A Pilot's Lack Of Concentration (United Express Flight 6291) - DISASTER BREAKDOWN

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It was a quiet Winter’s evening in Columbus Ohio on January 7th, 1994. That was until a commuter plane crashed on its approach into the local airport. United Express Flight 6291 was making a very routine trip when it abruptly crashed just moments from its arrival. What could have gone wrong so quickly in the flight’s final moments? And what roles did the flight crew play in contributing to this accident? -intro- The timeline of events which transpired that January Evening begins at Dulles Airport outside of Washington DC. A small commuter plane was preparing to transport just a handful of passengers to Columbus, Ohio. The flight was being operated by a little-known airline of the time called “Atlantic Coast Airlines”. They were under a contractual agreement with United Airlines to do business as United Express. This meant that some of Atlantic Coast’s planes were painted in the Blue and Grey United Livery of the time. By simply looking at the airline at the surface level, this would appear like it were any other United Airlines flight. This business practice is still prevalent to this day in North America. The largest of these regional carriers today is SkyWest Airlines. Although you would never know as they have painted all of their planes in the colors of all of the US legacy carriers plus Alaska Airlines. Because the airline and airplane appeared as two different airlines, the accident flight of discussion had two different flight numbers. The pilots were using the Callsign of “Blue Ridge 291”. For the sake of consistency in this video we will refer to the flight by its United Express flight number. Atlantic Coast Airlines operated for both United and Delta with a fleet consisting of a mixture of regional jets and turboprop aircraft. In their propeller fleet were some Brazilian built Embraer 120’s but also a number of their aircraft were British Turboprops. For this video the subject aircraft was the British Aerospace Jetstream 41. Produced in the 1990s the Jetstream 41 is a versatile high performance commuter plane. British Aerospace produced exactly 100 of these plane before the company’s demise in the late 1990s. Throughout its life, the plane has enjoyed an excellent safety record with all-time fatalities in air accidents amounting to a single digit figure. United Express flight 6291 would be one of only two fatal incidents where one fatality occurred on a positioning flight in South Africa. Otherwise the United Express incident has been the only fatal accident to involve the plane on a commercial passenger flight. By and large, the Jetstream 41 has proved to be a robust ideal commuter plane which is still in use today all over the world. In the 1990s the plane was one of the most modern and sleekest turboprops around. On the flight deck is what is called a “Glass Cockpit”. Though the standard today as its now common for general aviation aircraft to have a glass cockpit. The digital displays were a new concept in 1994. Though a very modern plane for its time, one system the plane did not have was auto-throttle. The pilots must monitor their airspeed and manipulate the thrust setting throughout the flight where appropriate. United Express Flight 6291 was being flown by two pilots. 35-year-old Captain Derrick White was from Connecticut. Before making a career in aviation he achieve a university degree in “Urban Systems”. He worked as a flight instructor and gained a total of over 3,600 hours flying experience. His First Officer was 29-year-old Anthony Samuels. He was from New York. He himself was a pilot of over 2,400 flight hours. He is still very new to the Jetstream plane with just 32 hours logged. Being only the start of his flying career, this was his first pilot job performing commercial passenger flights. In the cabin were just 5 passengers and one flight attendant named Manuela Walker from Rockville, Maryland. With just 5 passengers on board, the plane is lightly filled, even for a commuter plane that can hold 30 passengers. Regardless flight 6291 left the gate at Washington Dulles just before 10pm at 9:58 on January 7th. It was a cold night that night, with snow in the area. It was the seventh flight that day for the plane. For Captain White and First Officer Samuels, this was their first flight of the day. The flight to their destination, Columbus Ohio is a 90-minute flight away in this plane. The Columbus area was under a high-pressure system that night. Rain and Fog had been forecast. The meteorological observations taken at 8:45pm note moderate turbulence with patches of severe turbulence. As