Back on December 18 a United Airlines Boeing 777-200 took off from Maui’s airport and nearly dropping to the ocean. Despite flight 1722 to San Francisco climbing to 2,200 feet and then plunging to within 775 feet of impact, news of the incident had not been reported for two months until new broke in The Air Current.
The aircraft descended down below 750 feet before recovering. Maui was experiencing heavy rain at the time of the departure, and the event came a day after a Hawaiian Airlines flight from Phoenix experienced severe turbulence injuring several people enroute to Honolulu. So there was speculation around the role of wind shear. I suggested one possibility was that they raised their flaps too far.
According to a View From The Wing reader who was on the aircraft,
My husband and I were on this flight sitting in the back of the aircraft. It happened soon after takeoff when we were all seated with seatbelts on. The plane dipped down and then up like a quick fall and recovery. While several people screamed, no one was injured and it was over quickly. We did not realize how close the plane got to the ocean. The rest of the flight was uneventful, so while it was scary, it ended up being a blip in the flight- though a memorable one.
While United Airlines didn’t file a report with the National Transportation Safety Board, after the incident became public NTSB investigated. And they’ve filed their report. They didn’t have cockpit voice or data recorders to work from (since those weren’t preserved after the flight, as the aircraft continued to fly for two months until the investigation).
- They found that the captain, who hand-flew the takeoff, called for flaps to be reduced from 20 to 5. However the first officer “thought that he heard the captain announce flaps 15.”
- The plane wasn’t flying fast as the captain expected, and reduced the engine thrust “to avoid a flap overspeed and began to diagnose the flap condition.” That’s when he noticed they were at flaps 15, he called for flaps 5, and confirmed that the first officer this done had done this.
Both pilots recalled hearing the initial warnings from the ground proximity warning system (GPWS), and the first officer recalled announcing “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 cause of the incident was attributed to “[t]he 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.”
(HT: @WandrMe)
Great.
Fewer hours of flying required to hire new pilots.
Leads to this.
Is the purpose of the article to Pat yourself on the back?
I would agree. Rushing them through. I recall when my husband had to build time just to apply.
Obviously you folks couldn’t be bothered to read the report. Pilot had 19,000 hours, co-pilot over 5,300. They obviously made errors but they weren’t newbies in the cockpit.
The Captain was not only the PIC, he was the PF (pilot flying). The FO incorrectly put the flaps at 15, but the first rule in flying is “Fly the Aircraft”. This is similar to the Eastern Airlines Everglades crash. A factor in the incident is the FO hearing Flaps 15 instead of 5, but ultimately the Captain was at fault.
I’m confused by the comments. Do you think that there are 777 pilots with under 1500 hours experience? Or maybe that 1500 hours is kind of irrelevant to whether you know how to fly?
Wow, the title alone is enough to give anyone chills. It’s vital that we hold airlines and their staff to the highest standards of safety and professionalism, especially considering the immense responsibility they bear. I’m relieved to hear that a major catastrophe was averted, but it also serves as a stark reminder that continuous training, mental health check-ups, and strict safety protocols are of paramount importance in the aviation industry. Thanks for shedding light on this incident – it’s a crucial conversation to have as we all want to feel safe when taking to the skies. Safe travels to all!
I’m not pointing fingers–in my few hundred hours of flying I made enough errors of my own, though obviously flying the heavy metal is on a totally different level (or plane, as it were). But it does sound like United should have reported this incident, as it is obvious that it would come out. (Also it could be a good teaching lesson in safety.) And Americans often hate a cover-up more than an action.
@Stephen
How many hours do you think the f/o had? Less than 1500?
https://t.co/poG94L8wAK
Pilot 19600 hours (Total, all aircraft), 500 hours (Total, this make and model), 10900 hours (Pilot In
Command, all aircraft), 100 hours (Last 90 days, all aircraft), 30 hours (Last 30 days, all aircraft)
Co-Pilot 5300 hours (Total, all aircraft), 120 hours (Total, this make and model), 2395 hours (Pilot In
Command, all aircraft), 120 hours (Last 90 days, all aircraft), 30 hours (Last 30 days, all aircraft), 5
hours (Last 24 hours, all aircraft)
I’m not a pilot and not at all familiar with cockpit lingo, but I would think something like “flaps 5” and “flaps 15” (or however such a request is made) would sound so distinctly different that it would be almost impossible to confuse or mishear the call. Too bad we don’t have CVR to show what was said.
A United coverup. Has the first officer received remedial training? One way to make sure that commands are followed precisely is to have them repeated back precisely as said. Is this supposed to be done in the cockpit? I am in a different industry and that is how things are done so no one gets killed.
Well said, @drrichard… For sure I’m agreed with you that the attempt to cover it up is particularly egregious, although you mention United as the party who did not report it. In my mind, I can imagine the pilots themselves agreeing that “what happens on the flight deck stays on the flight deck”. It begs the question, other than the pilots themselves, who else knew and when did they know it ? Lots of pilots read this blog, they can probably clarify this for us, thanks guys (meant in the gender neutral way)….
