Crash of Pinnacle Airlines Flight 3701 Bombardier CL-600 ...

1 AviationCrash of Pinnacle Airlines Flight 3701 Bombardier CL-600 -2B19, N8396 AJefferson City, MissouriOctober 14, 2004 ACCIDENT REPORTNTSB/AAR-07/01PB2007-910402 Aircraft Accident ReportCrash of Pinnacle Airlines Flight 3701 Bombardier CL-600 -2B19, N8396 AJefferson City, MissouriOctober 14, 2004 NTSB/AAR-07/01PB2007-910402 National Transportation Safety BoardNotation 7695E490 L Enfant Plaza, January 9, 2007 Washington, 20594E PLURIBUS UNUM NATIONAL TRASPORTATION BOARDSAFETYNN ational Transportation Safety Board. 2007. Crash of Pinnacle Airlines Flight 3701, BombardierCL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004. Aircraft Accident ReportNTSB/AAR-07/01. Washington, : This report explains the accident involving a Bombardier CL-600 -2B19, N8396A, whichcrashed into a residential area about miles south of Jefferson City Memorial Airport, JeffersonCity, Missouri.

2 During the Flight , both engines flamed out after a pilot-induced aerodynamic stalland were unable to be restarted. Safety issues discussed in this report focus on Flight crew trainingin the areas of high altitude climbs, stall recognition and recovery, and double engine failures; Flight crew professionalism; and the quality of some parameters recorded by Flight data recorderson regional jet 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 BoardAct of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, studytransportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation.

3 The Safety Boardmakes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, andstatistical publications are available in their entirety on the Web at < >. Other information about available publications alsomay be obtained from the Web site or by contacting:National Transportation Safety BoardPublic Inquiries Section, RE-51490 L Enfant Plaza, , 20594(800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. Topurchase this publication, order report number PB2007-910402 from:National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 Section 1154(b), precludes the admission into evidence or use of Board reportsrelated to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

4 IiiAircraft Accident ReportContentsFigures .. viAbbreviations .. viiExecutive Summary .. x1. Factual Information .. History of Flight .. Injuries to Persons .. Damage to Airplane .. Other Damage .. Personnel Information .. Captain .. and Simulator Instructor Interviews Regarding the Captain .. First Officer .. and Simulator Instructor Interviews Regarding the First Officer .. Airplane Information .. Records .. Meteorological Information .. Aids to Navigation .. Communications .. Airport Information .. Air Traffic Control .. Flight Recorders .. Cockpit Voice Recorder .. Flight Data Recorder .. Wreckage and Impact Information .. Powerplants .. Systems .. Medical and Pathological Information .. Fire .. Survival Aspects .. Tests and Research.

5 Aircraft Performance Study .. Climb to 41,000 Feet .. Aerodynamic Stall and Upset Event .. Descent and Glide Performance .. Cockpit Voice Recorder Studies .. Engine Tests .. Load Control Valve Simulation Study .. Organizational and Management Information .. Ground School and Simulator Training .. 28ivAircraft Accident Upset Training .. High Altitude Climbs .. Double Engine Failure .. Stall Recognition and Recovery Training .. Crew Resource Management Training .. Leadership Training .. Flight Manuals .. High Altitude Climbs .. Double Engine Failure .. Stall Protection System .. Flight Operations .. Federal Aviation Administration Oversight .. Additional Information .. Oxygen Mask Use During the Accident Flight .. Core Lock .. Previous Related Safety Recommendations.

6 Core Lock .. Crew Professionalism .. Flight Data Recorder Data .. Federal Aviation Administration Notice .. Bombardier All Operator Message .. 422. Analysis .. General .. Accident Sequence .. to 41,000 Feet .. Stall and Upset Event .. Engine Failure .. of the Double Engine Failure Checklist .. With Air Traffic Controllers and Management of Forced Landing .. Sequence Summary .. Flight Crew Training .. Altitude Training .. Recognition and Recovery Training .. Engine Failure Training .. Flight Crew Professionalism .. 91 Operations .. Issues .. Responsibilities .. Responsibilities .. Quality of Flight Data Recorder Data for Regional Jet Airplanes .. 683. Conclusions .. Findings .. Probable Cause .. 73 ContentsvAircraft Accident Report4. Safety Recommendations.

