Serious incident Boeing 777-222 N212UA,
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ASN Wikibase Occurrence # 308186
 
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Date:Sunday 18 December 2022
Time:14:51
Type:Silhouette image of generic B772 model; specific model in this crash may look slightly different    
Boeing 777-222
Owner/operator:United Airlines
Registration: N212UA
MSN: 30218/293
Year of manufacture:2000
Total airframe hrs:74017 hours
Engine model:P&W PW4077
Fatalities:Fatalities: 0 / Occupants: 281
Aircraft damage: None
Category:Serious incident
Location:near Kahului Airport, HI (OGG/PHOG) -   United States of America
Phase: Initial climb
Nature:Passenger - Scheduled
Departure airport:Kahului Airport, HI (OGG/PHOG)
Destination airport:San Francisco International Airport, CA (SFO/KSFO)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
United flight UA1722, a Boeing 777-222, lost altitude about 1 minute after departure from Kahului Airport (OGG), Hawaii, 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 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 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.

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.

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.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: DCA23LA172
Status: Investigation completed
Duration: 7 months
Download report: Final report

Sources:

https://theaircurrent.com/aviation-safety/united-maui-dive-ua1722-close-call/
https://www.flightradar24.com/data/flights/ua1722#2e95b73f

NTSB
https://data.ntsb.gov/Docket?ProjectID=106734

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Revision history:

Date/timeContributorUpdates
10-Aug-2023 19:55 Captain Adam Updated
14-Aug-2023 08:38 harro Updated
30-Aug-2023 17:21 harro Updated

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