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The official Canadian accident report said that the nonflying pilot’s altimeter, course track indicator and heading settings had not been set accurately to enable accurate monitoring of the nonprecision night approach.
The official report of the Netherlands Aviation Safety Board concluded that the crew was unaware of the consequences of making an approach with one engine in flight idle. Moreover, the crew did not understand the aircraft’s engine-oil system. Investigators determined that an oil-pressure switch failed and resulted in cockpit warnings, but there was no evidence of any other failure or defect on the aircraft, including the engines and systems.
An inspection of the operator by Canada’s Transportation Safety Board, after the accident, resulted in the removal of the company’s maintenance certificate and suspension of its operating certificate, the official report said.
The pilot of the accident flight, carrying members
of a country music band, had three conversations with an FAA Flight
Service Station specialist before takeoff. But the conversations
still left the pilot with a misunderstanding of the correct departure
Poorly Flown Approach in Fog Results in Collision With Terrain Short of Runway 8 pages. [PDF 108K]
“This approach was exactly the type of high-workload and stressful operation that would exceed the captain’s normal capabilities,” the official report said. Crew fatigue and lack of GPWS may also have contributed to the fatal accident.
Inadequate grounding between radome and fuselage could have resulted in unreliable glideslope indications, official U.S. report says.
The official U.K. accident report identified flight crew training, Emergency Checklist use and crew resource management as factors in the accident. The role of air traffic control during emergencies was also examined.
Rejected Takeoff in Icy Conditions Results in Runway Overrun 8 pages. [PDF 58K]
The flight crew failed to comply with checklist procedures, leading to erroneous airspeed indications and a rejected takeoff at a speed exceeding V1, the official U.S. Accident investigation
The crash of a twin-engine piston-powered Piper PA-31-350 Navajo Chieftain, owned and operated by Action Airlines Inc., in Stratford, Connecticut, U.S., has resulted in recommendations by the U.S. National Transportation Safety Board (NTSB) to the U.S. Federal Aviation Administration (FAA) regarding the inspection of U.S. Federal Aviation Regulations (FARs) Part 139–certificated airports for adequate runway safety areas and nonfrangible [resistant to breaking apart] objects.
Maintenance and inspection personnel who worked on the accident airplane were not adequately trained and qualified to perform the required maintenance and inspection functions, according to a special report by U.S. NTSB.
Poor cockpit discipline, nonstandard phraseology and poor radio communications technique, nonadherence to company procedures, limited crew experience and inadequate training were among the facts cited in the Portuguese controlled-flight-into-terrain accident report.
The captain elected to bleed off the aircraft’s excess speed by reducing power to idle thrust on both of the turboprop engines during the coupled approach. He failed to monitor the instruments and when the stick shaker activated, the captain was surprised. He called for retraction of the flaps and pulled back the flight controls, fighting the stick shaker.