On October 26, 1993, about 1552, N82, a Beech Super King Air 300/F, owned by the Federal Aviation Administration and operated by the Atlantic City, New Jersey, Flight Inspection Area Office, was destroyed when it crashed into mountainous terrain near Front Royal, Virginia. The three flight crewmembers aboard received fatal injuries.
We determined that the probable causes of this accident were the failure of the pilot-in-command to ensure that the airplane remained in visual meteorological conditions over mountainous terrain, and the failure of Federal Aviation Administration executives and managers responsible for the FAA flying program to:
- establish effective and accountable leadership and oversight of flying operations;
- establish minimum mission and operational performance standards;
- recognize and address performance-related problems among the organization's pilots; and
- remove from flight operations duty pilots who were not performing to standards.
As a result of this investigation, we made the following recommendations:
To the Federal Aviation Administration:
- Provide direct line authority to the executives and managers responsible for the management and oversight of the FAA flying program to ensure safety oversight and accountability of the program equal to that required of the air carrier industry by the FAA. (A-94-84)
- Establish minimum standards of operational experience for managers and executives who are identified as responsible for the management or oversight of the FAA flying program. (A-94-85)
- Establish inspection procedures of sufficient depth and scope that will reveal noncompliance with directives and the fundamental principles of flight safety. The procedures should include CMO-approved pilot flight check standards for the FAA flying program, overseen from the AVN Director's level. Such a system should include a central pilot record repository and a central check ainnen pool. Provide methodology and implement a plan to retrain, reassign or dismiss pilots who cannot meet the performance standards. (A-94-86)
- Improve criteria to specify the operational and maintenance-related incidents that are required to be reported to a central A VN authority; and implement procedures to verify that all incidents meeting such criteria are being reported as required. (A-94-87)
- Develop and implement a program guaranteeing tpat personnel who bring safety-related concerns to the attention of management can do so without fear of retribution, and with the assurance that such concerns will be addressed thoroughly and impartially. (A-94-88)
- Equip FAA-owned aircraft with state-of-the-art flight recorders and ground proximity warning systems at the earliest practicable opportunity. (A-94-89)
- For the purpose of mission management, establish formal mission briefing and debriefing requirements for FAA flying operations that involve an operations supervisor, the PIC, and all crewmembers. (A-94-90)
- Stipulate specific training and certification standards required of a substance abuse specialist, and specify the nature of the procedures required for the examination by such a specialist, similar to training and certification standards and examinations used in the air carrier industry, before his/her evaluation will be accepted by the FAA in its decision to issue an airman medical certificate. (A-94-91)