DCA97MA017

NTSB accident investigation · Embraer EMB-120RT · Monroe, MI · January 9, 1997

Accident · FatalClass 1 · MajorFinal report
Date
January 9, 1997, 15:54 local (20:54 UTC)
Place
Monroe, MI
Injuries
29 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N265CAEmbraer EMB-120RT
Weather
Instrument (IMC) · Day
Status
Completed · report August 21, 2001
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19970109000259A
Case key
11023

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

The Federal Aviation Adminstration's (FAA) failure to establish adequate aircraft certification standards for flight in icing conditions, the FAA's failure to ensure that at Centro Tecnico Aeroespacial/FAA-approved procedure for the accident airplane's deice system operation was implemented by U.S.-based air carriers, and the FAA's failure to require the establishment of adequate minimum airspeeds for icing conditions, which led to the loss of control when the airplane accumulated a thin, rough, accretion of ice on its lifting surfaces. Contributing to the accident were the flightcrew's decision to operate in icing conditions near the lower margin of the operating airspeed envelope (with flaps retracted) and Comair's failure to establish and adequately disseminate unambiguous minimum airspeed values for flap configurations and for flight in icing conditions.

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
Weather condition - icing conditionsCause
Aircraft control - not maintainedPilot in commandCause
Aircraft control - not maintainedCause
Airframe - iceCause
Inadequate certification/approvalFaa(organization)Cause
Information unclearCompany/operator managementCause
In-flight planning/decision - inadequatePilot in commandCause
Anti-ice/deice system
Airspeed - not maintainedPilot in commandCause
StallCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - open field

Analysis

The flight was being vectored for the approach to runway 3R at Detroit Metropolitan Wayne County Airport (DTW) when the aircraft descended and impacted the ground. The aircraft struck the ground in a steep nose-down attitude in a level field in a rural area about 19 nm southwest of DTW. The flight carried 26 passengers and 3 crew members. There were no survivors and the airplane was destroyed by impact forces and a post crash fire. Instrument meteorological conditions prevailed at the time of the accident. The investigation revealed that it was likely that the airplane gradually accumulated a thin, rough glaze/mixed ice coverage on the leading edge deicing boot surfaces, possibly with ice ridge formation on the leading edge upper surface, as the airplane descended from 7,000 feet mean sea level (msl) to 4,000 feet msl in icing conditions, which may have been imperceptible to the pilots. The pilots had been instructed by air traffic control to slow to 150 knots and according to flight data recorder information, the airplane began to show signs of departure from controlled flight as it decelerated from 155 to 156 knots while in a flaps-up configuration. The investigation disclosed that the FAA failed to adopt a systematic and proactive approach to the certification, and operational issues of turbopropeller-driven transport airplane icing. The icing certification process has been inadequate because it has not required manufacturers to demonstrate the airplane's flight handling and stall characteristics under a sufficiently realistic range of adverse ice accretion/flight handling conditions. The aircraft manufacturer had issued a revision in April, 1996 to the approved flight manual which included activation of the leading edge deicing boots at the first sign of ice formation. The airplane operator did not incorporate the procedure, because it was contrary to the company's trained procedures and practices and of the belief that enacting the changes would result in potentially unsafe operation. Investigators' discussion with management personnel at each of the seven U.S.-based operators of the aircraft indicated that at the time of the accident only two of these operators had changed their procedures to reflect the information in the revision. The FAA, at the time of the accident, did not require manufacturers of all turbine-engine driven airplanes to publish minimum airspeed information for various flap configurations and phases and conditions of flight. During Safety Board investigators postaccident interviews with company pilots, there were inconsistent answers on the complex and varied minimum airspeed requirements established by the company for both icing and nonicing conditions. It was also noted that the pilots uncertainty of the appropriate airspeeds might have been associated with the language used, the different airspeeds and criteria contained in the guidance, the company's methods of distribution, and the company's failure t o incorporate the guidance as a formal, permanent revision to the flight standards manual.

