1993 — Dec 1, Terrain Express II Airlines/Northwest Airlink Crash, Hibbing, MN — 18

— 18  Aircraft Crashes Record Office (Geneva, Switzerland).  Minnesota.

— 18  B3A. “Crash of a BAe Jetstream 31 in Hibbing: 18 killed.” Dec 1, 1993, 19:50 LT.

— 18  NTSB. Controlled Collision with Terrain, Express II Airlines, Inc./Northwest Airlink…

 

Narrative Information

 

NTSB: “On December 1, 1993, Express II flight 5719, a Jetstream BA-3100, registration N334PX, was operating as a regularly scheduled flight under 14 Code of Federal Regulations (CFR), Part 135, from Minneapolis/St. Paul International Airport, St. Paul, Minnesota, to International Falls, Minnesota, with an en route stop at Hibbing, Minnesota (HIB). The flight was operated by Express Airlines II, Inc., under the terms of a marketing agreement with Northwest Airlines, Inc., as Northwest Airlink. About 1950 central standard time, the airplane collided with terrain while on the localizer back course approach to runway 13 at HIB. The 2 flightcrew members and all 16 passengers were fatally injured in the accident. The airplane was destroyed.[1]

 

“The National Transportation Safety Board has determined that the probable causes of this accident were the captain’s actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flightcrew during an unstabilized approach in night instrument meteorological conditions. Contributing to the accident were: The failure of the company management to adequately address the previously identified deficiencies in airmanship and crew resource management of the captain; the failure of the company to identify and correct a wide-spread, unapproved practice during instrument approach procedures; and the Federal Aviation Administration’s (FAA’s) inadequate surveillance and oversight of the air carrier.

 

“The investigation of this accident revealed several deficiencies that the FAA should take action to correct. These deficiencies pertain to pilot training and procedures, FAA surveillance and oversight, and the need for wing observation lights on both sides of an airplane. Additionally, the investigation revealed that the pilots were provided only one set of instrument approach charts, which is a subject that has been addressed by the Safety Board in previous accident reports and safety recommendations.

 

“Pilot Training and Procedures

 

“Express 11 Airlines uses a contract pilot training facility in lieu of having its own training department. The current FAA Air Transportation Inspector’s Handbook, FAA Order 8400.10, contains only one paragraph on the evaluation of an operator’s training program, and that provides little qualitative information. There is no guidance whatsoever for FAA inspectors or principal operations inspectors (POIs) about surveillance of contract training of 14 CFR Part 135 flightcrews who are not employed by the air carrier until they pass their check rides. Therefore, the Safety Board believes that specific guidance for such programs should be developed and incorporated into FAA Order 8400.10.

 

“’The “Climb and Descent Crew Coordination” guidance, contained in Express II’s manual, progressively describes the duties of the flying and nonflying pilots from the top of the descent to the runway-in-sight or missed approach point. It states that during descents, the pilot not flying (PNF) will call out 1,000 feet and 300 feet above all assigned altitudes. This guidance further states: “Sink rate should be called out any time it exceeds 1,000 fpm [feet per minute] after reaching the initial approach fix altitude.”

 

“The guidance further requires the PNF to call out 500 feet and 100 feet above decision height (DH) or minimum descent altitude (MDA). The MDA for the approach was 1,780 feet, although at the position where the airplane struck the ground, the minimum altitude was 2,040 feet. When they were interviewed, Express II pilots expressed some confusion concerning callouts for this approach because an intermediate step down altitude inside the final approach fn (FAF) is not addressed in the “Descent Crew Coordination” section of the guidance. They were unsure whether the PNF should have called 500 feet and 100 feet, or 300 feet, above the 2,040-foot step down altitude, or above the MDA. In this accident, however, the PNF made none of these calls. Nor did he call out the MDA when the airplane passed through it….” (NTSB Safety Recommendation letter to FAA, 6-13-1994.)

 

Sources

 

Aircraft Crashes Record Office (Geneva, Switzerland). Minnesota. Accessed 3-9-2009 at:  http://www.baaa-acro.com/Pays/Etats-Unis/Minnesota.htm

 

B3A (Bureau of Aircraft Accidents Archives). “Crash of a BAe Jetstream 31 in Hibbing: 18 killed.” Dec 1, 1993, 19:50 LT. Accessed 3-18-2016 at: http://www.baaa-acro.com/1993/archives/crash-of-a-bae-jetstream-31-in-hibbing-18-killed/

 

National Transportation Safety Board. “Safety Recommendation” letter to the Honorable David R. Hinson, Administrator, Federal Aviation Administration, Washington, DC, dated 6-13-1994 in reference to the following report: Controlled Collision with Terrain, Express II Airlines, Inc./Northwest Airlink Flight 5719 Jetstream BA-3100, N334PX. Washington, DC: NTSB,  adopted 5-24-1994. Accessed 3-18-2016 at: http://www.ntsb.gov/safety/safety-recs/recletters/A94_113_117.pdf

 

 

 

 

[1] NTSB footnote 1: “For more detailed information, read Aircraft Accident Report – “Controlled Collision With Terrain, Express II Airlines, Inc./Northwest Airlink Flight 5719, Jetstream BA-3100, N334PX, Hibbing, Minnesota, December 1, 1993” (NTSB/AAR-94/05).