Crash During Approach to Landing Empire Airlines Flight 8284 Avions de Transport Régional ...

128 Pages·2011·1.32 MB·English

Crash During Approach to Landing 
Empire Airlines Flight 8284 
Avions de Transport Régional 
Aerospatiale Alenia ATR 42‐320, N902FX 
Lubbock, Texas 
January 27, 2009 

Accident Report
NTSB/AAR-11/02
PB2011-910402
National

Transportation

Safety Board

NTSB/AAR-11/02
PB2011-910402
Notation 8093A
Adopted April 26, 2011

Aircraft Accident Report
Crash During Approach to Landing
Empire Airlines Flight 8284
Avions de Transport Régional
Aerospatiale Alenia ATR 42-320, N902FX
Lubbock, Texas
January 27, 2009

National
Transportation
Safety Board

490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
National Transportation Safety Board. 2011. Crash During Approach to Landing, Empire Airlines
Flight 8284, Avions de Transport Régional Aerospatiale Alenia ATR 42-320, N902FX, Lubbock,
Texas, January 27, 2009. Aircraft Accident Report NTSB/AAR-11/02. Washington, DC.

Abstract: This accident report discusses the January 27, 2009, accident involving Empire Airlines
flight 8284, an Avions de Transport Régional Aerospatiale Alenia ATR 42-320, N902FX, which crashed
short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain
sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially
damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a
14 Code of Federal Regulations Part 121 supplemental cargo flight. Instrument meteorological conditions
prevailed, and an instrument flight rules flight plan was filed. The safety issues discussed in this report
include the flight crew’s actions in response to the flap anomaly, the continuation of the unstabilized
approach, the dispatch of the flight into freezing drizzle conditions, the efficiency of the emergency
response, and simulator-based training for pilots who fly in icing conditions. Nine safety
recommendations are addressed to the Federal Aviation Administration.

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.

Recent publications are available in their entirety on the Internet at <http://www.ntsb.gov>. Other information about
available publications also may be obtained from the website or by contacting:

National Transportation Safety Board
Records Management Division, CIO-40
490 L’Enfant Plaza, SW
Washington, DC 20594
[phone] or [phone]

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical
Information Service. To purchase this publication, order report number PB2011-910402 from:

National Technical Information Service
5285 Port Royal Road
Springfield, Virginia 22161
[phone] or [phone]

