aviation

Crash of Pinnacle Airlines Flight 3701

Bombardier CL-600-2B19, N8396A

Jefferson City, Missouri

October 14, 2004

ACCIDENT REPORT

NTSB/AAR-07/01

PB2007-910402

Aircraft Accident Report

Crash of Pinnacle Airlines Flight 3701

Bombardier CL-600-2B19, N8396A

Jefferson City, Missouri

October 14, 2004

NTSB/AAR-07/01

PB2007-910402 National Transportation Safety Board

Notation 7695E 490 L’Enfant Plaza, S.W.

Adopted January 9, 2007 Washington, D.C. 20594

E PLUR IBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N
National Transportation Safety Board. 2007. Crash of Pinnacle Airlines Flight 3701, Bombardier

CL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004. Aircraft Accident Report

NTSB/AAR-07/01. Washington, DC.

Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N8396A, which

crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson

City, Missouri. During the flight, both engines flamed out after a pilot-induced aerodynamic stall

and were unable to be restarted. Safety issues discussed in this report focus on flight crew training

in the areas of high altitude climbs, stall recognition and recovery, and double engine failures;

flight crew professionalism; and the quality of some parameters recorded by flight data recorders

on regional jet airplanes.

The 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.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2007-910402 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Aircraft Accident Report

Contents

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain . . . . . . . . . . . . 8

1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer . . . . . . . . 10

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.6.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.6.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.6.3 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.10.1 Air Traffic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.12.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.16.1 Aircraft Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.16.1.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.16.1.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.16.1.3 Descent and Glide Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.16.2 Cockpit Voice Recorder Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.16.3 Engine Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.16.4 Load Control Valve Simulation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1.17.1 Ground School and Simulator Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
iv Aircraft Accident Report

1.17.1.1 Upset Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1.17.1.2 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.17.1.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.17.1.4 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.17.1.5 Crew Resource Management Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.1.6 Leadership Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.2 Flight Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.17.2.1 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.17.2.2 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.2.3 Stall Protection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.17.2.4 Flight Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.17.3 Federal Aviation Administration Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.18.1 Oxygen Mask Use During the Accident Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.18.2 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.18.3 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.18.3.1 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.18.3.2 Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1.18.3.3 Flight Data Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.18.4 Federal Aviation Administration Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

1.18.5 Bombardier All Operator Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.2.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.2.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

2.2.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

2.2.3.1 Performance of the Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . . 50

2.2.4 Communications With Air Traffic Controllers 

and Management of Forced Landing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

2.2.5 Accident Sequence Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.3 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

2.3.1 High Altitude Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

2.3.2 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

2.3.3 Double Engine Failure Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2.4 Flight Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

2.4.1 Part 91 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

2.4.2 Industrywide Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

2.4.2.1 Pilot Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

2.4.2.2 Operator Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

2.5 Quality of Flight Data Recorder Data for Regional Jet Airplanes . . . . . . . . . . . . . . . . . 68

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Contents
v Aircraft Accident Report

4. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

4.1 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

4.2 Previously Issued Recommendation Reiterated and Classified in This Report . . . . . . . 75

4.3 Previously Issued Recommendations Resulting From This Accident Investigation . . . 76

5. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

A: Investigation and Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

B: Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

C: Pinnacle Airlines’ Double Engine Failure Checklist 

at the Time of the Accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

D: Pinnacle Airlines’ Revised Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . 149

E: Core Lock Safety Recommendation Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

Contents
vi Aircraft Accident Report

Figures

1. Components in the CRJ Pneumatic Supply and Start Systems . . . . . . . . . . . . . . . . . . . . . . 12

2. Glide Distances for the Accident Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
vii Aircraft Accident Report

Abbreviations

a.c. alternating current

AC advisory circular 

AD airworthiness directive 

ADG air-driven generator

AIRMET airman’s meteorological information

AIZ Lee C. Fine Memorial Airport, Kaiser Lake Ozark, Missouri

ALPA Air Line Pilots Association

AND airplane nose down 

ANU airplane nose up

AOA angle of attack 

APU auxiliary power unit 

ARTCC air route traffic control center 

ASAP Aviation Safety Action Program

ASOS automated surface observing system

ATC air traffic control

ATOS Air Transportation Oversight System

ATS air turbine starter

CFR Code of Federal Regulations

cg center of gravity 

CRJ Canadair regional jet 

CRM crew resource management 

CVR cockpit voice recorder 

DTW Detroit Metropolitan Wayne County Airport, Detroit, Michigan

EICAS engine indicating and crew alerting system 

FAA Federal Aviation Administration 

FCOM flight crew operating manual
Abbreviations viii Aircraft Accident Report

FDR flight data recorder

FMS flight management system

FOQA flight operational quality assurance 

fpm feet per minute 

FSDO flight standards district office

GAO Government Accountability Office

GE General Electric 

GPWS ground proximity warning system 

Hg mercury

ICAO International Civil Aviation Organization

ILS instrument landing system 

ISA International Standard Atmosphere

JEF Jefferson City Memorial Airport, Jefferson City, Missouri

KIAS knots indicated airspeed

LBO Floyd W. Jones Lebanon Airport, Lebanon, Missouri

LCV load control valve

LIT Little Rock National Airport, Little Rock, Arkansas 

LOSA Line Operations Safety Audit

METAR meteorological aerodrome report 

msl mean sea level 

MSP Minneapolis-St. Paul International Airport, Minneapolis, Minnesota

N1 engine fan speed

N2 engine core speed 

NWS National Weather Service

POI principal operations inspector

SB service bulletin

SGF Springfield-Branson Regional Airport, Springfield, Missouri

SMS safety management system

S/N serial number 
Abbreviations ix Aircraft Accident Report

SPS stall protection system

TBN Waynesville Regional Airport, Fort Leonard Wood, Missouri

VIH Rolla National Airport, Rolla/Vichy, Missouri
x Aircraft Accident Report

Executive Summary

On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines

flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A,

crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport,

Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock

National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport,

Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced

aerodynamic stall and were unable to be restarted. The captain and the first officer were

killed, and the airplane was destroyed. No one on the ground was injured. The flight was

operating under the provisions of 14 Code of Federal Regulations Part 91 on an

instrument flight rules flight plan. Visual meteorological conditions prevailed at the time

of the accident.

The National Transportation Safety Board determines that the probable causes of

this accident were (1) the pilots’ unprofessional behavior, deviation from standard

operating procedures, and poor airmanship, which resulted in an in-flight emergency from

which they were unable to recover, in part because of the pilots’ inadequate training;

(2) the pilots’ failure to prepare for an emergency landing in a timely manner, including

communicating with air traffic controllers immediately after the emergency about the loss

of both engines and the availability of landing sites; and (3) the pilots’ improper

management of the double engine failure checklist, which allowed the engine cores to stop

rotating and resulted in the core lock engine condition. Contributing to this accident were

(1) the core lock engine condition, which prevented at least one engine from being

restarted, and (2) the airplane flight manuals that did not communicate to pilots the

importance of maintaining a minimum airspeed to keep the engine cores rotating.

The safety issues discussed in this report focus on flight crew training in the areas

of high altitude climbs, stall recognition and recovery, and double engine failures; flight

crew professionalism; and the quality of some parameters recorded by flight data

recorders on regional jet airplanes. Safety recommendations concerning these issues are

addressed to the Federal Aviation Administration.
1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On October 14, 2004, about 2215:06 central daylight time,1 Pinnacle Airlines

flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19,2 N8396A,

crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport

(JEF), Jefferson City, Missouri. The airplane was on a repositioning flight3 from Little

Rock National Airport (LIT), Little Rock, Arkansas, to Minneapolis-St. Paul International

Airport (MSP), Minneapolis, Minnesota. During the flight, both engines flamed out4

 after

a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first

officer were killed, and the airplane was destroyed. No one on the ground was injured. The

flight was operating under the provisions of 14 Code of Federal Regulations (CFR)

Part 91 on an instrument flight rules flight plan. Visual meteorological conditions

prevailed at the time of the accident.

