Now to a different story concerning Maui. A final National Transportation Safety Board (NTSB) report on a near-crash involving a United Airlines 777 provides more chilling details about what exactly transpired off the coast of Maui.
Final Report Released On How United Airlines 777 Nearly Crashed Into Pacific Ocean Off Maui Coast
In February, I wrote about the chilling incident that occurred on UA1722 from Maui (OGG) to San Francisco (SFO) on December 18, 2022 utilizing a Boeing 777-200 aircraft.
After departing Kahului Airport, the aircraft reached 2,100 feet before beginning a steep descent at a rate of 8,600 feet per minute. The aircraft recovered, but not before it dropped to only 748 feet over the Pacific Ocean. In other words, the aircraft and everyone onboard was seconds from disaster.
The flight continues to San Francisco without further incident. A passenger onboard told View From The Wing:
“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.”
Now the NTSB has investigated and published its final report. The conclusions are not comforting.
“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.”
Here are key details from the final report (.pdf):
- 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 (five degrees)
- 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 condition
- 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 its operations training modules to address this occurrence and issued an awareness campaign about flight path management at their training center
Credit must be given to Jon Ostrower of The Air Current, who discovered this anomaly based on public data and wrote about it: this was not self-reported by United until the incident was exposed by him and United did not preserve flight data from the aircraft.
CONCLUSION
Pilot communication during the critical takeoff period nearly led to the loss of a 777-200 filled with passengers. This is no exaggeration. I am very thankful the pilots recovered with just seconds to spare and hope this near-miss will be used as a teaching moment for all pilots.
What are your thoughts on the incident?
