Beschrijving:
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
| Status: | Accident investigation report completed and information captured |
| Datum: | vrijdag 7 januari 1994 |
| Tijd: | 23:21 |
| Type: |  British Aerospace 4101 Jetstream 41 |
| Operated by: | Atlantic Coast Airlines |
| On behalf of: | United Express |
| Registratie: | N304UE |
| Constructienummer: | 41016 |
| Bouwjaar: | 1993 |
| Aantal vlieguren: | 1069 |
| Motoren: | 2 Garrett TPE331-14 |
| Bemanning: | slachtoffers: 3 / inzittenden: 3 |
| Passagiers: | slachtoffers: 2 / inzittenden: 5 |
| Totaal: | slachtoffers: 5 / inzittenden: 8 |
| Schade: | Vernield |
| Gevolgen: | Written off (damaged beyond repair) |
| Plaats: | 1,9 km (1.2 mijl) E of Columbus-Port Columbus International Airport, OH (CMH) ( Verenigde Staten)
|
| Fase: | Nadering (APR) |
| Soort vlucht: | Binnenlandse lijnvlucht |
| Vliegveld van vertrek: | Washington-Dulles International Airport, DC (IAD/KIAD), Verenigde Staten |
| Columbus-Port Columbus International Airport, OH (CMH/KCMH), Verenigde Staten | |
| Vluchtnummer: | 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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Bronnen:
» ICAO Adrep Summary 3/95 (#47)» NTSB Safety Recommendations A-94-67 through -69
» NTSB/AAR-94/07
Veiligheidsmaatregelen
NTSB issued 7 Safety Recommendations
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ground track
Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Washington-Dulles International Airport, DC en Columbus-Port Columbus International Airport, OH bedraagt 478 km (299 miles).
Accident location: Exact; as reported in the official accident report.
De afstand tussen Washington-Dulles International Airport, DC en Columbus-Port Columbus International Airport, OH bedraagt 478 km (299 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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