Flight 3701 departed LIT about 2121. The flight plan indicated that the

company-planned cruise altitude was 33,000 feet. About 5 seconds after takeoff, when the

airplane was at an altitude of about 450 feet mean sea level (msl)5

 (about 190 feet above

ground level), the first of three separate pitch-up maneuvers during the ascent occurred

when the flight crew moved the control column to 8o airplane nose up (ANU), causing the

airplane’s pitch angle to increase to 22o and resulting in a vertical load of 1.8 Gs.6 The rate

of climb during this pitch-up maneuver was 3,000 feet per minute (fpm). Immediately

afterward, the flight data recorder (FDR) recorded stickshaker and stickpusher

activations,7 a full airplane-nose-down (AND) control column deflection, a decrease in

pitch angle, and a drop in vertical load to 0.6 G.

About 2125:55, when the airplane was at an altitude of about 14,000 feet, the flight

crew engaged the autopilot. The air traffic control (ATC) transcript and FDR data showed

1 All times in this report are central daylight time based on a 24-hour clock.

2 The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in

the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired

Canadair in December 1986.

3 A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled.

Repositioning flights do not carry revenue passengers or cargo but can carry nonrevenue passengers.

4 A flameout is an interruption of a turbine engine’s combustion process that results in an

uncommanded engine shutdown.

5 All altitudes and elevations in this report are msl unless otherwise noted.

6 G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity

(32.174 feet/second2

).

7 The stickshaker produces vibrations in the control columns to warn pilots of an impending stall. If

the angle of attack (AOA) continues to increase, the stickpusher moves the control columns forward (nose

down) automatically to prevent an aerodynamic stall, which can occur afterward.
Factual Information 2 Aircraft Accident Report

that the flight crewmembers changed seats in the cockpit during this time,8 but the ATC

transcript did not indicate the reason for the seat change. About 2127:15, when the

airplane was at an altitude of about 15,000 feet, the flight crew disengaged the autopilot.

About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet,

the second pitch-up maneuver began when the flight crew moved the control column to

3.8o ANU, causing the airplane’s pitch angle to increase to 17o and resulting in a vertical

load of 2.3 Gs. The rate of climb during this pitch-up maneuver reached 10,000 fpm

briefly. Between about 2128:40 and about 2128:43, the flight crew made a left rudder

input of 4.2o, a right rudder input of 6.0o, and a left rudder input of 0.4o, resulting in lateral

loads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crew

made a right rudder input of 7.7o. About 2132:40, when the airplane was in level flight at

an altitude of 24,600 feet, the third pitch-up maneuver began when the flight crew moved

the control column to 4o ANU, which increased the airplane’s pitch angle to more than 10o

and resulted in a vertical load of 1.87 Gs.9

 The rate of climb during this pitch-up maneuver

reached 9,000 fpm briefly.

The ATC transcript showed that the captain requested a climb to 41,000 feet,

which is the Canadair regional jet (CRJ) maximum operating altitude,10 about 2135:3611

and received clearance to climb to that altitude about 2136:13.12 The cockpit voice

recorder (CVR) recording began about 2144:44 with the captain and the first officer

discussing the climb to 41,000 feet. About 2148:44, the first officer stated, “man we can

do it. Forty one it.” About 2151:51, the first officer stated, “there’s four one oh my man.”

About 2152:04, the CVR recorded the first officer laughing as he stated, “this is ... great.”

FDR data showed that, about 2152:08, the airplane was in level flight at 41,000 feet. FDR

data also showed that the airplane climbed from 37,000 to 41,000 feet at an airspeed that

decreased from 203 knots/0.63 Mach13 at the start of the climb to 163 knots/0.57 Mach as

the airplane leveled off.14 The FDR data further showed that the autopilot vertical speed

8 The cockpit voice recorder (CVR) did not preserve any information or sounds associated with the

seat change because the CVR had the capability to record only the final 30 minutes of the flight. For

information about the seat change, see section 1.16.2.

9 According to the ATC transcript, the controllers made no transmissions to the pilots that required

them to perform the three pitch-up maneuvers during the ascent. For more information about the three

pitch-up maneuvers, see section 1.16.1.1.

10 The maximum operating altitude of the CRJ-200 is the maximum density altitude at which the

airplane is certified to operate. For the CRJ-200, the maximum operating altitude of 41,000 feet represents

the maximum capability of the airplane; the actual altitude capability will primarily depend on airspeed,

weight, and ambient temperature. 

11 The airplane was at an altitude of about 32,000 feet at the time.

12 During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had expressed

curiosity about operating the airplane at 41,000 feet and that an informal “[flight level] 410 club” existed at

the airline. Managers at Pinnacle Airlines, including the chief pilot, the CRJ program manager, and the vice

president of safety and regulatory compliance, were not aware of the club’s existence. 

13 Mach is a number that expresses the ratio of the speed of an object to the speed of sound in the

surrounding medium. The Safety Board calculated Mach number using the computed airspeed and total air

temperature recorded on the FDR.

14 All airspeeds cited in this report are knots indicated airspeed unless noted otherwise.
Factual Information 3 Aircraft Accident Report

mode was engaged during the climb with a commanded vertical speed of 500 fpm and that

the airplane’s angle of attack (AOA) at 41,000 feet was initially 5.7o. 

About 2152:22, the CVR recorded the captain asking the first officer whether he

wanted something to drink and then the first officer responding that he wanted a soda.

CVR evidence indicated that the captain left his seat shortly afterward to get the drink.

About 2153:28, the CVR recorded the captain stating, “look how high we are.”

About 2153:42, a controller at the Kansas City Air Route Traffic Control Center (ARTCC)

asked the pilots whether they were flying a CRJ-200. The captain confirmed this

information, and the controller stated, “I’ve never seen you guys up at forty one there.”

About 2153:51, the captain replied, “we don’t have any passengers on board so we

decided to have a little fun and come on up here.” About 2153:59, the captain added, “this

is actually our service ceiling.”15 

About 2154:07, the captain told the first officer, “we’re losing here. We’re gonna

be ... coming down in a second here.” About 3 seconds later, the captain stated, “this thing

ain’t gonna ... hold altitude. Is it?” The first officer responded, “it can’t man. We ...

(cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated, “yeah

that’s funny we got up here it won’t stay up here.”

About 2154:32, the captain contacted the controller and stated, “it looks like we’re

not even going to be able to stay up here ... look for maybe ... three nine oh or three

seven.”16 About 2154:36, the FDR recorded the activation of the stickshaker.17 FDR data

showed that, at that point, the airplane’s airspeed had decreased to 150 knots, and its AOA

was about 7.5o.

The FDR recorded activations of the stickshaker and the stickpusher18 three times

between 2154:45 and 2154:54.19 FDR data showed that, after the second activation of the

stickshaker and stickpusher, the No. 1 (left) and No. 2 (right) engines’ N1 (fan speed) and

fuel flow indications began decreasing. FDR data also showed that, at the time of the

second stickpusher activation, the airplane’s AOA had increased to 12o and that, after the

stickpusher activated for the third time, the pitch angle decreased from 7o to -20o. 

15 The service ceiling is the altitude at which the best rate of climb airspeed will produce a 100-fpm

climb. The service ceiling varies depending on airspeed, weight, and ambient temperature. The accident

airplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at an

altitude of 41,000 feet if the airspeed had been maintained at Mach 0.7.

16 The ATC transcript showed that, after this request, the controller began coordinating the descent.

17 For the Mach number at this time, the CRJ-200 stickshaker AOA is about 7.8o at the time of shaker

activation. The stickshaker activates at an airspeed of about 150 knots. 

18 For the Mach number at this time, the CRJ-200 stickpusher AOA is about 10.5o at the time of pusher

activation. The stickpusher activates at an airspeed of about 142 knots.

19 For more information about the stickshaker and stickpusher activations, see section 1.16.1.2.
Factual Information 4 Aircraft Accident Report

About 2154:57, the FDR recorded the fifth activation of the stickshaker and the

fourth activation of the stickpusher. Even with the stickpusher’s activation, the motion of

the airplane continued to increase its AOA to the maximum measurable value of 27o.20

The pitch angle increased to 29o, and the airplane entered an aerodynamic stall. Afterward,

a left rolling motion began, which eventually reached 82o left wing down, the airplane’s

pitch angle decreased to -32o, and both engines flamed out. About 2155:06, the captain

stated to the controller, “declaring emergency. Stand by.” FDR data showed that, during

the next 14 seconds, the flight crew made several control column, control wheel, and

rudder inputs and recovered the airplane from the upset at an altitude of 34,000 feet.

