Flugunfall 26 DEC 1989 einer British Aerospace 3101 Jetstream 31 N410UE

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Accident

Last updated: 19 May 2013

Status:	Schlussbericht
Datum:	26 DEZ 1989
Zeit:	22:30 PST
Flugzeugtyp:	British Aerospace 3101 Jetstream 31
Betrieben durch:	United Express
Gemietet von :	North Pacific Airlines - NPA
Kennzeichen:	N410UE
Werknummer:	776
Baujahr:	1987
Betriebsstunden:	4972
Anzahl Zyklen der Zelle:	7168
Triebwerk:	2 Garrett TPE331-10UG-514H
Besatzung:	Todesopfer: 2 / Insassen: 2
Fluggäste:	Todesopfer: 4 / Insassen: 4
Gesamt:	Todesopfer: 6 / Insassen: 6
Sachschaden:	Zerstört
Konsequenzen:	Written off (damaged beyond repair)
Unfallort:	Pasco-Tri-Cities Airport, WA (PSC) (USA)
Flugphase:	Annäherung (APR)
Betriebsart:	Inländischer planmäßiger Passagierflug
Flug von:	Yakima Air Terminal, WA (YKM/KYKM), USA
Flug nach:	Pasco-Tri-Cities Airport, WA (PSC), USA
Flugnummer:	2415

Unfallbericht:
United Express Flight 2415 took off from Seattle for a flight to Pasco via Yakima. While flying into Yakima, the flight encountered icing conditions. After landing, the first officer (together with a deadheading pilot) knocked ice of the wings. The NPA station agent at Yakima asked the captain if he wanted to deice the aircraft, or just the tail plane, since both pilots just removed the ice from the wings. The captain declined both offers.
The aircraft took off again at 22.03 using runway 27. Since Pasco tower was closing at 22:30, Seattle Center cleared the flight for an ILS runway 21R approach. At 22:30 the aircraft was observed descending fast from a higher than normal altitude. The aircraft suddenly nosed over and crashed short of the runway.

PROBABLE CAUSE: "The flight crew's decision to continue an unstabilized instrument landing system approach that led to a stall, most likely of the horizontal stabilizer, and loss of control at low altitude. Contributing to the accident was the air traffic controller's improper vectors that positioned the airplane inside the outer marker while it was still well above the glide slope. Contributing to the stall and loss of control was the accumulation of airframe ice that degraded the aerodynamic performance of the airplane."

Informationsquelle:
» NTSB Safety Recommendations A-94-70 through -72
» Ian Churchill
» NTSB Safety Recommendations A-92-59 through -65
» NTSB/AAR-91/06

Official accident investigation report

investigating agency:	National Transport Safety Bureau (NTSB) - USA
report status:	Final
report number:	NTSB/AAR-91-06
report released:	04-NOV-1991
duration of investigation:	678 days (1 year 10.4 months)
download report:	Unstabilized Approach and Loss of Controll NPA, Inc. dba United Express Flight 2415 British Aerospace BA-3101, N410UE, Tri-Cities Airport Pasco, Washington December 26, 1989. (NTSB/AAR-91-06)

