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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: January 9, 2007
SB-07-03
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NTSB DETERMINES PILOTS' POOR AIRMANSHIP CAUSED 2004 PINNACLE
ACCIDENT IN JEFFERSON CITY, MISSOURI
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Washington, DC -- The National Transportation Safety Board
determined today that the probable cause of the October 14,
2004 accident of Pinnacle Airlines flight 3701 was 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; 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 the pilots' failure
to achieve and maintain the target airspeed in the double
engine failure checklist, which caused the engine cores to
stop rotating and resulted in the core lock engine condition.
Contributing to the cause of this accident were the engine
core lock condition, which prevented at least one engine
from being restarted, and the airplane flight manuals that
did not communicate to pilots the importance of maintaining
a minimum airspeed to keep the engine cores rotating.
"This accident was caused by the pilots' inappropriate and
unprofessional behavior," said NTSB Chairman Mark V.
Rosenker. "Simply adhering to standard operating procedures
and correctly implementing emergency procedures would have
gone a long way to adverting this tragic accident."
On October 14, 2004, a Bombardier CL-600-2B19 (N8396A)
operated by Pinnacle Airlines (doing business as Northwest
Airlink) departed Little Rock National Airport about 9:21
p.m. central daylight time en route to Minneapolis-St. Paul,
Minnesota for a repositioning flight. The flight plan
indicated that the planned cruise altitude was 33,000 feet.
At about 9:26 p.m., the airplane was at an altitude of
about 14,000 feet and the flight crew engaged the autopilot.
A few seconds later, the captain requested and received
clearance to climb to the Commuter Regional Jet's maximum
operating altitude of 41,000 feet. After the aircraft
reached 41,000 feet, the airplane entered several stalls and
shortly thereafter had double engine failure. The crew
declared an emergency with the tower, informing them of an
engine failure. However, they failed to inform the tower
that both engines had failed while they made several
unsuccessful attempts to restart the engines. The crew also
continued to try to restart the engines after the controller
asked if they wanted to land.
The flight crew attempted to make an emergency landing at
the Jefferson City, Missouri airport but crashed in a
residential area about three miles south of the airport. The
airplane was destroyed by impact forces and a post crash
fire. The two crewmembers were fatally injured. There were
no passengers on board and no injuries on the ground.
The Safety Board issued eleven recommendations to the
Federal Aviation Administration, as a result of this
accident, dealing with pilots training and high altitude
stall recovery techniques.
On November 20, 2006, the Safety Board also issued the
following urgent safety recommendations, as a part of its
investigation into this accident:
To the Federal Aviation Administration
1. For airplanes equipped with CF34-1 or CF34-3
engines, require manufacturers to perform
high power, high altitude sudden engines
shutdowns; determine the minimum airspeed
required to maintain sufficient core
rotation; and demonstrate that all methods of
in-flight restart can be accomplished when
the airspeed is maintained.
2. Ensure that airplane flight manuals of
airplanes equipped with CF34-1 or CF34-3
engines clearly state the minimum airspeed
required for core engine rotation and that,
if this airspeed is not maintained after a
high power, high altitude sudden engine
shutdown, a loss of in-flight restart
capability as a result of core lock may
occur.
3. Require the operators of CRJ-100, -200, and
400 airplanes include in airplane flight
manuals the significant performance
penalties, such as loss of glide distance and
increase descent rate, that can be incurred
from maintaining the minimum airspeed
required for core rotation and windmill
restart attempts.
A synopsis of the Board's report, including the probable
cause and recommendations, is available on the Board's
website,
www.ntsb.gov. The Board's full report will be
available on the website in several weeks.
Media Contact: Terry N. Williams
[email protected]
202) 314-6100
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