During the recovery, the CVR recorded a sound similar to decreasing engine rpm, and

FDR data showed that the No. 1 and No. 2 engines’ N1 indications continued to decrease

and that the engines’ fuel flow indications were at zero.21

About 2155:14, the controller told the pilots to descend and maintain an altitude of

24,000 feet; about 5 seconds later, the captain acknowledged the assigned altitude. About

2155:20, the FDR stopped recording because normal a.c. power to the airplane was lost.

(The CVR had a different source of power and continued to record.) The last reliable N2

(core speed) recorded by the FDR before it stopped operating was 46 percent for the No. 1

engine and 51 percent for the No. 2 engine.

About 2155:23, one pilot stated to the other, “we don’t have any engines,” and,

about 10 seconds later, the captain stated, “double engine failure.” About 2156:42, the

flight crew began performing the double engine failure checklist,22 which required pilots

to maintain 240 knots until they were ready to initiate the double engine failure

procedure.23 The checklist indicated that, if the airplane were at or below 21,000 feet and

above 13,000 feet, pilots should relight the engines using the windmill restart procedure,24

which required an airspeed of at least 300 knots. The procedure indicated that an altitude

loss of 5,000 feet could be expected when accelerating from 240 to 300 knots.

The FDR resumed operation about 2159:16.25 FDR data showed that the auxiliary

power unit (APU) was supplying electrical power to the airplane, both engines’ N1

indications continued to decrease, and both engines’ N2 indications were at zero. FDR

data also showed that the airplane’s altitude was 29,200 feet and that its airspeed was

178 knots.

20 The 27o AOA value is the physical limit of the sensor that measures this parameter. AOAs that are

physically higher were recorded as this limit.

21 FDR data and the CVR recording indicated that the engines were operating normally before the

upset.

22 For information about this checklist, see section 1.17.2.2.

23 This requirement was a checklist memory item.

24 A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing

through the engine provides rotational energy to turn the engine’s core. 

25 At that time, the cabin altitude warning signal was being recorded by the FDR. The FDR did not

record the cabin altitude warning signal any time before the loss of engine power or the beginning of the gap

in FDR data. The CVR recorded the first activation of the cabin pressure warning about 2157:04. For

information about the cabin pressurization system and oxygen mask use during the flight, see sections 1.6.2

and 1.18.1, respectively.
Factual Information 5 Aircraft Accident Report

About 2200:38, the captain told the first officer to increase the airspeed to above

300 knots, and the first officer acknowledged this instruction. FDR data showed that the

airplane pitched down to -4.4o and accelerated to an airspeed of 200 knots but that, during

the next 25 seconds, the airplane pitched up to 0o while its airspeed remained at 200 knots.

About 1 minute later, the captain again told the first officer to increase the airspeed to

300 knots. FDR data showed that the airplane pitched down to -7.5o and accelerated to an

airspeed of 236 knots (the maximum airspeed achieved during the windmill restart

attempt) but that, during the next 22 seconds, the airspeed decreased to 200 knots.26 

About 2201:51, the captain stated, “we’re not getting any N two at all. So we’re

gonna have ... to go to ... thirteen thousand feet. We’re going to use the APU bleed air

[restart] procedure.”27 Shortly afterward, the captain resumed the double engine failure

checklist, which indicated that pilots were to maintain between 170 and 190 knots until

they were ready to initiate the APU bleed air restart procedure. 

About 2203:09, the controller asked the flight crew about the nature of the

emergency. The captain responded, “we had an engine failure up there ... so we’re gonna

descend down now to start our other engine.” About 2203:30, the captain stated, “we’re

descending down to thirteen thousand to start this other engine,” and the controller

replied, “understand controlled flight on a single engine right now.” FDR data showed

that, during the next several minutes, four APU-assisted engine restarts were attempted,

but the N2 speed for both engines remained at zero throughout the restarts. About 2206:40,

the controller asked the flight crewmembers whether they wanted to land; the captain

replied, “just stand by right now we’re gonna start this other engine and see ... if

everything’s okay.” About 2206:54, the controller informed the flight crew that JEF was

up ahead, and the captain acknowledged this information. 

About 2208:17, the CVR recorded the captain stating, “switch.” About 2209:02,

the captain instructed the first officer to tell the controller that they needed “to get direct to

[an] airport neither engine’s started right now.” The first officer informed the controller for

the first time of the double engine failure,28 and the controller then asked the pilots if they

wanted to go direct to JEF. The captain stated, “any airport and closest airport,” and the

first officer told the controller, “closest ... airport. We’re descending fifteen hundred feet

per minute we have ... nine thousand five hundred feet left.” 

Between about 2210:21 and about 2211:20, the controller provided information

about the winds, the approach frequency, and the localizer frequency for an instrument

landing system (ILS) landing to runway 30 at JEF. About 2212:24, the first officer asked

the controller where to look for the airport,29 and the controller provided position,

distance, and heading information. About 1 minute later, the controller provided additional

location information for JEF. About 2213:37, the captain asked the first officer whether

26 For more information about these and other events during the airplane’s descent, see section 1.16.1.3.

27 Bleed air refers to pressurized air that is provided by the engines or the APU.

28 At this time, the first officer was recorded transmitting from the right seat, which was his proper

position in the cockpit. 

29 The airplane had descended out of clouds at an altitude of about 5,000 feet.
Factual Information 6 Aircraft Accident Report

the airplane was aligned with the runway, and the first officer notified the controller that

he did not see the runway. The controller provided further directional information, and the

first officer told the controller that he thought he had the approach end of the runway in

sight. The controller received no further transmissions from the flight crew. 

About 2214:02, the first officer told the captain that he had the runway in sight.

The captain questioned the first officer about the location of the runway and then stated,

about 2214:17, “we’re not gonna make this.” About 2214:38, the captain stated, “is there a

road? We’re not gonna make this runway.” Radar data showed that the airplane then

turned left and headed toward a straight and lit section of highway. About 2214:46, the

captain stated, “let’s keep the gear up ... I don’t want to go into houses here.” About

2214:53, the final radar return was received when the airplane was about 0.58 nautical

mile southeast of the crash site and at an altitude of 930 feet.

About 2214:54, 2214:58, and 2215:00, the CVR recorded the enhanced ground

proximity warning system (GPWS) alerts “too low gear,” “too low terrain,” and “pull up,”

respectively. About 2215:03, the CVR recorded the captain stating, “we’re gonna hit

houses,” and, about 2 seconds later, the enhanced GPWS alert “pull up.” About 2215:06,

the CVR recorded a sound similar to an impact and stopped recording about 1 second

afterward.

1.2 Injuries to Persons

Table 1. Injury chart.

1.3 Damage to Airplane

The airplane was destroyed by impact forces and a postcrash fire.

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 2 0 00 2

Serious 0 0 00 0

Minor 0 0 00 0

None 0 0 00 0

Total 2 0 00 2
Factual Information 7 Aircraft Accident Report

1.4 Other Damage

Trees were damaged during the accident sequence. Also, a garage and items in the

backyards of six houses were damaged by the impact of the airplane, a property line fence

was damaged when the No. 1 engine separated from the airframe after impact, and nearby

houses received heat damage from the postcrash fire.

1.5 Personnel Information

1.5.1 The Captain

The captain, age 31, held an airline transport pilot certificate and a Federal

Aviation Administration (FAA) first-class medical certificate dated July 22, 2004, with a

limitation that required him to wear corrective lenses while exercising the privileges of

this certificate. The captain received a type rating on the CL-65 in August 2004. (The

CL-600-2B19 airplane is included in the CL-65 type rating.)

The captain was hired by Pinnacle Airlines in February 2003. According to the

captain’s application for employment, he graduated in May 1995 from Embry-Riddle

Aeronautical University in Florida with a bachelor of science degree in aeronautical

science. The application indicated that the captain worked as a flight instructor for

Embry-Riddle Aeronautical University from August 1996 to October 1999, a first officer

on the British Aerospace Jetstream at Trans States Airlines from January 1999 to

May 2000, and a captain on the Beech 1900 at Gulfstream International Airlines from

June 2000 to September 2002.30 The captain’s résumé indicated that he had received FAA

high altitude physiological training.

Pinnacle Airlines employment and flight records indicated that the captain had

accumulated 6,900 hours of total flying time, including 5,055 hours as a

pilot-in-command, 973 hours on the CL-65, and 150 hours as a CL-65 pilot-in-command.

