On January 7, 1994, about 2321 eastern standard time, a Jetstream 4101, registration N304UE, operated by Atlantic Coast Airlines, Sterling, Virginia, and doing business as United Express flight 6291, crashed 1.2 nautical miles east of runway 28L at Port Columbus International Airport, Columbus, Ohio.
The airplane was being operated as a regularly scheduled commuter flight under 14 Code of Federal Regulations, Part 135, from Washington Dulles International Ahport, Chantilly, Virginia, to Columbus, Ohio. The flight had been cleared for an instrument landing system approach to runway 28L and was in contact with the local tower controller when it crashed into a storage warehouse. The pilot, copilot, flight attendant, and two passengers were fatally injured. Two of the other three passengers received minor injuries, while the third was not injured. The airplane was destroyed. lnstrument meteorological conditions prevailed at the time, and the airplane was on an instrument flight rules flight plan.
We determined that the probable causes of this accident to be:
- An aerodynamic stall that occurred when the flightrrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence of procedural discipline;
- Improper pilot response to the stall warning, including fai!ure to advance the power levers to maximum, and inappropriately raising the flaps:
- Flightcrew inexperience in "glass cockpit" automated aircraft, aircraft type, and in seat position, a situation excerbated by a side letter of agreement between the company and its pilots; and
- The company's failure to provide adequate stabilized approach criteria, and the Federal Aviation Adrninistration 's failure to require such criteria.
As a reult of this investigation, we made the following recommendations:
to the Federal Aviation Administration:
- Immediately notify all operators of the safety board's finding, including the u.s. department of defense and foreign governments, and require all operators whose aircraft have the affected pacific scientific safety belt buckles to inform passengers and crewmembers about the need to align the buckle insert to assure easy release of the safety belts. (A-94-67)
- Issue an airworthiness directive to require the removal and replacement of all safety belts manufactured by pacific scientific for part number 1108435 buckles, with the 45 degrees lift levers, and part number 1108460 buckles with the 90 degrees lift levers, with belts having buckles of a different design as expeditiously as possible, consistent with the availability of replacement buckles. (A-94-068)
- Amend TSO-C22F to incorporate procedures which place material representative of soft abdominal tissue between the test apparatus and the release buckle to ensure that safety belts can be released when subjected to loads specified in the TSO. (A-94-069)
- Conduct an in-depth review of its policies and procedures for the processing of ACOBs, and develop a system to ensure that the safety information contained is acted on in a timely and accurate manner. the system should include a process to verify that the actions contemplated by the ACOM are effectively implemented. (A-94-070)
- Issue immediate guidance to all pois to verify that the intended safety-related actions contained in ACOB 8-93-4 have been accomplished for air carrier under their jurisdiction. (supersedes safety recommendations a-91-122, a-92-059 through a-92-061) (A-94-071)
- Take the appropriate actions to verify that ACOBs issued in the past few years have been implemented as intended. (A-94-072)
- Ensure that the training programs for 14 Code of Federal Regulations Part 135 pilots place an increased emphasis on stall warning recognition and recovery techniques, to include stick shaker and stick pusher during training. (A-94-173)
- Ensure that all Part 135 operators that incorporate both a high speed approach profile and a coupled approach profile in the training manual for all airplanes train pilots to proficiency for those approach profiles. (Class II, Priority Action) (A-94-174)
- Ensure that Atlantic Coast Airlines trains its flightcrews in approved high speed approach techniques, similar to the manufacturer's airplane flight manual. The present procedures show a nonnal stabilized approach procedure, but the pilots typically fly faster to keep up with jet traffic and therefore do not fo1low their own procedures, (Class II, Priority Action) (A-94-175)
- Immediately issue an emergency airworthiness directive infonning all operators and affected parties, including the U. S. Department of Defense and foreign governments, of the Safety Board's findings, and require an operators whose aircraft have the affected Pacific Scientific safety belt buckles to inform passengers and crewmembers before each flight about the need to align the buckle insert when lifting the buckle release lever to ensure easy release of the safety belts. (A-94-176)
