Pilots of a doomed corporate jet did not maintain proper air speed for icing conditions before the aircraft stalled in midair and crashed near Pueblo in 2005, the National Transportation Safety Board ruled Tuesday.
The two-person crew and six passengers died in the crash.
Board members decided the pilots' "failure to effectively monitor and maintain airspeed" or to comply with de-icing procedures caused the crash of a Cessna Citation owned by Circuit City stores the morning of Feb. 16, 2005.
The board also found, in a split decision, that a contributing factor was the Federal Aviation Administration's failure to update certification requirements for flying into icy conditions.
If the agency had, board members believe, that would have led to technical changes to cause the plane's stall-warning system to warn pilots earlier, before the plane lost too much speed, stalled, rolled sharply and plummeted to the ground.
"How many more accidents is it going to take before the FAA decides they're going to force this change?" board member Debbie Hersman asked during a more than three-hour hearing Tuesday morning.
She was one of two board members who dissented on the "contributing factor" vote because she wanted the warning-system issue to be listed as one of the primary causes of the accident.
'A little ice'
NTSB investigators, who spent nearly two years looking into the crash, decided that while a warning system might have helped pilots recover, the accident was triggered by the crew's earlier actions.
The jet, operated for the company by Martinair Inc., crashed into ranchland a few miles east of Pueblo Memorial Airport, where it was making the second of two fuel stops on a cross-country flight from Virginia to Orange County, Calif.
Weather played a role in the crash. There were reports of freezing drizzle in the area, and pilots were heard on cockpit voice recorders talking about "a little ice here and there" on the wings just minutes before the crash at 9:12 a.m.
Board members said the pilots appeared to be conscientious in monitoring the ice. But they did not follow through and activate the de-icing equipment as they should have, and they apparently were distracted by a last-minute runway change as they began their final approach.
"I feel this was a responsible flight crew. I think they just got themselves distracted," said board member Steven Chealander.
"Listening to the (cockpit voice recorder), it broke my heart listening to these guys go through what they were going through," Chealander said. "They were a good crew. They were just off their game."
Instead of maintaining a speed of 114 knots, as they should have in icing conditions, they airplane was going only about 90 knots when it stalled, rolled and began falling, investigators said.
"This airplane rolled severely and sharply," said investigator- in-charge Frank Hilldrup.
"The pilots were trying to re-establish control. They ran out of altitude."
Stall warning delayed
The stall-warning system was not activated because the aircraft stalled before it got slow enough to trigger a warning to pilots. In icing conditions, planes can stall at higher speeds, and that's the reason board members want the FAA to take action.
Along with determining the cause, the board recommended more training for pilots on de-icing procedures, maintaining the proper air speed and learning to manage multiple tasks simultaneously in the cockpit.
They said pilots need to activate de-icing equipment early and often when there is any ice on wings, and they urged the FAA and airline manufacturers to update manuals that might be leading pilots to delay until they think icing is sufficiently severe.
In this case, although the pilots detected ice on the wings, "they didn't seem scared of it," Hersman said. "Why?"
She blamed unclear guidance and the fact that many pilots - including the ones involved in the Pueblo crash - fly in and out of freezing rain conditions frequently.
"This being normal does not mean it's safe," she said.
INFOBOX
Crash investigation
The National Transportation Safety Board on Tuesday concluded a nearly two-year investigation into the Feb. 16, 2005, crash of a Cessna Citation 560 jet near Pueblo. The board found:
* The crash was caused by "the flight crew's failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on their approach to Pueblo, Colorado, which led to an aerodynamic stall."
* A contributing factor was "the (Federal Aviation Administration's) failure to establish adequate certification requirements for flight into icing conditions, which led to the inadequate stall warning margin provided by the airplane's stall warning system."
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