British Aerospace Jetstream 32CORPORATE AIRLINES
Kirksville, MO, USA · 2004-10-20·N875JX
What happened
NTSB summary, verbatimThe Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-06/01. On October 19, 2004, about 1937 central daylight time, Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport, in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed at the time of the accident, and the flight operated on an instrument flight rules flight plan.
Photographs
15the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationthe pilots' failure to follow established procedures and properly conduct a nonprecision instrument approach at night in IMC, including their descent below the minimum descent altitude (MDA) before required visual cues were available (which continued unmoderated until the airplane struck the trees) and their failure to adhere to the established division of duties between the flying and nonflying (monitoring) pilot. Contributing to the accident was the pilots' failure to make standard callouts and the current Federal Aviation Regulations that allow pilots to descend below the MDA into a region in which safe obstacle clearance is not assured based upon seeing only the airport approach lights. The pilots' unprofessional behavior during the flight and their fatigue likely contributed to their degraded performance. .
Safety recommendations
7 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Direct the principal operations inspectors of all 14 Code of Federal Regulations Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures and to emphasize the preference for that technique where practicable. (Superseded by safety recommendation A-14-076)
TO THE FEDERAL AVIATION ADMINISTRATION: Revise applicable 14 Code of Federal Regulations Part 121 and 135 regulations to prohibit pilots from descending below the minimum descent altitude during nonprecision instrument approaches unless conditions allow for clear visual identification of all obstacles and terrain along the approach path or vertical guidance to the runway is available and being used.
TO THE FEDERAL AVIATION ADMINISTRATION: Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. (A-06-10) (This recommendation supersedes Safety Recommendation A-99-45.)
TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. (Superseded by A-08-44)
TO THE FEDERAL AVIATION ADMINISTRATION: Develop guidance, based on empirical and scientific evidence, for operators to establish fatigue management systems, including information about the content and implementation of these systems. (A-08-44) (This safety recommendation supersedes Safety Recommendation A-06-11)
TO THE FEDERAL AVIATION ADMINISTRATION: Develop and use a methodology that will continually assess the effectiveness of fatigue management systems implemented by operators, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents.
Sequence of events
2 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- entire flight (plot 3), last 10 minutes (plot 2), last 65 seconds (plot 1)approachp.3Approach and impact plotted at three time scales; no narrative values in the report text
- 19:37:00.51-19:37:00.64 CDT (SRN 467,139.5-467,139.6)impactp.3Last recorded second: pressure altitude 23,057.94 ft and indicated airspeed 465.39 knots recorded - physically impossible, marked invalid (impact)
NTSB analysis
from the final reportThe Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-06/01. On October 19, 2004, about 1937 central daylight time, Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport, in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed at the time of the accident, and the flight operated on an instrument flight rules flight plan.