Investigation Summary
The accident occurred during a night instrument approach in light snow and fog. As the aircraft intercepted the glideslope, the captain reduced engine torque to between 6 and 11 percent at 23:20:10 to slow down, eventually reaching near zero torque by 23:20:28. However, he failed to re-apply power as the aircraft reached its target approach speed of 130 knots. The autopilot, attempting to maintain the glideslope as speed bled away, continued to trim the aircraft nose-up, increasing the angle of attack. Airspeed eventually dropped to 104 knots, triggering the stick shaker and autopilot disconnect. Cockpit Voice Recorder (CVR) data revealed a severe breakdown in Crew Resource Management (CRM). Immediately following the autopilot disconnect and the first stick shaker activation, the captain's first reaction was to blame his subordinate, asking in an alarmed tone, "Tony! What did you do?" This accusation occurred while the aircraft was already in a critical aerodynamic stall. Rather than initiating a standard stall recovery, the captain fought the automated stick pusher by applying nose-up elevator inputs and, contrary to all established procedures, ordered the flaps to be retracted. These actions prevented the aircraft from recovering. The investigation highlighted that the captain had a history of failed check rides, including a failed initial type rating on the Jetstream 41 just months prior, while the first officer was relatively inexperienced in turboprop operations and new to the airline.
Final Conclusions
The National Transportation Safety Board (NTSB) determined the probable cause was the failure of the flightcrew to plan and execute a stabilized approach, their failure to monitor airspeed, and their improper response to the stall warning and stick pusher. Contributing to the accident were the airline's failure to provide adequate stabilized approach criteria and CRM training, and the pairing of a captain with a known history of performance deficiencies with an inexperienced first officer.
Photographic Evidence (1)
Video Analysis
A Pilot's Lack Of Concentration (United Express Flight 6291) — Accident Case Study of United Express Flight 6291, examining the human factors and pilot errors that led to a fatal stall on approach to Columbus, Ohio.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Hours on type refers to transition training; he had failed his initial type rating check ride in Sept 1993.
First Officer
Had only 110 total hours in turboprop aircraft.
Systems & Failure Modes
Stick Shaker / Stick Pusher
Safety systems designed to prevent stalls. The shaker provides tactile warning, while the pusher applies nose-down elevator to reduce angle of attack. The captain actively resisted the pusher's nose-down input.
Autopilot
The system attempted to maintain the glideslope by trimming the nose up as speed decreased, which inadvertently led the aircraft closer to a stall.
Electronic Flight Instrument System (EFIS)
The 'glass cockpit' display. The NTSB noted the crew's lack of experience with these digital displays may have contributed to their loss of airspeed awareness.
Interesting Facts
- 01The aircraft was a British Aerospace Jetstream 41, a type the captain had previously failed a check ride on in September 1993.
- 02The aircraft was less than a year old at the time of the accident, having been delivered in 1993, and featured a modern 'glass cockpit' digital display system.
- 03The minimum required approach speed was 130 knots, but the aircraft slowed to 104 knots before the stall warning.
- 04The captain fought the stick pusher by applying nose-up elevator commands instead of allowing the nose to drop to gain speed.
- 05Three passengers, a Taiwanese family, survived the crash and escaped the burning wreckage.
- 06Survivors reported difficulty releasing their seatbelts, leading to NTSB recommendations for seatbelt design changes.
Safety Actions & Advisories
Seatbelt Design Review
The NTSB recommended that the type of seatbelts used in the Jetstream 41 be removed and that future designs be tested for ease of release under accident conditions.
Crew Pairing Policies
The investigation led to recommendations regarding the pairing of inexperienced first officers with captains who have histories of training or performance deficiencies.