# NTSB DCA94MA022: Jetstream BA-3100, N334PX, Hibbing, MN, December 2, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: December 1, 1993, 19:50 local (Dec 2, 1993, 01:50 UTC) - Place: Hibbing, MN - Coordinates: 47.399787, -92.940635 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.3998&lon=-92.9406&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 18 fatal - Status: Completed, report December 27, 1994 - Report: Board-adopted at Board Meeting - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 10980 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA94MA022.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10980/pdf - Page: https://openairdocs.org/ntsb/DCA94MA022 ## Probable cause THE CAPTAIN'S ACTIONS THAT LED TO A BREAKDOWN IN CREW COORDINATION AND THE LOSS OF ALTITUDE AWARENESS BY THE FLIGHTCREW DURING AN UNSTABILIZED APPROACH IN NIGHT INSTRUMENT METEOROLOGICAL CONDITIONS. CONTRIBUTING TO THE ACCIDENT WERE: THE FAILURE OF THE COMPANY MANAGEMENT TO ADEQUATELY ADDRESS THE PREVIOUSLY IDENTIFIED DEFICIENCIES IN AIRMANSHIP AND CREW RESOURCE MANAGEMENT OF THE CAPTAIN; THE FAILURE OF THE COMPANY TO IDENTIFY AND CORRECT A WIDESPREAD, UNAPPROVED PRACTICE DURING INSTRUMENT APPROACH PROCEDURES; AND THE FEDERAL AVIATION ADMINISTRATION'S INADEQUATE SURVEILLANCE AND OVERSIGHT OF THE AIR CARRIER. (NTSB REPORT AAR-94/05) ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - proper descent rate - not attained, pilot in command (cause) - insufficient standards/requirements, company/operator mgmt (contributing factor) - aircraft handling - poor, pilot in command (cause) - inadequate training, company/operator management (contributing factor) - inadequate surveillance of operation, faa(organization) (contributing factor) - crew/group coordination - not maintained, pilot in command (cause) - crew/group coordination - not maintained, copilot/second pilot (cause) - proper altitude - not maintained, pilot in command (cause) - proper altitude - not maintained, copilot/second pilot (cause) ## Analysis WHILE ON A LOCALIZER BACK COURSE APPROACH THE AIRPLANE COLLIDED WITH TREES AND THE TERRAIN APRX 3 MI FROM THE RUNWAY THRESHOLD. THE CAPTAIN DELAYED THE START OF THE DESCENT THAT SUBSEQUENTLY REQUIRED AN EXCESSIVE DESCENT RATE TO REACH THE FAF AND MDH. THE CAPTAIN'S ACTIONS LED TO DISTRACTIONS DURING CRITICAL PHASES OF THE APPROACH. THE FLIGHTCREW LOST ALTITUDE AWARENESS AND ALLOWED THE AIRPLANE TO DESCEND BELOW MANDATORY LEVEL OFF POINTS. THE CAPTAIN'S RECORD RAISED QUESTIONS ABOUT HIS AIRMANSHIP AND BEHAVIOR THAT SUGGESTED A LACK OF CREW COORDINATION DURING FLIGHT OPERATIONS, INCLUDING INTIMIDATION OF FIRST OFFICERS. COMPANY MANAGEMENT DID NOT ADDRESS THESE MATTERS ADEQUATELY. THE AIRLINE'S FLIGHT OPERATIONS MANAGEMENT FAILED TO IMPLEMENT PROVISIONS TO ADEQUATELY OVERSEE THE TRAINING OF THEIR FLIGHTCREWS AND THE OPERATION OF THEIR AIRCRAFT. FAA GUIDANCE TO THEIR INSPECTORS CONCERNING IMPLEMENTATION OF OPS BULLETINS IS INADEQUATE AND HAS FAILED TO TRANSMIT VALUABLE SAFETY INFORMATION AS INTENDED TO AIRLINES. ## Factual narrative See section 1.1, History of the Flight, in NTSB Aircraft Accident Report "Express II Airlines, Inc.,/Northwest Airlink Flight 5719, Jetstream BA-3100, N334PX, Hibbing, Minnesota, December 1, 1993." (AAR-94/05) ## Aircraft - Registration: [N334PX](https://openairdocs.org/deregistered/N334PX-1994-05-25), registration cancelled 1994-05-25, S/N 706 (OpenAirDocs) - Reported make and model: JETSTREAM BA-3100 - Registry model: [British Aerospace BAE JETSTREAM 3101](https://openairdocs.org/model/british-aerospace-bae-jetstream-3101) (registry code 1500216) (OpenAirDocs) - Category: Airplane - Serial number: 706 - Airframe hours: 17156 - Engines: GARRETT TPE-331-10 900 horsepower turbo prop - Damage: Destroyed - Flight: Part 135 - Operator: Express Airlines II, Inc., doing business as Northwest Airlink - Registered owner: Meridian Trust Company - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, November 30, 1993, 6 hours before - Departed: MSP, MINNEAPOLIS, MN - Flight plan: IFR - Airport: HIB, Chisholm-Hibbing, runway 13, 6,758 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; flight instructor, airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 7,853 total, 2,267 in this make and model ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 180° at 10 knots - Visibility: 1 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 28 °F, dew point 27 °F - Altimeter: 29.00 inHg - Observed at: HIB, 3 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19931202045359A](https://openairdocs.org/incident/19931202045359A), Dec 2, 1993: Bag JETSTM3101, Hibbing, MN, Destroyed, 18 fatal. Distabilized approach by PIC led to confusion and descent below mda. Struck trees and crashed. Ops inadequate. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.