Description
conduct an in-depth case study of a specific aircraft accident utilizing the NTSB accident report as well as other sources. The specific accident to be examined will be assigned by the instructor. Students will be expected to write an in-depth analysis of the accident, addressing the following: 1. A brief timeline of the accident (including the events leading up to the accident) and the probable cause (as determined by the NTSB). 2. The role of the other crew members, i.e., flight attendants if applicable. The style required for formatting the paper is the American Psychological Association (APA) guide lines. The paper should be a minimum of 2 pages of content and a minimum of 2 quality references, appropriately (cited in the text), and appropriately listed on the reference page, should be used. In addition to the five pages of content, a title page and a reference list are required PLEASE DO NOT USE AI OR CHAT GPT. Make sure to use the NTSP report. 600-650words. Important note: APA_Citation_Style.
Unformatted Attachment Preview
Crash of Pinnacle Airlines Flight 3701
Bombardier CL-600-2B19, N8396A
Jefferson City, Missouri
October 14, 2004
aviation
ACCIDENT REPORT
NTSB/AAR-07/01
PB2007-910402
this page intentionally left blank
Aircraft Accident Report
E
SA
NTSB/AAR-07/01
PB2007-910402
Notation 7695E
Adopted January 9, 2007
R A N S PO
FE
RI
P LU B US UNUM
T Y B OA
AT I O N
NATI ON
LT
RT
A
Crash of Pinnacle Airlines Flight 3701
Bombardier CL-600-2B19, N8396A
Jefferson City, Missouri
October 14, 2004
R
D
National Transportation Safety Board
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
National Transportation Safety Board. 2007. Crash of Pinnacle Airlines Flight 3701, Bombardier
CL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004. Aircraft Accident Report
NTSB/AAR-07/01. Washington, DC.
Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N8396A, which
crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson
City, Missouri. During the flight, both engines flamed out after a pilot-induced aerodynamic stall
and were unable to be restarted. Safety issues discussed in this report focus on flight crew training
in the areas of high altitude climbs, stall recognition and recovery, and double engine failures;
flight crew professionalism; and the quality of some parameters recorded by flight data recorders
on regional jet airplanes.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.
Recent publications are available in their entirety on the Web at . Other information about available publications also
may be obtained from the Web site or by contacting:
National Transportation Safety Board
Public Inquiries Section, RE-51
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
(800) 877-6799 or (202) 314-6551
Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2007-910402 from:
National Technical Information Service
5285 Port Royal Road
Springfield, Virginia 22161
(800) 553-6847 or (703) 605-6000
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
iii
Aircraft Accident Report
Contents
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain . . . . . . . . . . . . 8
1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer . . . . . . . . 10
1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.6.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.6.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.6.3 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.10.1 Air Traffic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.12.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.12.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.16.1 Aircraft Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.16.1.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.16.1.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.16.1.3 Descent and Glide Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.16.2 Cockpit Voice Recorder Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.16.3 Engine Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.16.4 Load Control Valve Simulation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.17.1 Ground School and Simulator Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Contents
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Aircraft Accident Report
1.17.1.1 Upset Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.17.1.2 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
1.17.1.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
1.17.1.4 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
1.17.1.5 Crew Resource Management Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.17.1.6 Leadership Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.17.2 Flight Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
1.17.2.1 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
1.17.2.2 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
1.17.2.3 Stall Protection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
1.17.2.4 Flight Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
1.17.3 Federal Aviation Administration Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.18.1 Oxygen Mask Use During the Accident Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.18.2 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.18.3 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
1.18.3.1 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
1.18.3.2 Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
1.18.3.3 Flight Data Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.18.4 Federal Aviation Administration Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
1.18.5 Bombardier All Operator Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.2.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.2.3.1 Performance of the Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . . 50
2.2.4 Communications With Air Traffic Controllers
and Management of Forced Landing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
2.2.5 Accident Sequence Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.3 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.3.1 High Altitude Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.3.2 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2.3.3 Double Engine Failure Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.4 Flight Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
2.4.1 Part 91 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
2.4.2 Industrywide Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
2.4.2.1 Pilot Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
2.4.2.2 Operator Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
2.5 Quality of Flight Data Recorder Data for Regional Jet Airplanes . . . . . . . . . . . . . . . . . 68
3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Contents
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Aircraft Accident Report
4. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.1 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
4.2 Previously Issued Recommendation Reiterated and Classified in This Report . . . . . . . 75
4.3 Previously Issued Recommendations Resulting From This Accident Investigation . . . 76
5. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
A: Investigation and Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
B: Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
C: Pinnacle Airlines’ Double Engine Failure Checklist
at the Time of the Accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
D: Pinnacle Airlines’ Revised Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . 149
E: Core Lock Safety Recommendation Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
vi
Aircraft Accident Report
Figures
1. Components in the CRJ Pneumatic Supply and Start Systems . . . . . . . . . . . . . . . . . . . . . . 12
2. Glide Distances for the Accident Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
vii
Aircraft Accident Report
Abbreviations
a.c.