Sicherheitsempfehlungen

NTSB issued 7 Safety Recommendations

Issued: 26-SEP-1990	To: FAA	A-90-133
IMMEDIATELY TERMINATE THE PRACTICE, AT THE SEATTLE AIR ROUTE TRAFFIC CONTROL CENTER, OF PROVIDING RADAR VECTORS TO THE FINAL APPROACH COURSE WHEN USING A RADAR DISPLAY SET TO AN EXPANDED RANGE AND WHEN USING A VIDEO MAP ON WHICH THE APPROACH GATE IS NOT DEPICTED. (Closed - Acceptable Action)
Issued: 26-SEP-1990	To: FAA	A-90-134
AT AIR ROUTE TRAFFIC CONTROL CENTERS THAT PROVIDE EN ROUTE SERVICE, IMMEDIATELY TERMINATE THE PRACTICE OF PROVIDING RADAR VECTORS TO THE FINAL APPROACH COURSE WHEN USING A RADAR DISPLAY SET TO AN EXPANDED RANGE AND WHEN USING A VIDEO MAP ON WHICH THE APPROACH GATE IS NOT DEPICTED. (Closed - Acceptable Action)
Issued: 19-NOV-1991	To: FAA	A-91-087
AMEND THE ICING CERTIFICATION RULES TO REQUIRE FLIGHT TESTS WHEREIN ICE IS ACCUMULATED IN THOSE CRUISE AND APPROACH FLAP CONFIGURATION IN WHICH EXTENSIVE EXPOSURE TO ICING CONDITIONS CAN BE EXPECTED, AND REQUIRE SUBSEQUENT CHANGES IN CONFIGURATION, TO INCLUDE LANDING FLAPS. (Closed - Acceptable Action)
Issued: 19-NOV-1991	To: FAA	A-91-088
REVIEW THE AIRRAME ICING CERTIFICATION DATA FOR EXISTING PART 23 AND PART 25 AIRPLANES TO VERIFY THAT THE FLIGHT PROFILES EXAMINED INCLUDED ICE ACCUMULATED AT THOSE CRUISE AND APPROACH FLAP CONFIGURATIONS IN WHICH EXTENSIVE EXPOSURE TO ICING CONDITIONS CAN BE EXPECTED, WITH SUBSEQUENT CHANGES IN CONFIGURATION, TO INCLUDE LANDING FLAPS. REQUIRE ADDITIONAL FLIGHT TESTS AS NECESSARY. (Closed - Acceptable Action)
Issued: 19-NOV-1991	To: FAA	A-91-089
REQUIRE MANUFACTURERS TO REVIEW THE PNEUMATIC DEICE BOOT SYSTEM DESIGNS FOR AIRCRAFT USED IN 14 CFR PARTS 121 AND 135, TO ENSURE THAT THE PNEUMATIC PRESSURE THEREHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT IS DESIGNED TO ILLUMINATE IS SUFFICIENT PRESSURE FOR EFFECTIVE PNEUMATIC DEICE BOOT OPERATION, AND ISSUE AIRWORTHINESS DIRECTIVES TO MODIFY SYSTEMS FOUND TO BE DEFICIENT IN THIS REGARD. (Closed - Acceptable Action)
Issued: 19-NOV-1991	To: FAA	A-91-090
REVISE ADVISORY CIRCULAR (AC) 20-73, "AIRCRAFT ICE PROTECTION," AND AC 23.1419-1, "CERTIFICATION OF SMALL AIRPLANES FOR FLIGHT IN ICING CONDITIONS," TO INCLUDED GUIDANCE FOR THE FULFILLMENT OF 14 CFR PARTS 23.1416(C) AND 25.1416(C) BY ENSURING THAT PNEUMATIC PRESSURE THRESHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT IS DESINGED TO ILLUMINATE IS SUFFICIENT PRESSURE FOR EFFECTIVE PNEUMATIC DEICE BOOT OPERATION. (Closed - Acceptable Alternate Action)
Issued: 19-NOV-1991	To: FAA	A-91-122
Issue an operations bulletin to the principal operations inspectors of 14 CFR 121 and Part 135 air carriers to verify that air carriers have established procedures for flightcrews to take appropriate actions when they have encountered icing conditions during a flight, to check for the presence of, and to rip airplanes of accumulated airframe ice prior to initiating final approach, in accordance with airplane manufacturers\' recommendations on the use of deice systems. (superseded by A-94-71) (Closed - Acceptable Action/Superseded)

Show all AD's and Safety Recommendations

Fotos

Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Yakima Air Terminal, WA to Pasco-Tri-Cities Airport, WA as the crow flies is 114 km (71 miles).

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