Accident Information:
Date of the accident: January 27, 2009
Time of the accident: 0437 U.S local time
Flight Origin: Fort Worth Alliance Airport, Fort Worth, Texas
Destination: Lubbock Preston Smith International Airport (LBB), Lubbock, Texas
Location of accident: 200feet off the runway centre line at Lubbock Preston Smith International Airport, Lubbock, Texas
Airline: Empire Airlines Flight 8284
Type of aircraft: ATR 42-320
Aircraft registration: N902FX
Owner of aircraft: It was registered to FedEx Corporation
Passengers on board: 0
Flight crew: 2
Fatality injuries: 0
Survivors: 2
Cause of accident: Pilot error.
Accident summary:
On January 27, 2009, an ATR 42-320 operated as Empire Airlines flight 8284, crashed short at the runway of Lubbock Preston Smith International Airport (LBB) in Texas. The aircraft was registered to FedEx Corporation, it was operated by Empire Airlines as a cargo flight. There were two flight crew members on board with no passengers. The crash has caused the 52 year-old captain and 26 year-old first officer suffered serious and minor injuries respectively. The plane took off at Fort Worth Alliance Airport (AFW) and was flying to Lubbock Preston Smith International Airport (LBB) in Texas. It was operated under instrument flight rules (IFR).
The NTSB determines the cause of crash is due to pilot error. The flight crew failed to monitor and maintain a minimum safe airspeed whilst performing an instrument approach in icing conditions, which resulted stalling at low altitude. 1. The pilots did not follow standard operating procedures when experiencing a flap anomaly. 2. The captain made a wrong decision to continue the unstabilized approach. 3. The pilots were lack of crew resource management. 4. Fatigue is a potential factor that affected the captain’s decision making.
Investigation Outline:
- Examine aircraft wreckage
- Examine the flight crew’s medical and health information
- Interview with the captain and first officer of the crash
- Analyse the ATR 42 flap system
- Analyse the anti-icing system
- Analyse the airspeed indicator
- Analyse autopilot system (When stall warning occurred, the captain did not hear the sound notification when autopilot was disengaged.)
- Analyse stall protection system
- Analyse meteorological Information
- Examine maintenance history
- Examine Empire Airlines pilot procedures and training
(Crew resource management training, and stall recovery training is provided at Empire Airlines.)
Investigation Operations:
- Analyse the flight crew’s sleep opportunities
The time when the flight was operated was in late evening. Their workload increased when they were experiencing the problem of flaps. Fatigue could
be the factor which affected their decision making.
- Analyse the ATR 42 flap system
(Ice was found at the separated outboard section of the right aileron, which explained the result of an increase in stall speed of Flight 8284)
- Analyse the anti-icing system
- Analyse the airspeed indicator
- Evaluate cockpit voice recorder
- Perform simulator evaluation and further study of the aircraft performance
(Simulate flap asymmetry situation.)
Human performance involved in this accident:
- Take-offs and landings are two high workload flight phase for pilots. Performing these tasks in emergency situations involves with increase effort and workload, therefore increases stress, human cognitive limitations. According to the analysis of NTSB findings, inherent limitations in cognitive processes and stress could decrease the level of performance, narrowing of attention and impairment of short-term memory.
- When captain declared “no flaps” and acknowledged the flap anomaly, there was no further action to be taken regarding this this problem. The first officer stated she was concerned about the captain’s action but did not verbalise her concerns.
- The flight crew failed to monitor airspeed. The failure of monitoring airspeed demonstrates the importance of active monitoring skills, which was found not specified in the flight crew’s CRM training.
- CRM deficiency. The captain did not provide enough leadership to response to flap anomaly. He did not communicate with his first officer and did not address his intention for solutions, instead he followed with his own plan without informing his first officer.
- Fatigue consideration. The accident happened at 0437, which was during their normal circadian rhythm. The crew’s failure to monitor airspeed could be the effect of fatigue. The captain’s repeated error and foregoing procedures could also be the degrading effects of fatigue.
Recommendations to FAA:
- Require training to first officers to raise their concerns and leadership training to captains through role-play and simulator-based exercises.
- Review the training programs and procedures for pilots, dispatchers, and flight followers and educate them regarding to the dangers of flight operations in freezing conditions and ground deicing and in-flight icing operations.
- Develop an active communicating method to present information such as the number of persons on board, hazardous materials to emergency
responders when airport emergency response or search and rescue is activated.
- Provide guidance in monitoring and ensuring the operability of emergency facilities and aids in winter operations.
- Advise all ATR 42 and ATR 72 aircraft to be equipped with an aircraft performance monitoring system.
- Advise all ATR 42 aircraft to be equipped with a flap asymmetry annunciator light.
Want to know more?
Aircraft Accident Report: Crash During Approach to Landing. Empire Airlines Flight 8284. NTSB/AAR-11/02. PB2011-910402.
For pictures and more information about the crash, refer to NTSB accident report: NTSB/AAR-11/02. PB2011-910402