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence
or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter
mentioned in the report.
NTSB Aircraft Accident Report
Contents
Figures ........................................................................................................................................... iv 
Abbreviations and Acronyms .......................................................................................................v 
Executive Summary ..................................................................................................................... ix 
1. Factual Information ...................................................................................................................1 
1.1 History of Flight .........................................................................................................................1 
1.2 Injuries to Persons ......................................................................................................................5 
1.3 Damage to Airplane ...................................................................................................................5 
1.4 Other Damage ............................................................................................................................5 
1.5 Personnel Information ................................................................................................................6 
1.5.1 The Captain ......................................................................................................................6 
1.5.2 The First Officer ..............................................................................................................6 
1.5.3 Flight Crew’s Rest Opportunities ....................................................................................7 
1.5.3.1 The Captain ....................................................................................................... 7 
1.5.3.2 The First Officer ............................................................................................... 8 
1.6 Airplane Information .................................................................................................................8 
1.6.1 General .............................................................................................................................8 
1.6.2 Flap System .....................................................................................................................9 
1.6.3 Deicing, Anti-Icing, and Anti-Icing Advisory Systems ................................................11 
1.6.4 Flight Instruments ..........................................................................................................11 
1.6.4.1 Airspeed Indicator ........................................................................................... 11 
1.6.4.2 Electronic Flight Information System ............................................................. 13 
1.6.5 Automatic Flight Control System ..................................................................................13 
1.6.6 Stall Protection System ..................................................................................................13 
1.7 Meteorological Information .....................................................................................................14 
1.8 Aids to Navigation ...................................................................................................................14 
1.9 Communications ......................................................................................................................15 
1.10 Airport Information ................................................................................................................15 
1.10.1 Emergency Plan ...........................................................................................................15 
1.10.2 Snow and Ice Control Plan ..........................................................................................16 
1.11 Flight Recorders .....................................................................................................................16 
1.11.1 Cockpit Voice Recorder ..............................................................................................16 
1.11.2 Flight Data Recorder ....................................................................................................17 
1.12 Wreckage and Impact Information ........................................................................................17 
1.13 Medical and Pathological Information ...................................................................................18 
1.14 Fire .........................................................................................................................................18 
1.15 Survival Aspects ....................................................................................................................18 
1.15.1 Flight Crew Egress ......................................................................................................18 
1.15.2 Emergency Response ...................................................................................................18 
1.16 Tests and Research .................................................................................................................21 
1.16.1 Airplane Performance Study and Simulator Evaluations ............................................21 
i
NTSB Aircraft Accident Report
1.16.1.1 Effects of Flap Asymmetry ........................................................................... 21 
1.16.1.2 Effects of Airframe Ice Accretion ................................................................. 22 
1.16.2 Terrain Awareness and Warning System ....................................................................23 
1.16.3 Flap System Component Examinations .......................................................................24 
1.16.3.1 Hydraulic Fluid Testing ................................................................................ 25 
1.16.3.2 Maintenance History ..................................................................................... 25 
1.16.3.3 Flap Asymmetry Event Involving Another Airplane .................................... 25 
1.16.4 Deicing and Anti-Icing System Examinations ............................................................26 
1.16.5 Autopilot Disconnect Alert ..........................................................................................26 
1.17 Organizational and Management Information .......................................................................26 
1.17.1 Pilot Standard Operating Procedures and Training .....................................................27 
1.17.1.1 Flap Anomalies ............................................................................................. 27 
1.17.1.2 Stabilized Approach and Go Around ............................................................ 31 
1.17.1.3 Terrain Awareness and Warning System ...................................................... 32 
1.17.1.4 Airspeed Bugs ............................................................................................... 32 
1.17.1.5 Aileron Mistrim with Autopilot Engaged ..................................................... 33 
1.17.1.6 Deicing and Anti-Icing Systems ................................................................... 33 
1.17.1.7 Crew Resource Management ........................................................................ 34 
1.17.1.8 Weather Information and Training ............................................................... 35 
1.17.1.9 Stall and Near-Stall Recoveries .................................................................... 36 
1.17.2 Aircraft Deicing Program (Ground) ............................................................................36 
1.17.3 Flight Dispatch .............................................................................................................36 
1.17.4 Hazardous Materials ....................................................................................................38 
1.17.5 Federal Aviation Administration Oversight ................................................................38 
1.17.6 Previous Accidents ......................................................................................................39 
1.18 Additional Information ..........................................................................................................40 
1.18.1 Postaccident Safety Action ..........................................................................................40 
1.18.1.1 Federal Aviation Administration .................................................................. 40 
1.18.1.2 Empire Airlines ............................................................................................. 41 
1.18.1.3 FedEx Feeder Operations .............................................................................. 42 
1.18.2 Previously Issued Safety Recommendations ...............................................................43 
1.18.2.1 Flight Crew Monitoring and Workload Management Skills for Single and
Multiple Abnormal Situations..................................................................................... 43 
1.18.2.2 Go-Around Callout ....................................................................................... 45 
1.18.2.3 Low-Airspeed Alerting Systems ................................................................... 45 
1.18.2.4 First Officer Assertiveness ............................................................................ 46 
1.18.3 Airplane Equipment Options .......................................................................................47 
1.18.3.1 Aircraft Performance Monitoring System .................................................... 47 
1.18.3.2 Flap Malfunction or Asymmetry Light ......................................................... 48 
1.18.3.3 Ice Evidence Probe ....................................................................................... 49 
2. Analysis .....................................................................................................................................50 
2.1 General .....................................................................................................................................50 
2.2 Accident Sequence ...................................................................................................................52 
2.3 Human Performance ................................................................................................................54 
2.3.1 Captain’s Nonstandard Responses .................................................................................55 
2.3.2 Flight Crew’s Failure to Monitor Airspeed ...................................................................57 
ii
NTSB Aircraft Accident Report
2.3.2.1 Airspeed References ....................................................................................... 58 
2.3.2.2 Flight Crew Monitoring Skills and Techniques .............................................. 60 
2.3.3 Crew Resource Management .........................................................................................61 
2.3.4 Go-Around Callout ........................................................................................................63 
2.3.5 Training for Single and Multiple Abnormal Situations Occurring at Low Altitude .....64 
2.3.6 Fatigue Considerations ..................................................................................................65 
2.3.6.1 Role of Fatigue in Flight Crew Performance .................................................. 67 
2.4 Operations Issues .....................................................................................................................69 
2.4.1 Dispatch into Freezing Drizzle Conditions ....................................................................69 
2.4.1.1 Flight Crewmember and Dispatcher Training Related to Icing Conditions ... 70 
2.4.1.2 Proposed Rulemaking for Airplane Certification Requirements for Flight in
Icing Conditions .......................................................................................................... 72 
2.4.2 Training Program and Manual Discrepancies ...............................................................72 
2.5 Survival Aspects ......................................................................................................................73 
2.5.1 Lack of Occupant and Hazardous Materials Information Available
to First Responders .................................................................................................................73 
2.5.2 Inoperative Emergency Response and Mutual Aid Gate ...............................................75 
2.6 Airplane Equipment Options ...................................................................................................75 
2.6.1 Aircraft Performance Monitoring ..................................................................................75 
2.6.2 Flap Malfunction or Asymmetry Light ..........................................................................77 
2.6.3 Ice Evidence Probe ........................................................................................................77 
2.7 Simulator Training for Icing Encounters .................................................................................78 
3. Conclusions ...............................................................................................................................80 
3.1 Findings....................................................................................................................................80 
3.2 Probable Cause.........................................................................................................................83 
4. Recommendations ....................................................................................................................84 
Board Member Statements .........................................................................................................86 
5. Appendixes ...............................................................................................................................93 
Appendix A: Investigation and Hearing ........................................................................................93 
Appendix B: Cockpit Voice Recorder Transcript ..........................................................................94 