alternating current
AC
advisory circular
AD
airworthiness directive
ADG
air-driven generator
AIRMET
airman’s meteorological information
AIZ
Lee C. Fine Memorial Airport, Kaiser Lake Ozark, Missouri
ALPA
Air Line Pilots Association
AND
airplane nose down
ANU
airplane nose up
AOA
angle of attack
APU
auxiliary power unit
ARTCC
air route traffic control center
ASAP
Aviation Safety Action Program
ASOS
automated surface observing system
ATC
air traffic control
ATOS
Air Transportation Oversight System
ATS
air turbine starter
CFR
Code of Federal Regulations
cg
center of gravity
CRJ
Canadair regional jet
CRM
crew resource management
CVR
cockpit voice recorder
DTW
Detroit Metropolitan Wayne County Airport, Detroit, Michigan
EICAS
engine indicating and crew alerting system
FAA
Federal Aviation Administration
FCOM
flight crew operating manual
Abbreviations
viii
Aircraft Accident Report
FDR
flight data recorder
FMS
flight management system
FOQA
flight operational quality assurance
fpm
feet per minute
FSDO
flight standards district office
GAO
Government Accountability Office
GE
General Electric
GPWS
ground proximity warning system
Hg
mercury
ICAO
International Civil Aviation Organization
ILS
instrument landing system
ISA
International Standard Atmosphere
JEF
Jefferson City Memorial Airport, Jefferson City, Missouri
KIAS
knots indicated airspeed
LBO
Floyd W. Jones Lebanon Airport, Lebanon, Missouri
LCV
load control valve
LIT
Little Rock National Airport, Little Rock, Arkansas
LOSA
Line Operations Safety Audit
METAR
meteorological aerodrome report
msl
mean sea level
MSP
Minneapolis-St. Paul International Airport, Minneapolis, Minnesota
N1
engine fan speed
N2
engine core speed
NWS
National Weather Service
POI
principal operations inspector
SB
service bulletin
SGF
Springfield-Branson Regional Airport, Springfield, Missouri
SMS
safety management system
S/N
serial number
Abbreviations
ix
Aircraft Accident Report
SPS
stall protection system
TBN
Waynesville Regional Airport, Fort Leonard Wood, Missouri
VIH
Rolla National Airport, Rolla/Vichy, Missouri
x
Aircraft Accident Report
Executive Summary
On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines
flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A,
crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport,
Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock
National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport,
Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced
aerodynamic stall and were unable to be restarted. The captain and the first officer were
killed, and the airplane was destroyed. No one on the ground was injured. The flight was
operating under the provisions of 14 Code of Federal Regulations Part 91 on an
instrument flight rules flight plan. Visual meteorological conditions prevailed at the time
of the accident.
