Flugunfall 27 JAN 2009 einer ATR-42-320 N902FX - Lubbock Preston Smith International Airport, TX (LBB)

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Accident

Last updated: 18 May 2013

Status:	Schlussbericht
Datum:	27 JAN 2009
Zeit:	04:37
Flugzeugtyp:	ATR-42-320
Betrieben durch:	Empire Airlines
Gemietet von :	FedEx
Kennzeichen:	N902FX
Werknummer:	175
Baujahr:	1990
Betriebsstunden:	28768
Anzahl Zyklen der Zelle:	32379
Triebwerk:	2 Pratt & Whitney Canada PW121
Besatzung:	Todesopfer: 0 / Insassen: 2
Fluggäste:	Todesopfer: 0 / Insassen: 0
Gesamt:	Todesopfer: 0 / Insassen: 2
Sachschaden:	Zerstört
Konsequenzen:	Written off (damaged beyond repair)
Unfallort:	Lubbock Preston Smith International Airport, TX (LBB) (USA)
Flugphase:	Landung (LDG)
Betriebsart:	Frachtflug
Flug von:	Fort Worth Alliance Airport, TX (AFW/KAFW), USA
Flug nach:	Lubbock Preston Smith International Airport, TX (LBB/KLBB), USA
Flugnummer:	8284

Unfallbericht:
Empire Airlines flight CFS8284 departed Fort Worth Alliance Airport, TX (AFW) at 03:21 CST on a cargo flight to Lubbock Preston Smith International Airport, TX (LBB). Weather at Lubbock was poor with an overcast at 500 feet, freezing drizzle and mist.
The aircraft encountered icing conditions while en route to Lubbock. And although the airplane accumulated some ice during the flight that degraded its performance, the NTSB determined that the aircraft could have landed safely had the airspeed been maintained.
During the approach to Lubbock runway 17R, at about 1400 feet above the ground and about 90 seconds from the runway, the captain indicated a flight control problem saying, "We have no flaps." Although the crewmembers had been trained to perform a go-around and refer to a checklist if a flap problem occurred during an approach, the captain chose to continue the approach as he attempted to troubleshoot the flap anomaly while the first officer flew the plane. Neither flight crewmember adequately monitored the airspeed, which decayed to the extent that the stick shaker activated, which warned of an impending aerodynamic stall.
The captain continued the unstabilized approach even though he received additional stick shaker activations and an aural "pull up" warning from the terrain awareness and warning system (TAWS). At that point, the plane was descending at a rate of over 2,000 ft per minute.
Although procedures for responding to either the stick shaker or the TAWS warning require the immediate application of maximum engine power, the captain did not apply maximum power until 17 seconds after the TAWS warning. Seconds after maximum power was applied, the airplane entered an aerodynamic stall and crashed.

Weather about the time of the accident (10:37 UTC) was reported as:
KLBB 270953Z 01014KT 3SM -FZDZ BR OVC005 M08/M09 A3013 RMK AO2 PRESRR SLP227 P0000 T10781094=
(03:53 CST: wind at 10 degrees, 14 kts, visibility 3 miles in mist and freezing drizzle, ceiling 500 feet overcast, temperature -7.8 deg C, dewpoint -9.4 deg C)
KLBB 271053Z 02011G18KT 2SM -FZDZ BR OVC005 M08/M09 A3013 RMK AO2 CIG 004V009 SLP228 P0000 T10781094=
(04:53 CST: wind at 20 degrees, 11 kts gusting to 18 kts, visibility 2 miles in mist and freezing drizzle, ceiling 500 feet overcast, temperature -7.8 deg C, dewpoint -9.4 deg C)

PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were 1) the flight crew's failure to follow published standard operating procedures in response to a flap anomaly, 2) the captain's decision to continue with the unstabilized approach, 3) the flight crew's poor crew resource management, and 4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain's performance."

