Two pilots who took their commuter jet on a high-altitude joyride, then failed to follow proper procedures after both engines failed, were to blame for the October 2004 crash of the plane in Jefferson City, Mo.
Federal investigator says pilots committed a number of errors and airline failed to properly train them. The National Transportation Safety Board determined Tuesday a laundry list of causes led to the October 14, 2004 "joyride" accident of Pinnacle Airlines flight 3701.
"This accident was caused by the pilots' inappropriate and unprofessional behavior," said NTSB Chairman Mark V. Rosenker (right). "Simply adhering to standard operating procedures and correctly implementing emergency procedures would have gone a long way to adverting this tragic accident."
But the National Transportation Safety Board said the accident shows a need for regional air carriers to adopt more stringent professional standards for pilots - as major airlines have done - and improve training procedures for pilots flying at high altitudes.
Pilots Jesse Rhodes and Richard Peter Cesarz were ferrying the 50-seat Pinnacle Airlines regional jet from Little Rock, Ark., to Minneapolis without passengers when they decided "to have a little fun" according to the cockpit voice recorder transcript.
They took the plane to an unusually high altitude of 41,000 feet, performed aggressive flight maneuvers, switched seats during the flight and ignored repeated cockpit warnings that the plane was about to stall.
First one, then the second engine stalled. But the pilots didn't follow the proper procedures to restart them and didn't tell air traffic control than both engines had shut down.
"Overall, the pilots' behavior during this flight was not consistent with the degree of discipline, maturity and responsibility required of professional pilots," said Evan Byrne, the NTSB's acting deputy director of aviation safety.
According to the NTSB, the probable causes of the crash -- which killed the two pilots ferrying the aircraft -- were as follows:
- the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots'
inadequate training (regarding how to fly at high altitudes and how to handle emergencies...).
- the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites.
- and the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition.
Contributing to the cause of the accident a problem with the GE jet engines were the engine core lock condition (engine froze), which prevented at least one engine from being restarted, and the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.
On October 14, 2004, the Bombardier CL-600-2B19 (N8396A) operated by Pinnacle Airlines (dba Northwest Airlink) departed Little Rock National Airport about
9:21 pm CDT en route to Minneapolis-St. Paul, MN for a repositioning flight.
The flight plan indicated the planned cruise altitude was 33,000 feet. At about 9:26 pm, the airplane was at an altitude of about 14,000 feet and the flight crew engaged the autopilot.
A few seconds later, the captain requested and received clearance to climb to the CRJ-200's maximum operating altitude of 41,000 feet. After the aircraft reached FL410, the airplane entered several stalls, and shortly thereafter had double engine failure.
The crew declared an emergency with the tower, informing them of an engine failure. However, they failed to inform the tower that both engines had failed while they made four unsuccessful attempts to restart the engines.
The crew also continued to try to restart the engines after the controller asked if they wanted to land.
The flight crew attempted to make an emergency landing at the Jefferson City, Missouri airport but crashed in a residential area about three miles south of the airport. The airplane was destroyed by impact forces and a post crash fire.
The two crewmembers were fatally injured. There were no passengers on board and no injuries on the ground.
The safety agency also found the plane's engines had a history of locking up at high altitudes during test flights and that flight manuals did not explain the importance of keeping a minimum air speed to keep engine cores rotating.
The Safety Board issued eleven recommendations to the Federal Aviation Administration, as a result of this accident, dealing with pilots training and high altitude stall recovery techniques.
As reported, in November 2006 the Board also issued a series of urgent safety recommendations, stating the FAA should require:
- operators of CRJs equipped with CF34-1 or CF34-3 engines be well-versed in compressor stall, engine shutdown, and inflight restart procedures.
- aircraft manufacturers to perform tests on planes equipped with General Electric CF34-1 or CF34-3 engines to determine when they are likely to shut down and how they should be restarted.
During the federal safety hearing following the accident, Edward Orear told a National Transportation Safety Board (NTSB) panel
that General Electric Co. engine is widely used in regional jets
locked up frequently (phenomenon, in which the
engine rotors temporarily freeze) in the past when test pilots flew planes outside
recommended operating limits.
Edward Orear, a GE company manager who formerly oversaw GE's work on the engine, said design
improvements have reduced the rate of core lock during test flights,
from 80 percent in 1988 to 1.5 percent today.
The NTSB was giving the crash special attention because of the multiple
issues it raises about the growing use of regional jets by commuter
airlines such as Memphis-based Pinnacle, which is partly owned by
Eagan-based Northwest Airlines and operates as Northwest Airlink.
Canadian regulators approved the GE engine, and the Federal Aviation
Administration (FAA) did not learn about the problem until recently,
NTSB officials said.
A decades-old FAA engine certification standard requires that if
a passenger plane has been piloted appropriately and the engines
stall or shut down, the engines must be able to be restarted.
Orear said GE first learned of core lock problems in its CF34 engine
in 1985, when Bombardier used it in a forerunner of the regional
jet -- a smaller private jet called the Challenger. The engine also
was used in the Army's A10 "Warthog" tank-killer attack
aircraft. He said Bombardier developed a test, in which planes were
flown beyond normal operating limits to identify engines needing
small adjustments to prevent core lock.
Noting that such erratic flight is unusual, Orear said the engine
has been used in civil aviation for 25 million hours without problems.
Orear said a post-crash examination of the Pinnacle jet's engines
indicated that they could have restarted. But GE advised
the NTSB that in two test incidents, it took 15 minutes and 24 minutes
after shutdown before the engine cores began to rotate again.
"This was an extremely tragic case for us to have to deal with," said NTSB Chairman Mark Rosenker. "There were many times that, had the procedures been followed and followed correctly, it would have gone a long way to averting the accident."
NTSB board member Robert Sumwalt said Pinnacle's safety system was deficient. All large carriers now monitor flights with computers and encourage employees to report safety problems without fear of discipline — programs that would have made the pilots' actions less likely. But Pinnacle, like most regional airlines, had none of those programs before the crash, the NTSB said.
"They didn't cause the accident, but I'm going to suggest that they may have enabled the accident," Sumwalt said of the airline.
Pinnacle spokesman Philip Reed said that the airline has added safety monitoring and reporting programs found at larger airlines. It's also revamped pilot training.
"The culture of safety does exist," Reed said. "We practice it every day."
Several board members said that the accident raised broader questions about safety among regional carriers, which have grown rapidly in recent years as the larger carriers have suffered financial setbacks. Only two regional carriers, Pinnacle and ExpressJet, have computerized flight monitoring, the NTSB said.
"There is still a big differential between what is happening at these regional carriers and the major carriers," board member Kitty Higgins said.
Regional Airline Association President Roger Cohen said most regional carriers are adopting safety programs similar to large carriers. The federal standards governing regional and large airlines are the same, Cohen said.