iii
NTSB Aircraft Accident Report
Figures
Figure 1. Aerial view of approach end of runway 17R and location of wreckage. ....................... 5 
Figure 2. Flap position indicator. Inset shows the likely needle pointer position during the
flap asymmetry.............................................................................................................................. 10 
Figure 3. Exterior flap position fairing. ....................................................................................... 10 
Figure 4. Airspeed indicator showing needle pointer; selector knob; and internal, yellow,
white, and red bugs. ...................................................................................................................... 12 
Figure 5. View of airport showing relative locations of airport access gates and accident site. . 20 
Figure 6. Right side of fuselage showing extensive fire damage to right wing and
flap components. ........................................................................................................................... 24 
Figure 7. Quick reference handbook page 2.21 with “FLAPS JAM/UNCOUPLED/ASYM” and
“REDUCED FLAPS LANDING” procedures. ............................................................................ 28 
Figure 8. General information on page 0.02 of quick reference handbook. ................................ 29 

iv
NTSB Aircraft Accident Report
Abbreviations and Acronyms
AAS anti-icing advisory system
AC advisory circular
AD airworthiness directive
ADP aircraft deicing program
ADU advisory display unit
AEP airport emergency plan
AFFF aqueous film forming foam
AFM airplane flight manual
AFW Fort Worth Alliance Airport
agl above ground level
AIM Aeronautical Information Manual
AIRMET airmen’s meteorological information
AOA angle of attack
APM aircraft performance monitoring
ARAC Aviation Rulemaking Advisory Committee
ARFF aircraft rescue and firefighting
ATC air traffic control
ATCT air traffic control tower
ATOS air transportation oversight system
ATR Avions de Transport Régional
ATR 42 Aerospatiale Alenia ATR 42-320
BEA Bureau d’Enquêtes et d’Analyses
CFR Code of Federal Regulations
v
NTSB Aircraft Accident Report
CG center of gravity
CRM crew resource management
CVR cockpit voice recorder
DGAC Direction Générale de l’Aviation Civile
EADI electronic attitude direction indicator
EASA European Aviation Safety Agency
EFS engineering flight simulator
ELP El Paso International Airport
EMS emergency medical service
FAA Federal Aviation Administration
FAF final approach fix
FCOM flight crew operating manual
FDR flight data recorder
FedEx FedEx Corporation
FL flight level
fpm feet per minute
FR Federal Register
FSDO flight standards district office
FSIB flight standards information bulletin
FTM flight training manual
GOM general operations manual
HAZMAT hazardous materials
Hg mercury
IEP ice evidence probe
vi