Narrative:After being cleared by air traffic control for the instrument landing system (ILS) approach to runway 05 at Anniston, the flight crew turned the airplane toward the north away from the airport in the erroneous belief that the airplane was south of the airport. The flight crew did not perform the manoeuvres specified on the approach chart, which required flying outbound from the airport, then performing the "procedure turn" back toward the airport. The investigation determined that in actuality, the airplane had intercepted the back course localizer signal for the ILS approach, and the flight crew had commenced the approach at a high airspeed about 2,000 feet above the specified altitude for crossing the final approach fix. The airplane continued a controlled descent until it impacted terrain.
Probable Cause:
PROBABLE CAUSE: "The failure of senior management of GP Express to provide adequate training and operational support for the start-up of the southern operation, which resulted in the assignment of an inadequately prepared captain with a relatively inexperienced first officer in revenue passenger service and the failure of the flight crew to use approved instrument flight procedures, which resulted in a loss of situational awareness and terrain clearance. Contributing to the causes of the accident was GP Express' failure to provide approach charts to each pilot and to establish stabilized approach criteria. Also contributing were the inadequate crew coordination and a role reversal on the part of the captain and first officer."
Accident investigation:
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Investigating agency: | NTSB |
Status: | Investigation completed |
Duration: | 267 days (9 months) | Accident number: | NTSB/AAR-93-03 | Download report: | Final report
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Classification:
Controlled Flight Into Terrain (CFIT) - Mountain
Follow-up / safety actions
NTSB issued 6 Safety Recommendations
Issued: 06-JAN-1993 | To: FAA | A-92-133 |
REQUIRE, FOR AIRCRAFT THAT MUST BE OPERATED BY TWO CREWMEMBERS AND BE EQUIPPED WITH A FOUR-CHANNEL COCKPIT VOICE RECORDER (CVR), THE EXCLUSIVE USE OF THE THIRD CVR RADIO CHANNEL TO RECORD ONLY AUDIO SIGNALS FROM THE COCKPIT CREW INTERCOM SYSTEM AND THE TWO "HOT" BOOM MICROPHONES. (Closed - Unacceptable Action) |
Issued: 02-APR-1993 | To: FAA | A-93-35 |
REQUIRE THAT ALL PILOTS OPERATING AIRCRAFT UNDER 14 CFR PART 135 HAVE ACCESS TO THEIR OWN SET OF INSTRUMENT APPROACH CHARTS. (Closed - Unacceptable Action) |
Issued: 02-APR-1993 | To: FAA | A-93-36 |
REQUIRE THAT SCHEDULED AIR CARRIERS OPERATING UNDER 14 CFR PART 135 DEVELOP AND INCLUDE IN THEIR FLIGHT OPERATION MANUALS AND TRAINING PROGRAMS STABILIZED APPROACH CRITERIA. THE CRITERIA SHOULD INCLUDE SPECIFIC LIMITS OF LOCALIZER, GLIDESLOPE, AND VOR NEEDLE DEFLECTIONS AND RATES OF DESCENT, ETC., NEAR THE AIRPORT, BEYOND WHICH INITIATION OF AN IMMEDIATE MISSED APPROACH WOULD BE REQUIRED. (Closed - Acceptable Alternate Action) |
Issued: 02-APR-1993 | To: FAA | A-93-37 |
DEVELOP GUIDANCE AND EVALUATION CRITERIA FOR PRINCIPAL OPERATIONS INSPECTORS TO USE TO ENSURE THAT AIRLINE COCKPIT RESOURCE MANAGEMENT TRAINING PROGRAMS ADEQUATELY ADDRESS CREW INTERACTION, DECISION-MAKING PROCESS, INFORMATION GATHERING, FLIGHTCREW COMMUNICATION, AND LEADERSHIP SKILLS. (Closed - Acceptable Action) |
Issued: 02-APR-1993 | To: FAA | A-93-38 |
FOR AIRLINES THAT UTILIZE CONTRACTED FLIGHT AND GROUND TRAINING PROGRAMS, REQUIRE THAT PILOTS HIRED DIRECTLY TO BE CAPTAINS RECEIVE ADDITIONAL FLIGHT INSTRUCTION PERTAINING TO THE OPERATING ENVIRONMENT AND PROCEDURES UNIQUE TO THE AIRLINE FROM AN FAA-APPROVED COMPANY CHECK AIRMAN OR INSTRUCTOR, RATHER THAN ONLY FROM THE CONTRACTOR INSTRUCTOR. (Closed - Reconsidered) |
Issued: 02-APR-1993 | To: FAA | A-93-39 |
AMEND 14 CFR 135.243(C)(2) TO REQUIRE THAT THE PILOT-IN-COMMAND OF A COMMUTER AIR CARRIER FLIGHT THAT REQUIRES TWO CREWMEMBERS HAVE AT LEAST 100 HOURS OF FLIGHT TIME OR AN EQUIVALENT LEVEL OF TRAINING IN COMMUTER AIR CARRIER OPERATIONS REQUIRING TWO PILOTS. (Closed - Acceptable Action) |
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Photos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Atlanta-William B. Hartsfield International Airport, GA to Anniston-County Airport, AL as the crow flies is 132 km (82 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.