January 27, 2009
NTSB Number: AAR-11-02
NTIS Number: PB2011-910402
Adopted April 26, 2011
Aerospatiale Alenia ATR 42-320, N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed.
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.
As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
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. (A-11-39)
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. (A-11-40)
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. (A-11-41)
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. (A-11-42)
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. (A-11-44)
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. (A-11-45)
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. (A-11-46)
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. (A-11-47)