Accident Overview
On September 23, 1985, Henson Airlines Flight 1517, a scheduled domestic passenger flight operating under 14 CFR 135, departed Baltimore-Washington International Airport in Baltimore, Maryland. The destination was Shenandoah Valley Airport in Weyers Cave, Virginia. On board were 12 passengers and 2 crew members. Instrument meteorological conditions were present at the destination airport.
Flight Sequence
At 0959, air traffic control cleared Flight 1517 for an instrument approach. Radar service ended at 1003. The flight crew then communicated with the Henson station agent and the Shenandoah unicom. The final radar return was recorded at 1011, showing the aircraft east of the localizer course at an altitude of 2,700 feet mean sea level, flying a magnetic track of approximately 075°. At 1014, the pilot transmitted, "..we're showing a little west of course..." and at 1015, asked if the aircraft was east of course. At 1017, the controller recommended a missed approach if the aircraft was not aligned with the localizer. No further transmissions were received from the crew after 1016. The wreckage was discovered around 1842 roughly six miles east of the airport. All 14 individuals on board sustained fatal injuries.
Investigation and Findings
The investigation revealed that the accident aircraft belonged to the airline's Beech 99 fleet. The probable cause was a navigational error by the flightcrew, resulting from their use of an incorrect navigational facility and their failure to properly monitor flight instruments. Several factors contributed to these errors: the non-standardized navigational radio systems across the Beech 99 fleet, difficulties in intra-cockpit communication due to high ambient noise, inadequate pilot training provided by the airline, the first officer's limited multi-engine and instrument flying experience, the pilots' limited time in their positions on the Beechcraft 99, and stress-inducing events in the pilots' personal lives. Additionally, the Federal Aviation Administration's insufficient oversight of the airline contributed to the accident by not identifying the existing deficiencies.