Détails:
Flight 6291 departed Washington-Dulles for a 90-minute flight to Columbus. At 23:10 Columbus Approach Control was contacted, advising the controller that the flight was descending through 13200 feet for 11000 feet. The crew were then assigned a 285 degree heading to intercept the ILS for runway 28L and was cleared for 10000 feet. An updated weather report was received five minutes later, reading a measured ceiling 800 feet overcast, visibility 2,5 miles in light snow and fog with wind 300 deg. at 4 knots. A runway 28L ILS approach clearance was given when the flight passed the SUMIE final approach fix. A clearance to land on 28L was given two minutes later. The aircraft was descending through ca 1250 feet msl (runway elevation 814 feet msl) when the stick shaker activated and sounded for 3 seconds and continued again after 1,5 seconds The aircraft continued to descend below the glide slope until it collided with a stand of trees in a high nose-up attitude, coming to rest upright in a commercial building, 1,2 miles short of the runway. The aircraft burst into flames.
PROBABLE CAUSES: "(1) An aerodynamic stall that occurred when the flight crew 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) Flight crew experience in 'glass cockpit' automated aircraft, aircraft type and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots; and (4) the company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria.
Member Vogt concluded that the last factor was contributory but not causal to the accident. Additionally, for the following two factors, Chairman Hall and Member Lauber concluded that they were causal to the accident, while Members Vogt and Hammerschmidt concluded they were contributory to the accident:
(5) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training; and (6) the unavailability of suitable training simulators that precluded fully effective flight crew training."
» NTSB Safety Recommendations A-94-67 through -69
» NTSB/AAR-94/07
ground track
| Statuts: | Accident investigation report completed and information captured |
| Date: | vendredi 7 janvier 1994 |
| Heure: | 23:21 |
| Type/Sous-type: |  British Aerospace 4101 Jetstream 41 |
| Operated by: | Atlantic Coast Airlines |
| On behalf of: | United Express |
| Immatriculation: | N304UE |
| Numéro de série: | 41016 |
| Année de Fabrication: | 1993 |
| Heures de vol: | 1069 |
| Moteurs: | 2 Garrett TPE331-14 |
| Equipage: | victimes: 3 / à bord: 3 |
| Passagers: | victimes: 2 / à bord: 5 |
| Total: | victimes: 5 / à bord: 8 |
| Dégats de l'appareil: | Détruit |
| Conséquences: | Written off (damaged beyond repair) |
| Lieu de l'accident: | 1,9 km (1.2 milles) E of Columbus-Port Columbus International Airport, OH (CMH) ( Etats-Unis d'Amérique)
|
| Phase de vol: | En approche (APR) |
| Nature: | Transport de Passagers Nat. |
| Aéroport de départ: | Washington-Dulles International Airport, DC (IAD/KIAD), Etats-Unis d'Amérique |
| Columbus-Port Columbus International Airport, OH (CMH/KCMH), Etats-Unis d'Amérique | |
| Numéro de vol: | 6291 |
Flight 6291 departed Washington-Dulles for a 90-minute flight to Columbus. At 23:10 Columbus Approach Control was contacted, advising the controller that the flight was descending through 13200 feet for 11000 feet. The crew were then assigned a 285 degree heading to intercept the ILS for runway 28L and was cleared for 10000 feet. An updated weather report was received five minutes later, reading a measured ceiling 800 feet overcast, visibility 2,5 miles in light snow and fog with wind 300 deg. at 4 knots. A runway 28L ILS approach clearance was given when the flight passed the SUMIE final approach fix. A clearance to land on 28L was given two minutes later. The aircraft was descending through ca 1250 feet msl (runway elevation 814 feet msl) when the stick shaker activated and sounded for 3 seconds and continued again after 1,5 seconds The aircraft continued to descend below the glide slope until it collided with a stand of trees in a high nose-up attitude, coming to rest upright in a commercial building, 1,2 miles short of the runway. The aircraft burst into flames.
Probable Cause:
PROBABLE CAUSES: "(1) An aerodynamic stall that occurred when the flight crew 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) Flight crew experience in 'glass cockpit' automated aircraft, aircraft type and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots; and (4) the company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria.
Member Vogt concluded that the last factor was contributory but not causal to the accident. Additionally, for the following two factors, Chairman Hall and Member Lauber concluded that they were causal to the accident, while Members Vogt and Hammerschmidt concluded they were contributory to the accident:
(5) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training; and (6) the unavailability of suitable training simulators that precluded fully effective flight crew training."
Accident investigation:
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Sources:
» ICAO Adrep Summary 3/95 (#47)» NTSB Safety Recommendations A-94-67 through -69
» NTSB/AAR-94/07
Opérations de secours
NTSB issued 7 Safety Recommendations
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Photos
ground track
Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Washington-Dulles International Airport, DC et Columbus-Port Columbus International Airport, OH est de 478 km (299 miles).
Accident location: Exact; as reported in the official accident report.
La distance entre Washington-Dulles International Airport, DC et Columbus-Port Columbus International Airport, OH est de 478 km (299 miles).
Accident location: Exact; as reported in the official accident report.
Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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