CEN09MA142

NTSB accident investigation · Aerospatiale Alenia ATR 42-320 · Lubbock, TX · January 27, 2009

Accident · Serious injuriesClass 1 · MajorFinal report
Date
January 27, 2009, 04:37 local (10:37 UTC)
Place
Lubbock, TX
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N902FXAerospatiale Alenia ATR 42-320
Defining event
Approach-IFR initial approach: Aerodynamic stall/spin
Weather
Instrument (IMC) · Night/dark
Status
Completed · report April 26, 2011
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Central Region
Parties
Pratt and Whitney, Aerospatiale Alenia (ATR), Empire Airlines, Federal Aviation Administration, Bureau d'Enquetes, Federal Express
Safety recommendations
Yes
FAA report
20090127001639A
Case key
73279

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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.

Findings · 10

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedAerospatiale/Aeritalia ATR 42-320: 1 caseAll aircraft: 1,681 casesProbable cause
Ceiling/visibility/precip: freezing rain/sleetEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentAerospatiale/Aeritalia ATR 42-320: 1 caseAll aircraft: 26 casesProbable cause
Info processing/decisionPersonnel issues › Action/decision · Flight crewAerospatiale/Aeritalia ATR 42-320: 1 caseAll aircraft: 25 casesProbable cause
Airport facilities/designEnvironmental issues › Operating environment · Effect on operationAerospatiale/Aeritalia ATR 42-320: 1 caseAll aircraft: 52 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

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.

Factual narrative

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.

Aircraft

Registration
N902FX
Reported as
Aerospatiale Alenia ATR 42-320
Category
Airplane
Serial number
325
Airframe hours
29,767.9
Engines
Pratt and Whitney Canada PW 121, 1,950 horsepower, turbo propPratt and Whitney Canada PW 121, 1,950 horsepower, turbo prop
Damage
Substantial damage
Fire
On-Ground
Flight
Part 121
Operator
Empire Airlines
Registered owner
Federal Express Corp/Attn Vp Supplemental Air Ops
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · January 9, 2009
Departed
AFW · Fort Worth, TX
Destination
LBB · Lubbock, TX
Flight plan
IFR
Airport
LBB · Lubbock Preston Smith, runway 17R, 11,500 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
Serious
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 5, 2008
Seat
Left
Flight hours
13,200 total
Role
Co-pilot
Age
26
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
2,000 total

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
350° at 10 knots
Visibility
2 statute miles
Lowest ceiling
500 ft overcast
Temperature
46 °F, dew point 48 °F
Altimeter
30.21 inHg
Observed at
LBB

Docket · 140

The files NTSB released with the investigation on September 22, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 153 MB in all.