With data storage so cheap these days, why not save all CVR and FDR data for all flights for at least a year? It’s flummoxing that ‘five’ could be misheard as ’15’ – and don’t pilots repeat back verbal control input commands as a precaution and confirmation? And especially in a case where the verbal control input command seems ‘off’. Also, it’s likely that the computer called out ‘sink rate!’ several seconds before it said ‘terrain, pull up! Not saving CVR and FDR data come from back when they were saved to metal or acetate tape, physically space consuming and difficult to access as archives. But digital data isn’t. Even though it might not be life-threatening like confirmation bias-caused mistakes by pilots, we’ve-always-done-it-this-way bias isn’t optimal either.
This is a very basic element that pilots master way before flying 1,500 hours. But the words five and fifteen sound nothing alike. Was somebody inattentive, distracted or what? This sort of thing just can’t happen.
It was a misunderstanding between pilots. Nothing more.
Job one should be gender and race equity in the cockpit…
I hope the author doesn’t make as many mistakes flying as he does writing – “The plane wasn’t flying fast as the captain expected, and reduced the engine thrust “to avoid a flap overspeed and began to diagnose the flap condition.” That’s when he noticed they were at flaps 15, he called for flaps 5, and confirmed that the first officer this done had done this.”
It’s not to minimize or excuse this mistake but thankfully they self-reported. Otherwise it’s unlikely we’d ever know about it. The author seems upset that we don’t have CVR data. This is why! We want pilots to report so that we can learn, not blame. The CVR is for post-accident, which thankfully this wasn’t.
The real concern, like in the AA runway incursion incident at JFK, was that both incidents were reported late so that the cockpit recorders were not preserved and in the UA case here, it took Jon Ostrower to analyze the data from reports to even get the ball rolling on a federal review – which both the FAA and NTSB downplayed at the time.
The bigger concerns is not just that the pilots made an error but that the pilots and UA knowingly allowed data to be wiped out and that the FAA and NTSB didn’t take the investigation seriously at first until the NTSB ultimately uncovered what really happened.
and the NTSB says the Capt only had 500 hours in the 777 and the FO had only 120 hours – both were very green on the aircraft even if they had lots of other experience. SFO is apparently a very junior base for UA.
I am seeing a whole lot more young pilots on US commercial flights these days.
@TexasTJ
I’m not sure there was much of a cover-up– and I question Gary’s premise here– since I am a part-time Maui resident and have a family member working at OGG airport.
EVERYBODY was talking about this by the following morning– and it was covered on national news. I think it reflects badly on UAL not to have been out in front of the bad press (they had a “new hire pilot” screw up just the other day)– and this class of mishap should never happen in a widebody cockpit.
But it was hardly a secret.
I fly the B767 so similar philosophy. Flaps 20 is used for takeoff during windshear advisories and retracting from 20 to 5 is standard once you have adequate speed. With that being said, when I call for flaps, gear, etc. to be moved, I have a responsibility to ensure my command is followed. The captain is equally at fault + a few more percent because the captain has ultimate responsibility for every aspect of the flight.
I also do not fully believe this explanation the way it’s explained here. Stopping the flaps at 15 would not cause the aircraft to dramatically sink, in fact it’d have the opposite effect. I do think that the changes in acceleration with the thrust reduction, combined with the anticipated (yet never realized) “seat of the pants feel” with the retraction of flaps 20 to flaps 5, along with a serious black hole effect are all great ingredients for some serious illusions that could lead to what happened here.
Extremely poorly written article… read it again and look at the flight path rendering. The Captain called for “Flaps 15” (From 20) which is a small 5 degree reduction. This is not an unusually large change as you slowly climb while accelerating. The First Officer took it to 15, then 5, then 1… most likely the timeline-delay was just the time it naturally took the flaps to retract as the actual lever went from the 20 degree to the 1 degree position with a couple awkward movements of the flap handle.
At 2,000 feet, a heavy aircraft, with a high density altitude, in a slow climb while accelerating at night (with no horizon to reference) the avionics did what they were meant to do and the Captain responded appropriately.
@TexasTJ Modern airliners like this store data commonly referred to as FOQA that logs any flight envelope exceedance, GPWS alert, power plant exceedance etc. These logs are regularly analyzed, but they’re scrubbed and anonymous. The pilot’s union has “gatekeepers” and they are the only ones with the ability to pair events with actual named crews. They will reach out and counsel the individuals and establish additional training if needed to remedy whatever the issue is. The pilots also submit reports usually right after a questionable event to explain what happened, why it happened, and what was learned so that can be disseminated to others who may benefit. This data is collected by NASA to determine trends within the industry. This is all non-punitive as long as no rules were intentionally broken. It’s designed so that pilots will be up front and open about mistakes so others can learn from them. It’s a great system and has made flying remarkably safer since it was implemented.
