Investigation Summary
The accident occurred during a straight-in visual approach to Runway 09. The First Officer, who was the pilot flying, suffered from a color vision deficiency that made it difficult to distinguish the red and white lights of the Precision Approach Path Indicator (PAPI). As the aircraft descended, it fell well below the 3-degree glide path. At 500 feet above ground level, all four PAPI lights were red, yet the Captain verbalized that the approach was 'stable.' The crew's performance was further degraded by significant fatigue, as the flight took place during a period of circadian low. The investigation highlighted that the crew failed to follow Standard Operating Procedures (SOPs), including the requirement to initiate a go-around when the approach became unstabilized below 500 feet.
Final Conclusions
The NTSB determined the probable cause was the failure of the captain and first officer to establish and maintain a proper glidepath during a night visual approach. Contributing factors included crew fatigue, failure to adhere to company SOPs, inadequate monitoring of the approach by the captain and flight engineer, and the first officer's color vision deficiency which hindered his ability to correctly interpret the PAPI lights.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Total hours estimated between 13,000 and 14,000. Medical certificate required him to wear corrective lenses.
First Officer
Pilot flying; had color vision deficiency.
Flight Engineer
Systems & Failure Modes
PAPI
Precision Approach Path Indicator; a system of lights next to the runway that provides visual glide slope guidance.
GPWS
Ground Proximity Warning System; provided a 500-foot altitude callout which the crew acknowledged but did not act upon to correct the glide path.
Interesting Facts
- 01The First Officer had a documented color vision deficiency but had passed Navy vision tests 13 times previously.
- 02The Tallahassee ATC tower was closed at the time of the accident; the flight was being monitored by Jacksonville Center.
- 03The aircraft was a Boeing 727-232 originally delivered to Delta Air Lines in 1974, sold to FedEx in 1986, and converted to a freighter in 1989.
- 04The crash occurred during the crew's circadian low, contributing to significant fatigue.
- 05The aircraft rotated 260 degrees during the ground slide and came to rest facing the opposite direction of travel.
Safety Actions & Advisories
Color Vision Testing Standards
The investigation led to calls for more rigorous and standardized pilot eyesight medical examinations, particularly regarding color vision.
Fatigue Management Training
The NTSB highlighted the need for more effective fatigue management training and scheduling practices to prevent performance degradation during night operations.