1988 — Feb 19, AVAir Inc. Fairchild Metro III (Air Virginia) takeoff crash, Cary, NC– 12

–12 NTSB. AAR. AVAIR Inc., Flight 3378 Fairchild Metro III… Cary, North Carolina, Feb 19, 1988.
–12 NTSB. Safety Recommendation A-88-153 through -155. To FAA Administrator, 12-28-1988.
–12 Planecrashinfo.com. “1988. Accident Details. AV Air/American Eagle, Cary, NC, Feb 19.”

Narrative Information

NTSB AAR Executive Summary: “On February 19, 1988, an AVAir Inc. Fairchild Metro III, N622AV, operating as Air Virginia (AVAir) flight 3378, crashed in Cary, North Carolina, shortly after it departed runway 23R at Raleigh Durham International Airport (RDU), Morrisville, North Carolina, with 2 flightcrew members and 10 passengers on board. The airplane struck water within 100 feet of the shoreline of a reservoir, about 5,100 feet west of the midpoint of runway 23R. The airplane was destroyed and all 12 persons on board were killed.”

“The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flightcrew to maintain a proper flightpath because of the first officer’s inappropriate instrument scan, the captain’s inadequate monitoring of the flight, and the flightcrew’s response to a perceived fault in the airplane’s stall avoidance system. Contributing to the accident was the lack of company response to documented indications of difficulties in the first officer’s piloting and inadequate Federal Aviation Administration (FAA) surveillance of AVAir (Two board members dissented from the probable cause.)

“The safety issues examined in this investigation include the stall avoidance system of the Fairchild Metro, FAA oversight of AVAir, and the company’s management of its operations.

“As a result of this investigation, the Safety Board issued two recommendations to the FAA regarding the stall avoidance system (SAS) of the Fairchild Metro. One urges the FAA to conduct flight tests in the Metro III to determine the benefits that the SAS stick pusher provides to crewmembers in the stall regime and, if benefits are not demonstrated, to permanently disengage the stick pusher. The other calls for the FAA to review and modify, if necessary, the crew response to an SAS fault in the approved airplane flight manual of the Metro, to reflect the cautionary, nonemergency nature of the fault. The Safety Board also recommended that the FAA provide principal operations inspectors of operators under 14 CFR Parts 135 and 121 with indications of financial distress that suggest when increased surveillance of those operators is warranted.” (NTSB AAR, 1988, p. v.)

NTSB History of the Flight: “At 2125 [9:25] eastern standard time on February 19, 1988, an AVAir Inc., Fairchild Metro III, N622AV, operating as Air Virginia (AVAir) flight 3378, departed runway 23R at Raleigh-Durham International Airport (RDU), Morrisville, North Carolina, with 2 flightcrew members and 10 passengers on board. AVAir 3378, en route from RDU to Richmond, Virginia (RIC), was a regularly scheduled flight conducted under 14 Code of Federal Regulations (DFR) Part 135….

“At 2124:54 the RDU local controller cleared AVAir 3378 to taxi into position and to hold, following the departure of an American Airlines MD-30. The captain of flight 3378, who was performing all communications with air traffic control, acknowledged. According to AVAir’s former manager of training, company standard operating procedure called for the nonflying pilot to perform all communications with air traffic control. At 2125:20, the local controller directed AVAir 3378 to continue to hold but to amend its original clearance from maintaining a runway heading of 230° after departure to turning right to a heading of 290°. The captain acknowledged. At 2125:49 AVAir 3378 was cleared for an immediate takeoff. At 2126:33, the flight was told to ‘report established on the 290° heading and make that turn as soon as feasible, jet traffic to depart behind you.’ The captain responded ‘three seventy eight.’ This was the last transmission from the flight…” (NTSB AAR, 1988, p. 1.)

NTSB Analysis: “….AVAir 3378 departed RDU’s runway 23R and began its turn about 10 seconds after liftoff at an approximate height of 200 feet agl. Analysis of radar data indicates that the airplane continued to climb at an appropriate climb speed but at an excessive rate of turn and then began to descend. The data suggest the absence of abrupt maneuvers. Within 5 seconds of the 2126:39 transmission from the flight, ‘Three seventy eight,’ the airplane entered a 40° to 45° angle of bank and maintained that for at least 10 seconds. A standard rate turn would have required an approximate 22° bank angle. After 10 seconds, a roll out was initiated; however, at that time, the airplane was in a high rate of descent. The airplane was aloft for less than 1 minute….

“The ability to determine the potential contribution of any factor was limited by the absence of both a cockpit voice recorder (CVR) and a flight data recorder (FDR) on AVAir 3378. However, since the accident, the FAA has mandated the installation of flight recorders in such aircraft. In fact, shortly after the accident, AMR Corporation announced that it was placing CVRs and FDRs in the airplanes of the affiliated carriers that it owned in advance of the implementation of the FAA’s rule. The Safety Board is pleased with the actions of AMR and encourages all regional carriers to do the same….” (NTSB AAR, 1988, p. 25.)