Strange commentary about a cover up. There are very clear regulatory reporting requirements, and in the NTSB report it specifically says in the first paragraph “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.” The event was presumably reported to the regulator, which is the FAA, as required.
The “low hour pilot” comments don’t seem particularly relevant here since the FO had 5000 hours.
Both pilots were very well qualified. The Captain had over 19,000 hours and the First Officer had over 5000. UA was not required to report this incident to the NTSB since it did not qualify as an accident. It sounds like the crew had their hands full taking off on heavy rain which can be very loud in the cockpit and moderate turbulence. Add to thst some miscommunication regarding flapp retraction.
It’s pretty obvious the opposite happened. The captain called for flaps 15, and the FO mistakenly set 5 instead without having enough speed for flaps 5. Crew probably experienced a stick shaker low speed event and executed the stall recovery, hence getting as low as 750 ft.
Their story doest add up and no way to prove otherwise at this point without CVR and CDR data.
Too easy to jump at this one incident, and claim that pilots are being pushed through, too quickly. Regardless of the details, there are a multitude of checks to ensure that this happens rarely. It was noticed because the aircraft took a sudden pitch down, an unusual occurrence.
I’m not a pilot but, Why didn’t they use autothrottle as it sets the engine take off thust after you set the autopilot parameters?
That’s AF447 level stuff. If one notices the plane is flying slower than expected during the initial climb, that is not the time to abruptly reduce thrust because of worrying about flap speed limits. That’s illogical. You don’t put the initial climb at risk especially when the initial cause of high flap settings was wind sheer and downdraft concerns. The reduction in thrust and bringing flaps to 1 killed the lift. You never reduce thrust like that when you are flying slower than expected.
What a bizarre title for this article.
Here’s what Simple Flying says happened after the flaps were lowered to 15:
“”Once this happened, the captain noticed that the aircraft’s maximum operating speed indicator shifted to a lower value than expected, and the airspeed started to accelerate rapidly”
Why would going to 15 instead of 5 cause the plane’s speed to rapidly accelerate?
Pilot was worried about overspending flaps so he reduced power at low altitude on initial climb out? Why not just raise the nose to climb and control airspeed? This could have been a tragedy. Luckily they caught it in time but but reducing power on climb out, if proper, should require paying very close attention to one’s vertical flight path. Neither pilot was doing that. This should be required reading for all commercial pilots.
Please stop approving comments from “Drewry.” It is transparently an LLM. No reason to encourage whoever thinks it’s worth doing.
Seems to me that the problem lies in a flawed “system” of allowing verbal instructions to be given (in this instance compounded by a cockpit more noisy than usual b,/c of the storm) without a read back, coupled with the pilot not verifying that the correct instructions had been followed, constituting failure to insist on and follow three factor verification. Fortunately saved by the technology which maybe should have been in charge all along.
Wouldn’t it be nicer to hear that CVR.
Sterile Flight Deck
PIC. FLAPS 5
FO. Confirmed FLAPS 15
Then what happened.
?
Jim Lukas – thanks for the white supremacist’s POV. Conversation made so much more valuable…
Why, other than a powerful union, do cockpits not have digital cameras and audio that are streamed to satellites and preserved (in addition to local storage)?
School buses, trains, etc have these common sense tools to ensure accountability for our (and our families) lives.
Why do aircraft pilots have a different standard than the people who drive our children to school or take dozens/hundreds of us across the country on buses and trains?
I still think they had the AP altitude set at Zero and never properly set it to the altitude they were cleared to clime to. Hence when they engaged CMD the airplane dove. Not the first time an airplane has dived after engaging the autopilot due to an incorrect altitude setting on the AP panel. But since the pilots appeared to make sure all documentation of the event was deleted we will never know unless they fess up.
I’m old enough to remember when an Emirates flight crew misconfigured the aircraft on takeoff from Dubai and almost flew the plane into the ground and the cockpit crew was immediately scrutinized and ultimately (I think) fired and it was a major aviation news event for a month – that was in fact only a year or so ago. How is it that a US airline and the US Pilot’s Union was able to keep this story so under the radar and insulate the cockpit crew from scrutiny or punishment (as far as I know)?
I’d be interested if the pilot actually said fifteen or one five. Like when they say heading one five zero degrees. If he said one five that could be heard as five more easily.
@Charlie We would never say “Flaps One Five”. The command would be “Flaps Fifteen” or “Flaps Five”. Headings would be verbalized as “one five zero, zero five zero, two seven zero, etc.”
Well, The FO was not pilot flying. This mistake took TWO to tango.
Perfectly poorly written synopsis of this incident. There is so much more to this. Leave it to the pros to explain.
I am a GA pilot with about 5,000 hours, so familiar with stalls, but not familiar with the specific dynamics involved with the 777 stall. I was on this flight seated in the front. My initial reaction was that the aircraft stalled. Right wing quit flying and the aircraft immediately nosed down into a right turn.