He had flown 667, 154, and 75 hours in the 12 months, 90 days, and 30 days, respectively,

before the accident. The captain’s last recurrent ground training occurred on December 8,

2003; his last recurrent proficiency check was on August 10, 2004; and his last

pilot-in-command line check occurred on August 26, 2004. FAA records indicated no

accident or incident history or enforcement action, and a search of records at the National

Driver Register found no history of driver’s license revocation or suspension.

According to his wife, the captain was in good health and exercised regularly. He

did not smoke and used alcohol only occasionally. He did not take prescription or

nonprescription medicine (other than daily vitamins and ibuprofen when needed). He had

not been sick in the days before the accident. He would generally wake at 0745 and go to

sleep no later than 2300 when on reserve and not flying. A company first officer (who

knew the captain since they were at Gulfstream International Airlines) stated that no

30 In August 2000, the captain received a type rating on the Beech 1900.
Factual Information 8 Aircraft Accident Report

significant changes had occurred in the captain’s life during the year preceding the

accident.

The captain went to a movie with his wife on the evening before the accident. On

the day of the accident, he went to a park with his family, went shopping, and went out for

lunch. The captain was on standby status at Detroit Metropolitan Wayne County Airport

(DTW), Detroit, Michigan, on the day of the accident. Crew scheduling notified him about

1700 that he was to “deadhead” (that is, travel on a company flight as a nonrevenue

passenger) on flight 5809 from DTW to LIT, reposition the accident airplane from LIT to

MSP, and remain in Minneapolis overnight. Flight 5809 departed DTW about 1919 and

arrived at LIT about 2036. Two Northwest Airlines31 customer service agents, who spoke

briefly with the captain after he deplaned, reported that he “looked fine,” “did not appear

tired,” and “appeared to be in a good mood.” The captain’s wife did not think that he had

flown with the accident first officer before the accident flight.

The captain’s wife stated that he had experienced only one previous emergency

during his flying career, which occurred while he was with Gulfstream International

Airlines. She stated that the landing gear did not extend and that the flight crew had to use

the emergency extension procedures. She also stated that the captain had received a letter

of commendation from the president of Gulfstream International Airlines, which

recognized the captain’s actions during a landing in challenging crosswind conditions.

1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain

Most pilots who had flown with the captain had favorable comments about his

flying abilities. These pilots stated that the captain operated the airplane in a standard

manner, demonstrated good crew resource management (CRM) skills, and was “easy to

get along with.” Also, a first officer (who had known the captain since they were at

Gulfstream International Airlines) stated that the captain was “the best stick and rudder

pilot he had ever flown with.” Another first officer stated that the captain set a tone in the

cockpit that made the first officer feel comfortable bringing concerns to the captain’s

attention.

A first officer who flew with the captain from October 7 to 8, 2004, stated that the

flights were conducted in a standard manner with no deviations from the flight crew

operating manual (FCOM). Another first officer (who had also known the captain since

they were at Gulfstream International Airlines) stated that the captain did not seem to be a

risk taker. All of the pilots who were interviewed after the accident stated that the captain

had never discussed flying at 41,000 feet.

The simulator instructor who conducted part of the captain’s upgrade training

stated that, during training, the captain did not always perform checklists according to

company procedures and did not always use the correct checklists.32 For example, the

instructor stated that the captain would, at times, misstate the status of a checklist item,

31 At LIT, Northwest Airlines provided ground support for Pinnacle Airlines.

32 The simulator instructor stated that he debriefed the captain about these deficiencies.
Factual Information 9 Aircraft Accident Report

read a checklist item but not accomplish it, or take action on an airplane system that was

not the one noted in the checklist. The instructor also stated that the captain would, at

times, see the appropriate checklist displayed in an engine indicating and crew alerting

system (EICAS) message33 but would still call for the wrong checklist. In addition, the

instructor stated that the captain flew the airplane “just fine” but that his biggest

weaknesses were his critical decision-making and judgment. In contrast, the captain’s

simulator partner thought that all checklists during their training had been performed

according to company procedures and stated that, during the debriefing sessions, the

instructor did not make any negative comments about the captain’s decision-making.

Another simulator instructor who conducted part of the captain’s upgrade training

stated that he had no recollections of the captain rushing checklists and that the captain’s

judgment was “above average.” A check airman who conducted part of the captain’s

upgrade operating experience stated that the captain displayed the profile that he looked

for in upgrading captains: proficiency, judgment, initiative, leadership, deliberate and

thoughtful actions, and no rushing.

1.5.2 The First Officer

The first officer, age 23, held a commercial pilot certificate with airplane singleand multiengine land and instrument airplane ratings. The first officer also held an FAA

first-class medical certificate dated January 14, 2004, with a limitation that required him

to wear corrective lenses while exercising the privileges of this certificate.

The first officer was hired by Pinnacle Airlines in April 2004. According to the

first officer’s application for employment, the first officer attended Broward Community

College in Florida from May 2001 to December 2003 and received an associate of science

degree in professional pilot technology. In October 2002, the first officer began training at

Gulfstream Academy of Aeronautics and subsequently became a first officer on the

Beech 1900 for Gulfstream International Airlines.34

Pinnacle Airlines employment and flight records indicated that the first officer had

accumulated 761 hours of total flying time, including 222 hours as a CL-65

second-in-command. He had flown 380, 192, and 60 hours in the 12 months, 90 days, and

30 days, respectively, before the accident. The first officer’s initial proficiency check

occurred on June 27, 2004. FAA records indicated no accident or incident history or

33 Pinnacle Airlines’ checklists were typically used with EICAS messages. Pilots were to call for the

checklist noted in an EICAS message and then use that checklist to guide them through a sequence of

actions.

34 The first officer’s personnel file contained letters of recommendation from Gulfstream International

Airlines pilots. For example, in an August 10, 2003, letter, a captain who had trained and flown with the first

officer wrote that he displayed “capable skills in maneuvering the aircraft smoothly and safely” and that he

exhibited “excellent situational awareness and decision-making ability.” The letter further stated that the

first officer showed strict adherence to company procedures, emphasized CRM, and had strong

communication skills.
Factual Information 10 Aircraft Accident Report

enforcement action, and a search of records at the National Driver Register found no

history of driver’s license revocation or suspension.

According to his father, the first officer was in good health and exercised regularly.

The first officer was a nonsmoker and used alcohol only occasionally. He was not taking

any prescription or nonprescription medications. The first officer was described as

someone who had a positive attitude, was motivated, and was happy to be with Pinnacle

Airlines.

The first officer was on reserve duty beginning on October 11, 2004. He flew a trip

from October 11 to 12 and was on reserve duty on October 13. As with the captain, the

first officer was notified during the afternoon of October 14 of the repositioning flight, and

he departed DTW about 1919 as a deadheading crewmember and arrived at LIT about

2036. A Northwest Airlines customer service agent, who spoke briefly with the first

officer after he deplaned, reported that he “appeared to be in a good mood” and “did not

seem tired.” According to his father, the first officer had not previously flown with the

accident captain.

1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer

During postaccident interviews, captains who had flown with the first officer

described him as a confident pilot who was good with checklists and as someone who

would ask questions if he did not understand something. The captain who flew with the

first officer on the trip from October 11 to 12, 2004, described him as an “average” first

officer. This captain did not note any problems with checklists during the trip. All of the

pilots interviewed stated that the first officer had not expressed curiosity about flying at

41,000 feet.

A simulator instructor who trained the first officer stated that he was a good pilot

with a positive attitude. The instructor also stated that he was not concerned about the first

officer’s abilities and that he would have made a fine captain. The simulator check airman

who conducted the first officer’s simulator checkride stated that he did a good job on the

checkride and that he made only minor mistakes that were not uncommon for first officers

to make. 

1.6 Airplane Information

The accident airplane, a Bombardier CL-600-2B19, serial number (S/N) 7396, was

delivered new to Pinnacle Airlines on May 18, 2000. At the time of the accident, the

airplane had accumulated 10,168 total flight hours and 9,613 total flight cycles.35

35 An aircraft cycle is one complete takeoff and landing sequence.
Factual Information 11 Aircraft Accident Report

On the day of the accident, another flight crew was scheduled to fly the accident

airplane from LIT to MSP. The flight crew rejected the takeoff after receiving an EICAS

message that read “R 14TH DUCT.” The airplane returned to the gate,36 and a

maintenance contractor was called to examine the problem. The maintenance contractor

could not find the source of the problem, so two Pinnacle Airlines mechanics were

dispatched from Memphis, Tennessee, to LIT to resolve the problem. The mechanics

found that the No. 2 engine pylon 14th stage bleed air duct sensing loop had some chafing

damage where it passed through a rib in the pylon. The loop was replaced, and the No. 2

engine was tested for about 30 minutes. The airplane was then released for service.