Informationsquelle:
» NTSB

Official accident investigation report

investigating agency:	National Transport Safety Bureau (NTSB) - USA
report status:	Final
report number:	NTSB/AAR-11-02
report released:	26-APR-2011
duration of investigation:	819 days (2 years 3 months)
download report:	Crash During Approach to Landing Empire Airlines Flight 8284 Avions de Transport Regional Aerospatiale Alenia ATR 42-320, N902FX (NTSB/AAR-11-02)

Sicherheitsempfehlungen

NTSB issued 13 Safety Recommendations

Issued: 18-MAY-2011	To: FAA	A-11-39
Require that role-playing or simulator-based exercises that teach first officers to assertively voice their concerns and that teach captains to develop a leadership style that supports first officer assertiveness be included as part of the already required crew resource management training for 14 Code of Federal Regulations Part 121, 135, and 91 subpart K pilots.
Issued: 18-MAY-2011	To: FAA	A-11-40
Prohibit all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators of pneumatic deice boot-equipped airplanes from dispatching or deliberately operating these airplanes in known freezing rain or freezing drizzle of any intensity, unless the airplane manufacturer has demonstrated that the airplane model can safely operate in those conditions.
Issued: 18-MAY-2011	To: FAA	A-11-41
Review the approved pilot, dispatcher, and flight follower training programs and procedures for all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and require revisions to the programs and procedures, as necessary, to include standardized training and aircraft-specific information to educate pilots, dispatchers, and flight followers of the dangers of flight operations in freezing precipitation and of the differences between ground deicing considerations and in-flight icing operations.
Issued: 18-MAY-2011	To: FAA	A-11-42
Develop a method to quickly communicate information regarding the number of persons on board and the presence of hazardous materials to emergency responders when airport emergency response or search and rescue is activated
Issued: 18-MAY-2011	To: FAA	A-11-43
Amend Advisory Circular 150/5200-30C to include guidance on monitoring and ensuring the operability of emergency response and mutual aid gates during winter operations. (A-11-43) Require all operators of Avions de Transport Régional Aerospatiale Alenia ATR 42- and ATR 72-series airplanes to retrofit the airplanes with an aircraft performance monitoring system if they are not already so equipped.
Issued: 18-MAY-2011	To: FAA	A-11-44
Require all operators of Avions de Transport Régional Aerospatiale Alenia ATR 42- and ATR 72-series airplanes to retrofit the airplanes with an aircraft performance monitoring system if they are not already so equipped.
Issued: 18-MAY-2011	To: FAA	A-11-45
Require all Avions de Transport Régional Aerospatiale Alenia ATR 42-series airplanes to be equipped with a flap asymmetry annunciator light if they are not already so equipped.
Issued: 18-MAY-2011	To: FAA	A-11-46
Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents.
Issued: 18-MAY-2011	To: FAA	A-11-47
Once the simulator model fidelity requirements requested in Safety Recommendation A-11-46 are implemented, require that flight crews of all aircraft certificated for flight in icing conditions be trained in flight training simulators that meet these fidelity requirements. Such simulation training should emphasize the following: (1) cues for recognizing changes in the aircraft\'s flight characteristics as airframe icing develops; (2) procedures for monitoring and maintaining appropriate airspeeds in icing conditions, including the use of icing airspeed reference indices; and (3) procedures for responding to decaying airspeed situations, stall protection system activation, and early stalls that can occur without stall protection system activation.
Issued: 26-JUN-2012	To: FAA	A-12-24
Require that Avions de Transport Régional (ATR) 42-series airplanes operating in the United States incorporate a revised stick pusher activation angle of attack (AOA), such that the stick pusher activates before the stall AOA in the presence of airframe ice accretions.
Issued: 26-JUN-2012	To: FAA	A-12-25
Evaluate all U.S.-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.
Issued: 26-JUN-2012	To: EASA	A-12-26
Require Avions de Transport Régional (ATR) to revise the stick pusher’sactivation angle of attack (AOA) on ATR 42-series airplanes to ensure that the stick pusher activates before the stall AOA in the presence of airframe ice accretions.
Issued: 26-JUN-2012	To: EASA	A-12-27
Evaluate all European Aviation Safety Agency-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.

Show all AD's and Safety Recommendations

Fotos

N15827 was converted to cargo plane and bought by FedEx as N902FX in May 2003

Video/animation

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 Fort Worth Alliance Airport, TX to Lubbock Preston Smith International Airport, TX as the crow flies is 422 km (264 miles).

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