1985 — Sep 23, Henson Airlines 1517 approach crash, Hall Mt. (near Staunton), VA — 14

— 14  NTSB. AAR. Henson Airlines Flight 1517…Grottoes, Virginia, Sept 23, 1985. 1986, p. i.

— 14  Daily News-Record, Harrisonburg, VA. “14 Die in Henson Crash.” 9-24-1985, p. 13.

 

Narrative Information

 

NTSB Synopsis: “Henson Airlines Flight 1517, a Beech B99, was cleared for an instrument approach to the Shenandoah Valley Airport, Weyers Cave, Virginia,[1] at 0959 on September 23, 1985, after a routine flight from Baltimore-Washington International Airport, Baltimore, Maryland. Instrument meteorological conditions prevailed at Shenandoah Valley Airport. There were 12 passengers and 2 crewmembers aboard the scheduled domestic passenger flight operating under 14 CFR 135. Radar service was terminated at 1003. The crew of 1517 subsequently contacted the Henson station agent and Shenandoah UNICOM. The last recorded radar return was at 1011, at which time the airplane was east of the localizer course at 2,700 feet mean sea level… At 1014 the pilot said, ‘…we’re showing a little west of course…,’ and at 1015 he asked if he was east of course. At 1017, the controller suggested a missed approach if the airplane was not established on the localizer course. There was no response from the crew of flight 1517 whole last transmission was at 1016.

 

“The wreckage of flight 1517 was located about 1842 approximately 6 miles east of the airport.[2] Both crewmembers and all 12 passengers were fatally injured.

 

“The National Transportation Safety Board determines that the probable cause of this accident was a navigational error by the flightcrew resulting from their use of the incorrect navigational facility and their failure to adequately monitor the flight instruments. Factors which contributed to the flightcrew’s errors were: the non-standardized navigational radio systems installed in the airline’s Beech 99 fleet; intra-cockpit communications difficulties associated with high ambient noise levels in the airplane; inadequate training of the pilots by the airline; the first officer’s limited multi-engine and instrument flying experience; the pilots’ limited experience in their positions in the Beech 99; and stress-inducing events in the lives of the pilots. Also contributing to the accident was the inadequate surveillance of the airline by the Federal Aviation Administration which failed to detect deficiencies which led to the accident.” [p. 1.] ….

 

“The crew had reported for duty about 0515 and had flown from the Washington County Regional Airport, Hagerstown, Maryland (HGR) to BWI, from BWI to HGR, and from HGR to BWI….” [p. 2.]

 

“Analysis…. The Safety Board concludes that the first officer was flying, since the captain made all of the radio communications throughout the flight from Baltimore-Washington International Airport, and since it was company policy for the nonflying pilot to operate the radios…..

 

“It was determined that the airplane had impacted…in controlled flight with landing lights on and with gear and flaps retracted….The trees were broken in a relatively level straight line, indicating that the airplane was in a wings level, fuselage level flight at initial impact. There were propeller slash marks on both sides of the centerline, indicating that both engines were running and under power.

 

“…the Safety Board concludes that there was no in-flight failure or malfunction of the airplane structure in this accident and that there was no on-flight fire…. [p. 25.]

 

“The apparent controlled flight into the trees at 2,400 feet suggests that the pilots were in control of the airplane and may have been slowly descending intentionally without great concern…. [28]

 

“Given that there were no known problems with the airplane, its flight systems, the weather, or the airborne or ground based navigation equipment, and there was no evidence of flightcrew incapacitation, it is clear that operational and human performance issues played a significant role in this accident. If all of Henson’s procedures had been followed, and if the correct navigational frequencies had been selected, the approach should have been flown successfully by this flightcrew. Therefore, the Safety Board believes that the most plausible reasons for the navigational error that placed the airplane almost 6 miles east of the ILS localizer course included the flightcrew’s failure to follow recommended instrument flight procedures, such as properly tuning and identifying navigation facilities, maintaining prescribed altitudes, making prescribed altitude callouts, observing TO/FROM indications, observing ‘flags,’ cross-checking the navigational displays, and comparing VHF navigation indications with the ADF indications.[3] …. [p. 31.]

