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United Airlines Flight 1722

18 Dec 2022 · Kahului, HI, United States

Boeing 777 222 · Incident: altitude deviation en route

From Kahului International Airport (OGG) to San Francisco International Airport (SFO)

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Event

NTSB case
DCA23LA172
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Incident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
0
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Airline
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Instrument Meteorological Cond

Boeing 777 222

Aircraft type
Boeing 777
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N212UA
Onboard fatalities
Unknown
Route
From Kahului International Airport (OGG), Kahului, HITo San Francisco International Airport (SFO), San Francisco, CA
Aircraft age
About 22 years (built 2000)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 121: Air Carrier
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
En route · climb to cruise
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Altitude deviation
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
None

Cause areas

  • Personnel issues › Action/decision
  • Personnel issues › Task performance

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

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 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.

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.

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record DCA23LA172
Event ID
20230214106734
Case number
DCA23LA172
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status, cause areas, damage. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 2022-12-19.
  • API snapshot SHA-256: db1627e4e37e04a671e06b3a14348316d0141d7ed83ff56fa32d4bb9a4ae9227; retrieved 2026-09-16T17:20:24.656Z.