Cites Flight Crew Failures In Crash Of Airplane Carrying
Senator Wellstone, 7 Others
The NTSB has determined
that the probable cause of the crash late last year of a Raytheon
(Beechcraft) King Air 100 airplane, carrying Senator Paul Wellstone
and seven others, was the "flight crew's failure to maintain
adequate airspeed, which led to an aerodynamic stall from which
they did not recover."
The airplane, operated by Aviation Charter, Inc., was on a
flight from St. Paul to Eveleth, MN, when it crashed, on October
25, 2002, on approach to the Eveleth-Virginia Municipal Airport.
The airplane was destroyed and there were no survivors. "This
tragic accident that took the lives of a respected U.S. Senator,
members of his family, staff, and the flight crew, shocked us all,"
said NTSB Chairman Ellen G. Engleman. "It sadly and starkly points
out the need for more aggressive action to improve safety in the
on-demand charter industry."
Reviewing the results of the extensive investigation into this
accident, NTSB Members concluded that the flight crew failed to
maintain an appropriate course and speed for the approach to
Eveleth and did not properly configure the airplane at the start of
"During the later stages of the approach," the Board said, the
flight crew "failed to monitor the airplane's airspeed and allowed
it to decrease to a dangerously low level (as low as about 50 knots
below the company's recommended approach speed) and to remain below
the recommended approach speed for about 50 seconds." The airplane
then entered a stall from which it did not recover.
The Board judged that
while cloud cover might have prevented the flight crew from seeing
the airport, icing did not affect the airplane's performance during
the descent. Cockpit instrument readings on course alignment and
airspeed should have prompted the flight crew to execute a
The Board did not find indications of any preexisting medical or
other physical condition that might have adversely affected the
crew's performance during the accident flight. Crew fatigue also
does not appear to have been a factor in the accident. A review of
flight crew records and interviews with co-workers, the Board said,
indicated that both pilots had "previously demonstrated serious
performance deficiencies consistent with below- average flight
proficiency." There was no clear evidence as to which crewmember
was the flying pilot at the time of the accident.
The Board determined that the accident airplane was properly
certificated, equipped and maintained in accordance with Federal
regulations. The recovered components showed no evidence of
preexisting powerplant, system or structural failures. The Board
also concluded that the out-of-tolerance condition and slight bends
in the Eveleth-Virginia airport VOR signal were not a factor in
With respect to the operator, the Board found that Aviation
Charter, Inc., was not making crewmembers sufficiently aware of its
Standard Operating Procedures, and also cited the company's failure
to provide adequate stall recovery guidance. Further, the company
was not training its pilots in crew resource management in
accordance with its FAA- approved training program. Consequently,
the Board recommended that the FAA make such training mandatory for
Part 135 on-demand charter companies that conduct dual-pilot
The Board, noting that
FAA surveillance of Aviation Charter, Inc., was not sufficient to
detect the discrepancies that existed at the company, recommended
that the agency conduct en route inspections and observe training
and proficiency checks at all Part 135 on-demand charter
operations, as is done at Part 121 and Part 135 commuter
operations, to ensure the adequacy, quality and standardization of
pilot training and flight operations.
Additionally, the Board recommended that the FAA convene a panel
of experts to determine the feasibility of a requirement for the
installation of low-airspeed alert systems in airplanes engaged in
commercial operations under Parts 121 and 135, and act accordingly
on the panel's findings.
The complete report will be available in about six weeks.