 

“The Safety Board believes that there are several human performance, as well as operational factors which could help to explain how…errors many have been compounded and not detected by the pilots in sufficient time to execute a missed approach. These factors include training to ‘proficiency’ in minimum time, the assignment of a new captain to fly with a new first officer, the limited experience of the first officer in multiengine airplanes and in instrument flying, the effects of a ‘noisy’ cockpit…documented dissatisfaction on the part of the first officer in communicating, the lack of an interphone system, the effect the proximity of the passengers to the cockpit to the cockpit had on crew communication, Henson’s policy of providing en route and approach charts to the captain only, and several significant stress producing events in the lives of both pilots. [p. 35.]

 

“The facts illustrate that this flightcrew were not sufficiently prepared to conduct safe instrument flight operations and that the management and oversight of this commuter airline was inadequate. The Safety Board believes that the shortcomings on the parts of Henson management and the FAA are among the underlying reasons for this accident…. [p. 36.]

 

“Flightcrew Training. Although Henson’s classroom facilities were found to be adequate, the only training aids for the Beech 99 were slides and overhead transparencies. In ground school, the Beech 99 cockpit, instrument panel, and circuit breaker panels were presented in 35 millimeter slides and, before flight training, pilot candidates received briefings on the cockpit layout and instrumentation. No specific training was provided to address the differences in cockpit configurations of the various Beech 99 airplanes in the Henson fleet. The availability of a basic cockpit mockup or a ground procedures trainer, either of which could have easily been fabricated by Henson, would have greatly increased the student’s familiarity with the airplane’s controls and systems before beginning flight training, especially considering that the pilots currently being hired tend to have less experience than previous new hires.[4] [p. 37.] ….

 

“Ground Proximity Warning System. As a result of this and two other approach phase accidents involving scheduled domestic passenger commuter flights operating under 14 DFR 135, which occurred between August 1985 and March 1986, and in which 25 persons were fatally injured, the Safety Board believes that the time has come for the FAA and the commuter airline industry to address the installation of ground proximity warning systems (GPWS) aboard those aircraft commonly used by the commuter airlines for the commercial transport of 30 or fewer passengers. While Henson flight 1517 was flying toward rapidly rising terrain, it failed to clear a Hall Mountain ridge by only about 200 feet. A ground proximity warning devise to monitor height above the ground may have been sufficient to direct the flightcrews’ attention to the possibility of ground contact in time to avoid an accident….” (pp. 49-59.) (NTSB. AAR. Henson Airlines Flight 1517, Beech B99, N339HA, Grottoes, Virginia, September 23, 1985. 1986.)

 

Sep 24: Daily News-Record: “Weyers Cave — A Henson Airlines commuter plane crashed into the west slope of the cloud-covered Blue Ridge Mountains east of Grottoes Monday killing all 14 people aboard. The plane was spotted by a Civil Air Patrol plane about 8½ hours after the airliner vanished from radar screens at the Federal Aviation Administration’s Washington Center flight control at Leesburg, state police reported. Later, two doctors lowered to the sight from Marine helicopters that joined the search reported that everyone aboard apparently died….

 

“The Beech 99 was flying to Shenandoah Valley airport…when it crashed on 3,250-foot Hall Mountain in Shenandoah National Park. The crash site was near the Rockingham-Augusta County line about six miles due east of the airport….CAP officials said they had information that the plane, which had to make an instrument landing because of the cloud cover, many have had trouble with its localizer. A localizer picks up signals transmitted from the airport to give a pilot his direction and altitude from the runway.

 

“Flight 1517, a daily flight from BWI to Shenandoah Valley, was scheduled to arrive at 10:15 a.m. Monday…The air search was hampered until about 4:30 p.m. by fog still shrouding the mountains and heavy vegetation.” (Daily News-Record, Harrisonburg, VA. “14 Die in Henson Crash.” 9-24-1985, p. 13.)

Sources

 

Daily News-Record (Randy Murphy and Jim Denery), Harrisonburg, VA. “14 Die in Henson Crash.” 9-24-1985, p. 13. Accessed 1-28-2017 at: http://newspaperarchive.com/us/virginia/harrisonburg/harrisonburg-daily-news-record/1985/09-24/page-13?tag

 

National Transportation Safety Board. Aircraft Accident Report. Henson Airlines Flight 1517, Beech B99, N339HA, Grottoes, Virginia, September 23, 1985 (NTSB/AAR-86/07). Washington, DC: NTSB, 9-30-1986, 87 pages. Accessed 1-27-2017 at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR86-07.pdf

[1] Near Grottoes, which is to the east, and several miles northeast of Staunton, VA

[2] West side of Shenandoah National Park.

[3] Automatic Direction Finder

[4] Noting earlier that Henson had a high and increasing pilot turnover rate.