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Safety Recommendation Details

Safety Recommendation A-06-009
Details
Synopsis: On October 19, 2004, about 1937 central daylight time,1 Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at the Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport (STL), in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed for the flight, which operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Revise applicable 14 Code of Federal Regulations Part 121 and 135 regulations to prohibit pilots from descending below the minimum descent altitude during nonprecision instrument approaches unless conditions allow for clear visual identification of all obstacles and terrain along the approach path or vertical guidance to the runway is available and being used.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Aviation
Location: Kirksville, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA05MA004
Accident Reports: Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX
Report #: AAR-06-01
Accident Date: 10/19/2004
Issue Date: 2/7/2006
Date Closed: 12/18/2012
Addressee(s) and Addressee Status: FAA (Closed - Reconsidered)
Keyword(s): Approach: Non-Precision

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/18/2012
Response: The FAA previously indicated that, although the pertinent regulations were appropriate as written, improved guidance for pilots would be beneficial, and therefore it planned to add language to advisory circular (AC) 120 71A, “Standard Operating Procedures for Flight Deck Crewmembers,” and to the Aeronautical Information Manual (AIM), to explain a pilot’s responsibilities before descending below the MDA. On November 9, 2006, we replied that the planned actions would address the problem of a pilot’s misunderstanding when it is permissible to descend below the MDA and would constitute an acceptable alternative solution to address the issue. The FAA’s current letter states that it has found that, without its planned revisions, AC 120-71A and the AIM provide pilots with unambiguous parameters relating to descent below the MDA. Based on a review it performed of applicable sections of Parts 121 and 135 and FAA guidance material dealing with nonprecision instrument approaches, the FAA now believes that current guidance adequately addresses this recommendation. Therefore, the FAA no longer plans to revise either AC 120-71A or the AIM. We reviewed the justification for this decision that the FAA provided in its letter, including its review of our findings from the investigation of the Kirksville accident, and we agree with the FAA’s decision not to revise either document. Consequently, Safety Recommendation A-06-9 is classified CLOSED—RECONSIDERED.