Order of Hearing: 1AItem 1 · .PDF · 39 KBNotice of Designation of Chairman of Board of Inquiry: 1BItem 2 · .PDF · 48 KBDesignation of Hearing Officer: 1CItem 3 · .PDF · 48 KBDesignation of Parties to the Hearing: 1DItem 4 · .PDF · 40 KBNotice of Hearing: 1EItem 5 · .PDF · 42 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 6 · .PDF · 3.9 MBOperations 2A - Factual Report of Group ChairmanItem 7 · .PDF · 3.1 MBOperations 2B - Flight Crew Training Events Summary and Issued DocumentsItem 8 · .PDF · 277 KBOperations 2C - Flight Crew Flight Time and Duty RecordItem 9 · .PDF · 520 KBOperations 2D - Empire Airlines January 2009 ATR Trip PairingsItem 10 · .PDF · 74 KBOperations 2E - Witness Statements (Including Empire Dispatch Log Information)Item 11 · .PDF · 277 KBOperations 2F - Interview Summaries of Captain Rodney HolbertonItem 12 · .PDF · 1.0 MBOperations 2G - Interview Summaries of First Officer Heather CornellItem 13 · .PDF · 928 KBOperations 2H - Interview Summaries of Empire Airlines Dispatch PersonnelItem 14 · .PDF · 392 KBOperations 2I - Interview Summaries of FAA POI and Assistant POIItem 15 · .PDF · 216 KBOperations 2J - Interview Summaries of Director of Operations and Chief PilotItem 16 · .PDF · 371 KBOperations 2K - Interview Summaries of Empire Training Manager and Check AirmenItem 17 · .PDF · 524 KBOperations 2L - Interview Summaries of Empire Airlines Director of Safety and ComplianceItem 18 · .PDF · 765 KBOperations 2M - Interview Summaries of Empire Airlines Technical Publications PersonnelItem 19 · .PDF · 82 KBOperations 2N - Interview Summaries of Pilots Previously Paired with the Accident CrewItem 20 · .PDF · 1.2 MBOperations 2O - Interview Summaries of Flight Safety International PersonnelItem 21 · .PDF · 1.5 MBMemorandum for Record: Witness Statement and Interview Summary Changes/ClarificationsItem 22 · .PDF · 55 KBOperations 2P - Weight and Balance InformationItem 23 · .PDF · 210 KBOperations 2Q - Part 121 Flight Release and Weather (MAF to ELP)Item 24 · .PDF · 670 KBOperations 2R - Part 91 Flight Release and Weather (ELP to AFW) Note: Example, Not OriginalItem 25 · .PDF · 758 KBOperations 2S - Part 121 Flight Release and Weather (AFW to LBB)Item 26 · .PDF · 1.0 MBOperations 2T - LBB METARSItem 27 · .PDF · 193 KBOperations 2U - Flight Profiles and BriefingsItem 28 · .PDF · 181 KBOperations 2V - Airport and Approach Information (LBB)Item 29 · .PDF · 130 KBOperations 2W - TOLD Card, Flight Data Card, and F/O NotesItem 30 · .PDF · 831 KBOperations 2X - ATR 42 Normal ChecklistItem 31 · .PDF · 256 KBOperations 2Y - Airspeed Bug InformationItem 32 · .PDF · 746 KBOperations 2Z - Excerpts from Empire ATR 42 Quick Reference Handbook (QRH)Item 33 · .PDF · 738 KBOperations 2AA - Excerpts from ATR 42 Airplane Flight Manual (AFM)Item 34 · .PDF · 670 KBOperations 2BB - Excerpt from Empire General Operations Manual (GOM), IcingItem 35 · .PDF · 101 KBOperations 2CC - Excerpts from Empire Airlines ATR 42 Pilot Handbook (Adverse Weather)Item 36 · .PDF · 604 KBOperations 2DD - Empire Operations Specifications (A009)Item 37 · .PDF · 69 KBOperations 2EE - List of Examined/Recovered Cockpit Items and Issued DocumentsItem 38 · .PDF · 349 KBOperations 2FF - Excerpt from Empire Airlines Aircraft Deicing Program (ADP)Item 39 · .PDF · 300 KBOperations 2GG - Excerpts from Empire Airlines GOM (Flight Following Procedures)Item 40 · .PDF · 181 KBOperations 2HH - Excerpts from Empire Airlines GOM (Braking Action Reports)Item 41 · .PDF · 91 KBOperations 2II - Excerpts from Empire Airlines GOM (Takeoffs and Landings by First Officer)Item 42 · .PDF · 103 KBOperations 2JJ - Excerpts from Empire Airlines GOM (Emergency Operations)Item 43 · .PDF · 174 KBOperations 2KK - Excerpts from Empire GOM (Component Failure/Captain's Responsibility)Item 44 · .PDF · 171 KBOperations 2LL - Empire Airlines Stabilized Approach CriteriaItem 45 · .PDF · 247 KBOperations 2MM - Excerpts from ATR 42 FCOM (Stall Alert and Activation)Item 46 · .PDF · 68 KBOperations 2NN - Excerpts from ATR 42 FCOM (Air Data System)Item 47 · .PDF · 74 KBOperations 2OO - Excerpts from ATR 42 FCOM (Fast/Slow Indicator)Item 48 · .PDF · 114 KBOperations 2PP - Excerpts from ATR 42 FCOM (Anti Icing Advisory System)Item 49 · .PDF · 110 KBOperations 2QQ - Schematic of ATR 42 Flap SystemItem 50 · .PDF · 96 KBOperations 2RR - Excerpts from Empire Airlines GOM (C208 Icing Restrictions)Item 51 · .PDF · 86 KBOperations 2SS - ATR Winter Operations Reminder (December 6, 2002)Item 52 · .PDF · 104 KBOperations 2TT - ATR Letter to EASA (Freezing Drizzle/Freezing Rain) February 12, 2009Item 53 · .PDF · 124 KBOperations 2UU - Empire Airlines Flight Operations Bulletin 09-04 (Icing/Post Accident)Item 54 · .PDF · 141 KBOperations 2VV - Excerpts from ATR 42 Pilot Handbook (Task Sharing/Post Accident)Item 55 · .PDF · 164 KBOperations 2WW - Empire Flight Information Bulletin 09-06 (Flaps Asymmetry/Post Accident)Item 56 · .PDF · 73 KBOperations 2XX - Excerpts from Empire GOM (Conduct of Non-Revenue Flights/Post Accident)Item 57 · .PDF · 247 KBOperations 2YY - Excerpts from Empire FTM (Pilot Ground Training and ATR Ground Training)Item 58 · .PDF · 282 KBOperations 2ZZ - ATOS System/Subsystem/Element Chart (Operations)Item 59 · .PDF · 115 KBOperations 2AAA - Excerpts from Empire Operations Specifications (Training Organizations)Item 60 · .PDF · 88 KB
All 140 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.