Investigation Summary
The investigation revealed that the captain, Michael Hillis, had a history of performance deficiencies at previous airlines that Flagship Airlines failed to fully identify during the hiring process. Specifically, Hillis had previously resigned from Comair following a failed check ride, a fact that was not uncovered due to inadequate background check procedures. During the approach, Hillis became fixated on the left engine ignition light. This light was designed to illuminate when the auto-ignition system activated, which could occur during a negative torque situation even if the engine was producing power. Hillis incorrectly announced a flameout and attempted a go-around. During this maneuver, he failed to advance both power levers, a deviation from standard procedures that resulted in significant asymmetric thrust and a rapid loss of airspeed. The first officer, Matthew Sailor, recognized the decaying airspeed and repeatedly urged the captain to lower the nose, but his interventions were not assertive enough to prevent the stall. The NTSB also found that the airline's simulator training was inadequate, as it had inadvertently taught pilots to associate the IGN light with engine failure and did not emphasize advancing both power levers during a suspected single-engine go-around.
Final Conclusions
The NTSB determined the probable causes were the captain's improper assumption that an engine had failed and his subsequent failure to follow approved procedures for engine failure identification, single-engine approach, go-around, and stall recovery. Contributing to the accident was the failure of AMR Eagle/Flagship management to identify, document, monitor, and remedy deficiencies in pilot performance and training. The investigation also highlighted the lack of a centralized pilot record system, leading to the passage of the Pilot Records Improvement Act (PRIA) of 1996.
Photographic Evidence (1)
Video Analysis
Flagship Airlines Flight 3379: The 1994 Raleigh-Durham Jetstream 32 Crash — Analysis of the 1994 crash involving a Jetstream 32 where pilot misinterpretation of an engine ignition light led to a fatal stall during a go-around at Raleigh-Durham International Airport.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Michael Hillis, age 29.
First Officer
Matthew Sailor, age 25.
Systems & Failure Modes
Auto-Ignition System
A system designed to automatically relight the engine if a flameout is sensed; its activation light (IGN) was misinterpreted by the captain as proof of a total engine failure.
Stall Warning System
The aircraft was equipped with dual stall warning horns that activated when the airspeed decayed to approximately 111 knots during the go-around attempt.
Interesting Facts
- 01Both engines were found to be operating under power at the moment of impact.
- 02The left engine IGN light illuminated due to a negative torque condition, not a mechanical failure.
- 03The aircraft entered a descent rate exceeding 10,000 feet per minute before impact.
- 04The captain had been cited for failing to follow cockpit procedures at previous airlines.
- 05The aircraft serial number was 918.
- 06Weather at the time of the accident included a 500-foot ceiling, 2 miles visibility, light rain, and fog, with a temperature of 37-38 degrees Fahrenheit.
Safety Actions & Advisories
Pilot Records Improvement Act (PRIA) of 1996
Congress passed legislation requiring air carriers to request and receive training and performance records from a pilot applicant's previous employers for the preceding 5 years.
Training Program Revision
The NTSB recommended that airlines maintain standardized information on pilot performance during training and check flights to identify substandard performance trends.
Location
ACCIDENT SITE · Coordinates taken from the wikidata coordinate.