NTSB determines pilots' poor airmanship caused 2004 Pinnacle accident

Citation

(2007), "NTSB determines pilots' poor airmanship caused 2004 Pinnacle accident", Aircraft Engineering and Aerospace Technology, Vol. 79 No. 3. https://doi.org/10.1108/aeat.2007.12779cab.017

NTSB determines pilots' poor airmanship caused 2004 Pinnacle accident

NTSB determines pilots' poor airmanship caused 2004 Pinnacle accident

The National Transportation Safety Board determined recently that the probable cause of the 14 October 2004 accident of Pinnacle Airlines flight 3701 was the pilots' unprofessional behaviour, deviation from standard operating procedures, and poor airmanship, which resulted in an in- flight emergency from which they were unable to recover, in part because of the pilots' inadequate training; the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition.

Contributing to the cause of this accident were the engine core lock condition, which prevented at least one engine from being restarted, and the aeroplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.

“This accident was caused by the pilots' inappropriate and unprofessional behaviour” said NTSB Chairman Mark V. Rosenker. “Simply adhering to standard operating procedures and correctly implementing emergency procedures would have gone a long way to adverting this tragic accident.”

On 14 October 2004, a Bombardier CL-600-2B19 (N8396 A) operated by Pinnacle Airlines (doing business as Northwest Airlink) departed Little Rock National Airport about 9.21 p.m. central daylight time en route to Minneapolis-St Paul, Minnesota for a repositioning flight. The flight plan indicated that the planned cruise altitude was 33,000ft. At about 9.26 p.m., the aeroplane was at an altitude of about 14,000ft and the flight crew engaged the autopilot.

A few seconds later, the captain requested and received clearance to climb to the Commuter Regional Jet's maximum operating altitude of 41,000ft. After the aircraft reached 41,000ft, the aeroplane entered several stalls and shortly thereafter had double engine failure. The crew declared an emergency with the tower, informing them of an engine failure. However, they failed to inform the tower that both engines had failed while they made several unsuccessful attempts to restart the engines. The crew also continued to try to restart the engines after the controller asked if they wanted to land.

The flight crew attempted to make an emergency landing at the Jefferson City, Missouri airport but crashed in a residential area about three miles South of the airport. The aeroplane was destroyed by impact forces and a post-crash fire. The two crew members were fatally injured. There were no passengers on board and no injuries on the ground.

The Safety Board issued 11 recommendations to the Federal Aviation Administration, as a result of this accident, dealing with pilots training and high altitude stall recovery techniques.

On 20 November 2006, the Safety Board also issued the following urgent safety recommendations, as a part of its investigation into this accident.

To the Federal Aviation Administration:

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  For aeroplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to perform high power, high altitude sudden engines shutdowns; determine the minimum airspeed required to maintain sufficient core rotation; and demonstrate that all methods of in-flight restart can be accomplished when the airspeed is maintained.

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  Ensure that aeroplane flight manuals of aeroplanes equipped with CF34-1 or CF34-3 engines clearly state the minimum airspeed required for core engine rotation and that, if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss of in-flight restart capability as a result of core lock may occur.

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  Require the operators of CRJ-100, -200, and 400 aeroplanes include in aeroplane flight manuals the significant performance penalties, such as loss of glide distance and increase descent rate, that can be incurred from maintaining the minimum airspeed required for core rotation and windmill restart attempts.