Accident · 1994-01-08

What the record says

Event date

1994-01-08

Event type

Accident

Highest injury level

Fatal injury

Aircraft

JETSTREAM 4101 (N304UE)

Operating rule

Part 135

Operator

ATLANTIC COAST AIRLINES Operator named in NTSB report

Operated by (per NTSB report)

ATLANTIC COAST AIRLINES

Probable cause

(1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a very poorly planned and executed approach characterized by an absence of procedural discipline; (2) Improper pilot response to the stall warning, including failure to advance the power levers to maximum, and inappropriately raising the flaps; (3) Flightcrew inexperience in 'glass cockpit' automatic aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots; (4) The company's failure to provide adequate crew resource management training, and the FAA's failure to require such training; (5) The company's failure to provide adequate stabilized approach criteria, and the FAA's failure to require such criteria; and (6) The unavailability of suitable training simulators that precluded fully effective flightcrew training. Note: Items 1, 2, and 3 were approved by a Board vote of 4-0. Item 5 was adopted 3-1, with the dissenting Member believing the item was a contributory cause. The Board was divided 2-2 on items 4 and 6, two Members believing them causal and two Members, contributory. (NTSB Report AAR-94/07)

Flight crew

Flight-crew details for this event aren't in the NTSB database extract we hold (its coverage starts with 2008 events) — a gap in our data, not an absence of crew.