NTSB Cites Fatigue, Poor Training In Fatal Crash

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Pilot error was to blame for the crash of a Hawker Beechcraft 125-800A in July 2008, the NTSB said on Tuesday. The airplane, operated by East Coast Jets, crashed when the crew attempted a go-around after landing on a wet runway at Owatonna Degner Regional Airport, in Minnesota. Both pilots and all six passengers were killed. The captain's decision to attempt the go around late in the landing roll with insufficient runway remaining was the probable cause of the accident, the NTSB found. Contributing factors were poor crew coordination and lack of cockpit discipline; fatigue, which likely impaired both pilots' performance; and the FAA's failure to require crew resource management training and standard operating procedures for Part 135 operators.

"This accident serves as a reminder that aviation is an unforgiving environment," said NTSB Chairman Deborah Hersman. "No detail is too small to be overlooked -- not the winds, or the communication between crew members, or even how much sleep they get. The small things do matter and in this case they accumulated to result in tragedy." The flight was a nonscheduled passenger flight. Visual meteorological conditions prevailed at the time of the accident. The NTSB investigators looked at several other safety issues, including go-around guidance for turbine-powered aircraft; Part 135 preflight weather briefings; inadequate arrival landing distance assessment guidance and requirements; Part 135 on- demand, pilot-in command line checks; and cockpit image recording systems. The safety board issued several safety recommendations to the FAA regarding training, operating procedures, and sleep disorders. Those recommendations, along with a synopsis of the accident investigation report, are posted on the NTSB web site. The complete report will be available on the web site in a few weeks.