What happened
On the morning of September 23, 1985, Henson Airlines flight 1517 was conducting a scheduled domestic service from Baltimore-Washington International Airport to Weyers Cave, Virginia. While approaching Shenandoah Valley Airport under instrument meteorological conditions, the crew was cleared for an instrument approach at 0959.
During the descent, radar service for the aircraft ended at 1003. Following this, the flight crew communicated with local station agents and unicom services. The final radar contact occurred at 1011, showing the Beechcraft 99 at an altitude of 2,700 feet mean sea level, positioned east of the localizer course.
Radio transmissions from the cockpit indicated confusion regarding the aircraft's position relative to the course. At 1014, the pilot noted they were showing west of the course, and by 1015, he inquired if they were actually east of it. After a controller suggested performing a missed approach if not established on the localizer, the crew ceased all communications following their last transmission at 1016. The wreckage was later discovered approximately six miles east of the airport. The accident resulted in 14 fatalities, including both crew members and all 12 passengers.
Findings
Investigations determined that a navigational error caused by the use of an incorrect navigational facility and insufficient monitoring of flight instruments was the primary cause. Several contributing factors were identified, including:
- The presence of non-standardized radio equipment within the airline's fleet.
- High levels of ambient noise in the cockpit which hindered communication.
- Insufficient pilot training provided by the operator.
- Limited multi-engine and instrument flight experience of the first officer.
- Lack of familiarity with the specific aircraft type among the crew members.
- Personal stressors affecting the pilots.
Additionally, it was noted that FAA oversight failed to identify these operational deficiencies.