Investigation Summary
The accident occurred during a period of significant internal turmoil at Downeast Airlines. The airline's owner, Robert Stenger, was noted for a management style that several pilots found aggressive and intimidating, leading to the departure of several senior crew members. This environment created 'inordinate management pressure' to complete flights despite Maine's notoriously difficult coastal weather. The flight crew for Flight 46 consisted of the Chief Pilot, who was suffering from extreme stress and chronic fatigue, and a First Officer with only two months of experience at the airline and a history of poor instrument proficiency. Post-crash evidence suggested the First Officer was flying the aircraft at the time of impact. Furthermore, the aircraft itself had known maintenance deficiencies, including poor cockpit lighting that made overhead flap controls and engine gauges difficult to see at night, and a reported 100-foot discrepancy between the Captain's and First Officer's altimeters that had not been formally resolved.
Final Conclusions
The NTSB determined the probable cause was the flight crew's failure to arrest the aircraft's descent at the minimum descent altitude for the non-precision approach without the runway environment in sight. Contributing factors included management pressures, the first officer's marginal instrument proficiency, the captain's inadequate supervision and chronic fatigue, and inadequate crew training and procedures.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Chief Pilot; reported to be under extreme stress and chronic fatigue.
First Officer
Had only two months experience with the airline and limited multi-engine experience.
Systems & Failure Modes
Cockpit Lighting
The overhead flap control area and windscreen center post flap indicator were poorly illuminated, making them barely visible at night.
Altimeters
Pilots had reported a 100-foot discrepancy between the two altimeters during descent, though no formal logbook entry existed.
Engine Gauges
Some gauge lights had been incorrectly replaced with red bulbs instead of white, making them difficult to read in the dark.
Interesting Facts
- 01The sole survivor was 16-year-old John McCafferty, who was seated in the rear of the aircraft.
- 02The aircraft had a known issue where the right engine ran hotter and used more fuel than the left.
- 03Cockpit lighting was so poor that pilots frequently made errors in flap settings during night flights.
- 04The First Officer had only flown single-engine aircraft before joining Downeast Airlines two months prior.
- 05The Captain was the airline's Chief Pilot but had less than a year of experience in that management role.
Safety Actions & Advisories
NTSB Safety Recommendations A-80-42/43
Source ↗The NTSB issued recommendations regarding pilot training, crew coordination, and management oversight following the investigation.