The National Transportation Safety Board determines that the probable causes of
this accident were (1) the pilots’ unprofessional behavior, deviation from standard
operating procedures, and poor airmanship, which resulted in an in-flight emergency from
which they were unable to recover, in part because of the pilots’ inadequate training;
(2) the pilots’ failure to prepare for an emergency landing in a timely manner, including
communicating with air traffic controllers immediately after the emergency about the loss
of both engines and the availability of landing sites; and (3) the pilots’ improper
management of the double engine failure checklist, which allowed the engine cores to stop
rotating and resulted in the core lock engine condition. Contributing to this accident were
(1) the core lock engine condition, which prevented at least one engine from being
restarted, and (2) the airplane flight manuals that did not communicate to pilots the
importance of maintaining a minimum airspeed to keep the engine cores rotating.
The safety issues discussed in this report focus on flight crew training in the areas
of high altitude climbs, stall recognition and recovery, and double engine failures; flight
crew professionalism; and the quality of some parameters recorded by flight data
recorders on regional jet airplanes. Safety recommendations concerning these issues are
addressed to the Federal Aviation Administration.
1
Aircraft Accident Report
1. Factual Information
1.1 History of Flight
On October 14, 2004, about 2215:06 central daylight time,1 Pinnacle Airlines
flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19,2 N8396A,
crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport
(JEF), Jefferson City, Missouri. The airplane was on a repositioning flight3 from Little
Rock National Airport (LIT), Little Rock, Arkansas, to Minneapolis-St. Paul International
Airport (MSP), Minneapolis, Minnesota. During the flight, both engines flamed out4 after
a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first
officer were killed, and the airplane was destroyed. No one on the ground was injured. The
flight was operating under the provisions of 14 Code of Federal Regulations (CFR)
Part 91 on an instrument flight rules flight plan. Visual meteorological conditions
prevailed at the time of the accident.
Flight 3701 departed LIT about 2121. The flight plan indicated that the
company-planned cruise altitude was 33,000 feet. About 5 seconds after takeoff, when the
airplane was at an altitude of about 450 feet mean sea level (msl)5 (about 190 feet above
ground level), the first of three separate pitch-up maneuvers during the ascent occurred
when the flight crew moved the control column to 8º airplane nose up (ANU), causing the
airplane’s pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs.6 The rate
of climb during this pitch-up maneuver was 3,000 feet per minute (fpm). Immediately
afterward, the flight data recorder (FDR) recorded stickshaker and stickpusher
activations,7 a full airplane-nose-down (AND) control column deflection, a decrease in
pitch angle, and a drop in vertical load to 0.6 G.
About 2125:55, when the airplane was at an altitude of about 14,000 feet, the flight
crew engaged the autopilot. The air traffic control (ATC) transcript and FDR data showed
1
All times in this report are central daylight time based on a 24-hour clock.
2
The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in
the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired
Canadair in December 1986.
3
A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled.
Repositioning flights do not carry revenue passengers or cargo but can carry nonrevenue passengers.
4
A flameout is an interruption of a turbine engine’s combustion process that results in an
uncommanded engine shutdown.
5
All altitudes and elevations in this report are msl unless otherwise noted.
6
G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity
(32.174 feet/second2).
7
The stickshaker produces vibrations in the control columns to warn pilots of an impending stall. If
the angle of attack (AOA) continues to increase, the stickpusher moves the control columns forward (nose
down) automatically to prevent an aerodynamic stall, which can occur afterward.
Factual Information
2
Aircraft Accident Report
that the flight crewmembers changed seats in the cockpit during this time,8 but the ATC
transcript did not indicate the reason for the seat change. About 2127:15, when the
airplane was at an altitude of about 15,000 feet, the flight crew disengaged the autopilot.
About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet,
the second pitch-up maneuver began when the flight crew moved the control column to
3.8º ANU, causing the airplane’s pitch angle to increase to 17º and resulting in a vertical
load of 2.3 Gs. The rate of climb during this pitch-up maneuver reached 10,000 fpm
briefly. Between about 2128:40 and about 2128:43, the flight crew made a left rudder
input of 4.2º, a right rudder input of 6.0º, and a left rudder input of 0.4º, resulting in lateral
loads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crew
made a right rudder input of 7.7º. About 2132:40, when the airplane was in level flight at
an altitude of 24,600 feet, the third pitch-up maneuver began when the flight crew moved
the control column to 4º ANU, which increased the airplane’s pitch angle to more than 10º
and resulted in a vertical load of 1.87 Gs.9 The rate of climb during this pitch-up maneuver
reached 9,000 fpm briefly.
