NTSB/AAR-92/01 NTSB Aircraft Accident Report, L'express Airlines
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E PB92-910401 NTSB/AAR-92/O 1 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAm ACCIDENT REPORT L’EXF’RESS AIRLINES, INC., FLIGHT 508 BEECH C99, N7217L WEATHER ENCOUNTER AND CRASH NEAR BIRMINGHAM, ALABAMA JULY lo,1991 5558A The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSBIAAR-92101 PB92-910401 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT L’EXPRESS AIRLINES, INC., FLIGHT 508 BEECH C99, N7217L WEATHER ENCOUNTER AND CRASH NEAR BIRMINGHAM, ALABAMA JULY lo,1991 Adopted: March 3,1992 Notation 5558A Abstract: This report explains the weather encounter and crash of L’Express Flight 508 while the airplane was conducting an instrument landing system approach to runway 5 at the Birmingham Airport, Birmingham, Alabama. The safety issues discussed in this report include pilot training in recognizing thunderstorm hazards and recovering from unusual attitudes, radar interpretation, and the relaying of complete weather information to pilots by air traffic controllers. Recommendations concerning these issues were made to the Federal Aviation Administration. CONTENTS EXECUTIVE SUMMARY . vi 1. FACTUAL INFORMATION 1.1 History of Flight ................................................................................. 1 1.1.1 General ............................................................................................... 1 1.1.2 Activity En Route to BHM ................................................................. 2 1.1.3 Activity During the Instrument Approach........................................... 5 1.1.4 Observations of Witnesses.................................................................. 7 1.1.4.1 LEX508 Captain................................................................................. 7 1.1.4.2 Piper Aerostar CONAERO 209 Flightcrew ........................................ 8 1.1.4.3 Learjet N45ZP Flightcrew .................................................................. 10 1.1.4.4 Surviving Passenger ........................................................................... 11 1.1.4.5 Individuals on the Ground .................................................................. 12 1.15 Relay of Weather Information by the South Radar Controller ............ 13 1.2 Injuries to Persons .............................................................................. 15 1.3 Damage to Aircraft ............................................................................. 15 1.4 Other Damage .................................................................................... 15 1.5 Personnel Information ........................................................................ 15 15.1 The Captain ........................................................................................ 15 1.5.2 The First Officer................................................................................. 20 15.3 L’Express Flightcrew Training............................................................ 22 1.5.3.1 General ............................................................................................... 22 1.5.3.2 Weather Training Aids and Materials ................................................. 22 1.5.3.3 Conduct of Training and Documentation ............................................ 22 1.5.3.4 Initial General Ground Training ......................................................... 23 1.5.3.5 Recurrent Ground Training................................................................. 25 1.5.3.6 Crew Coordination ............................................................................. 25 1.5.3.7 Initial C99 Flight Training .................................................................. 25 1.5.3.8 Recurrent C99 Flight Training ............................................................ 26 1.5.3.9 Required Flight Training Maneuvers .................................................. 26 1.5.4 The South Radar Controller................................................................ 27 1.6 Aircraft Information ........................................................................... 27 1.6.1 Previous Flightcrew Comments/Maintenance Activity....................... 29 1.6.2 Pre- and Postaccident Weight and Balance Calculations .................... 29 1.6.3 Cockpit Flight Instrumentation ........................................................... 29 1.6.4 Bendix RDR- 160 Weathervision System............................................ 30 1.7 Meteorological Information ................................................................ 31 1.7.1 General . 31 . 111 1.7.2 Synoptic Information .......................................................................... 31 1.7.3 Weather Forecasts and Advisories ...................................................... 31 1.7.4 Surface Observations .......................................................................... 32 1.7.5 Weather Information Provided to LEX508 ......................................... 34 1.7.6 Radar-derived Weather Information ................................................... 34 1.7.7 Satellite Information ........................................................................... 36 1.7.8 Astronomical Information................................................................... 36 1.7.9 Automatic Terminal Information Service (ATIS) Information ............ 36 1.8 Aids to Navigation ............................................................................. 37 1.9 Communications................................................................................. 37 1.10 Aerodrome Information ...................................................................... 38 1.11 Flight Recorders ................................................................................. 38 1.12 Wreckage and Impact Information...................................................... 39 1.12.1 Wreckage Distribution........................................................................ 39 1.12.2 Structural Damage to the Airframe ..................................................... 41 1.12.3 Systems Damage ................................................................................ 41 1.12.4 The Engines........................................................................................ 43 1.13 Medical and Pathological Information ................................................ 44 1.14 Fire ..................................................................................................... 46 1.15 Survival Aspects................................................................................. 46 1.15.1 Avenues of Escape ............................................................................. 46 1.15.2 Occupant Survival .............................................................................. 46 1.15.3 Crash/Fire/Rescue Response .............................................................. 47 1.16 Tests and Research ............................................................................. 47 1.17 Additional Information ....................................................................... 47 1.17.1 Airline Operations Information........................................................... 47 1.17.2 FAA Oversight of L’Express ............................................................... 48 1.17.2.1 Noncompliance Reports ..................................................................... 48 1.17.2.2 Excerpts From Aviation Safety Inspectors Handbook 8400.10, Change 4, August 31,199O .............................................................. 49 1.17.2.3 Regulations On Unusual Attitude Training ......................................... 50 1.17.2.4 Air Traffic Control Weather Dissemination Procedures...................... 51 2. ANALYSIS 2.1 General ............................................................................................... 53 2.2 Flightcrew Experience and Training ................................................... 55 2.2.1 Meteorological Training ..................................................................... 56 2.2.2 Radar Training ................................................................................... 56 2.2.3 Training in Recognizing and Recovering from Unusual Attitudes ...... 57 2.2.4 Aeronautical Decision Making ........................................................... 59 iv c 2.3 Weather at the Time of the Accident .................................................. 60 2.4 Pilot/Controller Physical and Psychological Factors