Accidents & Incidents Week Ending 17 Nov 2003

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NTSB Cites Flight Crew Failures in Crash of Airplane Carrying Senator Wellstone, 7 Others

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Washington, DC (18 Nov 03) - The National Transportation Safety Board today determined that the probable cause of the crash late last year of a Raytheon (Beechcraft) King Air 100 airplane, carrying Senator Paul Wellstone and seven others, was the "flight crew's failure to maintain adequate airspeed, which led to an aerodynamic stall from which they did not recover."

The airplane, operated by Aviation Charter, Inc., was on a flight from St. Paul to Eveleth, MN, when it crashed, on October 25, 2002, on approach to the Eveleth-Virginia Municipal Airport.  The airplane was destroyed and there were no survivors.

"This tragic accident that took the lives of a respected U.S. Senator, members of his family, staff, and the flight crew, shocked us all," said NTSB Chairman Ellen G. Engleman.
 "It sadly and starkly points out the need for more aggressive action to improve safety in the on-demand charter industry."

Reviewing the results of the extensive investigation into this accident, NTSB Members concluded that the flight crew failed to maintain an appropriate course and speed for the
approach to Eveleth and did not properly configure the airplane at the start of approach procedures.

"During the later stages of the approach," the Board said, the flight crew "failed to monitor the airplane's airspeed and allowed it to decrease to a dangerously low level (as low as about 50 knots below the company's recommended approach speed) and to remain below the recommended approach speed for about 50 seconds."  The airplane then entered a
stall from which it did not recover.

The Board judged that while cloud cover might have prevented the flight crew from seeing the airport, icing did not affect the airplane's performance during the descent.  Cockpit instrument readings on course alignment and airspeed should have prompted the flight crew to execute a go-around.

The Board did not find indications of any preexisting medical or other physical condition that might have adversely affected the crew's performance during the accident flight.  Crew fatigue also does not appear to have been a factor in the accident. A review of flight crew records and interviews with co-workers, the Board said, indicated that both pilots had "previously demonstrated serious performance deficiencies consistent with below-average flight proficiency."  There was no clear evidence as to which crewmember was the flying pilot at the time of the accident.

The Board determined that the accident airplane was properly certificated, equipped and maintained in accordance with Federal regulations.  The recovered components showed no
evidence of preexisting powerplant, system or structural failures.

The Board also concluded that the out-of-tolerance condition and slight bends in the Eveleth-Virginia airport VOR signal were not a factor in this accident.

With respect to the operator, the Board found that Aviation Charter, Inc., was not making crewmembers sufficiently aware of its Standard Operating Procedures, and also cited the
company's failure to provide adequate stall recovery guidance.  Further, the company was not training its pilots in crew resource management in accordance with its FAA-approved training program.  Consequently, the Board recommended that the FAA make such training mandatory for Part 135 on-demand charter companies that conduct dual-pilot operations.

The Board, noting that FAA surveillance of Aviation Charter, Inc., was not sufficient to detect the discrepancies that existed at the company, recommended that the agency conduct en route inspections and observe training and proficiency checks at all Part 135 on-demand charter operations, as is done at Part 121 and Part 135 commuter operations, to ensure the adequacy, quality and standardization of pilot training and flight operations.

Additionally, the Board recommended that the FAA convene a panel of experts to determine the feasibility of a requirement for the installation of low-airspeed alert systems in airplanes engaged in commercial operations under Parts 121 and 135, and act accordingly on the panel's findings.

A synopsis of the accident investigation report, including the findings, probable cause, and safety recommendations, can be found on the Publications page of the Board's web
site, http://www.ntsb.gov.  The complete report will be available in about six weeks.