The airplane’s actual takeoff weight was 39,336 pounds, which was less than the

maximum takeoff weight of 53,000 pounds. The takeoff center of gravity (cg) was

21.6 percent mean aerodynamic chord, which was within the cg limits of 9.0 to

35.0 percent. 

1.6.1 Powerplants

The airplane was equipped with two General Electric (GE) CF34-3B1 turbofan

engines. The No. 1 (left) engine, S/N 872746, was installed on the airplane on

April 6, 2004, and had accumulated 8,856 total flight hours and 8,480 total flight cycles

since new. The No. 2 (right) engine, S/N 873514, was installed new on the airplane on

October 23, 2003, and had accumulated 2,304 total flight hours and 1,971 total cycles

since new.

The No. 1 engine’s fuel control had been replaced on January 3, 2002. The No. 1

engine had been removed from another company airplane on October 30, 2003 (when the

engine had accumulated 7,594 flight hours and 7,422 flight cycles); afterward, Pinnacle

Airlines maintenance personnel replaced the stage 9 compressor blades, the scavenge oil

lube pump, and the fan inlet sensor and installed the engine on the accident airplane. The

No. 2 engine’s fan inlet sensor and fuel control unit had been removed from an engine on

another company airplane and were installed on the accident airplane’s No. 2 engine. No

other major engine components had been changed on either engine since the time of

manufacture. 

1.6.2 Systems

The airplane was equipped with a Honeywell (formerly Garrett Airesearch)

GTCP 36-150RJ APU. The APU can provide electrical and pneumatic power to the

airplane’s systems when the main engines are not powering those systems. The maximum

altitude permitted for the use of bleed air with this APU is 15,000 feet, although design

documents showed that the APU was capable of providing pneumatic power at

21,000 feet. For the CRJ-200, the APU can be started when the airplane is at an altitude

that is less than 30,000 feet. A load control valve (LCV) was mounted on the APU

36 Afterward, the crew and passengers were put on another airplane so that the flight to MSP could

resume.
Factual Information 12 Aircraft Accident Report

pneumatic supply outlet. When the LCV opens, it allows pneumatic power from the APU

to become available to each engine’s 10th stage bleed air valves37 and then to the air

turbine starters (ATS), which turn energy from pneumatic air into mechanical torque for

rotation of the engine cores. Figure 1 shows components in the airplane’s pneumatic

supply and start systems, including the APU, LCV, 10th stage bleed air valves, and ATS.

Figure 1. Components in the CRJ Pneumatic Supply and Start Systems

The pneumatic system also supplied air to the cabin pressurization system, which

was digitally controlled to maintain a maximum cabin altitude of 8,000 feet (± 100 feet).

The system was designed to provide a cabin altitude/cabin pressure warning38 at a cabin

altitude of 10,000 feet and to deploy cabin oxygen masks at a cabin altitude of 14,000 feet. 

The airplane was equipped with a stall protection system (SPS), which provides

the flight crew with warnings of an impending stall condition.39 The stickshaker is one

component of the system.40 After stickshaker activation, the SPS protects against

aerodynamic stalls via a stickpusher.

37 FDR data showed that the LCV opened at an altitude of 13,000 feet. The LCV remained open during

each of the four APU-assisted engine restart attempts and then closed afterward. Bombardier maintenance

training manuals indicated that opening the LCV at altitudes above 15,000 feet would result in a cockpit

warning. The accident CVR recorded a cockpit warning associated with the LCV opening. FDR data from

the accident flight showed that the LCV opened when the airplane was at 15,400 feet and then closed a few

seconds later.

38 When this warning occurs, “CABIN ALT” is displayed on the EICAS, and “cabin pressure” is

announced in the cockpit.

39 SPS activation criteria depend on the airplane’s AOA, as measured by vanes mounted on the forward

fuselage.

40 In addition to the stickshaker, stall warnings are indicated by activation of the engine autoignition,

autopilot disconnect, aural warning, and red “STALL PUSH” lights on the glareshield.
Factual Information 13 Aircraft Accident Report

1.6.3 Maintenance Records

The Pinnacle Airlines maintenance program requires a service check every 3 days

and a routine check every 100 hours. The last service check performed on the accident

airplane was on October 13, 2004, and the last routine check was performed on October 7,

2004; no discrepancies were noted during either check.

 The Pinnacle Airlines maintenance program also requires an A check every

500 hours; this check consists primarily of system inspections, lubrications, and

adjustments. The last A check was accomplished on August 18, 2004. Also, the

maintenance program includes C checks, which involve detailed visual inspections of

flight controls, powerplants, and structures. Until the time that an airplane accumulates

8,000 total flight hours, the C check is performed at phased intervals to prevent the

airplane from being out of service for an extended period of time. Once the airplane

accumulates 8,000 flight hours, it must be out of service for an extended period of time to

perform the full C check.41 The accident airplane’s full C check was performed in

September 2003.

Finally, Pinnacle Airlines uses a calendar inspection program for “maintenance

significant items” and “structural significant items.” These inspections occur every 12, 24,

36, 48, 60, 72, and 96 months. The last inspections that were performed on the accident

airplane were the 24- and 48-month inspections, which occurred concurrently during

February and March 2004.

The airplane’s daily aircraft maintenance logs between April 2001 and

October 2004 showed no discrepancies related to the circumstances of this accident. Also,

the airplane’s discrepancy list for the 30 days before the accident showed no evidence of

any major repairs to the airplane.

1.7 Meteorological Information

JEF has an automated surface observing system (ASOS), which is maintained by

the National Weather Service (NWS). The ASOS records continuous information on wind

speed and direction, cloud cover, temperature, precipitation, and visibility.42 The ASOS

transmits an official meteorological aerodrome report (known as a METAR) each hour.

The 2153 METAR indicated the following: wind from 290o at 6 knots, visibility

unrestricted at 10 miles, ceiling overcast at 4,400 feet, temperature 10o C, dew point 5o C,

and altimeter 29.63 inches of mercury (Hg). The 2253 METAR indicated the following:

wind from 270o at 5 knots, visibility unrestricted at 10 miles, sky clear below 12,000 feet,

temperature 8o C, dew point 5o C, and altimeter 29.63 inches of Hg.

41 After the first full C check at 8,000 hours, all subsequent full C checks are performed every

4,000 hours.

42 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles.
Factual Information 14 Aircraft Accident Report

The closest upper air sounding43 along the route of flight was from Springfield,

Missouri, which was about 50 miles west-southwest of the upset location and about

90 miles south of the accident site. The 1900 sounding showed that the approximate base

of the clouds was at an altitude of 4,135 feet, the freezing level was at an altitude of

4,699 feet, the top of the clouds was at an altitude of about 7,000 feet, and another cloud

layer was at an altitude of about 18,000 feet. The atmosphere was classified as stable. The

maximum wind was from 345o at 60 knots at an altitude of 29,000 feet. The wind was

from 315o at 48 knots at an altitude of 41,000 feet.

The NWS issued Airman’s Meteorological Information (AIRMET)44 Tango for

turbulence, which was valid from 2045 on October 14 to 0300 on October 15, 2004, along

the route of flight and over the location of the upset. The AIRMET indicated that

occasional light to moderate turbulence could be encountered between 20,000 and

39,000 feet.

1.8 Aids to Navigation

No problems with any navigational aids were reported.

1.9 Communications

The airplane was handled by air traffic controllers at LIT, the Memphis ARTCC,

and the Kansas City ARTCC. No communications problems were reported.

1.10 Airport Information

JEF is located 2 miles northeast of Jefferson City at an elevation of 549 feet. The

airport has two runways, 9/27 and 12/30. The flight crew was attempting to land on

runway 30, which had an ILS available. The airport’s ATC tower was closed at the time of

the accident.

1.10.1 Air Traffic Control

ATC radar data were primarily obtained from the Kansas City ARTCC long range

radar site located in Crocker, Missouri.45 Additional radar data were provided by the LIT

ATC tower, the Memphis ARTCC, and the Airport Surveillance Radar-9 radar site located

in Columbia, Missouri.

43 An upper air sounding shows the wind profile and the expected clear air turbulence, cloud layers, and

icing potential.

44 An AIRMET is an in-flight advisory that notifies en route pilots of the possibility of encountering

hazardous flying conditions that may not have been forecast at the time of a preflight briefing.

45 At this radar site, air route surveillance radar data are obtained once every 12 seconds.
Factual Information 15 Aircraft Accident Report

The Kansas City ARTCC comprises several sectors (altitudes/areas of

responsibility), and the sectors are denoted by numbers. The sector 30 radar controller at

the ARTCC handled the accident flight when it was at an altitude of 24,000 feet and

above, and the sector 53 radar controller at the ARTCC handled the airplane when it was

below an altitude of 24,000 feet. The National Transportation Safety Board conducted

postaccident interviews with these controllers.

The sector 30 radar controller first became aware of the accident flight when he

accepted a handoff from the sector 29 radar controller.46 The flight was at an altitude of

41,000 feet at the time. The sector 30 radar controller stated that he asked the flight crew

to confirm that the type of airplane was actually a CRJ because the flight level seemed

“odd” for that airplane model. The radar controller stated that the flight crew confirmed

that the airplane was a CRJ and that, 1 minute later, the flight crew requested a lower

altitude. The radar controller stated that he was coordinating the descent with the sector 29

controller when he heard one of the pilots saying something similar to “emergency” in a

stressed voice. The sector 30 radar controller stated that he immediately handled the

airplane as if it were experiencing an emergency, notified his supervisor of the situation,

and instructed the sector 29 controller to turn away another airplane from the accident

airplane.

The sector 30 radar controller stated that the flight crew did not provide him with

much information about the in-flight situation, so he assumed that the flight crew did not

want to deal with additional ATC transmissions during this time. The airplane’s data block

had lost altitude information, so the controller began switching between the main and

backup radar systems to monitor altitude and rate of descent. The controller stated that he

did not receive an altitude readout until the airplane reached 33,000 feet.

The sector 30 radar controller stated that the flight crew requested a descent to

13,000 feet. The controller stated that he first coordinated with underlying radar sectors to

permit the airplane to descend below 24,000 feet and that he then issued the clearance to

13,000 feet. The controller stated that he then instructed the flight crew to contact the

sector 53 radar controller. The sector 30 radar controller assisted the sector 53 radar

controller by referring to the JEF approach charts for information about the ILS frequency

and the airport beacon.

The sector 53 radar controller first became aware of the accident flight when she

overheard the sector 30 controller notifying their supervisor of an emergency airplane. She

then began monitoring the airplane from her position. The sector 53 radar controller stated

that, once the pilots were on the sector 53 frequency and reported that the airplane was

descending to 13,000 feet, she advised them of the airports that were available for a

landing. After the flight crew requested a lower altitude for the engine restart, the

controller assigned an altitude of 11,000 feet. Shortly afterward, the airplane descended

through 10,500 feet, and the flight crew notified the controller of a double engine failure.

46 The sector 29 controller was also responsible for the accident flight when it was at an altitude of

24,000 feet and above. 
Factual Information 16 Aircraft Accident Report

The sector 53 radar controller stated that she immediately called Mizzou approach control

to advise that the airplane had lost power and would be descending to land at JEF.

The sector 53 radar controller stated that she directed the flight to JEF and

provided the minimum instrument altitude for the area and the localizer frequency for the

runway 30 ILS approach. The controller stated that the pilots asked her where the airport

beacon was located, and she provided them with a description of the beacon in relation to

the runway. The controller stated that she received no further voice transmissions from the

flight crew and that the last radar contact with the airplane was at an altitude of about

900 feet. The controller stated that, after losing radar contact, she tried to contact the

airplane several times but received no response.

In addition, ATC transcripts showed that, after the loss of radar contact with the

airplane (the final radar return was received about 0.58 nautical mile southeast of the crash

site and at an altitude of 930 feet), the Mizzou approach controllers reported the location

of a probable accident to the police and fire services in Jefferson City. 

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The airplane was equipped with a Fairchild model A100S solid-state CVR,

S/N 02804. The CVR did not sustain any heat or structural damage, and the audio

information was extracted normally and without difficulty.

The CVR recording contained four channels of audio data.47 The first channel

recorded excellent audio quality information from the observer’s seat audio panel.48 The

second channel recorded excellent audio quality information from the copilot’s station.

The third channel recorded good audio quality information from the pilot’s station. The

fourth channel contained fair audio quality information from the cockpit area microphone.

A transcript was prepared of the entire 30-minute 23-second digital recording (see

appendix B).

The first, second, and third channels all contained audio information from the

airplane’s aural warning system, including the synthesized voice of the crew alerting

system. The fourth channel also recorded aural warnings but did so via a cockpit speaker.

47 The Safety Board rates the audio quality of CVR recordings according to a five-category scale:

excellent, good, fair, poor, and unusable. Appendix B describes each of these categories.

48 Federal regulations state that the first channel is to record audio information from the third flight

crewmember station. Because a third flight crewmember was not required for the CRJ-200, the source for

the information recorded by the first channel could be determined by the operator. The first channel did not

record any intercom or radio communications.
Factual Information 17 Aircraft Accident Report

1.11.2 Flight Data Recorder

The accident airplane was equipped with an L3 Communications Fairchild model

F-1000 FDR, S/N 01094. The FDR recorded flight information in a digital format using

solid-state memory as the recording medium.

The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The

FDR was in good condition, and the data were extracted normally. About 51 hours of data

were recorded on the FDR, including about 55 minutes of data from the accident flight.

During the flight, power was lost to the FDR, which resulted in a data dropout of about

3 minutes 56 seconds (2155:20 to 2159:16). Data recorded immediately before the

dropout, from 2155:16 to 2155:19, and immediately after the FDR was back on line, from

2159:16 to 2159:21, had some parameters that appeared to be valid but others that

appeared to be invalid.

The accident airplane’s FDR was not in compliance with the requirements in

14 CFR 121.344, Appendix M. Specifically, the source of the vertical acceleration

parameter was not updated at a rate that met the required recording intervals. Also, the

pitch attitude parameter was recorded at a higher sample rate than the source was updated.

On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the FAA

because of problems with the quality of FDR data recorded by several regional jet

airplanes, including the CRJ. Section 1.18.3.3 provides information about this safety

recommendation.

1.12 Wreckage and Impact Information

The main airplane wreckage was located at an elevation of 740 feet. Several tree

strikes were identified along the airplane’s flightpath before the main wreckage location.

The direction of the tree strikes was on a magnetic heading of about 304o. The first signs

of tree strikes were found on a tree that was located about 474 feet from the main

wreckage location; the top branches of the tree were severed very slightly. The first tree

that showed signs of a major impact was located about 425 feet from the main wreckage

location. The tree’s limbs were severed at a height of 43 feet above ground level, and

small fragments of the airplane wreckage were found near this tree.

About 14 feet of the outboard left wing, including the winglet, was located about

187 feet before the main wreckage location. This wing section showed two large

indentations in the leading edge; two large tree limbs with the same diameter as the

indentations were located within 12 feet of the wing section. The tree that was struck was

located 190 feet before the left wing section.

About 92 feet before the main wreckage location, a large tree was slightly

damaged on one side. A large group of trees about 18 feet to the right of that tree also

showed slight damage. The airplane traveled through the 18-foot gap between the trees.

The left wing impacted the ground at the same location as a small tree that was sheared at

a height of about 12 feet above ground level. A large ground scar measuring about 87 feet
Factual Information 18 Aircraft Accident Report

in length and having a shape similar to the top of the airplane’s nose was located 30 feet

before the main wreckage location. The ground scar contained material from the top of the

forward cabin.

Measurements of tree strikes along the flightpath showed that the airplane was

descending at a pitch attitude of about -2.5o. The airplane struck the first trees in a 40o

left-wing-down attitude. The airplane impacted the ground nose first in a close-to-inverted

attitude. All of the airplane wreckage was accounted for at the accident site. The airplane’s

wreckage extended along a 1,234-foot path, beginning with the initial impact point (the

first major tree strike), continuing through six residential backyards, and ending past a

residential street.