The ATC transcript showed that the captain requested a climb to 41,000 feet,
which is the Canadair regional jet (CRJ) maximum operating altitude,10 about 2135:3611
and received clearance to climb to that altitude about 2136:13.12 The cockpit voice
recorder (CVR) recording began about 2144:44 with the captain and the first officer
discussing the climb to 41,000 feet. About 2148:44, the first officer stated, “man we can
do it. Forty one it.” About 2151:51, the first officer stated, “there’s four one oh my man.”
About 2152:04, the CVR recorded the first officer laughing as he stated, “this is … great.”
FDR data showed that, about 2152:08, the airplane was in level flight at 41,000 feet. FDR
data also showed that the airplane climbed from 37,000 to 41,000 feet at an airspeed that
decreased from 203 knots/0.63 Mach13 at the start of the climb to 163 knots/0.57 Mach as
the airplane leveled off.14 The FDR data further showed that the autopilot vertical speed
8
The cockpit voice recorder (CVR) did not preserve any information or sounds associated with the
seat change because the CVR had the capability to record only the final 30 minutes of the flight. For
information about the seat change, see section 1.16.2.
9
According to the ATC transcript, the controllers made no transmissions to the pilots that required
them to perform the three pitch-up maneuvers during the ascent. For more information about the three
pitch-up maneuvers, see section 1.16.1.1.
10
The maximum operating altitude of the CRJ-200 is the maximum density altitude at which the
airplane is certified to operate. For the CRJ-200, the maximum operating altitude of 41,000 feet represents
the maximum capability of the airplane; the actual altitude capability will primarily depend on airspeed,
weight, and ambient temperature.
11
The airplane was at an altitude of about 32,000 feet at the time.
12
During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had expressed
curiosity about operating the airplane at 41,000 feet and that an informal “[flight level] 410 club” existed at
the airline. Managers at Pinnacle Airlines, including the chief pilot, the CRJ program manager, and the vice
president of safety and regulatory compliance, were not aware of the club’s existence.
13
Mach is a number that expresses the ratio of the speed of an object to the speed of sound in the
surrounding medium. The Safety Board calculated Mach number using the computed airspeed and total air
temperature recorded on the FDR.
14
All airspeeds cited in this report are knots indicated airspeed unless noted otherwise.
Factual Information
3
Aircraft Accident Report
mode was engaged during the climb with a commanded vertical speed of 500 fpm and that
the airplane’s angle of attack (AOA) at 41,000 feet was initially 5.7º.
About 2152:22, the CVR recorded the captain asking the first officer whether he
wanted something to drink and then the first officer responding that he wanted a soda.
CVR evidence indicated that the captain left his seat shortly afterward to get the drink.
About 2153:28, the CVR recorded the captain stating, “look how high we are.”
About 2153:42, a controller at the Kansas City Air Route Traffic Control Center (ARTCC)
asked the pilots whether they were flying a CRJ-200. The captain confirmed this
information, and the controller stated, “I’ve never seen you guys up at forty one there.”
About 2153:51, the captain replied, “we don’t have any passengers on board so we
decided to have a little fun and come on up here.” About 2153:59, the captain added, “this
is actually our service ceiling.”15
About 2154:07, the captain told the first officer, “we’re losing here. We’re gonna
be … coming down in a second here.” About 3 seconds later, the captain stated, “this thing
ain’t gonna … hold altitude. Is it?” The first officer responded, “it can’t man. We …
(cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated, “yeah
that’s funny we got up here it won’t stay up here.”
About 2154:32, the captain contacted the controller and stated, “it looks like we’re
not even going to be able to stay up here … look for maybe … three nine oh or three
seven.”16 About 2154:36, the FDR recorded the activation of the stickshaker.17 FDR data
showed that, at that point, the airplane’s airspeed had decreased to 150 knots, and its AOA
was about 7.5º.
