In closing, I want to recognize the NTSB staff for their hard work in
developing and presenting this excellent safety report. Investigator-in-Charge
Dan Bower and his team did a thorough job of comprehensively addressing the many
facts surrounding this crash.
I also want to thank my fellow Board Members for their very helpful
participation in the process.
As you have heard here today, steps could have been taken to lessen the
likelihood of this accident. For example, the first officer could have taken
advantage of available off-duty rest time. The dispatcher could have
communicated several key safety concerns about the planned approach. The pilot
could have gone around when the planned approach could not be executed.
But ultimately the accident was caused by the continuation of an approach
that was not stabilized.
The recommendations that we voted on today will address many opportunities
If acted upon, they will result in better access to terrain awareness and
warning systems for future pilots, annual joint training for pilots and
dispatchers to reinforce the need for better communication, and, most
importantly, the end of "dive-and-drive" non-precision approaches.
We have also recommended that FAA principal operations investigators review
operator guidance and training material for clear language requiring that an
approach be abandoned if it is not stabilized by the final approach fix.
An unstabilized approach is a less safe approach.
Although this flight crew faced some challenges, they failed to take several
important actions during their approach. They failed to monitor their altitude
and communicate their respective actions during the approach. And at the crucial
moment, the captain failed to discontinue the unstabilized approach and
Air transportation is as safe as it is today largely because rigorous
aviation safety practices have been developed out of respect for the inherently
unforgiving nature of flight.
We hope that the recommendations adopted today will help to reinforce the
continuing need for that rigor.
We stand adjourned.