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Pilot error led to deadly 2004 crash, NTSB says

Pilot mistakes caused the deadly crash of a commuter airliner in northeast Missouri in 2004, and the crew’s nonstop joking and expletive-laden banter in the cockpit didn’t help, federal investigators said Tuesday.
/ Source: The Associated Press

Pilot errors caused the deadly crash of a commuter airliner in northeast Missouri in 2004, and the crew’s nonstop joking and expletive-laden banter in the cockpit didn’t help, federal investigators said Tuesday.

The two-man crew and 11 of 13 passengers were killed when Corporate Airlines Flight 5966 crashed on Oct. 19, 2004. It was the country’s deadliest civilian air crash that year.

The National Transportation Safety Board said the pilot and co-pilot failed to follow established procedures for landing at night without precision instruments and descended too low before they could see the ground clearly.

The pilot, Capt. Kim Sasse, 48, focused too much on looking outside the cockpit window instead of monitoring flight instruments as the plane approached Kirksville Regional Airport under limited visibility, the board said.

Based on a transcript of the cockpit voice recorder, investigators also found that Sasse and his co-pilot, Jonathan Palmer, 29, “lacked a professional tone” in the cockpit. Sasse and Palmer distracted themselves with a steady stream of quips, laughter and more than 45 expletives, investigators said.

“The discipline in that cockpit didn’t seem to exist, which really created an environment for mistakes to be made,” said NTSB Acting Chairman Mark Rosenker. “This was extremely disappointing to hear what we heard on that cockpit voice recorder.”

No problems with maintenance
The NTSB found no mechanical failure or maintenance problems with the twin-engine turboprop and no fault with training procedures at Smyrna, Tenn.-based Corporate Airlines, now called RegionsAir.

The crew had little warning of any problems until the final seconds of the flight, which originated in St. Louis. The plane clipped treetops and stalled before crashing in a field one mile short of the runway.

According to the transcript, Sasse claimed to see the ground and continued descending below 400 feet even though Palmer said he couldn’t see anything. The board said Palmer failed to challenge Sasse’s observations, defying established rules.

The Kirksville airport is one of about 50 out of 589 airports nationwide that is not equipped with an instrument landing system, which gives pilots more precise guidance.

The NTSB recommended that the Federal Aviation Administration revise its rules to prohibit pilots without precision guidance from descending below a minimum altitude unless they have a clear view of the ground near the runway.

The agency also said the FAA should reemphasize the importance of keeping a professional atmosphere in the cockpit, known as the “sterile cockpit rule.”

Fatigue was a factor, investigator says
Pilot fatigue also was a factor, said NTSB investigator Malcolm Brenner. The pilots had been on duty for more than 14 hours at the time of the 7:37 p.m. crash. This was the sixth landing of the day in challenging weather for a crew that reported for duty around 5 a.m.

That’s within FAA regulations, which allow up to 16 hours of duty time and limit pilots to no more than eight hours of time at the flight controls. But the rules don’t consider multiple stops, layovers or the number of takeoffs and landings in that period.

The NTSB urged the FAA to upgrade its regulations to account for the time pilots report for duty, work load and other factors. NTSB members also said the FAA should consider the latest studies on pilot fatigue.

Duane Woerth, president of the Air Line Pilots Association, the largest pilots union, said it’s unreasonable to expect pilots not to make mistakes in judgment when they are fatigued.

“As long as we’re legal, fatigue’s not supposed to be an issue, even if it’s unreasonable,” Woerth said. “If you’ve been on duty 14 1/2 hours, you’re going to be fatigued.”

Last words
The plane was less than 300 feet off the ground before Sasse spotted the approach lights of the airport. Less than 10 seconds later, the crew spoke the final words recorded during the flight.

Sasse: “No.”

Palmer: “Trees.”

Sasse: “No, stop.” (Sound of impact.)

Sasse: “Oh, my God.” (Sounds of numerous impacts.)

Palmer: “Holy (expletive).”

The 19-seat Jetstream 32 was not equipped with an updated system that warns pilots when they fly too low, though it had an older version of the terrain warning system that met regulations at the time.

Corporate Airlines operated the flight under contract with American Airlines’ commuter service.

Passengers included doctors and other medical professionals en route to a conference at the Kirksville College of Osteopathic Medicine. The survivors, Wendy Bonham, 44, and Dr. John Krogh, 68, escaped from the wreckage with broken bones and some burns.