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Cases › CEN09MA142 · Major investigation · Class 1

AEROSPATIALE ALENIA ATR 42-320Empire Airlines

Lubbock, TX, USA · 2009-01-27·N902FX

0
fatal
1
serious
Serious injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

The Safety Board’s full report is available at http://www.ntsb.gov/Publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/02. On January 27, 2009, about 0437 central standard time, an Avions de Transport Régional Aerospatiale Alenia ATR 42 320, N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it 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 Federal Express Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
Scbriml n902fx
Steve Brimley · CC BY-SA 4.0 · Wikimedia Commons

Probable cause

the Board's determination
The flight crew's failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were 1) the flight crew's failure to follow published standard operating procedures in response to a flap anomaly, 2) the captain's decision to continue with the unstabilized approach, 3) the flight crew's poor crew resource management, and 4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain's performance.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Approach-IFR final approach
    Collision with terr/obj (non-CFIT)
  2. 2 · Approach-IFR initial approach
    Aerodynamic stall/spin
    defining event

Findings

8 causal · 2 contributing
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Flight crew
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Airspeed — Not attained/maintained
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Freezing rain/sleet — Effect on equipment
  • CAUSE
    Personnel issues › Action/decision › Action › Incorrect action performance — Pilot
  • CAUSE
    Personnel issues › Action/decision › Info processing/decision — Flight crew
  • CAUSE
    Personnel issues › Physical › Alertness/Fatigue › Lack of sleep — Pilot
  • CAUSE
    Personnel issues › Physical › Alertness/Fatigue › Circadian rhythms or jetlag — Pilot
  • CAUSE
    Personnel issues › Task performance › Communication (personnel) › CRM/MRM techniques — Flight crew
  • FACTOR
    Organizational issues › Management › Communication (organizational) › Between groups/organizations — Emergency services
  • FACTOR
    Environmental issues › Operating environment › Airport facilities/design — Effect on operation

Safety recommendations

13 issuedwhat changed because of this accident
  • A-11-039Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that role-playing or simulator-based exercises that teach first officers to assertively voice their concerns and that teach captains to develop a leadership style that supports first officer assertiveness be included as part of the already required crew resource management training for 14 Code of Federal Regulations Part 121, 135, and 91 subpart K pilots.

  • A-11-040Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Prohibit all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators of pneumatic deice boot-equipped airplanes from dispatching or deliberately operating these airplanes in known freezing rain or freezing drizzle of any intensity, unless the airplane manufacturer has demonstrated that the airplane model can safely operate in those conditions.

  • A-11-041Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Review the approved pilot, dispatcher, and flight follower training programs and procedures for all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and require revisions to the programs and procedures, as necessary, to include standardized training and aircraft-specific information to educate pilots, dispatchers, and flight followers of the dangers of flight operations in freezing precipitation and of the differences between ground deicing considerations and in-flight icing operations.

  • A-11-042Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Develop a method to quickly communicate information regarding the number of persons on board and the presence of hazardous materials to emergency responders when airport emergency response or search and rescue is activated.

  • A-11-043Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Amend Advisory Circular 150/5200-30C to include guidance on monitoring and ensuring the operability of emergency response and mutual aid gates during winter operations.

  • A-11-044Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of Avions de Transport Régional Aerospatiale Alenia ATR 42- and ATR 72-series airplanes to retrofit the airplanes with an aircraft performance monitoring system if they are not already so equipped.

  • A-11-045Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require all Avions de Transport Régional Aerospatiale Alenia ATR 42-series airplanes to be equipped with a flap asymmetry annunciator light if they are not already so equipped.

  • A-11-046Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents.

  • A-11-047Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Once the simulator model fidelity requirements requested in Safety Recommendation A-11-46 are implemented, require that flight crews of all aircraft certificated for flight in icing conditions be trained in flight training simulators that meet these fidelity requirements. Such simulation training should emphasize the following: (1) cues for recognizing changes in the aircraft’s flight characteristics as airframe icing develops; (2) procedures for monitoring and maintaining appropriate airspeeds in icing conditions, including the use of icing airspeed reference indices; and (3) procedures for responding to decaying airspeed situations, stall protection system activation, and early stalls that can occur without stall protection system activation.

  • A-12-024Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require that Avions de Transport Régional (ATR) 42-series airplanes operating in the United States incorporate a revised stick pusher activation angle of attack (AOA), such that the stick pusher activates before the stall AOA in the presence of airframe ice accretions.

  • A-12-025Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate all U.S.-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.

  • A-12-026Closed - Unacceptable ActionCLASS IIletter ↗

    TO THE EUROPEAN AVIATION SAFETY AGENCY: Require Avions de Transport Régional (ATR) to revise the stick pusher’s activation angle of attack (AOA) on ATR 42-series airplanes to ensure that the stick pusher activates before the stall AOA in the presence of airframe ice accretions.

  • A-12-027Open - Acceptable ResponseCLASS IIletter ↗

    TO THE EUROPEAN AVIATION SAFETY AGENCY: Evaluate all European Aviation Safety Agency-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.

Sequence of events

10 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)
  1. 03:19 CSTclimb/cruisep.7
    Departed Fort Worth Alliance, climbing to 18,000 ft; autopilot engaged at 03:23 through 4,700 ft; airframe de-ice on at 03:31 through 16,300 ft; level at 18,000 ft at 03:36
  2. 04:02-04:31 CSTdescentp.7
    Descent begun 04:02, level 13,900 ft at 04:08; descent 04:18, de-ice off through 10,000 ft at 04:22; level 5,800 ft at 04:27; descent 04:30 with de-ice selected on; level 4,800 ft at 04:31
  3. 04:33-04:34:20 CSTapproachp.7
    Left turn onto the approach; localizer 0.0-0.5 dots, glideslope about -1.0 dot
  4. 04:34:25-04:34:26 CSTapproachp.7
    Flap position began increasing from 0 deg; at about 4 deg a flap asymmetry was recorded and a left roll
  5. 04:34:50-04:34:54 CSTfinal approachp.7
    Descent on the glideslope began (localizer 0.0, glideslope 1.0 dot); engine power reduced on both engines
  6. 04:35:29-04:35:30 CSTfinal approachp.7
    Autopilot disengaged and power increased on both engines at 3,990 ft pressure altitude, 125 kts, AOA 11.3 deg; aircraft rolled to about 12 deg right then about 10 deg left
  7. 04:35:50-04:35:58 CSTfinal approachp.8
    Localizer -1.5 dots, glideslope 2.0 dots (above), radio altitude about 700 ft; momentary autopilot engage selections at 04:35:54 and 04:35:58; power reduced on both engines
  8. 04:36:00-04:36:18 CSTfinal approachp.8
    Glideslope deviation approached 0.0 dots then increased; power increased on both engines at 04:36:18 at about 200 ft radio altitude
  9. 04:36:20-04:36:27 CSTstall/impactp.8
    Loss of control: roll from 6 deg right varying between 35 deg right and 50 deg left; AOA from 13.6 deg varying -0.2 to 29.3 deg; pitch from 2 deg nose up varying between 11 deg nose up and 6 deg nose down (stall)
  10. 04:36:27 CSTimpactp.8
    Approximate time of ground impact; airspeed, pressure altitude, pitch, roll and TAT/SAT unreliable thereafter

NTSB analysis

from the final report

The Safety Board’s full report is available at http://www.ntsb.gov/Publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/02. On January 27, 2009, about 0437 central standard time, an Avions de Transport Régional Aerospatiale Alenia ATR 42 320, N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it 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 Federal Express Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed.