Investigation Summary
The accident occurred during the captain's first day of unsupervised line operations; he had completed his Initial Operating Experience (IOE) just five days prior on June 3, 1992. Throughout the flight, the crew struggled with a voice-activated intercom system that allowed excessive ambient noise, making communication difficult. As they approached Anniston, the crew became confused about their position relative to the BOGGA initial approach fix. The captain, who had previously served in a regimented military environment, became passive and allowed the first officer to 'coach' him through the approach. The first officer provided incorrect navigation information, stating the inbound course was 085 degrees when it was actually 265 degrees. The crew failed to conduct a proper approach briefing or consult the single set of approach charts available in the cockpit. Believing they were south of the airport, they actually intercepted the back course localizer and commenced a descent from 4,000 feet while still north of the airport. The aircraft impacted a ridge at approximately 1,800 feet MSL while the crew was still discussing the missed approach point and its associated altitude of 1,200 feet.
Final Conclusions
The National Transportation Safety Board determined the probable cause was the failure of GP Express senior management to provide adequate training and operational support, leading to the assignment of an inadequately prepared captain and an inexperienced first officer. This resulted in the crew's failure to use approved instrument flight procedures and a subsequent loss of situational awareness. Contributing factors included the lack of individual approach charts for each pilot, the absence of stabilized approach criteria, poor crew coordination, and a role reversal between the captain and first officer. The NTSB report (AAR-93/03) was adopted on March 2, 1993.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
First day of unsupervised revenue service.
First Officer
Relatively new to the airline's southern operation.
Systems & Failure Modes
Intercom System
A recently installed voice-activated system that allowed high levels of ambient cockpit noise to interfere with crew communication.
Autofeather System
The crew noted undefined problems with this system during the flight, increasing their workload and distraction.
ILS / Localizer
The crew intercepted the localizer signal but failed to verify their position relative to the outer marker, leading them to descend prematurely.
Interesting Facts
- 01The captain was on his first day of unsupervised revenue service as an airline pilot.
- 02The fatalities consisted of the captain and two passengers; the first officer and two other passengers survived with serious injuries.
- 03The aircraft was not equipped with, nor required to have, a Ground Proximity Warning System (GPWS).
- 04Only one set of approach charts was provided in the cockpit, which was standard for the airline at the time.
- 05The crew mistakenly identified the outbound radial (085) as the inbound course (265).
- 06The aircraft impacted terrain 7.5 miles northeast of the airport while attempting an approach to Runway 5 (facing northeast).
Safety Actions & Advisories
Approach Chart Availability
The NTSB recommended that the FAA require all Part 135 operators to provide each pilot with a complete set of current approach charts.
Stabilized Approach Criteria
The investigation highlighted the need for airlines to establish and enforce specific criteria for stabilized approaches to prevent high-energy or poorly configured arrivals.