Aviation Accidents and Lessons Unlearned LXXVIII: United Express flight 6291
On January 7, 1994, at 11:21 PM (23:21) Eastern Standard Time, United Express (UE) flight 6291 (UE6291), an Atlantic Coast Airlines (ACA) Jetstream 4101, registration number N304UE, crashed while approaching from the east to Columbus International Airport (CMH). The flight was operated Title 14 code of federal regulations (CFR) Part 135 as a regularly scheduled commuter flight from Dulles International Airport. The accident was assigned National Transportation Safety Board (NTSB) accident number DCA94MA027; the accident report, AAR-94/07, was published in April 1995, 16 months after the accident. The NTSB Archives have no investigatory information record for DCA94MA027; the NTSB web page shows the disclaimer: “The docket for this investigation has not been released.”
A sister airliner to UE6291
The NTSB, “… determines the probable causes of this accident to be:
· (1) An aerodynamic stall that occurred when the flightcrew allowed the airspeed to decay to stall speed following a 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’ automated aircraft, aircraft type, and in seat position, a situation exacerbated by a side letter of agreement between the company and its pilots; and,
· (4) The company’s failure to provide adequate stabilized approach criteria, and the [Federal Aviation Administration] FAA’s failure to require such criteria.
AAR-94/07 was written more like a review of things that went wrong, not as a preventive measure. The report reflected (as all NTSB reports do) a desire to return to some point – in this case January 5th – pre-accident and warn the pilots against actions that led to the tragedy. But UE6291’s accident investigation should’ve been an analysis of events aiming to give trainers and management what they need to prevent future unsafe behavior at ACA … and elsewhere. What elsewhere? UE6291 was a regional flight for United Airlines; other regional operators would’ve benefited from a quality investigation.
The fact the docket wasn’t released is confusing since the accident occurred 30 years ago. When will the NTSB release the docket? Will they ever release the docket? If not, why not? Information available through AAR-94/07 was ambiguous and incomplete. No attempt was made to understand root cause, nor was any effort made to look beyond UE6291 to prevent similar circumstances from re-occurring.
For example, there’s no sign of the ‘side letter of agreement’. There was a letter between ALPA – the Airline Pilots Association union – and ACA on page 66, but what was the exacerbation caused by it? What about ‘glass cockpit’ problems? What problems? There’s too much blind trusting of what investigators say they found but no substantiation of facts. The recorder transcript didn’t answer any questions. The NTSB didn’t seem to understand this.
Why is this important? AAR-94/07 has inappropriate report writing actions. Consider the probable causes the NTSB investigators referred to, they were cultural issues. Questions were raised about internal battles such as pilot training, seniority, ‘moving-up-to-the-left-seat’, union interests, crossing over to different equipment, and managerial procedural interference. These cultural issues are often exclusive to each air operator. But if analyzed correctly, if discussed with the FAA inspectors responsible for the operator, could’ve opened industry’s eyes to larger issues brewing at the time. These investigatory confusions consistently blindside inexperienced NTSB investigators. If these problems can’t be identified, they can’t be fixed.
In 1994, the airline industry was going through difficult-to-foresee certificate upheavals. One reason was the commotion around regional air operators – feeders. They began as Part 135 commuters to the major airlines before upgrading to Title 14 CFR Part 121 operators themselves. Part 135 commuters-turned-regionals were lost in deregulation mayhem. Why? Because the FAA measured oversight and surveillance needs, like FAA manpower, by a certificate holder’s complexity. Regionals didn’t start out complex but became increasingly complicated from the late 1980s to 2009, as seen with Britt Airways, Air Midwest, Executive Airlines, and Colgan Air, each later involved in their own unique accidents.
The FAA was unable to recognize the rapid growth to meet contractual obligations between regionals and the majors – as opposed to uncontrolled growth by operators like ValuJet. This meant the FAA had to meet the increasing complexity of the regionals with manpower they could only budget for two fiscal years later. The NTSB never recognized this; their thinking was – is – two-dimensional (past and present); they can’t think ‘future’ because they couldn’t – still can’t – understand the industry. They only know how to react.
