Pilot Debrief

BAE BAE125 near Detroit, MI — 2019-12-03

Final reportCEN20LA028
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Date
2019-12-03
Location
Detroit, MI, USA
Airport
DET
Aircraft
BAE BAE125
Registration
N469RJ
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The pilots’ failure to increase approach speed as recommended for flight in icing conditions, which resulted in an aerodynamic stall and subsequent impact with terrain. Contributing to the accident was the failure of the stall warning system to advise the crew of the approaching stall.

NTSB narrative

The airline transport pilot rated crew was conducting an instrument landing system (ILS) approach. The air traffic controller at the departure airport advised them of the icing conditions present so the crew turned on the anti-ice system. The airplane did not have any airspeed oscillations during the approach. The flying pilot reported that the right wing "dropped" and a stall occurred as they approached the runway. He stated, “Although flight crew selected the correct Vref speed for the aircraft weight, they failed to add 10 kts for the ‘operation in icing conditions’ statement, per the aircraft checklist.” The stick shaker should have alerted the crew of the approaching stall. However, the flying pilot said that there was no shaker activation during the flight. The non-flying pilot felt the shaker was activated after the airplane came to rest. The reason for the lack of a stick shaker warning was not determined during the investigation. However, the cockpit voice recording confirmed the pilots’ statements. The accident is consistent with the airplane stalling on approach due to ice buildup, and the accident likely would not have occurred had the pilot’s flown the higher approach speed recommended for flight in icing conditions.

Analysis

Primary failure mode
Human factors
First missed decision gate
Failed to add 10 kts for operation in icing conditions per checklist.

NTSB coding

Evidence available

  • CVR
  • Video
  • ADS-B / radar
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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