1.12.1 Powerplants

Examination of the engines at the accident site found that neither engine exhibited

classic rotational damage49 or ingestion evidence. The engines were disassembled and

inspected at GE’s manufacturing facility in Lynn, Massachusetts. The engine core rotors

were rotated, and neither core was found seized. Teardown inspections found no

mechanical failures or evidence of seizure in either engine.50 A materials investigation of

the high pressure turbine seal hardware found no abnormal rotational marks. 

1.12.2 Systems

Inspection and testing of the airplane’s pneumatic supply and start systems found

nothing that would have prevented them from providing torque to either engine.

The APU was found in its installed position with light soot on its top surfaces. The

APU was subsequently examined at Honeywell’s facility in Phoenix, Arizona. A

borescope inspection noted no internal physical damage. After the replacement of an

impact-damaged part, the APU operated and exceeded the performance requirements for a

newly overhauled unit.

The LCV was found with light soot and no observable damage. During

postaccident testing, the LCV hesitated initially before opening fully the first time, and,

with each subsequent opening, the LCV opened more freely than the previous time. (The

first test was performed with opening commands that were intentionally applied slower

than normal,51 and the subsequent tests were performed at the conditions under which the

49 Classic rotational damage includes reverse bending of rotating airfoils and circumferential scraping

signatures along fan blade paths.

50 The inspection disclosed thermal damage to the turbine blades in the No. 2 engine that would have

impeded the engine from producing thrust but would not have prevented the core from rotating. (The

inspection found no preimpact damage to the No. 1 engine.)

51 Other possible reasons for the initial hesitation included the impact forces that caused the

surrounding structure (including the APU mount and housing where the LCV was positioned) to buckle and

the dirt and debris that was found inside the APU and the LCV. 
Factual Information 19 Aircraft Accident Report

LCV was designed to operate.) The testing showed that the LCV was capable of allowing

pneumatic power from the APU to enter the 10th stage bleed air valves and then the ATS.

Flight control cable continuity could not be established because of the impact

damage to the forward portion of the airplane, but CVR and FDR evidence indicated that

the flight controls operated normally during the flight.

1.13 Medical and Pathological Information

Tissue specimens from the captain and the first officer tested negative for ethanol

and a wide range of drugs, including major drugs of abuse.

1.14 Fire

The airplane wreckage showed no evidence of an in-flight fire. Major portions of

the wreckage showed postcrash fire damage. 

1.15 Survival Aspects

According to the Boone/Calloway County Medical Examiner’s office, the cause of

death for the captain and the first officer was blunt force trauma.

1.16 Tests and Research

1.16.1 Aircraft Performance Study

The Safety Board performed an aircraft performance study for this accident. FDR,

CVR, weather, and ATC radar and communications data were used to develop the time

history of the accident airplane’s motion. These data were time correlated. The study

results for the airplane’s performance during the climb to 41,000 feet, aerodynamic stall

and upset event, and descent and glide are presented in sections 1.16.1.1 through 1.16.1.3,

respectively.

1.16.1.1 Climb to 41,000 Feet

FDR data showed that the airplane’s initial takeoff rotation occurred about 2121:45

and that, 3immediately after liftoff, the pitch angle of the airplane was about 6o. Four

seconds later, when the airplane was at an altitude of about 450 feet, the first of three

pitch-up maneuvers during the ascent occurred when the flight crew moved the control
Factual Information 20 Aircraft Accident Report

column to 8o ANU,52 causing the airplane’s pitch angle to increase to 22o and resulting in a

vertical load of 1.8 Gs. Immediately afterward, the FDR recorded stickshaker and

stickpusher activations, a full AND control column deflection, a decrease in pitch angle,

and a drop in vertical load to 0.6 G. After the stickpusher deactivation, the airplane

continued to climb at a pitch angle between 10o and 14o ANU.

About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet

and with the autopilot in vertical speed mode, the second pitch-up maneuver during the

ascent began. FDR data showed that the control column moved to 3.8o ANU, causing the

airplane’s pitch angle to increase to 17o and resulting in a vertical load of 2.3 Gs. About

2127:26, the flight crew moved the control column 2.5o AND, decreasing the pitch angle

to about 6o and the vertical load to 0.3 G about 5 seconds later. Afterward, the flight crew

moved the control column 3.4o ANU. Between about 2128:40 and about 2128:43, the

flight crew made a left rudder input of 4.2o, a right rudder input of 6.0o, and a left rudder

input of 0.4o,53 resulting in lateral loads of -0.16 G, 0.34 G, and -0.18 G, respectively.

About 17 seconds later, the flight crew made a right rudder input of 7.7o.

About 2132:40, when the airplane was in level flight at an altitude of 24,600 feet

with the autopilot engaged and a vertical speed of 600 fpm, the third pitch-up maneuver

during the ascent began. The flight crew moved the control column 4o ANU, which

increased the airplane’s pitch angle to more than 10o, resulted in a vertical load of 1.87 Gs,

and increased the airplane’s vertical speed to 5,000 fpm for several seconds. About

2132:46, the flight crew disconnected the autopilot and moved the control column to 3.8o

ANU, which increased the airplane’s pitch angle to about 15o. About 2133:10, the flight

crew reengaged the autopilot with a vertical speed of 3,000 fpm, which was reduced to

1,400 fpm by 2133:30 and 1,000 fpm by 2134:00.

The autopilot remained engaged in vertical speed mode between the altitudes of

34,000 and 41,000 feet. Between 34,000 and 35,000 feet, the airplane’s vertical speed was

1,000 fpm, the calculated Mach number was about 0.60, and the engines maintained N1

indications of 95.5 percent. As the airplane climbed through 35,000 feet, its vertical speed

was reduced to 0. About 2141:00, the airplane leveled off at an altitude of 36,500 feet.

Within the next minute, the calculated Mach number increased to 0.64. When the climb

resumed, the airplane’s vertical speed was 500 fpm, and the engines’ N1 indications were

52 According to FDR documentation, the control column has a range from -11.9o (forward) to 13.8o

(aft).

53 On November 10, 2004, about 1 month after this accident, the Safety Board issued Safety

Recommendation A-04-59 to the FAA as a result of its findings from the November 2001 American Airlines

flight 587 accident in Belle Harbor, New York. Safety Recommendation A-04-59 asked the FAA to “develop

and disseminate guidance to transport-category pilots that emphasizes that multiple full deflection,

alternating flight control inputs should not be necessary to control a transport-category airplane and that

such inputs might be indicative of an adverse aircraft-pilot coupling event and thus should be avoided.” On

January 9, 2006, the FAA stated that it issued Safety Alerts for Operators 05002, “Multiple Full Deflection,

Alternating Flight Control Inputs,” which urged directors of safety, directors of operations, and pilots of

transport-category airplanes to be familiar with the content of the Airplane Upset Recovery Training Aid and

to pay particular attention to the cautions against alternating flight control inputs and aircraft-pilot

couplings. As a result, the Board classified Safety Recommendation A-04-59 “Closed—Acceptable Action”

on June 9, 2006.
Factual Information 21 Aircraft Accident Report

about 95.7 percent. About 2144:00, the airplane was climbing through 37,400 feet. The

airplane continued to climb at a vertical speed of 500 fpm during the next 7 minutes until

reaching an altitude of 41,000 feet. During this time, the calculated Mach number

decreased to 0.57, the pitch angle increased from 3o to 6o, and the engines’ N1 indications

decreased to 94.7 percent.

Once the airplane reached the selected altitude of 41,000 feet, the autopilot

reduced the airplane’s vertical speed to 0, and the airplane leveled off. During the next

3 1/2 minutes, the calculated Mach number decreased to 0.53, the pitch angle and AOA

increased to about 7o, and the engines’ N1 indications decreased to 94.2 percent. 

1.16.1.2 Aerodynamic Stall and Upset Event

About 2154:34, the airplane’s airspeed was 150 knots.54 About 2 seconds later, the

stickshaker activated, causing the autopilot to disconnect; at that point, the airplane’s

AOA had increased to about 7.5o. Within the next second, the control column moved to

about 0o. About 3 1/2 seconds after autopilot disconnect, the flight crew moved the control

column 3.5o ANU. The flight crew then moved the control column back toward neutral

until it reached about 1.1o ANU. During the next few seconds, the flight crew moved the

control column to 4o ANU, which caused the pitch angle to increase to about 8.5o.