Another concern with AAR-94/07 was an early demonstration of NTSB investigators’ opinions making their way into accident reports, especially where conflicting opinions can’t be argued, due to flight crew fatalities. On page 58 of AAR-94/07, NTSB investigators gave their thoughts on the accident flight’s captain and first officer, who both died in the accident. “The evidence suggests that each crewmember possessed unique deficiencies that affected his performance …” What evidence? What did it suggest? Where are the archived facts? In the next paragraph, “The first officer, who was considered an above average pilot, nevertheless …” Who considered this? How do NTSB investigators, without experience in Parts 135 and Part 121, determine a flightcrew’s quality?
This is the problem with non-industry investigators judging deceased industry pilots without being aware of the conditions within the operator. Opinions are then assumed and added as part of the accident report. Speculations should’ve been left in the Operations Lead Investigator’s analysis report, away from public scrutiny. There isn’t any docket, so no information was there to verify or argue against what the NTSB put in AAR-94/07 or many of its reports.
In addition, AAR-94/07’s probable cause was amended to include two additional sub-causes by two of the five board members. One mentioned inadequate crew resource management (CRM) and the other spoke of simulator training. These two sub-causes were left out of this analysis because their input was uninformed and speculative, based solely on both board members’ opinions and a lack of involvement in the investigation; they didn’t warrant comment. Besides, topics like CRM and simulator training are buzz words to people wanting to speak with authority to subjects they neither experienced nor participated in. What do political appointees know about CRM or simulator training?
12/14/94: UE 6291 moves to page 9 in the Toledo Blade
Consider the time: 1994. UE6291 was a little publicized accident, one where a small operator crashed; moved from the headlines within a day or two. UE6291’s headlines were soon lost among a few better known (and better covered) events, such as FedEx 705’s hijacking, USAir 1016’s wind shear, and US Air 427’s sudden plunge. The NTSB’s limited resources were pulled towards Charlotte and Pittsburgh, allowing NTSB board members to fill the vacuum with their technically-poor, judgment-deprived approaches to safety. What’s worse was industry stood by and allowed this transition from fundamental safety-mindedness to political attention-seeking amid aviation’s greatest transitions due to Deregulation. Board members then became empowered to express their opinions … unchallenged.
If one counts accidents of to-be-regional carriers from 1987, forward to 1997, there were 16 regional air carrier accidents: Ryan Air Express 101, Northwest Airlink (NWAL) 2268, American Eagle (AE) 5452, UE 2415, Atlantic Southeast Airlines (ASA) 2254, ASA 2311, L’Express 508, Continental Express 2574, Commutair 4821, AE 5456, NWAL 5719, UE 6291, AE 4184, ASA 529, UE 5925, and Comair 3272. This does not count the 25 Part 121 accidents in the same 10-year timeframe, including highly publicized accidents, like TWA 800, US Air 427, and ValuJet 592. How much attention could the – would the – NTSB devote to the smaller regional air operators? How much thought could the NTSB give cultural issues between the regionals and their major airline contracts, even if NTSB investigators had the industry experience to identify them?
This brings up how NTSB board members are not technically trained in any transportation mode – aviation, rail, pipeline, highway, or marine – events. They’re political appointees; their opinions are editorial – an outsider’s view – of reports, never technical. Board members don’t actively participate in investigations; they’re spokespersons, updating the media. Even those board members who made their way through the transportation industry as a participant are there to verify the quality of a report’s words by being the sample audience, to have investigators explain reports to them – not the other way around.
Board member interference in the report process has become the norm instead of the exception. Board members who change an accident report’s direction obstruct the very safety items the investigation was intended to bring out. Take UE6291: Why did the two board members dismiss what investigators found as ‘not enough’? The two board members presented no evidence; conducted no interviews with pilots; no training was reviewed. The two board members … just decided, they knew more than all investigators at the NTSB and industry combined. Even worse was what they did with the Recommendations.
Board members are politically confused; they’re back seat drivers without licenses, no driving experience. This arrogance alters what’s been investigated, not only by the NTSB investigators, but by experienced representatives of industry and party members to the investigation. Analysis is sidelined for agendas forwarded by non-aviation – non-marine, non-highway, non-rail, and non-pipeline – persons whose pride makes them oblivious to facts.
The transportation industry needs to wake up to this insanity that’s gripped it for decades, the one labeled ‘accident investigation’, no matter what transportation mode the investigation takes place in. Look at the headlines; are we getting safer? Are we allowing those who don’t know to dictate what they don’t know or are we going to set safety standards again, removing the preening and second-guessing? We must leave politics out of investigatory reports. We’re condemning ourselves to mediocrity and years of scratching our heads wondering what happened.