From: FAA
To: NTSB
Date: 9/17/2012
Response: -From Michael P. Huerta, Acting Administrator: As stated in the Federal Aviation Administration's (FAA) letter dated May 31, 2006, we reviewed existing guidance to determine it inconsistencies could be found that would cause confusion among pilots. instructors or FAA inspectors about crew responsibilities during non-precision approaches. Specific focus was on obstacle clearance requirements and procedures. The FAA determined that Advisory Circular (AC) 120-71 A. Appendix 2 (enclosed) and the Aeronautical Information Manual (enclosed) provide pilots with unambiguous parameters relating to descent below minimal descent altitude (MDA). It should be noted that this discussion is about instrument approach procedures (IAP in themselves among the most demanding and strictly performed aviation maneuvers. From the beginning of the IAP through touchdown, precision and discipline are required and expected. In the Board's November 9, 2006 letter they agreed that modifying existing guidance material rather than amending the regulations would be an acceptable alternate response for this recommendation. The FAA reviewed the applicable sections of parts 121 and 135 and FAA guidance material dealing with non-precision instrument approaches. Based on this review, the FAA believes current guidance adequately addresses the concerns raised by this recommendation. The FAA therefore no longer plans to add language to AC 120-71 A Standard Operating Procedures for Flight Deck Crewmembers, or the Aeronautical Information Manual. We changed our position, compared to what was stated in our May 31, 2006 letter for the reasons discussed in the following paragraphs. The FAA agrees with the determination of probable cause as stated by the Board. The crew allowed or intentionally operated the aircraft contrary to published regulations, instructions, standard operating procedures, and advisory material to descend below MDA prior to acquisition of the runway environment. The FAA was unable to find anything in the regulations or guidance material that may have caused the crew to believe they could descend through MDA prior to acquisition of the approach lights or runway environment and continue that descent unabated to 100 feet above the touchdown zone elevation. A review of the existing regulations finds that to receive an instrument rating and subsequently work for a part 121 air carrier, regulations require that pilots demonstrate proficiency in the approach criteria listed in §91.175 and 121.651 (enclosed). Part 135 approach operations are regulated by §91.175. These standards must be met during both initial and recurrent training for a pilot operating under part 121. Both sections either state or reference that an aircraft operated under parts 121 and 135 cannot leave MDA unless a normal rate of descent is used, which will allow touchdown to occur within the touchdown zone of the runway. The FAA believes this guidance is clear and consistent. The FAA also reviewed FAA Order 8900. 1. Flight Standards Information Management System (FSIMS) (enclosed) and determined the guidance to inspectors contained in FSIMS provides adequate direction that does not conflict with any regulation or other guidance pertaining to instrument approach procedures. The FAA also examined the Instrument Procedures Handbook (FAA-H-8261-1A) and the Instrument Flying Handbook (FAA-H8083-15) and could not identify any inconsistencies between these documents and other referenced publications. The FAA then reviewed NTSB Aircraft Accident Report AAR-06-01. The accident aircraft maintained a 1,200 feet per minute rate of descent throughout the approach. This was approximately 50 percent higher than required or recommended. Critically, this high rate of descent was not arrested at MDA. Activities reflected on the cockpit voice recorder (CVR) indicate a lack of' discipline between the crew. Neither the graphs of the approach nor CVR transcript establish that the crew intended to stabilize the descent at 100 feet above the touchdown zone elevation to begin a search for the runway. The FAA believes the crew was acting in a manner that would indicate they were either not attentive or not concerned with a regulatory statement regarding 100 feet above the touchdown zone elevation. The FAA and Board agree that during instrument approaches one crew member must be monitoring instruments while the other crew member acquires or uses outside references. Requiring all obstacles and terrain be identified would. in the critical time allotted require both pilots' concentration outside of the aircraft. IAPs are designed and constructed to establish conditions whereby obstacles are cleared and instrument monitoring is conducted. Adoption of the recommendation would compromise that design for which crews are trained resulting in a negative unintended consequence. Had the crew properly intercepted the visual approach slope Indicator (VAS]) from MDA with approach light acquisition as the approach and procedures are designed, a normal descent and landing would have been likely. If the VASI indicated solid red or red-over-red as the Board’s report suggests, the FAA believes this would have provided the crew accurate and relevant information. The FAA believes that all regulations and guidance material are clear. The FAA does not believe that additional language will either enhance understanding of or clarify existing regulations and guidance materials, nor address the probable b use of this accident. I believe that the FAA effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 11/9/2006
Response: The FAA states that the pertinent regulations are appropriate as written, but that improved guidance for pilots would be beneficial. The FAA plans to add language to AC 120 71A, and to the Aeronautical Information Manual (AIM), indicating that the additional guidance will explain a pilot's responsibilities before descending below the minimum descent altitude (MDA). In the Kirksville accident, the Safety Board found that the pilots saw the approach lights only after they descended below the MDA. The Board notes that although approach lights are not on the runway, their sighting is a valid reason to descend below the MDA. The Board also notes that the FAA does not guarantee terrain clearance below the MDA. Thus, the Kirksville crew either misunderstood the existing regulations, or willfully elected to ignore those regulations. The FAA's proposed actions will address the problem of a pilot's misunderstanding when it is permissible to descend below the MDA. Therefore, the FAA's proposed action is an acceptable alternative that meets the intent of the recommendation. Pending issuance of revisions to AC-120-71A and the AIM, Safety Recommendation A-06-9 is classified OPEN -- ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 5/31/2006
Response: Letter Mail Controlled 6/13/2006 10:06:23 AM MC# 2060284: - From Marion C. Blakey, Administrator: The FAA finds that pertinent regulations are appropriate as written, but that clear guidance might be helpful to pilots who do not understand the significance of all of the rule language. Accordingly, the FAA plans to add language to AC 120-71A, "Standard Operating Procedures for Flight Deck Crewmembers," Appendix 2, and to the Aeronautical Information Manual (AIM) that will clearly explain a pilot's responsibilities before electing to descend below the minimum descent altitude. It is anticipated that the AC and AIM will be revised by March 2007.