大西洋东南航空2311班机.pdf

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 ATLANTIC SOUTHEAST AIRLINES, INC., FLIGHT 2311 UNCONTROLLED COLLISION WITH TERRAIN AN EMBRAER EMB-120, BRUNSWICK, GEORGIA APRIL 5, 1991 5511A -’EnfantThe National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 Plaza, S.W. Washington, D.C. 20594 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 NTSBIAAR-92103 WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT ATLANTIC SOUTHEAST AIRLINES, INC., FLIGHT 2311UNCONTROLLED COLLISION WITH TERRAINAN EMBRAER EMB-120, BRUNSWICK, GEORGIAAPRIL Adopted: April Notation Abstract: This report explains the loss of control in flight and crash of Atlantic Southeast Airlines, Inc., Flight 2311, while the airplane was conducting a landing approach to runway 07 at the Glynco Jetport, Brunswick, Georgia. The safety issues discussed in this report include the certification and inspection requirements for the Hamilton Standard model 14RF and other model propeller systems, and the scheduling of reduced flightcrew rest periods that are beyond the intent of Federal regulations. Safety recommendations concerning these issues were made to the Federal Aviation Administration, Atlantic Southeast Airlines, Inc., and the Regional Airline Association. I' • CONTENTS VEXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. FACTUAL INFORMATION 1.1 History of the Flight.............................................................................. 11.2 Injuries to Persons ................................................................................. 31.3 Damage to Aircraft ............................................................................... 31.4 Other Damage ....................................................................................... 31.5 Personnel Information ........................................................................... 1.6 Aircraft Information .............................................................................. 61.7 Meteorological Information .................................................................. 71.8 Aids to Navigation ................................................................................ 71.9 Communications ................................................................................... 71.10 Aerodrome Information......................................................................... 71.11 Flight Recorders.................................................................................... 81.12 Wreckage and Impact Information ........................................................ 81.13 Medical and Pathological Information .................................................. 91.14 Fire ....................................................................................................... 91.15 Survival Aspects ................................................................................... 91.16 Tests and Research ............................................................................... 101.16.1 Airplane Systems .................................................................................. 101.16.2 Engine and Propeller Inspections .......................................................... 111.16.3 Propeller System Static Testing............................................................. 141.16.4 Propeller System Flight Tests................................................................ 161.16.5 Flight Simulator Tests ........................................................................... 181.17 Other Information ................................................................................. 221.17.1 Hamilton Standard Alert Service Bulletin ............................................. 221.17.2 Transfer Tube Finish Change ................................................................ 241.17.3 Propeller Control Unit Servo Ballscrew Wear ....................................... 271.17.4 Flightcrew Scheduling ....................。