Factual narrative

On January 9, 1997, Comair flight 3272, an Embraer EMB-120RT, N265CA, crashed while being vectored for approach to runway 3R at Detroit Metropolitan Wayne County Airport. The flight was operated under Code of Federal Regulations (CFR) Part 135 and carried 26 passengers and 3 crew members. There were no survivors, and the airplane was destroyed by impact forces and a post crash fire. Instrument meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N265CA
Reported as
Embraer EMB-120RT
Category
Airplane
Serial number
120257
Airframe hours
12,752
Engine
P&W PW118, 1,800 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Comair, Inc., doing business as Comair Airlines
Registered owner
First Security Bank Of Utah,
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 27, 1996 · 89 hours before
Departed
CVG · Cincinnati, OH
Destination
DTW · Detroit, MI
Flight plan
IFR
Airport
DTW · Detroit Metropolitan, runway 3R, 10,000 × 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
42
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
5,329 total · 2,302 in this make and model · 3,400 as pilot in command · 234 in the last 90 days · 85 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
28
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Rear

Weather

Conditions
Instrument (IMC) · Day
Wind
70° at 5 knots
Visibility
0.75 statute miles
Lowest ceiling
600 ft broken
Temperature
28 °F, dew point 27 °F
Altimeter
29.00 inHg
Observed at
DTW, 19 nm away

