NTSB AmEx-IRK 04-1019 Accident Rpt 06-0124

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Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966 BAE Systems BAE-J3201, N875JX Kirksville, Missouri October 19, 2004

Aircraft Accident ReportNTSB/AAR-06/01 PB2006-910401 Notation 7694A

National Transportation Safety BoardWashington, D.C.

THE CORRECTIONS BELOW ARE INCLUDED IN THIS VERSION OF THE PUBLISHED REPORT

AVIATION ACCIDENT REPORT NTSB/AAR-06/01 (PB2006-910401) COLLISION WITH TREES AND CRASH SHORT OF THE RUNWAY CORPORATE AIRLINES, FLIGHT 5966 BAE SYSTEMS BAE-J3201, N875JX KIRKSVILLE, MISSOURI OCTOBER 19, 2004

Page 27, first paragraph has been corrected to indicate 10 seconds instead of 19 seconds as originally printed. (7 MARCH 2006) Page 44, first complete paragraph has been corrected to indicate 10 seconds instead of 19 seconds as originally printed. (7 MARCH 2006)

Aircraft Accident ReportCollision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966 BAE Systems BAE-J3201, N875JX Kirksville, Missouri October 19, 2004

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NTSB/AAR-06/01 PB2006-910401 Notation 7694A Adopted January 24, 2006

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National Transportation Safety Board 490 LEnfant Plaza, S.W. Washington, D.C. 20594

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National Transportation Safety Board. 2006. Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004. Aircraft Accident Report NTSB/AAR-06/01. Washington, DC. Abstract: This report explains the accident involving Corporate Airlines flight 5966, a BAE Systems BAE-J3201, N875JX, that crashed short of the runway on approach to land at Kirksville Regional Airport, Kirksville, Missouri. Safety issues in this report focus on operational and human factors issues, including the pilots professionalism and sterile cockpit procedures, nonprecision instrument approach procedures, flight and duty time regulations, fatigue, and flight data/image recorder requirements.

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 LEnfant 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 PB2006-910401 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.

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ContentsFigures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii 1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.7.1 Official Kirksville Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.7.2 Kirksville Weather Information Provided by Witnesses . . . . . . . . . . . . . . . . . . . . . 14 1.7.3 Predeparture Weather Information Obtained by the Pilots . . . . . . . . . . . . . . . . . . . 15 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.2.1 Flight Data Recorder Parameter Requirements/Information . . . . . . . . . . . . . . . 17 1.12 Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.14 Fire/Explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.15.1 Emergency Response Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.15.1.1 Emergency Response Personnel Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.15.1.2 Postaccident Emergency Response Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.16.1 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.16.2 Ground Proximity Warning System Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17 Operational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17.1 Corporate Airlines Policies/Procedures/Training . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17.1.1 Training InformationGeneral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17.1.2 Non-Precision Approach/Missed Approach Guidance . . . . . . . . . . . . . . . . . . . . 28 1.17.1.3 Crew Schedule Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.17.2 Federal Aviation Administration Oversight of Corporate Airlines . . . . . . . . . . . . . 31 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.18.1 Sterile Cockpit Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Contents

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1.18.2 Additional Flight Crew-Related Accident Information . . . . . . . . . . . . . . . . . . . . . 35 1.18.3 Nonprecision Instrument Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.18.4 Flight and Duty Time Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.18.5 Fatigue-Related Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.5.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.5.2 Previously Issued Fatigue-Related Recommendations . . . . . . . . . . . . . . . . . . . . 41 1.18.5.3 Department of Transportation Operator Fatigue Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .