# NTSB DCA94MA027: Jetstream 4101, N304UE, Columbus, OH, January 8, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: January 7, 1994, 23:21 local (Jan 8, 1994, 04:21 UTC) - Place: Columbus, OH - Coordinates: 40.010005, -82.920913 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.0100&lon=-82.9209&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 5 fatal, 2 minor, 1 uninjured - Status: Completed, report April 12, 1995 - Report: Board-adopted at Board Meeting - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 10981 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA94MA027.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10981/pdf - Board report AAR9407 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9407.pdf - Page: https://openairdocs.org/ntsb/DCA94MA027 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - faf/outer marker to threshold (ifr) - planned approach - poor, pilot in command (cause) - lack of total experience in type of aircraft, flightcrew (cause) - insuff standards/requirements,operation/operator, company/operator mgmt (cause) - insuff standards/requirements,operation/operator, faa(organization) (cause) - aircraft handling - improper, pilot in command (cause) - inadequate training, company/operator management (cause) - insuff standards/requirements,operation/operator, faa(organization) (cause) - airspeed - not maintained, flightcrew (cause) - stall - inadvertent, flightcrew - In flight collision with terrain/water, approach - 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](https://openairdocs.org/deregistered/N304UE-1994-10-11), registration cancelled 1994-10-11, S/N 41016 (OpenAirDocs) - Reported make and model: JETSTREAM 4101 - Registry model: [Jetstream JETSTREAM 4101](https://openairdocs.org/model/jetstream-jetstream-4101) (registry code 1500501) (OpenAirDocs) - Category: Airplane - Serial number: 41016 - Airframe hours: 1069 - Engines: GARRETT TPE-331-14 1500 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; 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 (OpenAirDocs). - [Accident 19940107000199A](https://openairdocs.org/incident/19940107000199A), Jan 7, 1994: Jetair JETSTM4101, Columbus, OH, Destroyed, 4 fatal. High and fast. Unstablized approach. Crash landed. Crew lacked training experience in type. Proper procedures etc. 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.