Controlled Collision with Terrain GP Express Airlines, Inc., Flight 861 A Beechcraft C99, N118GP

What Happened

​​On June 8, 1992, GP Express Airlines, Inc., flight 861, a Beechcraft model C99, Nl 18GP, crashed while maneuvering to land at the Anniston Metropolitan Airport, Anniston, Alabama. The flight was a scheduled passenger flight from the William B. Hartsfield Atlanta International Airport in Atlanta, Georgia, on an instrument flight rules flight plan to Anniston, Alabama. 

The captain and two passengers received fatal injuries. The first officer and two passengers were seriously injured. The airplane was destroyed by impact and postcrash fire. 

What We Found

​The investigation revealed that the flightcrew was properly certificated and qualified in accordance with applicable Federal Aviation Regulations (FARs) and company requirements, and that there was no evidence of adverse medical conditions that affected the flightcrew, nor were they under the influence of, or impaired by, drugs or alcohol. The investigation determined that the airplane had been properly maintained and that there was no evidence of a malfunction or preexisting problem that would have either caused or contributed to the accident. Additionally, it was determined that weather was not a factor in the accident. ​

We determined that the flightcrew experienced a loss of situational awareness that led to a controlled collision with terrain. After being cleared by air traffic control for the instrument landing system (Il.S) approach to runway 5 at Anniston, the flightcrew turned the airplane toward the north away from the airport in the erroneous belief that the airplane was south of the airport. The flightcrew did not petform the maneuvers specified on the approach chart, which required flying outbound from the airport, then petfonning the "procedure tum" back toward the airport. The investigation determined that in actuality, the airplane had intercepted the back course localizer signal for the ILS approach, and the flightcrew had commenced the approach at a high airspeed about 2,000 feet above the specified altitude for crossing the final approach fix. The airplane continued a controlled descent until it impacted terrain. 

We determined that the probable causes of this accident were the failure of senior management of GP Express to provide adequate training and operational support for the startup of the southern operation, which resulted in the assignment of an inadequately prepared captain with a relatively inexperienced first officer in revenue passenger service, and the failure of the flightcrew to use approved instrument flight procedures, which resulted in a loss of situational awareness and terrain clearance. 

Contributing to the causes of the accident was GP Express failure to provide approach charts to each pilot and to establish stabilized approach criteria. Also contributing were the inadequate crew coordination and a role reversal on the part of the captain and first officer. ​

What We Recommended

​​As a result of this investigation, the National Transportation Safety Board makes the following new safety recommendations​. 

​To the Federal Aviation Administration:

  • ​​​​Require that all pilots operating aircraft under 14 CFR Part 135 have access to their own set of instrument approach charts. (A-93-35) 
  • Require that scheduled air carriers operating under 14 CFR Part 135 develop and include in their flight operation manuals and training programs stabilized approach criteria. The criteria should include specific limits of localizer, glideslope, and VOR needle deflections and rates of descent, etc., near the airport, beyond which initiation of an immediate missed approach would be required. (A-93-36) 
  • Develop guidance and evaluation criteria for Principal Operations Inspectors , to use to ensure that airline cockpit resource management training programs adequately address crew interaction, ​decision-making processes, information gahering, flightcrew communication, and leadership skills. (A-93-37) 
  • For airlines that utilize contracted flight and ground training programs, require that pilots hired directly to be captains receive additional flight instruction pertaining to the operating environment and procedures unique to 􀁍e airline from an FAA-approved company check airman or instructor, rather than only from the contractor instructor. (A-93-38) 
  • ​Amend 14 CFR 135.243(c)(2) to require that the pilot-in-command of a commuter air carrier flight that requires two crewmembers have at least 100 hours of flight time or an equivalent level of training in commuter air carrier operations requiring two pilots. (A-93- 39) 

Previously Issued Recommendations Reiterated in This Report

  • ​​​​Establish minimum experience levels for each pilot-in-command and second-in-command pilot, and require the use of such criteria to prohibit the pairing on the same flight of pilots who have less than the minimum experience in their respective positions. (A-88-137) 
  • Require that scheduled 14 CFR Part 135 operators develop and use Cockpit . Resource Management programs in their training methodology by a specified date. (A-90-135) 

Video

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

​​​​​​ ​
​
​