1994 — Dec 13, Flagship Airlines (American Eagle) Flight 3379 Crash, ~Raleigh, NC — 15

— 15  Aircraft Crashes Record Office (Geneva, Switzerland).  North Carolina.  Reg. N918AE.

— 15  NTSB. Uncontrolled Collision with Terrain, Flagship Airlines, Inc…. Morrisville,[NC]…

 

Narrative Information

 

NTSB Executive Summary: “On December 13, 1994, at 18:34, a Flagship Airlines Jetstream 3201, doing business as (dba) American Eagle (AMR) flight 3379, crashed about 4 nautical miles southwest of the runway 5L threshold during an instrument landing system (ILS) approach to the Raleigh-Durham International Airport (RDU). The flight was a regularly scheduled passenger flight under 14 Code of Federal Regulations (CFR), Pan 135. Thirteen passengers and the two crewmembers were fatally injured, and the other five passengers survived. The airplane was destroyed by impact and fire. The weather at the time of the accident was ceiling 500 feet, visibility 2 miles, light rain and fog. temperature 38′ F, and dew point 36′ F….

 

“About 1818 [1718], the agent requested the departure times from flight 3379 [from Greensboro NC], and the first officer advised her that they used 53 and 03 (taxi out at 1753 and takeoff at 1803). The delay was reportedly due to baggage rearrangement. The agent, who had previously met both pilots, reported they were in good moods. She described the captain as typically quiet and the first officer as outgoing.

 

“The flight plan called for a cruise altitude of 5,000 feet, and the time enroute was 23 minutes. Flight 3379 was assigned a cruising altitude of 9,000 feet. The crew contacted RDU approach control at 1814, and advised that it had received Automatic Terminal Information Service (ATIS) “Sierra.” The controller advised the crew to expect runway 5L. Following some discussion about the arrival clearance, the controller stated, “Eagle flight 379 reduce speed to uh … one eight zero then descend to six thousand ….’ The crew received continuing vectors and were switched to the final radar control position at 1825. The final controller instructed them to, “…reduce to one seven zero then descend and maintain three thousand.” At 1828. the controller cautioned them about wake turbulence from a B-727 that they were following, and assigned them a heading of 190°. At 1830, the final controller advised. “Eagle flight 379 eight from BARRT [the final approach fix] turn left heading zero seven zero join the localizer course at or above two thousand one hundred cleared ILS five left.” The crew acknowledged the clearance, and the subsequent change to the tower frequency.

 

“They contacted the tower at 1832, and were told “..cleared to land wind zero one zero at eight traffic three and a half mile final a seven twenty.” At 1832:25, the crew acknowledged the clearance, “Cleared to land five left 379.” This was the last known transmission from the flight. At 1834:17, an unintelligible noise was heard or, the frequency.

 

“Data from the flight data recorder (FDR), cockpit voice recorder (CVR), and the RDU radar plot were correlated for the last minute of flight to reconstruct the approach… There was a change in engine noise similar to an increase in engine RPM at 1833:28.7, seconds after the captain requested “speeds high,” This was followed immediately by a call for, “gear down and flaps 20.” Flight 3379 crossed slightly right of BARRT, the final approach fix, while descending through 2,100 feet and slowing below 160 knots about this time. At 1833:33.3, the captain asked. “Why’s that ignition light on? We just had a flameout’?” For the next seconds, the crew discussed the engine anomaly as the airplane heading drifted to the left at approximately 2/3 of a degree per second and eventually crossed the localizer centerline at 1833:45. At this time, flight 3379 was approximately 3.8 miles behind the preceding B-727.

 

“For the next several seconds, the airplane remained relatively level at approximately 1,800 feet, as the airspeed decreased from 140 knots to 122 knots, when the captain decided, “Let’s go missed approach.” In less than 2 seconds, at 1834:05.3, two momentary stall warnings occurred as the captain called, “Set max power,” and the left turn rate increased. The first officer called, “Lower the nose, lower the nose, lower the nose,” but the airplane remained at about 1,800 feet, and the airspeed continued to decay to approximately 119 knots as the left turn rate increased to about 5° per second.

