NTSB Faults Pilots for Fatal Crash During Non-Precision Approach

The U.S. National Transportation Safety Board (NTSB) said the cause of a fatal crash at Kirksville, Missouri, was the pilots' failure to properly conduct a non-precision instrument approach, including a descent below the MDA (minimum descent altitude) before required visual cues were available.

The Board also cited the pilot's failure to adhere to the established division of duties between the flying and non-flying pilot.

On October 19, 2004, a Corporate Airlines BAE-J3201 Jetstream struck trees and crashed short of the Kirksville Regional Airport runway during a night non-precision instrument approach.  Instrument meteorological conditions were prevailing at the time of the accident.

The Board indicated that the pilots failed to follow established procedures to effectively monitor the airplane's descent rate and height above terrain during the later stages of the approach, and relied too much on minimal external visual cues.  Although descent rate and altitude information were readily available through cockpit instruments, both pilots were largely preoccupied with looking for the approach lights, according to the report.

Current regulations permitting pilots to descend below the MDA into a region where obstacle clearance is not assured may result in reduced margins of safety for non-precision approaches, the Board concluded, especially in conditions of low ceilings, reduced visibility, and/or at night, and that "these regulations can have the unintended effect of encouraging some pilots to descend below the MDA in an attempt to acquire visual cues that will permit them to continue the approach, as evident in this case."

The Board also said that the pilots' failed to maintain a professional demeanor during the flight, including nonessential conversation below 10, 000 feet that was contrary to established sterile cockpit regulations, and that they may have suffered from fatigue that might have caused them to "make risky, impulsive decisions, become fixated on one aspect of a situation, and react slowly to warnings or signs, which could result in an approach being continued despite evidence that it should be discontinued."

These are some of the main recommendations the Board made to the FAA as a result of its investigation:

• Principal operations inspectors of all Part 121 and 135 operators should reemphasize the importance of strict compliance with the sterile cockpit rule.

• All Part 121 and 135 operators should incorporate the constant-angle-of-descent technique into their non-precision approach procedures and to emphasize the preference for that technique where practicable.

• Part 121 and 135 regulations should be revised to prohibit pilots from descending below the minimum descent altitude during non-precision instrument approaches unless conditions allow for clear visual identification of all obstacles and terrain along the approach path or vertical guidance to the runway is available and being used.

A synopsis of the report, including a complete list of the conclusions and recommendations, can be found on the Board's Website at www.ntsb.gov.  01-29-2006.

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