NTSB incident investigation · Boeing 777 · Kahului, HI · December 19, 2022

Incident · No injuriesClass 4 · LimitedFinal report
Date
December 18, 2022, 14:51 local (Dec 19, 2022, 00:51 UTC)
Place
Kahului, HI · departure airport
Injuries
281 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N212UABoeing 777
Defining event
Enroute-climb to cruise: Altitude deviation
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Major Investigations Division
Parties
FAA/AVP-100
Case key
106734

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The flight crew’s failure to manage the airplane’s vertical flightpath, airspeed, and pitch attitude following a miscommunication about the captain’s desired flap setting during the initial climb.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

United flight 1722 lost altitude about 1 minute after departure while in instrument meteorological conditions, which included heavy rain. The airplane descended from 2,100 ft to about 748 ft above the water before the crew recovered from the descent. No injuries were reported, and the airplane was not damaged. The NTSB was not originally notified of the event, since it did not meet the requirements of Title 49 Code of Federal Regulations Part 830.5. However, the NTSB learned of the event about 2 months later and chose to open an investigation. By that time, both the cockpit voice and flight data recorder durations had been exceeded. The investigation utilized flight crew statements and other records as information sources. The captain (who was the pilot flying) reported that he and the first officer had initially planned for a flaps-20 takeoff (flap setting of 20°) with a reduced-thrust setting, based on performance calculations. However, during taxi, the ground controller advised them that low-level windshear advisories were in effect. Based on this information, the captain chose a flaps-20 maximum thrust takeoff instead. He hand-flew the takeoff, with the auto throttles engaged. During the takeoff, the rotation and initial climb were normal; however, as the airplane continued to climb, the flight crew noted airspeed fluctuations as the airplane encountered turbulence. When the airplane reached the acceleration altitude, the captain reduced the pitch attitude slightly and called for the flap setting to be reduced to flaps 5. According to the first officer, he thought that he heard the captain announce flaps 15, which the first officer selected before contacting the departure controller and discussing the weather conditions. The captain noticed that the maximum operating speed indicator moved to a lower value than expected, and the airspeed began to accelerate rapidly. The captain reduced the engine thrust manually, overriding the auto throttle servos, to avoid a flap overspeed and began to diagnose the flap condition. He noticed that the flap indicator was showing 15°, and he again called for flaps 5, and he confirmed that the first officer moved the flap handle to the 5° position. The first officer stated that he “knew the captain was having difficulty with airspeed control”, and he queried the captain about it as he considered if his own (right side) instrumentation may have been in error. He did not receive an immediate response from the captain. Both pilots recalled that, about this time, the airplane’s pitch attitude was decreasing, and the airspeed was increasing. The first officer recalled that that the captain asked for flaps 1 soon after he had called for flaps 5, and when the first officer set the flaps to 1°, he then noticed the airspeed had increased further, and the control column moved forward. Both pilots recalled hearing the initial warnings from the ground proximity warning system (GPWS), and the first officer recalledannouncing “pull up pull up” along with those initial GPWS warnings. The captain then pulled aft on the control column, initially reduced power to reduce airspeed, and then applied full power to “begin the full CFIT [controlled flight into terrain] recovery.” The first officer recalled that, as the captain was performing the recovery, the GPWS alerted again as the descent began to reverse trend; data showed this occurred about 748 ft above the water. After noting a positive rate of climb, the captain lowered the nose to resume a normal profile, ensured that the flaps and speed brakes were fully retracted, and engaged the autopilot. The remainder of the flight was uneventful. Figure 1 shows a perspective view of the flight track. Figure 1- Flight Track with Annotations As a result of the event, United Airlines modified one of their operations training modules to address this occurrence and issued an awareness campaign about flight path management at their training center.

Aircraft

Registration
N212UA
Reported as
Boeing 777 (222)
Category
Airplane
Serial number
30218
Built
2000
Airframe hours
74,017
Engines
P&W PW4077, 60,000 lbs thrust, turbo jetP&W PW4077, 60,000 lbs thrust, turbo jet
Damage
No damage
Flight
Part 121
Operator
United Airlines Inc
Registered owner
United Airlines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 14, 2021
Departed
OGG · Kahului, HI
Destination
SFO · San Francisco, CA
Flight plan
IFR
Equipment
Stall warning system, Satellite tracking device, ADS-B, Onboard weather, Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Data recorder, Auto-pilot, Angle of attack indicator

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
None
Certificates
Flight engineer, Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
April 8, 2022
Seat
Left
Restraint
5-point
Flight hours
19,600 total · 5,000 in this make and model · 10,900 as pilot in command · 100 in the last 90 days · 30 in the last 30 days
Role
Co-pilot
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 7, 2023
Seat
Right
Restraint
5-point
Flight hours
5,300 total · 120 in this make and model · 2,395 as pilot in command · 120 in the last 90 days · 30 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
140° at 10 knots
Visibility
3 statute miles
Lowest ceiling
900 ft broken
Temperature
66 °F, dew point 64 °F
Altimeter
29.78 inHg
Turbulence
Unknown
Observed at
PHOG
METAR
PHOG 190050Z 14010KT 3SM +RA BR BKN009 OVC020 19/18 A2978 190 93 800 130/10 RMK AO2 SLP088 P0018 T01940183

Docket · 6

The files NTSB released with the investigation on August 10, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.6 MB in all.