 

“At 1834:09.4, a stall warning horn started again, and was followed at 1834:09.6 by the dual stall warning horns. At this time, the airplane was still at 1,775 feet, and the airspeed had slowed to 11 1 knots. The first officer inquired, “You got it?,” and the captain responded, “Yeah.” The airspeed decreased to 103 knots at 1834: 12, and the first officer said, “Lower the nose.” At 1834: 13.2, the first officer said. “It’s the wrong, wrong foot, wrong engine.” About this time, the rate of descent increased rapidly to more than 10,000 feet per minute. The rate of turn increased to about 14° per second at 1834:16, as the airspeed increased rapidly. There were several significant normal accelerations during this period. The airplane finally stabilized the last few seconds before impact at an airspeed of about 170 knots. a normal acceleration of 2.5 G absolute, and a heading of 290°. [pp. 2-3] ….

 

Conclusions

 

“Findings

 

  1. The flightcrew was properly certificated in accordance with Federal Aviation Regulations and company procedures.

 

  1. The airplane was certificated and maintained in accordance with existing regulations, except for the improper installation of the FPA-80 as a substitute for a GPWS.

 

  1. Air traffic control services were properly performed.

 

  1. Weather was not a factor in the accident.

 

  1. The captain associated the illumination of the left engine IGN light with an engine failure.

 

  1. The left engine IGN light illuminated as a result of a momentary negative toque condition when the propeller speed levers were advanced to 100 percent and the power levers were at flight idle.

 

  1. There was no evidence of an engine failure. The CVR sound spectrum analysis revealed that both propellers operated at approximately 100 percent RPM until impact, and examination of both engines revealed that they were operating under power at impact.

 

  1. The captain failed to follow established procedures for engine failure identification, single engine approach, single engine go-around, and stall recovery.

 

  1. The flightcrew failed to manage resources adequately; specifically, the captain did not designate a pilot to ensure aircraft control, did not invite discussion of the situation, and did not brief his intended actions; and the first officer did not assert himself in a timely and effective manner and did not correct the captain’s erroneous statement about engine failure.

 

  1. Although the first officer did perform a supportive role to the captain, his delayed assertiveness precluded an opportunity to avoid the accident.

 

  1. Flight 3379 did not encounter any wake turbulence during the approach to runway 5L, or during the departure from controlled flight.

 

  1. AMR Eagle training did not adequately address the cognition of engine failure at low power, the aerodynamic effects of asymmetric thrust from a “windmilling” propeller, and high thrust on the other engine.

 

  1. AMR Eagle provided “negative simulator training” to pilots by associating the IGN light with engine failure and by not instructing pilots to advance both power levers during single engine go-arounds as required by the operation manual.

 

  1. AMR Eagle and Flagship Airlines crew training records do not provide sufficient detail for management to track performance.

 

  1. Flagship Airlines management was deficient in its knowledge of the types of crew records available, and in the content and use of such records.

 

  1. Flagship Airlines did not obtain any training records on the accident captain from Comair. Further, Comair’s standard response for employment history would not, had it been obtained, have included meaningful information on training and flight proficiency, despite the availability of such data.

 

  1. The FAA did not provide adequate guidance for, or ensure proper installation of, the WA-80 as a substitute for a GPWS on Flagship’s fleet.

 

  1. The structure of the FAA’s oversight of AMR Eagle did not provide for adequate interaction between POIs and AMR Eagle management personnel who initiated changes in flight operations

by the individual Eagle carriers.

 

“Probable Cause. The National Transportation Safety Board determines that the probable causes of this accident were: 1) the captain’s improper assumption that an engine had failed, and 2) the captain’s subsequent failure to follow approved procedures for engine failure, single-engine approach and go-around, and stall recovery. Contributing to the cause of the accident was the failure of AMR Eagle/Flagship management to identify, document, monitor, and remedy deficiencies in pilot performance and training.” [pp. 67-69]  (NTSB. Uncontrolled Collision with Terrain, Flagship Airlines, Inc…. Morrisville,[NC]… 1995.)

 

Sources

 

Aircraft Crashes Record Office (Geneva, Switzerland).  North Carolina. Accessed 3/3/2009 at:  http://www.baaa-acro.com/Pays/Etats-Unis/Caroline%20du%20Nord.htm

 

National Transportation Safety Board. Aircraft Accident Report. Uncontrolled Collision with Terrain, Flagship Airlines, Inc., dba American Eagle Flight 3379, BAe Jetstream 3201, N918AE, Morrisville, North Carolina, December 13, 1994 (PB95-910407). Washington, DC: NTSB, adopted 10-24-1995. Accessed 2-25-2016 at: http://www.fss.aero/accident-reports/dvdfiles/US/1994-12-13-US.pdf