NTSB on AVAir Management: “The Safety Board believes that AVAir management created extraordinary conditions for the company, from early 1987 to the time of the accident, which limited its ability to adequately oversee its operations. During that time, AVAir moved its operations base several hundred miles, experienced considerable turnover in the management of its pilot operations as well s in its pilot ranks, acvquired and then phased out a new and considerably more complex aircraft type, dramatically increased its number of pilots, intensively trained pilots, furloughed pilots, significantly expanded its route structure, significantly reduced its route structure, sustained a major accident, and finally, filed for bankruptcy. These factors suggest that AVAir management significantly misjudged critical aspects of financial and operational planning. These misjudgments, the Safety Board believes, extended to oversight of the first officer.

“AVAir management had been informed by its training personnel and line captains that the first officer’s performance was marginal and that her potential advancement in the company was questionable. There is no evidence that the company provided her with additional training, or that it monitored her performance more carefully or more often. Rather, the evidence suggests that following some initial discussion about her difficulties in different training, the only action was the company took with regard to her performance after she had qualified to fly as first officer was to file the captain’s progress and evaluation report dated September 15, 1987, that had been completed by a captain with whom the first officer had flown.

“The Safety Board believes that AVAir’s effort to qualify the first officer during her training difficulties reflect positively on the company’s efforts to provide its employees every opportunity to succeed. Such efforts can often result in well motivated and loyal employees which may have been the case at AVAir. However, AVAir also had both a moral and legal obligation to provide its passengers with the highest degree of safety possible. The Safety Board believes that when it received the captain’s progress and evaluation report on the first officer’s performance, AVAir’s management should have responded in some positive manner. Its failure to respond can be accounted for, in part, by the turmoil AVAir was experiencing at that time. However, given the first officer’s training history, a prudent course of action would have been for the company to determine quickly the nature of the performance difficulties and, at a minimum, provide her with remedial training and additional flight checking, as needed. This was not done. Therefore, the Safety Board concludes that the company’s failure to respond adequately to the first officer’s piloting difficulties contributed to the accident….” (NTSB AAR, 1988, pp. 30-31.)

NTSB Dissenting Member Statement: “John K. Lauber, Member, filed the following concurring and dissenting statement:

“Because of the lack of cockpit voice and flight data recorder data, it is impossible to determine with any degree of confidence what happened to AVAir 3378. Based on analysis of recorded radar data, we can state with a reasonably high degree of confidence that the aircraft entered a steeply banked (45°) right turn at a low altitude (approximately 200 feet above the ground) about 10 seconds after liftoff. We also know that the aircraft started to descend shortly after the turn was initiated. We also can state with a fair degree of confidence that some time after takeoff, the crew disabled the stall avoidance system, which has an established history of uncommanded actuations. We know that the first officer had limited recent instrument flight experience and had not flown for nearly a month due to being furloughed; she had flown only in VFR conditions in the 2 days prior to the accident. We know the captain was not feeling well the night of the accident. We know from training records that both pilots had experienced performance difficulties at various stages of their careers at AVAir and, from other records, that AVAir was experiencing serious destabilizing effects due to financial distress and that the FAA’s surveillance of AVAir was abysmal.

“What we cannot state with any degree of confidence is how these factors, and perhaps others, conspired to result in this accident. We cannot state conclusively that an uncommanded stick pusher actuation did or did not occur. We can speculate, but not conclude, that the captain’s monitoring was inadequate, that one or both pilots experienced vertigo, or that the first officer’s instrument scan was deficient. We simply do not have enough evidence to elevate these factors, or others, from possible causes to probable causes.

“Accordingly, I believe the Probable Cause should read:

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flightcrew to maintain a proper flightpath in response to an actual or perceived fault in the airplane’s stall avoidance system. Contributing to the accident were ineffective management and supervision of flightcrew training and flight operations, and ineffective FAA surveillance of AVAir.

“Joseph T. Hall, Member, filed the following concurring and dissenting statement:

“….I am in concurrence with Member Lauber’s conclusion…[on] the probable cause of this accident….” (NTSB AAR, 1988, p. 34.)

Sources

National Transportation Safety Board. Aircraft Accident Report. AVAIR Inc., Flight 3378 Fairchild Metro III, SA227 AC, N622AV, Cary, North Carolina, February 19, 1988. Washington, DC: NTSB, 12-13-1988, 73 pages. Accessed 10-1-2016 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8810.pdf

National Transportation Safety Board. Safety Recommendation A-88-153 through -155. Letter Safety Recommendation for Federal Aviation Administration Administrator, 12-28-1988, 6 pages. Accessed 10-1-2016 at: http://www.ntsb.gov/safety/safety-recs/recletters/A88_153_155.pdf

Planecrashinfo.com. “1988. Accident Details. AV Air/American Eagle, Cary, NC, Feb 19, 1988.” Accessed at: http://www.planecrashinfo.com/1988/1988-12.htm