Crash During Approach to Landing Empire Airlines Flight 8284 PDF
Preview Crash During Approach to Landing Empire Airlines Flight 8284
Crash During Approach to Landing Empire Airlines Flight 8284 Avions de Transport Régional Aerospatiale Alenia ATR 42‐320, N902FX Lubbock, Texas January 27, 2009 Accident Report NTSB/AAR-11/02 PB2011-910402 National Transportation Safety Board NTSB/AAR-11/02 PB2011-910402 Notation 8093A Adopted April 26, 2011 Aircraft Accident Report Crash During Approach to Landing Empire Airlines Flight 8284 Avions de Transport Régional Aerospatiale Alenia ATR 42-320, N902FX Lubbock, Texas January 27, 2009 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2011. Crash During Approach to Landing, Empire Airlines Flight 8284, Avions de Transport Régional Aerospatiale Alenia ATR 42-320, N902FX, Lubbock, Texas, January 27, 2009. Aircraft Accident Report NTSB/AAR-11/02. Washington, DC. Abstract: This accident report discusses the January 27, 2009, accident involving Empire Airlines flight 8284, an Avions de Transport Régional Aerospatiale Alenia ATR 42-320, N902FX, which crashed short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The safety issues discussed in this report include the flight crew’s actions in response to the flap anomaly, the continuation of the unstabilized approach, the dispatch of the flight into freezing drizzle conditions, the efficiency of the emergency response, and simulator-based training for pilots who fly in icing conditions. Nine safety recommendations are addressed to the Federal Aviation Administration. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2011-910402 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. NTSB Aircraft Accident Report Contents Figures ........................................................................................................................................... iv Abbreviations and Acronyms .......................................................................................................v Executive Summary ..................................................................................................................... ix 1. Factual Information ...................................................................................................................1 1.1 History of Flight .........................................................................................................................1 1.2 Injuries to Persons ......................................................................................................................5 1.3 Damage to Airplane ...................................................................................................................5 1.4 Other Damage ............................................................................................................................5 1.5 Personnel Information ................................................................................................................6 1.5.1 The Captain ......................................................................................................................6 1.5.2 The First Officer ..............................................................................................................6 1.5.3 Flight Crew’s Rest Opportunities ....................................................................................7 1.5.3.1 The Captain ....................................................................................................... 7 1.5.3.2 The First Officer ............................................................................................... 8 1.6 Airplane Information .................................................................................................................8 1.6.1 General .............................................................................................................................8 1.6.2 Flap System .....................................................................................................................9 1.6.3 Deicing, Anti-Icing, and Anti-Icing Advisory Systems ................................................11 1.6.4 Flight Instruments ..........................................................................................................11 1.6.4.1 Airspeed Indicator ........................................................................................... 11 1.6.4.2 Electronic Flight Information System ............................................................. 13 1.6.5 Automatic Flight Control System ..................................................................................13 1.6.6 Stall Protection System ..................................................................................................13 1.7 Meteorological Information .....................................................................................................14 1.8 Aids to Navigation ...................................................................................................................14 1.9 Communications ......................................................................................................................15 1.10 Airport Information ................................................................................................................15 1.10.1 Emergency Plan ...........................................................................................................15 1.10.2 Snow and Ice Control Plan ..........................................................................................16 1.11 Flight Recorders .....................................................................................................................16 1.11.1 Cockpit Voice Recorder ..............................................................................................16 1.11.2 Flight Data Recorder ....................................................................................................17 1.12 Wreckage and Impact Information ........................................................................................17 1.13 Medical and Pathological Information ...................................................................................18 1.14 Fire .........................................................................................................................................18 1.15 Survival Aspects ....................................................................................................................18 1.15.1 Flight Crew Egress ......................................................................................................18 1.15.2 Emergency Response ...................................................................................................18 1.16 Tests and Research .................................................................................................................21 1.16.1 Airplane Performance Study and Simulator Evaluations ............................................21 i NTSB Aircraft Accident Report 1.16.1.1 Effects of Flap Asymmetry ........................................................................... 21 1.16.1.2 Effects of Airframe Ice Accretion ................................................................. 22 1.16.2 Terrain Awareness and Warning System ....................................................................23 1.16.3 Flap System Component Examinations .......................................................................24 1.16.3.1 Hydraulic Fluid Testing ................................................................................ 25 1.16.3.2 Maintenance History ..................................................................................... 25 1.16.3.3 Flap Asymmetry Event Involving Another Airplane .................................... 25 1.16.4 Deicing and Anti-Icing System Examinations ............................................................26 1.16.5 Autopilot Disconnect Alert ..........................................................................................26 1.17 Organizational and Management Information .......................................................................26 1.17.1 Pilot Standard Operating Procedures and Training .....................................................27 1.17.1.1 Flap Anomalies ............................................................................................. 27 1.17.1.2 Stabilized Approach and Go Around ............................................................ 31 1.17.1.3 Terrain Awareness and Warning System ...................................................... 32 1.17.1.4 Airspeed Bugs ............................................................................................... 32 1.17.1.5 Aileron Mistrim with Autopilot Engaged ..................................................... 33 1.17.1.6 Deicing and Anti-Icing Systems ................................................................... 33 1.17.1.7 Crew Resource Management ........................................................................ 34 1.17.1.8 Weather Information and Training ............................................................... 35 1.17.1.9 Stall and Near-Stall Recoveries .................................................................... 