Kirksville, Missouri
October 19, 2004
NTSB Number: AAR-06-01
NTIS Number: PB2006-910401
January 24, 2006
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On October 19, 2004, about 1937 central daylight time, Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at the Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport, in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed at the time of the accident, and the flight operated on an instrument flight rules flight plan.
The National Transportation Safety Board determines that the probable cause of the accident was the pilots' failure to follow established procedures and properly conduct a nonprecision instrument approach at night in IMC, including their descent below the minimum descent altitude (MDA) before required visual cues were available (which continued unmoderated until the airplane struck the trees) and their failure to adhere to the established division of duties between the flying and nonflying (monitoring) pilot.
Contributing to the accident was the pilots' failure to make standard callouts and the current Federal Aviation Regulations that allow pilots to descend below the MDA into a region in which safe obstacle clearance is not assured based upon seeing only the airport approach lights. The pilots' unprofessional behavior during the flight and their fatigue likely contributed to their degraded performance.
The safety issues in this report focus on operational and human factors issues, including the pilots' professionalism and sterile cockpit procedures, nonprecision instrument approach procedures, flight and duty time regulations, fatigue, and flight data/image recorder requirements.
As a result of the investigation of the Corporate Airlines flight 5966 accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
Direct the principal operations inspectors of all 14 Code of Federal Regulations Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule. (A-06-7)
Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures and to emphasize the preference for that technique where practicable. (A-06-8)
Revise applicable 14 Code of Federal Regulations Part 121 and 135 regulations to prohibit pilots from descending below the minimum descent altitude during nonprecision instrument approaches unless conditions allow for clear visual identification of all obstacles and terrain along the approach path or vertical guidance to the runway is available and being used. (A-06-9)
Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. (A-06-10) (This recommendation supersedes Safety Recommendation A-99-45.)
Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. (A-06-11)
Require that all aircraft operated under Title 14 CFR Part 121, 125, or 135 and currently required to be equipped with a cockpit voice recorder (CVR) and flight data recorder (FDR) be retrofitted...with a crash-protected cockpit image recording system. The cockpit image recorder system should have a 2-hour recording duration, as a minimum, and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit. The recording of these video images should be at a frame rate and resolution sufficient for capturing such actions. The cockpit image recorder should be mounted in the aft portion of the aircraft for maximum survivability and should be equipped with an independent auxiliary power supply that automatically engages and provides 10 minutes of operation whenever aircraft power to the cockpit image recorder and associated cockpit camera system ceases, either by normal shutdown or by a loss of power to the bus. The circuit breaker for the cockpit image recorder system, as well as the circuit breakers for the CVR and the digital FDR, should not be accessible to the flight crew during flight. (A-00-30)
Require all turbine-powered, nonexperimental, nonrestricted-category aircraft that are manufactured prior to January 1, 2007, that are not equipped with a flight data recorder, and that are operating under 14 Code of Federal Regulations Parts 135 and 121 or that are being used full-time or part-time for commercial or corporate purposes under Part 91 to be retrofitted with a crash-protected image recording system by January 1, 2010. (A-03-65)
The following previously issued recommendation is classified "Closed-Superseded" in this report:
Establish, within 2 years, scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest. (A-99-45)
