AEROSPATIALE ALENIA ATR 42-320 near Lubbock, TX — 2009-01-27

Probable cause

The flight crew's failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were 1) the flight crew's failure to follow published standard operating procedures in response to a flap anomaly, 2) the captain's decision to continue with the unstabilized approach, 3) the flight crew's poor crew resource management, and 4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain's performance.

NTSB narrative

The Safety Board’s full report is available at http://www.ntsb.gov/Publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-11/02. On January 27, 2009, about 0437 central standard time, an Avions de Transport Régional Aerospatiale Alenia ATR 42 320, N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to Federal Express Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

NTSB coding

• Aerodynamic stall/spin · Approach-IFR initial approach

Evidence available

• CVR
• FDR / data
• 140 docket documents

Docket documentsshowing 50 of 140

• ATC 3A - Factual Report of Group Chairmanatc
• ATC 3C - LBB ATCT Aircraft Accident Packageatc
• Operations 2E - Witness Statements (Including Empire Dispatch Log Information)atc
• Operations 2H - Interview Summaries of Empire Airlines Dispatch Personnelatc
• Survival Factors 6 - Attachment 1 ARFF Dispatch Logsatc
• Cockpit Voice Recorder 12 - Factual Report of Group Chairmancvr
• Flight Data Recorder 10A - Specialist's Factual Reportfdr
• Flight Data Recorder 10B - Attachment 1 - Tabular Data -Entire Flight - (CSV Format)fdr
• Flight Data Recorder 10C - Attachment 2 - Tabular Data - Last 15 Minutes (CSV Format)fdr
• Aircraft Performance 13 - Airplane Performance Studyform
• Aircraft Performance 13 - Airplane Performance Study Addendum 1form
• Aircraft Performance 13 - Airplane Performance Study Errataform
• Aircraft Performance 13B - ATR Design Changes Since Roselawnform
• Aircraft Performance 13C - ATR Aircraft Performance Monitoring Systemform
• Aircraft Performance 13D - ATR Performance Analysisform
• Aircraft Performance 13E - ATR Flap and Stall Warning Systemsform
• Aircraft Performance 13F - EASA Presentation on ATR-42 Certificationform
• Aircraft Performance 13G - FAA Presentation - Transport Category Certificationform
• Aircraft Performance 13H - FAA Presentation - ASIASform
• Aircraft Performance 13I - FAA Presentation - Proposed Icing Envelopeform
• Aircraft Performance 13J - FAA Presentation - National Simulator Programform
• Aircraft Performance 13K - FAA PAI Memo on Flap Asymmetry Indicationform
• Airworthiness 7F- Attachment 1.5 Cargo Conversion STC FAA Form 337form
• Animation in Quicktime Formatform
• Human Performance 14A - Factual Reportform
• Human Performance 14B - Empire Airlines Personnel Interviewsform
• Operations 2P - Weight and Balance Informationform
• Operations 2V - Airport and Approach Information (LBB)form
• Operations 2WW - Empire Flight Information Bulletin 09-06 (Flaps Asymmetry/Post Accident)form
• Operations 2Y - Airspeed Bug Informationform
• Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
• Reports from Parties to the Investigation: FAA response to the "No Action Memo" for the Airplane Performance Monitoring Systemform
• Survival Factors 6 - Attachment 7 HAZMAT Information & NOTACform
• Airworthiness 7K - Attachment 2.3 FAA Inspector Interviewsinterview
• Memorandum for Record: Witness Statement and Interview Summary Changes/Clarificationsinterview
• Operations 2F - Interview Summaries of Captain Rodney Holbertoninterview
• Operations 2G - Interview Summaries of First Officer Heather Cornellinterview
• Operations 2I - Interview Summaries of FAA POI and Assistant POIinterview
• Operations 2J - Interview Summaries of Director of Operations and Chief Pilotinterview
• Operations 2K - Interview Summaries of Empire Training Manager and Check Airmeninterview
• Operations 2L - Interview Summaries of Empire Airlines Director of Safety and Complianceinterview
• Operations 2M - Interview Summaries of Empire Airlines Technical Publications Personnelinterview
• Operations 2N - Interview Summaries of Pilots Previously Paired with the Accident Crewinterview
• Operations 2O - Interview Summaries of Flight Safety International Personnelinterview
• Airworthiness 7 - Addendum 1other
• Airworthiness 7- Addendum 2other
• Airworthiness 7B- Attachment 1.1 Previous Accidentother
• Airworthiness 7C- Attachment 1.2 History Prior to Purchaseother
• Airworthiness 7D - Attachment 1.3 Inspection Statusother
• Airworthiness 7E - Attachment 1.4 Daily Flight Logsother