Accident Summary
The accident occurred while the airplane was conducting a localizer back course approach. It collided with trees and the ground approximately 3 miles from the runway threshold. The aircraft was totally destroyed, and all 18 occupants were killed.
Operational Factors
Investigation revealed that the captain delayed the start of the descent, which subsequently required an excessive descent rate to reach the final approach fix (FAF) and minimum descent height (MDH). The captain's actions led to distractions during critical phases of the approach. The flight crew lost altitude awareness and allowed the airplane to descend below mandatory level-off points.
Crew and Management Issues
Records of the captain raised questions about his airmanship and behavior, suggesting a lack of crew coordination during flight operations, including intimidation of first officers. Company management did not adequately address these matters. The airline's flight operations management failed to implement provisions to adequately oversee the training of flight crews and the operation of their aircraft. Additionally, Federal Aviation Administration (FAA) guidance to inspectors concerning implementation of operations bulletins was found to be inadequate, failing to transmit valuable safety information as intended to airlines.
Probable Cause
The official probable cause of the accident was the captain's actions that led to a breakdown in crew coordination and the loss of altitude awareness by the flight crew during an unstabilized approach in night instrument meteorological conditions. Contributing to the accident were: the failure of company management to adequately address previously identified deficiencies in airmanship and crew resource management of the captain; the failure of the company to identify and correct a widespread, unapproved practice during instrument approach procedures; and the Federal Aviation Administration's inadequate surveillance and oversight of the air carrier.