The FDR recorded activations of the stickshaker and the stickpusher18 three times
between 2154:45 and 2154:54.19 FDR data showed that, after the second activation of the
stickshaker and stickpusher, the No. 1 (left) and No. 2 (right) engines’ N1 (fan speed) and
fuel flow indications began decreasing. FDR data also showed that, at the time of the
second stickpusher activation, the airplane’s AOA had increased to 12º and that, after the
stickpusher activated for the third time, the pitch angle decreased from 7º to -20º.
15
The service ceiling is the altitude at which the best rate of climb airspeed will produce a 100-fpm
climb. The service ceiling varies depending on airspeed, weight, and ambient temperature. The accident
airplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at an
altitude of 41,000 feet if the airspeed had been maintained at Mach 0.7.
16
The ATC transcript showed that, after this request, the controller began coordinating the descent.
17
For the Mach number at this time, the CRJ-200 stickshaker AOA is about 7.8º at the time of shaker
activation. The stickshaker activates at an airspeed of about 150 knots.
18
For the Mach number at this time, the CRJ-200 stickpusher AOA is about 10.5º at the time of pusher
activation. The stickpusher activates at an airspeed of about 142 knots.
19
For more information about the stickshaker and stickpusher activations, see section 1.16.1.2.
Factual Information
4
Aircraft Accident Report
About 2154:57, the FDR recorded the fifth activation of the stickshaker and the
fourth activation of the stickpusher. Even with the stickpusher’s activation, the motion of
the airplane continued to increase its AOA to the maximum measurable value of 27º.20
The pitch angle increased to 29º, and the airplane entered an aerodynamic stall. Afterward,
a left rolling motion began, which eventually reached 82º left wing down, the airplane’s
pitch angle decreased to -32º, and both engines flamed out. About 2155:06, the captain
stated to the controller, “declaring emergency. Stand by.” FDR data showed that, during
the next 14 seconds, the flight crew made several control column, control wheel, and
rudder inputs and recovered the airplane from the upset at an altitude of 34,000 feet.
During the recovery, the CVR recorded a sound similar to decreasing engine rpm, and
FDR data showed that the No. 1 and No. 2 engines’ N1 indications continued to decrease
and that the engines’ fuel flow indications were at zero.21
About 2155:14, the controller told the pilots to descend and maintain an altitude of
24,000 feet; about 5 seconds later, the captain acknowledged the assigned altitude. About
2155:20, the FDR stopped recording because normal a.c. power to the airplane was lost.
(The CVR had a different source of power and continued to record.) The last reliable N2
(core speed) recorded by the FDR before it stopped operating was 46 percent for the No. 1
engine and 51 percent for the No. 2 engine.
About 2155:23, one pilot stated to the other, “we don’t have any engines,” and,
about 10 seconds later, the captain stated, “double engine failure.” About 2156:42, the
flight crew began performing the double engine failure checklist,22 which required pilots
to maintain 240 knots until they were ready to initiate the double engine failure
procedure.23 The checklist indicated that, if the airplane were at or below 21,000 feet and
above 13,000 feet, pilots should relight the engines using the windmill restart procedure,24
which required an airspeed of at least 300 knots. The procedure indicated that an altitude
loss of 5,000 feet could be expected when accelerating from 240 to 300 knots.
The FDR resumed operation about 2159:16.25 FDR data showed that the auxiliary
power unit (APU) was supplying electrical power to the airplane, both engines’ N1
indications continued to decrease, and both engines’ N2 indications were at zero. FDR
data also showed that the airplane’s altitude was 29,200 feet and that its airspeed was
178 knots.
20
The 27º AOA value is the physical limit of the sensor that measures this parameter. AOAs that are
physically higher were recorded as this limit.
21
FDR data and the CVR recording indicated that the engines were operating normally before the
upset.
22
For information about this checklist, see section 1.17.2.2.
23
This requirement was a checklist memory it
