On December 1, 1993, Express 11 flight 5719, a Jetstream BA-3100, Rgistration N334PX, was operating as a regularly scheduled flight under 14 Code of Federal Regulations, Part 135, from Minneapolis/St. Faul International Airport, St. Paul, Minnesota, to International Falls, Minnesota, with an en route stop at Ebbing, MN. The flight was operated by Express Airlines II, Inc., under the terms of a marketing agreemeat with Northwest Airlines, hc., as Northwest Airlink.
About 1950 central standad time, the airplane collided with terrain while on the localizer back course approach to runway 13 at Ebbing. The 2 flightcrew members and alI 16 passengers were fatally injured in the accident. The airplane was destroyed.
We determined that the probable causes of this accident were the captain's actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flightcrew during an unstabilized approach in night instrument meteorological conditions.
Contribu:ing to the accident were:
- The failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource managzment of the captain;
- the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures; and
- the Federal Aviation Administration's inadequate surveillance and oversight of the air carrier.
As a result of this investigation we made the following mxxnmendations:
To the Federal Aviation Administration:
- Develop specific guidance for the evaluation and oversight of contract training programs used by air carriers and incorporate such guidance into FAA Order 8400.10 for FAA principal inspectors to use in approving training programs. (A-94-113)
- Issue an Air Carrier Operations Bulletin directing principal operations inspectors advise air carriers to reemphasize in pilot training materials the necessity for adhering to the maximum descent rate of 1,0OO feet per minute after passing the final approach fix, regardless ofthe existence of icing conditions. (A-94- 1 14)
- Based on the circumstances and findings of the investigation of the Express II Airlines accident at Hibbing. Minnesota, on December 1, 1993. develop a clear and specific directive to Flight Standards inspectors and managers that emphasizes the need for compliance with existing FAA Orders, Directives, and other guidance material during the certification and surveillance of commuter air carriers. (A-94- 1 15)
- Issue an Airworthiness Directive requiring operators of two pilot airplanes, inciuding the Jetstream 31001J200, presently equipped with only the left wing ice observation light to install a right wing ice observation light. (A-94-116)
- Amend 14 CFR Part 23.1419, Section (d), to require that airplanes certificated for two-pilot operation be configured with ice observation lights illuminating both wings. (A-94-117)
As a result of this investigation, we reiterated Safety Recommendation
A-93-35:
- Require that all pilots operating aircraft under 14 CFR 135 have access to their own set of instrument approach charts.