DCA94MA027

NTSB accident investigation · Jetstream 4101 · Columbus, OH · January 8, 1994

Accident · FatalClass 1 · MajorFinal report
Date
January 7, 1994, 23:21 local (Jan 8, 1994, 04:21 UTC)
Place
Columbus, OH
Injuries
5 fatal, 2 minor, 1 uninjured
Damage
Destroyed
Phase of flight
Approach
Aircraft
N304UEJetstream 4101
Weather
Instrument (IMC) · Night/dark
Status
Completed · report April 12, 1995
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19940107000199A
Case key
10981

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

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Probable cause

(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence of procedural discipline; (2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps; (3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots; (4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training; (5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and (6) The unavailability of suitable training simulators that precluded fully effective flightcrew training. Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory. (NTSB Report AAR-94/07)

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightApproach - faf/outer marker to threshold (ifr)
Planned approach - poorPilot in commandCause
Lack of total experience in type of aircraftFlightcrewCause
Insuff standards/requirements,operation/operatorCompany/operator mgmtCause
Insuff standards/requirements,operation/operatorFaa(organization)Cause
Aircraft handling - improperPilot in commandCause
Inadequate trainingCompany/operator managementCause
Insuff standards/requirements,operation/operatorFaa(organization)Cause
Airspeed - not maintainedFlightcrewCause
Stall - inadvertentFlightcrew
In flight collision with terrain/waterApproach - faf/outer marker to threshold (ifr)

Analysis

The airplane stalled and crashed 1.2 nautical miles east of runway 28L during an ILS approach. The captain initiated the approach at high speed & crossed the FAF at a high speed without first having the airplane properly configured for a stabilized approach. The airspeed was not monitored nor maintained by the flightcrew. The airline had no specified callouts for airspeed deviations during instrument approaches. The captain failed to apply full power & configure the airplane in a timely manner. Both pilots had low flight time and experience in in the airplane and in any EFIS-equipped airplane. Additionally, the captain had low time and experience as a captain. Inadequate consideration was given to the possible consequences of pairing a newly upgraded captain, on a new airplane, with a first officer who had no airline experience in air carrier operations, nor do current FAA regulations address this issue.

Factual narrative

On Friday, January 7, 1994, at 2321 eastern standard time, a Jetstream J4101, N304UE, operated by Atlantic Coast Airlines of Sterling, Virginia, and doing business as United Express 6291, a scheduled commuter flight from Dulles International Airport to Columbus Ohio,crashed 1.2 nautical miles east of runway 28L at Port Columbus International Airport, Columbus, Ohio. The aircraft had been cleared for an ILS approach to runway 28L and had been in contact with the tower when it crashed into a concrete block manufacturing structure about 1.2 miles from the airport. The pilot, co-pilot, flight attendant and two passengers were fatally injured. Two of the other three passengers received minor injuries while the third was not injured. The airplane was destroyed. Instrument meteorological conditions prevailed at the time and the airplane was on an instrument flight rules (IFR) flight plan. See Aircraft Accident Report, Atlantic Coast Airlines dba United Express flight 6291, Jetstream 4100, N304UE, Columbus, Ohio, January 7, 1994.

Aircraft

Registration
N304UE
Reported as
Jetstream 4101
Category
Airplane
Serial number
41016
Airframe hours
1,069
Engine
Garrett TPE-331-14, 1,500 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Atlantic Coast Airlines, doing business as United Express
Registered owner
First Security Bank Of Utah
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 6, 1994 · 14 hours before
Departed
IAD · Chantilly, VA
Flight plan
IFR
Airport
CMH · Port Columbus Intl, runway 28L, 10,250 × 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
3,660 total · 192 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
300° at 6 knots
Visibility
2.5 statute miles
Lowest ceiling
800 ft overcast
Temperature
23 °F, dew point 21 °F
Altimeter
29.00 inHg
Observed at
CMH, 1 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.