Docket · 140

The files NTSB released with the investigation on May 7, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 75.6 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 4.5 MBOperations 2 - Attachment 1 - COMAIR EMB-120 V-SpeedsItem 2 · .PDF · 20 KBOperations 2 - Attachment 2 - Airplane Weight and Balance CalculationsItem 3 · .PDF · 332 KBOperations 2 - Attachment 3 - Toxicology ReportsItem 4 · .PDF · 152 KBOperations 2 - Attachment 4 - Program Tracking and Reporting Subsystems ASA and Skywest AirlinesItem 5 · .PDF · 77 KBOperations 2 - Attachment 5 - Airworthiness Directive 96-02-4Item 6 · .PDF · 145 KBOperations 2 - Attachment 6 - COMAIR Flight Standards BulletinItem 7 · .PDF · 169 KBOperations 2 - Attachment 7 - Excerpts from Embraer EMB-120 Airplane Flight ManualItem 8 · .PDF · 170 KBOperations 2 - Attachment 8 - Excerpts from COMAIR EMB-120 Flight Standards ManualItem 9 · .PDF · 276 KBOperations 2 - Attachment 9 - Excerpts from EMB-120 1996 Recurrent Ground School Training GuideItem 10 · .PDF · 404 KBOperations 2 - Attachment 10 - Excerpts from COMAIR Flight Operations Traning Manual EMB-120Item 11 · .PDF · 252 KBOperations 2 - Attachment 11 - Excerpts from COMAIR EMB-120 Pilot Training ManualItem 12 · .PDF · 94 KBOperations 2 - Attachment 12 - COMAIR Inter-Office MemosItem 13 · .PDF · 160 KBOperations 2 - Attachment 13 - Embraer Operations Bulletin 120-002/96Item 14 · .PDF · 1.4 MBOperations 2 - Attachment 14 - CorrespondenceItem 15 · .PDF · 227 KBOperations 2 - Addendum 1 - Factual Report of Group ChairmanItem 16 · .PDF · 737 KBOperations 2 - Addendum 2 - Factual Report of Group Chairman - Interview with Barbara Carlson and Pam MockbeeItem 17 · .PDF · 52 KBOperations 2 - Addendum 3 - Factual Report of Group ChairmanItem 18 · .PDF · 706 KBOperations 2 - Addendum 4 - Factual Report of Group ChairmanItem 19 · .PDF · 1.3 MBATC 3 - Factual Report of Group ChairmanItem 20 · .PDF · 463 KBATC 3 - Attachment 1 - Preliminary Notice/Notification RecordItem 21 · .PDF · 164 KBATC 3 - Attachment 2 - FAA Report of Aircraft AccidentItem 22 · .PDF · 216 KBATC 3 - Attachment 3 - TranscriptsItem 23 · .PDF · 913 KBATC 3 - Attachment 4 - ATISItem 24 · .PDF · 111 KBATC 3 - Attachment 5 - Flight Tracks (NTSB + FAA Separation Log)Item 25 · .PDF · 425 KBATC 3 - Attachment 6 - Facility RecordsItem 26 · .PDF · 365 KBATC 3 - Attachment 7 - Personnel StatementsItem 27 · .PDF · 128 KBATC 3 - Attachment 8 - Flight StripItem 28 · .PDF · 55 KBATC 3 - Attachment 9 - SOP ExcerptsItem 29 · .PDF · 699 KBATC 3 - Attachment 10 - NOS ChartsItem 30 · .PDF · 165 KBATC 3 - Attachment 11 - Facility Layout DiagramItem 31 · .PDF · 48 KBATC 3 - Attachment 12 - Wake Turbulence Procedures, 7110.65Item 32 · .PDF · 432 KBATC 3 - Attachment 13 - Pirep Procedures, 7110.65Item 33 · .PDF · 338 KBATC 3 - Attachment 14 - Facility Manager's LetterItem 34 · .PDF · 41 KBWitness 4 - Group Chairman Factual ReportItem 35 · .PDF · 450 KBMeteorology 5 - Factual Report of Group ChairmanItem 36 · .PDF · 1.9 MBMeteorology 5 - Attachment 1 (Attachments A)Item 37 · .PDF · 1.7 MBMeteorology 5 - Attachment 2 (Attachments B)Item 38 · .PDF · 1.1 MBMeteorology 5 - Attachment 3 (Attachments C)Item 39 · .PDF · 889 KBMeteorology 5 - Attachment 4 (Attachments D)Item 40 · .PDF · 1.3 MBMeteorology 5 - Attachment 5 - (Attachments E)Item 41 · .PDF · 956 KBMeteorology 5 - Attachment 6 (Attachments F)Item 42 · .PDF · 1.0 MBMeteorology 5 - Attachment 7 (Attachments G)Item 43 · .PDF · 719 KBMeteorology 5 - Attachment 8 (Attachments H)Item 44 · .PDF · 553 KBMeteorology 5 - Attachment 9 (Attachments I)Item 45 · .PDF · 1.0 MBMeteorology 5 - Attachment 10 (Attachments J)Item 46 · .PDF · 1.3 MBMeteorology 5 - Attachment 11 (Attachments K)Item 47 · .PDF · 82 KBMeteorology 5 - Addendum 1 to Meteorological Factual ReportItem 48 · .PDF · 52 KBMeteorology 5 - Addendum 1 to Meteorological Factual Report - Attachment - LItem 49 · .PDF · 1.8 MBMeteorology 5 - Addendum II to Meteorological Factual Report - Weather Radar DataItem 50 · .PDF · 3.3 MBMeteorology 5 - Addendum III to Meteorological Factual Report - Information regarding the exhaust stack plume height of Detroit Edison's Monroe Power Plant exhaust stack plume are contained as Attachments 1-10Item 51 · .PDF · 514 KBMeteorology 5 - Addendum IV - A mesoscale meteorological review of the COMAIR 3272 crash of 9 January 1997 was prepared by scientists at the National Center for Atmospheric Research at the request of the NTSBItem 52 · .PDF · 3.6 MBMeteorology 5 - Addendum V - Mesoscale Analysis of the COMAIR-3272 Crash of 9 January 1997 (revised) by Ben C. Bernstein, National Center for Atmospheric ResearchItem 53 · .PDF · 1.9 MBMeteorology 5 - Addendum VI - Interview Summaries from the Captain and First Officer of Northeast Flight 272Item 54 · .PDF · 330 KBPowerplants 8 - Group Chairman Factual ReportItem 55 · .PDF · 1.5 MBPowerplants 8 - Photo 1. View of wreckage showing center crater and left and right engines and propellersItem 56 · .PDF · 39 KBPowerplants 8 - Photo 2. Left engine and propeller at crash siteItem 57 · .PDF · 44 KBPowerplants 8 - Photo 3. Right engine and propeller at crash siteItem 58 · .PDF · 53 KBPowerplants 8 - Photo 4. Left propeller blade tip fiberglass shell and foam coreItem 59 · .PDF · 44 KBPowerplants 8 - Photo 5. Left engine low pressure impeller leading edgeItem 60 · .PDF · 35 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.