Investigation Summary
The investigation revealed that the flight crew was not provided with a critical special weather observation issued seven minutes before their initial contact with approach control. This update indicated that cloud ceilings had dropped to 500 feet, which was below the 773-foot minimum descent altitude (MDA) for the VOR-A approach they requested. Despite the availability of a straight-in localizer approach with a lower MDA, the crew requested the VOR-A approach, likely to save time as it aligned more closely with their inbound path. Radar data showed the aircraft descended 120 feet below a stepdown altitude before reaching the FOGAG waypoint. Upon emerging from the cloud base at approximately 1,600 feet mean sea level, the captain initiated a high-rate descent and aggressive maneuvering to reach the runway. The NTSB noted that the captain had a history of marginal instrument flying skills and the first officer, due to an authority gradient, did not challenge the unstable approach. Furthermore, the operator lacked a formal safety oversight program to monitor pilots with known performance issues or ensure compliance with standard operating procedures.
Final Conclusions
The NTSB determined the probable cause was the flight crew's improper decision to conduct a circling approach contrary to standard operating procedures and the captain's excessive descent rate and maneuvering, which led to uncontrolled contact with the ground. Contributing factors included the operator's lack of a formal safety and oversight program to assess hazards and monitor pilots with previous performance issues. The investigation also noted the air traffic controller's failure to provide updated weather information, though the crew's procedural noncompliance was the primary driver of the accident.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Jonathan Alvarado. History of unsatisfactory checkride due to poor instrument flying.
First Officer
Anh Ho. Permanent pairing with the captain since December 2016.
Systems & Failure Modes
VOR-A Approach
A non-precision circling approach that requires higher weather minimums (773 feet agl) compared to straight-in approaches.
ATIS
Automatic Terminal Information Service; the controller failed to update this broadcast with the 06:30 special weather observation.
Interesting Facts
- 01The aircraft was not equipped with a Cockpit Voice Recorder (CVR) or Flight Data Recorder (FDR), nor was it required to be.
- 02The captain had previously failed a checkride due to poor instrument flying skills.
- 03The approach controller failed to relay a special weather report indicating the ceiling was below the VOR-A MDA.
- 04The aircraft's descent rate during the final approach was five times the company-recommended rate of 500 feet per minute.
- 05The left wing separated from the fuselage during the impact sequence as the aircraft slid down a steep embankment.
- 06A post-impact fire broke out after the aircraft exited the runway environment and crashed into trees.
Safety Actions & Advisories
NTSB Safety Recommendations to the FAA
Source ↗The NTSB recommended that the FAA require Part 135 operators to establish formal safety management systems (SMS) and flight data monitoring programs to better identify and mitigate risks such as procedural noncompliance.
Operator Oversight Improvements
Source ↗The investigation highlighted the need for operators to implement more robust pilot performance monitoring, particularly for pilots with a history of checkride failures or marginal performance.
Location
NO VERIFIED COORDINATES · This position predates coordinate provenance tracking. Treat it as an approximate marker for the area, not the accident site. No map is shown, because a marker here would imply a precision the record does not have.
Reported location: Charleston, West Virginia, United States