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WASHINGTON, B.C. 20594 AIRCRAFT ACCIDENT REPORT 1 CONTROLLED COLLISION WITH TERRAIN GP EXPRESS AIRLINES, INC., FLIGHT 861 A BEECHCRAFT 699, Nl18GP ANNISTON, ALABAMA JUNE 8,1992 ---- /' The National Transportation Safety Eoard is an independent Federal agency dedicated to promothg aviation, droad, 'lighway, marine, pipeline, and hazardous materials safety. Established in 1967, the ageacy is mdeted by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determins the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportatiou. The Safety Board makes public its actions and decisions through accidenr 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, RE41 490 L'Enfant Plaza, S.W. Washington, DX. 20594 (202)382-6735 Safety Board publications way be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springkld, Virginia 22161 (703)487-4600 AIRCRAFT ACCIDENT REPORT CONTROLLED COLLISION WITH TEXRAEV GP EXPRESS AIRLINES, INC., FLIGHT 861 A BEECHCRAFT C99, NlllBGP ANNETON, ALA.BAMA JUNE 8,1992 Adopted: March 2,1993 Nohtion S806A Abstract: This report explains the controlled collision into terrain of GP Express flight 861, a Beechcraft C99, N118GP. in Amiston, Alabama, on June 8, 1992. The safety issues discussed in the report are, for aircraft operating under 14 CFR Part 135, the importance of adequate preparation and experience of newly hired captains, available approach charts for each pilot, and adhsrence to specific stabilized approach criteria. The importance of adequate cockpit resource management- is also discussed. Recommendations concerning- these issues were made to the Federal Aviation Administration. CONTENTS EXECUTIVE SUMMARY ................................................................. V 1. FACTUAL INFORMATTON 1.1 History of the Flight ............................................................................ 1 1.2 Injuries to Persons ................................................................................. 6 1.3 Damage to Aircraft ................................................................................ 6 1.4 Other Daqage ....................................................................................... 6 1.5 Personne!. Information ........................................................................... 7 1.6 Aircraft Wonnation ............................................................................... 11 1.7 Meteorological Infomation ................................................................... 12 1.8 Aids to Navigation ................................................................................ 12 1.9 Communications .................................................................................... 12 1.10 Aerodrome lnformation ......................................................................... 13 1.11 Flight Recorders .................................................................................... 13 1.12 Wreckage ai?d Impact Information ......................................................... 13 1.13 Medical and Pathological Information ................................................... 14 1.14 Fire ....................................................................................................... 14 1.15 Survival Aspects .................................................................................... 14 @ 1.16 Tests and Research................................................................................ 14 1.16.1 Radar Study and Airplane Performance ................................................. 14 1.16.2 Ground Proximity Warning System (GPWS) ......................................... 15 1.17 Additional Information .......................................................................... 18 1.17.1 GP Express Instrument Approach Training Procedures .......................... 18 1.17.2 72-Hour History of Flightcrew ............................................................... 20 1 J7.3 Operator Information ............................................................................. 21 1.17.4 Southern Iioute Structure....................................................................... 22 1.17.5 FAA Surveillance .................................................................................. 24 2 . ANALYSIS 2.1 General ................................................................................................. 26 2.2 Crew Awareness ................................................................................... 26 2.3 The Flight and Crew Performance ......................................................... 28 2.4 Cockpit Resource Management Training ............................................... 38 2.5 GP Express Management Culture .......................................................... 40 2.6 FAA Surveillance .................................................................................. 44 ... 111 3 . ZONCLUSIQNS 3.1 Findings ................................................................................................ 46 3.2 Probable Cause ..................................................................................... 48 4. RECOMMENDATIONS .................................................................... 49 5 . APPENDIXES Appendix A.. Investigation and Hearing ................................................. 51 Appendix B.. Cockpit Voice Recorder Transcr;;pt .................................. 52 iv EXECUTIVE SUMMARY On June 8, 1992, GP Express Airlines, kc., flight 861, a Beechcraft model C99, N118GP, crashed while maneuvering to land at the Anniston Metropolitan Airport, Anniston, Alabama. The flight was a schedul-d passenger flight from the William B. Hartsfield Atlanta International Airport in Atlanta, Georgia, on an instrument flight rules fight plan to Anniston, Alabama. The captain and two passengers received fatal injuries. The first officer and two passengers were seriously injured. The airplane was destroyed by impact and postcrash fire. The investigation revealed that the flightcrew was properly certificated and qualified in -.xordance with applicable Federal Aviation Regulations (FARs) and company requirements, and that there was no evidence of adverse medical conditions that ar.?ected the flightcrew, nor were they under the influence of, or impaired by, drugs or alcohol. The investigation determined that the airplane had been properiy maintained and that there was no evidence of a malfunction or preexisting problem that would have either caused or contributed to the accident. Additionally, it was determined that weather was not a factor in the accident. The Safety Board determined that the flightcrew experienced a loss of situational awaremss that led to a controlled collision with terrain. After being cleared by air traffic control for the instrument landing system (ILS)approach to runway 5 at Anniston, the flightcxw turned the airplane toward the north away from the airport in the erroneous belief that the airplane was south of the airport. The flightcrew did not perform the maneuvers specified on the approach chart, which required flying outbound from the airport, then performing the “procedure turn” back toward the airport. The investigzbn determined that in actuality, the airplane had intercepted the back course localizer signal for the ILS approach, and the flightcrew had commenced the approach at a high airspeed about 2,000 feet above the specified altitude for crossing the final approach fix. The airplane continued a controlled descent until it impacted terrain. The National Transportation Safety Board determines that the probable causes of this accident were the failure of senior management of GP Express to provide adequate training and operational support for the startup of the southern operation, which resulted in the assignment of an inadequately prepared captain with a relatively inexperienced first officer in revenue passenger service, and the failure V of the flightcrew to use approved instrument flight procedures, which resulted in a loss of situational awareness and terrain clearance. Contributing to the causes of the accident was GP Express' failure to provide approach charts to each pilot and to establish stabilized approach criteria. Also contributing were the inadequate crew coordination and a role Izversal on the part of the captain and first officer. As a result of its investigation of this accident, the Safety Board made five recommendations to the Federal Aviation Administration (FAA): to require the availability of two sets of approach charts on aircraft requiring two pilots, to require the development and use of stabilized approach criteria, to develop evaluation criteria for cockpit resource management (CRM) training programs, captain flight training, and a minimum experience requirement for commuter air camer captains. Additionally, the Safety Board reiterated a recommendanon to the FAA to require that scheduled 14 CFR Part 135 operators develop and use CRM training programs and a recommendation to establish minimum experience levels for pairing flightcrews. vi NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT

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