flight 6291 was on their way to Ohio, at 10:59pm one hour into the flight, Air Traffic Control in Indianapolis gave a weather update regarding icing conditions. The pilots had already noticed they were getting quote “Moderate Icing” on their plane. Cruising at 14,000 feet, flight 6291 was approaching their top of descent at around this time but the pilots requested a step climb to 15,000. The request was granted, and the plane climbed. Also while the flight was enroute, an amendment was made to the weather observations. The Cloud base and visibility had decreasing. Though this is poor flying weather. For modern airplanes including the Jetstream 41, approaches can still be made so long as the plane and pilots are qualified for it. At 11:05pm, Air Traffic Control gave the pilots their first descent clearance down to 11,000 feet. Flight 6291 was handed off from the Indianapolis controller to an approach controller in Columbus Ohio. By this time, the Jetstream was passing through 13,200 feet. On the flight deck, the pilots were making their landing preparations as routine. They had informed the airport of the weather information they had received from the Columbus Airport ATIS frequency. 5 minutes later the United Express Flight was given clearance to intercept the ILS on Runway 28 Left, the runway on the south side of the airport. Another 5 minutes later at 11:15 there was new weather information on the ATIS. The controller informed them of the new weather to which there were some changes. The cloud base had fallen to 800 feet. Visibility had also fallen from the crew expecting 6 miles of visibility, the new weather would now say they had just two and a half miles. United Express 6291 continued on with the approach. At 11:16 the plane was 16 miles from the airport and was cleared to descend down to 3,000 feet. The approach controller handed the flight off to the Tower controller who would bring the plane down to the runway but not before asking the pilots to reduce their speed to 170 knots. In preparation for landing the thrust was reduced, the sounds of the propellers were easily picked up on the cockpit voice recording which gave investigators insight to how the pilots managed their plane. At this point in the timeline of events, flight 6291 was three minutes from crashing. On frequency with the tower controller, the pilots begin running through their checklists and configuring the plane for landing, including bringing out the plane’s trailing edge flaps on the wings. Interesting of note is that there was a verbal exchange between the two pilots regarding the flight’s callsign. The First Officer, the one handling radio communication incorrectly used the wrong flight number, substituting the two for a three. Regardless the tower cleared the plane to land straight away. Lined up with the runway, the landing gear was lowered at 11:20pm. The speed had also begun to fall quite considerably. This was because, as is normal, when the flaps are pulled out, this creates a substantial amount of drag on the airplane. The tradeoff of this is a physically bigger wing and thus more lift. Flaps are extremely useful for landing as it allow pilots to freely manipulate a planes attitude at lower speeds. In the case of United Express 6291, the flaps were set to a setting of 15 degrees. Along with that as the plane was passing to under 1,000 feet of altitude, the throttles were in the idle position as the torque was recorded of have a reading of 0 during this time at 11:20pm. The pilots were too busy configuring their aircraft to notice the rapidly decreasing airspeed, which at this point had dropped below the minimum approach speed of around 130 knots. The Jetstream plane had also started to fall below the glideslope. The Autopilot in command of the aircraft’s descent tries to compensate by raising the nose higher and higher to stay on the glideslope. This came to a head at 11:20 and 46 seconds as the stick shaker stall warning activates warning the pilots, they have entered an aerodynamic stall scenario. In the seconds that followed, Captain White would ask if his First Officer had done anything to the plane. This indicates that he did not know the predicament his aircraft was in. His plane was at a speed of just 104 knots with a high nose up attitude. The stall warning would sound twice, and the captain called for the Flaps to be retracted. This call by the captain to bring the flaps back up to 0 was criticized as these surfaces could have generated more lift at slower speed which would have been necessary for their stall recovery. With brining the flaps back up, this move decreased the amount of lift the wings would generate at a time it needed lift the