NTSB · Safety Recommendation
Safety Recommendation A-12-027
Recommendation
TO THE EUROPEAN AVIATION SAFETY AGENCY: Evaluate all European Aviation Safety Agency-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.
Safety Issue and Context
On January 27, 2009, about 0437 central standard time, an Avions de Transport Regional (ATR) Aerospatiale Alenia ATR 42-320 (ATR 42), 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 FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations (CFR) 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.
The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was 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.
Additional review of the stall protection system in the accident airplane and the events leading to the stall in this accident prompted the NTSB to make the following recommendations.
Response History
August 3, 2021 · NTSB Correspondence · European Aviation Safety Agency
On March 22, 2016, we noted that, in response to your July 5, 2013, request for information from all large airplane, European type certificate holders, you determined that the Saab 340 was the only airplane other than the ATR-42 equipped with a stick pusher that activates at the same angle of attack for both icing and non-icing conditions. We also noted that you were working with Saab to determine the next appropriate step. Pending our review of this information, and your completion of the recommended action, Safety Recommendation A-12-27 remained classified OPEN-- ACCEPTABLE RESPONSE. Copies of previous correspondence are enclosed.
As mentioned, we normally expect actions to address our recommendations to be completed within 3 to 5 years. It has now been 9 years since this recommendation was issued, and we have not received any additional information regarding the EASA’s actions to implement it. We would appreciate receiving a response from you within 90 days regarding actions that you have completed or planned to address this recommendation.
March 22, 2016 · NTSB Correspondence · European Aviation Safety Agency
We note that, in response to your request for information from all Large Aeroplane European Type Certificate holders, you determined that the Saab 340 is equipped with a stick pusher that activates at an AoA that is the same for both icing and non-icing conditions. We also note that you are working with Saab to determine the next appropriate step. Pending our review of this information, and your completion of the recommended action, Safety Recommendation A-12-27 remains classified OPEN—ACCEPTABLE ACTION.
January 7, 2016 · Recipient Response · European Aviation Safety Agency
-From Rachel Daeschler, Head of Safety Intelligence and Performance Department Strategy and Safety Management Directorate: EASA issued a letter to all Large Aeroplane European Type Certificate (TC) holders on 5 July 2013, inquiring which of their EASA certified types and models featured a stick pusher function/device as part of the stall protection, and when it is the case, was this device/function part of the compliance demonstration to Joint Aviation Requirements (JAR)/Certification Specifications (CS) 25 .201 and 25.203 or equivalent requirements.