Narrative:The aircraft, dispatched with an inoperative airframe de-ice system, approached Beckley in icing conditions. Ice accumulated on the aircraft and a higher than usual approach speed was used. When full flaps were selected (50deg) the aircraft began to buffet and pitched nose down. The Jetstream slammed onto the runway and slid to a stop. There was evidence of tail plane stall, lack of company training in cold weather operations, deficiencies in the use of de-icing systems, and lack of FAA surveillance.
PROBABLE CAUSE: "Flight into known adverse weather conditions by the pilot, which resulted in ice accumulation on the aircraft and subsequent loss of aircraft control (tail plane stall) as the flaps were fully extended. Factors related to the accident were: the pilot's inadequate use of the preflight briefing service, inadequate training provided to the pilots by company/management personnel, inadequate surveillance by the FAA, and icing conditions."
Sources:
» Flight International
» ICAO Adrep Summary 4/94 (#55)
» NTSB Safety Recommendations A-92-59 through -65
» NTSB/AAR-96/02
Follow-up / safety actions
NTSB issued 7 Safety Recommendations
| Issued: 22-JUL-1992 | To: FAA | A-92-059 |
| Amend FAA Order 8400.10, volume 3, chapter 7. Section 2, parts 121/135, "Weather Information Systems," paragraph 1425, to specify that principal operations inspectors ensure that operators under 14 CFR Part 135, who elect to use a weather information system, make available to flightcrews, as well as to dispatch and/or flight control personnel, weather products listed under section 2 that are appropriate to their flight operations. Principal operations inspectors should ensure that initial and recurrent flightcrew training include the use of computerized weather systems, if such systems are a source of flightcrew weather information. (superseded by A-94-71) (Closed - Acceptable Action/Superseded) |
| Issued: 22-JUL-1992 | To: FAA | A-92-060 |
| Issue an air carrier operations bulletin directing all principal operations inspectors having surveillance responsibility of operators of BA-3100 airplanes to alert operators of the danger of unanticipated and abrupt tailplane stall during changes in flap configuration as a result of horizontal stabilizer ice accumulation. (superseded by A-94-71) (Closed - Acceptable Action/Superseded) |
| Issued: 22-JUL-1992 | To: FAA | A-92-061 |
| Issue an air carrier operations bulletin directing all principal operations inspectors to examine the meteorological training curricula of 14 CFR Part 135 operators under their purview and ensure that they provide adequate information regarding icing conditions and cold weather operating limitations applicable to their particular aircraft, as well as preflight and in-flight deicing procedures. (superseded by A-94-71) (Closed - Acceptable Action/Superseded) |
| Issued: 22-JUL-1992 | To: FAA | A-92-062 |
| REQUIRE BRITISH AEROSPACE, INC. TO SHOW, BY FLIGHT TEST, THAT THE LIMITATION TO FLAPS 35 DEGREES, CURRENTLY INCORPORATED INTO ALL BA-3200 AIRPLANES AND AVAILABLE IN KIT FORM FOR INSTALLATION ON BA-3100 AIRPLANES, PROVIDES AN ADEQUATE SAFETY MARGIN AGAINST TAILPLANE STALL IN ICING CONDITIONS; AND IF THE MARGIN IS ADEQUATE, REQUIRE OPERATORS OF BA-3100 AIRPLANES TO INSTALL THE FLAP EXTENSION LIMITATION MODIFICATION ON THE AIRPLANE. IF THE MARGIN IS INADEQUATE, REQUIRE APPROPRIATE CHANGES TO ASSURE ITS ADEQUACY. (Closed - Acceptable Action) |
| Issued: 22-JUL-1992 | To: FAA | A-92-063 |
| REVIEW THE ADEQUACY OF ICE PROTECTION AND DETECTION CONTROLS ON BA-3100 AND BA-3200 AIRPLANES WITH REGARD TO THE PLACEMENT OR REDUNDANCY OF SWITCHES AND LIGHTS FOR PROPER COCKPIT COORDINATION, INSTRUMENT SCAN, AND ACCESSIBILITY TO BOTH PILOTS; AND REQUIRE APPROPRIATE MODIFICATIONS AS NECESSARY. (Closed - Acceptable Action) |
| Issued: 22-JUL-1992 | To: FAA | A-92-064 |
| ISSUE AN AIRWORTHINESS DIRECTIVE, APPLICABLE TO AIRPLANES USING PNEUMATIC AIRFRAME DEICING SYSTEMS, REQUIRING THAT THE CONTROL SWITCHES FOR THESE SYSTEMS BE MODIFIED SO THAT A SINGLE MANUAL ACTIVATION OF THE SWITCH WILL ALLOW A COMPLETE CYCLE OF THE WING AND TAIL LEADING EDGE DEICING SYSTEM. REQUIRE THAT MODELS OF THESE AIRPLANES CURRENTLY IN SERVICE BE RETROFITTED WITH THIS MODIFICATION. (Closed - Acceptable Action) |
| Issued: 22-JUL-1992 | To: FAA | A-92-065 |
| Issue an airworthiness directive applicable to two-pilot airplanes operating under the provisions of 14 CFR Part 135 that use leading edge ice detection lights, such as the BA-3100 and BA-3200, requiring that leading edge ice detection lights be installed to illuminate both wings. Require that models of these airplanes requiring two pilots be retrofitted with this modification. (Superseded by Safety Recommendations A-94-112 through A-94-117) (Closed - Unacceptable Action/Superseded) |
Show all AD's and Safety Recommendations
Photos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Charlotte-Douglas Airport, NC to Beckley Airport, WV as the crow flies is 285 km (178 miles).