most. They should have maintained an airspeed of around 130 knots for a regular approach. The speed continued to drop further to 101 knots. With just 400 feet of altitude above the ground the plane stalled and crashed after oscillating in a banking motion crashing around 2 kilometers short of the airport runway. The plane crashed into storage warehouse at exactly 11:21pm to the second. Both pilots, the flight attendant along with two passengers were killed. Incredibly, a family of three from Taiwan who were travelling on the flight survived. Injured… but alive. The other two passengers died of smoke and soot inhalation. Two of the surviving passengers noted difficulties in releasing their seatbelts. This would prompt a recommendation from the National Transportation safety board to replace all seat belts of that particular model number from that manufacturer. The investigation led by the National Transportation Safety board concluded that pilot error was the main cause of the crash. Highlighting that poor management of the plane included an improper response to a stall alert and the inappropriate use of the plane’s flaps. Captain white failed to monitor his airspeed and failed to apply power where needed. This was backed up further following test flights during the investigation with the help of the aircraft manufacturer. Pilots had no difficulty in performing a stall recovery in the Jetstream 41 when replicating the accident scenario. The accident report saying that is difficult to explain how a pilot could not respond to a stick shaker warning appropriately. It was found that the pilots did not slow the plane quick enough when they needed to reduce airspeed for their approach. This cost them substantial time which could have been used to perform the approach checks. Other contributing factors which are mentioned in the NTSB report include the pilots’ lack of experience of the Glass Cockpit and aircraft automation, suggesting the way in which airspeed and other parameters are presented confused the pilots. The operator, Atlantic Coast Airlines and United were also criticized for their part. It was revealed that the operator failed to provide criteria to pilots regarding a stabilized approach. Atlantic Coast Airlines continued to operate for a further 10 years after the accident. In 2004 the airline rebranded into Independence Air in an attempt to capture some of the low-cost airline market. They ceased operations in 2006. Patreon Outro Hello everyone and good evening. Thanks for watching and if you found this video interesting be sure to subscribe as there is always a new video every Saturday. Obviously, this video has gone out on a Tuesday as this month I have dedicated to being a big month of content. So this is the second video of hopefully 7 videos this month. There will be another video at the usual time on Saturday so be tuned in for then. Anyway I Shall keep this ending quick and move onto thanking my Patrons. If you’d like to have your name featured or read out at the end of the next video on Saturday, you can join the Disaster Breakdown Patreon from £3 per month and the link to that will be in the pinned comment below. And you have until Wednesday Evening to get your name in as I normally record these outros on a Thursday morning. Thanks to my £5 tier Patrons, Avery Teoda, Erynn Wilson, Hector Palma Tellez, Ken Zachmann, Kenneth Morenz, Kristi, Leon Sant Jennings, Marie Innes, MG, Pacman Seven, Panic Chicken, Pedro Cruz, Rebecca Rivers, Sariya Melody, Sleepy_, SoFP and SueSewsSue’sShoes. A big thank you to my Generous £10 tier Patrons for their support. Aiden Montgomery, And Sid, Daniel Hendricks, Derek Bean, karma, Mike Milton, Psydefect, Roger Meyer and WhereAreMyCheetos. Thank you all so much and thanks to everyone who has pledged on Patreon. That is it from me for now, I will be back at the regular time on Saturday and be on the ready as there should be another mid-week video this month. Thanks and Goodbye!
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Channel: Disaster Breakdown
Views: 227,740
Rating: undefined out of 5
Keywords: air disasters, plane crash, air crash investigation, united airlines, united express, flight 6291, united express flight 6291, united express flight 6291 air crash investigation, slam dunk, rime ice, port columbus, ohio, columbus, united airlines crash, jetstream 41, british aerospace, airplane crash, Disaster Breakdown, plane crash in winter, jetstream plane crash, plane crash video, plane crash documentary, united, atlantic coast airlines crash
Id: gwOb1N-RVV4
Channel Id: undefined
Length: 14min 25sec (865 seconds)
Published: Tue Oct 05 2021
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