Event Details


Title:Stall and loss of control on final approach, Atlantic Coast Airlines Inc dba United Express Flight 6291, Jetstream 4101, N304UE, Columbus, Ohio, January 7, 1994
Micro summary:This Jetstream 4101 crashed short of the runway while performing an ILS approach.
Event Time:1994-01-07 at 2321 EST
File Name:1994-01-07-US.pdf
Publishing Agency:National Transportation Safety Board (NTSB)
Publishing Country:USA
Report number:NTSB-AAR-94-07
Pages:125
Site of event:1.2 nm east of runway 28L at Port Columbus International Airport
Latitude/Longitude:N3959'31.8" W8250'49.8"
Departure:Washington Dulles International Airport, Washington DC, USA
Destination:Port Columbus International Airport, Columbus, Ohio, USA
Airplane Type(s):Jetstream 4101
Flight Phase:Approach
Registration(s):N304UE
Operator(s):United Express (Atlantic Coast Airlines)
Type of flight:Revenue
Occupants:8
Fatalities:5
Serious Injuries:2
Minor/Non-Injured:1
Other Injuries:0
Executive Summary:On January 7, 1994, about 2321 eastern standard time, a Jetstream 4101, registration N304UE, operated by Atlantic Coast Airlines, Sterling, Virginia, and doing business as United Express flight 6291, crashed 1.2 nautical miles east of runway 28L at Port Columbus International Airport, Columbus, Ohio. The airplane was being operated as a regularly scheduled commuter flight under 14 Code of Federal Regulations, Part 135, from Washington Dulles International Airport, Chantilly, Virginia, to Columbus, Ohio. The flight had been cleared for an instrument landing system approach to runway 28L and was in contact with the local tower controller when it crashed into a storage warehouse. The pilot, copilot, flight attendant, and two passengers were fatally injured. Two of the other three passengers received minor injuries, while the third was not injured. The airplane was destroyed. Instrument meteorological conditions prevailed at the time, and the airplane was on an instrument flight rules flight plan.

The National Transportation Safety Board determines the probable causes of this accident to be:

(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence of procedural discipline;

(2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps;

(3) Flightcrew inexperience in "glass cockpit" automated aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots; and

(4) The company's failure to provide adequate stabilized approach criteria, and the Federal Aviation Administration's failure to require such criteria.

Member Vogt concluded that the last factor was contributory but not causal to the accident. Additionally, for the following two factors, Chairman Hall and Member Lauber concluded that they were causal to the accident, while Members Vogt and Hammerschmidt concluded that they were contributory to the accident:

(5) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training; and

(6) The unavailability of suitable training simulators that precluded fully effective flightcrew training.

Safety issues discussed in the report include aircraft safety belts, and training programs for Part 135 pilots that place more emphasis on stall warning recognition and recovery techniques, and that train pilots to proficiency for both high speed approach profiles and coupled approach profiles. Safety recommendations concerning these issues were made to the Federal Aviation Administration. Also, the Safety Board reiterated safety recommendations to the Federal Aviation Administration concerning stabilized approaches and aircraft safety belts.
Learning Keywords:Operations - Crew Resource Management
Operations - Pilot Experience - Pairing
Operations - Uncontrolled Flight into Terrain
Operations - Unstabilized Approach
Operations - Upset in-flight (extreme attitudes, stall, spin)
Other - Post-Crash Survivability
Other - Regulatory Oversight
Consequence - Hull Loss

 




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