Investigation Summary
The flight was routine until the approach phase into Weyers Cave. At 10:14 EDT, the Captain expressed confusion regarding the aircraft's position, stating he believed they were west of the localizer course, while radar data later showed the aircraft was actually east of the course on a magnetic track of 075 degrees. The crew was likely tuned to an incorrect navigational aid or misinterpreting the non-standardized radio stack in N339HA, which differed from other Beech 99s in the Henson fleet. The high noise environment of the Beech 99 cockpit likely exacerbated communication difficulties between the Captain and the First Officer. According to Wikipedia, First Officer Zilda Spadaro-Wolan was the first female commercial airline pilot to perish in a U.S. crash. The NTSB also noted that both pilots were experiencing stress-inducing life events and had limited experience in their respective roles on this aircraft type.
Final Conclusions
The National Transportation Safety Board determined the probable cause was a navigational error resulting from the use of the incorrect navigational facility and failure to monitor flight instruments. Contributing factors included non-standardized navigational radio systems, high cockpit noise levels, inadequate training, the First Officer's limited instrument experience, and the pilots' limited time in their positions. The FAA was also cited for inadequate surveillance of the airline's operations.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Martin Burns III, age 27.
First Officer
Zilda Spadaro-Wolan, age 26.
Systems & Failure Modes
Navigational Radio Stack
The NTSB found the radio systems in the Henson Beech 99 fleet were not standardized, meaning the physical layout of dials and displays varied between individual aircraft, increasing the risk of selection errors.
Intra-cockpit Communications
High ambient noise levels in the Beech 99 cockpit made verbal communication difficult, contributing to the breakdown of coordination during the approach.
Interesting Facts
- 01The aircraft struck Hall Mountain at an elevation of 2,400 feet.
- 02First Officer Zilda Spadaro-Wolan was the first female commercial airline pilot to die in a U.S. crash.
- 03The airline's Beech 99 fleet had non-standardized navigational radio layouts, which contributed to crew confusion.
- 04Notable passengers included playwright Larry Shue and executives from Beiersdorf.
- 05The crash site was located 6 miles east of the destination airport.
Safety Actions & Advisories
Fleet Standardization
The investigation led to recommendations regarding the standardization of cockpit layouts and navigational equipment within commuter airline fleets to prevent selection errors.
FAA Surveillance Improvements
The NTSB criticized the FAA's oversight, leading to calls for more rigorous surveillance of Part 135 commuter operations to detect training and equipment deficiencies.