36 1.17.2 Aircraft Deicing Program (Ground) ............................................................................36 1.17.3 Flight Dispatch .............................................................................................................36 1.17.4 Hazardous Materials ....................................................................................................38 1.17.5 Federal Aviation Administration Oversight ................................................................38 1.17.6 Previous Accidents ......................................................................................................39 1.18 Additional Information ..........................................................................................................40 1.18.1 Postaccident Safety Action ..........................................................................................40 1.18.1.1 Federal Aviation Administration .................................................................. 40 1.18.1.2 Empire Airlines ............................................................................................. 41 1.18.1.3 FedEx Feeder Operations .............................................................................. 42 1.18.2 Previously Issued Safety Recommendations ...............................................................43 1.18.2.1 Flight Crew Monitoring and Workload Management Skills for Single and Multiple Abnormal Situations..................................................................................... 43 1.18.2.2 Go-Around Callout ....................................................................................... 45 1.18.2.3 Low-Airspeed Alerting Systems ................................................................... 45 1.18.2.4 First Officer Assertiveness ............................................................................ 46 1.18.3 Airplane Equipment Options .......................................................................................47 1.18.3.1 Aircraft Performance Monitoring System .................................................... 47 1.18.3.2 Flap Malfunction or Asymmetry Light ......................................................... 48 1.18.3.3 Ice Evidence Probe ....................................................................................... 49 2. Analysis .....................................................................................................................................50 2.1 General .....................................................................................................................................50 2.2 Accident Sequence ...................................................................................................................52 2.3 Human Performance ................................................................................................................54 2.3.1 Captain’s Nonstandard Responses .................................................................................55 2.3.2 Flight Crew’s Failure to Monitor Airspeed ...................................................................57 ii NTSB Aircraft Accident Report 2.3.2.1 Airspeed References ....................................................................................... 58 2.3.2.2 Flight Crew Monitoring Skills and Techniques .............................................. 60 2.3.3 Crew Resource Management .........................................................................................61 2.3.4 Go-Around Callout ........................................................................................................63 2.3.5 Training for Single and Multiple Abnormal Situations Occurring at Low Altitude .....64 2.3.6 Fatigue Considerations ..................................................................................................65 2.3.6.1 Role of Fatigue in Flight Crew Performance .................................................. 67 2.4 Operations Issues .....................................................................................................................69 2.4.1 Dispatch into Freezing Drizzle Conditions ....................................................................69 2.4.1.1 Flight Crewmember and Dispatcher Training Related to Icing Conditions ... 70 2.4.1.2 Proposed Rulemaking for Airplane Certification Requirements for Flight in Icing Conditions .......................................................................................................... 72 2.4.2 Training Program and Manual Discrepancies ...............................................................72 2.5 Survival Aspects ......................................................................................................................73 2.5.1 Lack of Occupant and Hazardous Materials Information Available to First Responders .................................................................................................................73 2.5.2 Inoperative Emergency Response and Mutual Aid Gate ...............................................75 2.6 Airplane Equipment Options ...................................................................................................75 2.6.1 Aircraft Performance Monitoring ..................................................................................75 2.6.2 Flap Malfunction or Asymmetry Light ..........................................................................77 2.6.3 Ice Evidence Probe ........................................................................................................77 2.7 Simulator Training for Icing Encounters .................................................................................78 3. Conclusions ...............................................................................................................................80 3.1 Findings....................................................................................................................................80 3.2 Probable Cause.........................................................................................................................83 4. Recommendations ....................................................................................................................84 Board Member Statements .........................................................................................................86 5. Appendixes ...............................................................................................................................93 Appendix A: Investigation and Hearing ........................................................................................93 Appendix B: Cockpit Voice Recorder Transcript ..........................................................................94 iii NTSB Aircraft Accident Report Figures Figure 1. Aerial view of approach end of runway 17R and location of wreckage. ....................... 5 Figure 2. Flap position indicator. Inset shows the likely needle pointer position during the flap asymmetry.............................................................................................................................. 10 Figure 3. Exterior flap position fairing. ....................................................................................... 10 Figure 4. Airspeed indicator showing needle pointer; selector knob; and internal, yellow, white, and red bugs. ...................................................................................................................... 12 Figure 5. View of airport showing relative locations of airport access gates and accident site. . 20 Figure 6. Right side of fuselage showing extensive fire damage to right wing and flap components. ........................................................................................................................... 24 Figure 7. Quick reference handbook page 2.21 with “FLAPS JAM/UNCOUPLED/ASYM” and “REDUCED FLAPS LANDING” procedures. ............................................................................ 28 Figure 8. General information on page 0.02 of quick reference handbook. ................................ 29 iv NTSB Aircraft Accident Report Abbreviations and Acronyms AAS anti-icing advisory system AC advisory circular AD airworthiness directive ADP aircraft deicing program ADU advisory display unit AEP airport emergency plan AFFF aqueous film forming foam AFM airplane flight manual AFW Fort Worth Alliance Airport agl above ground level AIM Aeronautical Information Manual AIRMET airmen’s meteorological information AOA angle of attack APM aircraft performance monitoring ARAC Aviation Rulemaking Advisory Committee ARFF aircraft rescue and firefighting ATC air traffic control ATCT air traffic control tower ATOS air transportation oversight system ATR Avions de Transport Régional ATR 42 Aerospatiale Alenia ATR 42-320 BEA Bureau d’Enquêtes et d’Analyses CFR Code of Federal Regulations v NTSB Aircraft Accident Report CG center of gravity CRM crew resource management CVR cockpit voice recorder DGAC Direction Générale de l’Aviation Civile EADI electronic attitude direction indicator EASA European Aviation Safety Agency EFS engineering flight simulator ELP El Paso International Airport EMS emergency medical service FAA Federal Aviation Administration FAF final approach fix FCOM flight crew operating manual FDR flight data recorder FedEx FedEx Corporation FL flight level fpm feet per minute FR Federal Register FSDO flight standards district office FSIB flight standards information bulletin FTM flight training manual GOM general operations manual HAZMAT hazardous materials Hg mercury IEP ice evidence probe vi
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