7 New Recommendations .. Previously Issued Recommendation Reiterated and Classified in This Report .. Previously Issued Recommendations Resulting From This Accident Investigation .. 765. Appendixes .. 79A: Investigation and Hearing .. 79B: Cockpit Voice Recorder .. 80C: Pinnacle Airlines Double Engine Failure Checklist at the Time of the Accident.. 143D: Pinnacle Airlines Revised Double Engine Failure Checklist .. 149E: Core Lock Safety Recommendation Letter.. 154 ContentsviAircraft Accident in the CRJ Pneumatic Supply and Start Systems .. Distances for the Accident Airplane .. 24viiAircraft Accident currentACadvisory circular ADairworthiness directive ADGair-driven generatorAIRMET airman s meteorological informationAIZLee C. Fine Memorial Airport, Kaiser Lake Ozark, MissouriALPAAir Line Pilots AssociationANDairplane nose down ANUairplane nose upAOAangle of attack APUauxiliary power unit ARTCCair route traffic control center ASAPA viation Safety Action ProgramASOS automated surface observing systemAT Cair traffic controlATO SAir Transportation Oversight SystemAT Sair turbine starterCFRCode of Federal Regulations cgcenter of gravity CRJC anadair regional jet CRMcrew resource management CVRcockpit voice recorder DTWD etroit Metropolitan Wayne County Airport, Detroit.

8 MichiganEICAS engine indicating and crew alerting system FA AFederal Aviation Administration FCOM Flight crew operating manualAbbreviationsviiiAircraft Accident ReportFDRflight data recorderFMSflight management systemFOQA Flight operational quality assurance fpmfeet per minute FSDO Flight standards district officeGAOG overnment Accountability OfficeGEGeneral Electric GPWS ground proximity warning system HgmercuryICAOI nternational Civil Aviation OrganizationILSinstrument landing system ISAI nternational Standard AtmosphereJEFJ efferson City Memorial Airport, Jefferson City, MissouriKIAS knots indicated airspeedLBOF loyd W. Jones Lebanon Airport, Lebanon, MissouriLCVload control valveLITL ittle Rock National Airport, Little Rock, Arkansas LOSALine Operations Safety AuditMETAR meteorological aerodrome report mslmean sea level MSPM inneapolis-St. Paul International Airport, Minneapolis, MinnesotaN1engine fan speedN2engine core speed NWSN ational Weather ServicePOIprincipal operations inspectorSBservice bulletinSGFS pringfield-Branson Regional Airport, Springfield, MissouriSMSsafety management systemS/Nserial number AbbreviationsixAircraft Accident ReportSPSstall protection systemTBNW aynesville Regional Airport, Fort Leonard Wood, MissouriVIHR olla National Airport, Rolla/Vichy, MissourixAircraft Accident ReportExecutive SummaryOn October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlinesflight 3701 (doing business as Northwest Airlink), a Bombardier CL-600 -2B19, N8396A,crashed into a residential area about miles south of Jefferson City Memorial Airport,Jefferson City, Missouri.

9 The airplane was on a repositioning Flight from Little RockNational Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport,Minneapolis, Minnesota. During the Flight , both engines flamed out after a pilot-inducedaerodynamic stall and were unable to be restarted. The captain and the first officer werekilled, and the airplane was destroyed. No one on the ground was injured. The Flight wasoperating under the provisions of 14 Code of Federal Regulations Part 91 on aninstrument Flight rules Flight plan. Visual meteorological conditions prevailed at the timeof the National Transportation Safety Board determines that the probable causes ofthis accident were (1) the pilots unprofessional behavior, deviation from standardoperating procedures, and poor airmanship, which resulted in an in- Flight emergency fromwhich they were unable to recover, in part because of the pilots inadequate training;(2) the pilots failure to prepare for an emergency landing in a timely manner, includingcommunicating with air traffic controllers immediately after the emergency about the lossof both engines and the availability of landing sites; and (3) the pilots impropermanagement of the double engine failure checklist, which allowed the engine cores to stoprotating and resulted in the core lock engine condition.

10 Contributing to this accident were(1) the core lock engine condition, which prevented at least one engine from beingrestarted, and (2) the airplane Flight manuals that did not communicate to pilots theimportance of maintaining a minimum airspeed to keep the engine cores safety issues discussed in this report focus on Flight crew training in the areasof high altitude climbs, stall recognition and recovery, and double engine failures; flightcrew professionalism; and the quality of some parameters recorded by Flight datarecorders on regional jet airplanes. Safety recommendations concerning these issues areaddressed to the Federal Aviation Accident Report1. Factual History of FlightOn October 14, 2004, about 2215:06 central daylight time,1 Pinnacle Airlinesflight 3701 (doing business as Northwest Airlink), a Bombardier CL-600 -2B19,2 N8396A,crashed into a residential area about miles south of Jefferson City Memorial Airport(JEF), Jefferson City, Missouri.