Investigation Summary
The flight was operating nearly an hour behind schedule following three missed approaches at its first stop in Groton, Connecticut. Upon reaching New Haven, Captain David Eastridge elected to perform a downwind landing on Runway 2, despite a company directive prohibiting such maneuvers at that airport. During the approach, the crew encountered intermittent fog and low clouds. The captain continued the descent past the MDA of 380 feet without having the runway in sight. First Officer James Walker called out the descent rates and airspeeds but did not take control of the aircraft, later testifying to the captain's strict command style. The aircraft struck three beach houses at an altitude of approximately 29 feet above sea level, roughly 4,890 feet short of the runway. The impact caused the airframe to break apart and catch fire. The high fatality rate was attributed to the failure of the rear emergency exit; 15 victims were found huddled near the door, which remained locked because the instructions were confusing and the cabin was filled with thick smoke and lacked emergency lighting. The final report provides a glimpse into the nascent understanding of human factors which defined the period.
Final Conclusions
The NTSB determined the probable cause was the captain's intentional descent below the prescribed minimum descent altitude under poor visibility conditions without having the runway environment in sight. The board noted that the captain's decision-making was likely influenced by a desire to maintain the schedule. A major contributing factor to the high death toll was the lack of adequate emergency lighting and the presence of misleading instructions for the operation of the emergency exit, which prevented a successful evacuation of the cabin before it was overcome by fire and smoke.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
David Gordon Eastridge, aged 39.
First Officer
James Alford Walker, aged 34. Survived the crash.
Systems & Failure Modes
Emergency Exit Lighting
The aircraft lacked adequate emergency lighting, which investigators found contributed to the passengers' inability to locate and operate the exit in the smoke.
Rear Service Door
The manual opening instructions for the rear door were described by the NTSB as 'misleading,' contributing to the failure of the evacuation.
Non-precision Approach Equipment
The aircraft was using non-precision approach aids; the NTSB suggested an ILS (Instrument Landing System) might have prevented the accident.
Interesting Facts
- 01Only the captain died from impact injuries; the other 27 fatalities were caused by smoke inhalation and burns.
- 02The rear service door lock was found in the closed position, indicating passengers could not figure out how to open it in the dark, smoke-filled cabin.
- 03The captain had 12,247 total flight hours, including 3,600 on the Convair CV-580.
- 04The aircraft was a Convair 440 built in 1956 and converted to a CV-580 turboprop in 1967.
- 05The First Officer and two passengers were the only survivors.
- 06Downwind landings at Tweed New Haven Regional Airport were prohibited by Allegheny Airlines company directive, yet the captain accepted one.
Safety Actions & Advisories
Emergency Exit Briefings
The NTSB recommended that flight attendants physically point to each exit during pre-flight briefings to improve passenger retention.
Exit Instruction Clarity
The board called for clearer, simpler instructions for opening emergency exits and the installation of emergency exit lighting.
Pilot Compensation Review
The NTSB suggested disassociating pilot pay from flight punctuality to prevent crews from taking unnecessary risks to stay on schedule.