By 2154:45, the AOA had increased to the point that both the stickshaker and the

stickpusher activated. The control column moved forward rapidly in response to the

activation of the stickpusher, decreasing the pitch angle to -3.5o, the AOA to 0o, and the

vertical load to 0 G. The stickpusher then deactivated, and the flight crew moved the

control column past neutral to about 5o ANU, which caused the pitch angle to increase to

8o and the AOA to increase to 11o.

During the next 8 seconds, while the airspeed was at 160 knots, the stickshaker and

stickpusher activated twice. The stickpusher, during both activations, moved the control

column forward in response, and, once the AOA decreased, the control column was then

moved past neutral to an ANU position.55 After the stickpusher activations, the control

column was moved to about 5.2o and about 5.9o ANU. About 2154:51, the No. 2 engine’s

N1 indication decreased from 94 to 84 percent, and the pitch angle decreased to -19.5o

about 2154:55. One second later, after the stickpusher had activated and released for the

third time, the flight crew moved the control column to 6.8o ANU (which was the largest

ANU movement during the pitch oscillations), and the vertical load decreased to -0.8 G.

By 2154:57, the stickshaker had activated for the fifth time, and the stickpusher

had activated a fourth time, pushing the control column to full nose down (where it

remained for the next 4 1/2 seconds). Despite the activation of the stickpusher, the airplane

entered an aerodynamic stall as the motion of the airplane continued to increase the AOA

54 All airspeeds in sections 1.16.1.2 through 1.16.1.4 are knots calibrated airspeed.

55 Public hearing testimony by Bombardier Aerospace indicated that, without pilot input, the control

column position would return to near neutral after stickpusher cancellation resulting from the AOA

decreasing below the deactivation angle.
Factual Information 22 Aircraft Accident Report

to its maximum ANU measurable value of 27o. Both engines’ fuel flow indications

decreased to near zero by 2154:58, and the airplane’s pitch angle reached a maximum

ANU value of 29o at 2154:59. During this time, the airplane’s recorded airspeed was

74 knots, and its recorded altitude increased from 41,000 to 42,000.56

As the pitch angle began to decrease, a left rolling motion began, which eventually

reached 82o left wing down. The pitch angle reached a maximum AND value of 32o by

about 2155:06. During the next 14 seconds, the flight crew made several control column,

control wheel, and rudder inputs to recover the airplane from the upset. During the

recovery, the stickpusher activated three more times, both engines’ fuel flow indications

remained near zero, and both engines’ N1 settings decreased to about 28 percent. The FDR

stopped recording data about 2155:20. The last reliable N2 speed recorded by the FDR

before it stopped operating was 46 percent for the No. 1 engine and 51 percent for the

No. 2 engine.

1.16.1.3 Descent and Glide Performance

The FDR resumed recording data about 2159:16 when the airplane was at an

altitude of 29,200 feet. During the 4-minute gap between recorded FDR data, the engines

had stopped operating. 

During the initial part of the descent, the airspeed increased, the pitch angle varied

between 1o and -4o, and the descent rate reached a maximum of 5,000 fpm. A maximum

airspeed of 236 knots was reached about 2202:12 when the airplane descended through an

altitude of 20,500 feet. At an altitude of about 20,300 feet, the airplane leveled off for

about 20 seconds and then began to descend again at a rate between 1,800 and 2,000 fpm

and at an airspeed of about 200 knots.

About 2204:46, the airplane descended through an altitude of 15,000 feet, and the

airspeed began to decrease as the pitch angle increased. During the next several minutes,

the airspeed remained about 170 knots, and the descent rate was between 1,000 and

2,000 fpm.

About 2209:06, when the airplane was at an altitude of 10,000 feet, the flight crew

notified the air traffic controller that the airplane needed to land at the closest airport. At

that point, the airspeed varied between 180 and 206 knots, and the descent rate varied

between 300 and 3,200 fpm. Also, several short control column movements occurred,

causing the pitch angle to vary from 3o AND to 2o ANU and the vertical load to increase to

1.3 Gs.

The Safety Board obtained glide performance calculations for the accident

airplane from Bombardier Aerospace. The reference airspeed for the glide performance

calculations was 170 knots, which was the best glide airspeed for the accident airplane’s

56 The recorded airspeed and altitude values may not be accurate because, according to Bombardier, the

static source error corrections that are programmed into the air data computers are not calibrated for the high

AOA (greater than 27o) experienced at this point in the flight.
Factual Information 23 Aircraft Accident Report

estimated gross weight.57 Data from the accident airplane’s FDR showed that the flight

spoilers deployed to 5.6o from 28,000 feet until the end of the recording. The glide

performance calculations included the drag from the flight spoilers and the air-driven

generator (ADG).58 According to the glide performance calculations, at an altitude of

30,000 feet, six airports (including JEF) were within the airplane’s best glide range. JEF

was located about 74 miles north-northeast of the upset location.59 The five other airports

were the following:60

• Waynesville Regional Airport (TBN), Fort Leonard Wood, Missouri, which

was located about 23 miles north-northeast of the upset location;

• Floyd W. Jones Lebanon Airport (LBO), Lebanon, Missouri, which was

located about 25 miles northwest of the upset location;

• Lee C. Fine Memorial Airport (AIZ), Kaiser Lake Ozark, Missouri, which was

located about 44 miles north of the upset location;

• Springfield-Branson Regional Airport (SGF), Springfield, Missouri, which

was located about 50 miles west-southwest of the upset location; and

• Rolla National Airport (VIH), Rolla/Vichy, Missouri, which was located about

53 miles north-northeast of the upset location.

At an altitude of 20,000 feet, five airports (including JEF) were within the

airplane’s best glide range.61 At an altitude of 10,000 feet, only one airport (AIZ) was

within the airplane’s best glide range; JEF was just outside the best glide range at that

altitude. Figure 2 shows the glide distances to the six airports for the accident airplane.

57 A best glide airspeed provides the airplane with the most distance forward for a given loss of altitude.

58 The ADG deploys automatically and provides backup power when the engines no longer power the

primary electrical generators.

59 As stated in section 1.16.1.2, the upset event is characterized by the 82o left-wing-down rolling

motion and the -32o pitch angle.

60 These five airports had runways in excess of 5,000 feet. 

61 SGF was no longer within the airplane’s best glide range.
Factual Information 24 Aircraft Accident Report

Figure 2. Glide Distances for the Accident Airplane

1.16.2 Cockpit Voice Recorder Studies

The Safety Board conducted a CVR study to determine flight crew seating

positions. The study correlated CVR and ATC audio information with FDR microphone
Factual Information 25 Aircraft Accident Report

key data. The audio communications system on the accident airplane sent pilot station

position (but not radio source) information to the FDR for its microphone key parameter.

This information and voice identification information from the CVR allowed the Board to

determine which pilot was transmitting on the radio from which crew seat position.

The correlation determined that, during takeoff, the captain made radio

transmissions from the left seat (the first officer was recorded from the right seat). The

correlation also determined that, about 6 minutes into the ascent, through the upset event,

and until after several engine restart attempts, the captain made radio transmissions from

the right seat (the first officer was recorded from the left seat). Finally, the correlation

determined that, after the flight crew requested to land at JEF until the last transmission to

the controller, the first officer made radio transmissions from the right seat (the captain

was not recorded during this time period). The flight crew seating positions are

summarized in table 2.

Table 2. Flight Crew Seating Positions 

Note: In the CRJ-200, the captain is normally seated on the left, and the first officer is normally seated on the right.

a

 Although the CVR and FDR were functioning during this time, they did not record any cockpit audio or microphone key

data from the left audio panel after 2205:53. The lack of CVR and FDR information from an audio panel indicates that its

dedicated controller board has lost power (even though the rest of the audio communication system remains powered) or

that the panel selector switch has been set to “EMER” (emergency). 

The CVR study also documented events related to engine checklist use and flight

crew oxygen mask use; some of these events are shown in table 3. Oxygen use by the

flight crew is further discussed in section 1.18.1.

Table 3. Engine Checklist and Oxygen Mask Use Events 

Time Left audio panel Right audio panel

2121:00 to 2124:14 Captain First officer

2126:43 to 2206:59 First officer Captain

2209:06 to 2214:39 No informationa First officer

Time Event

2156:42 Start of double engine failure checklist.

2157:04 Crew alerting system warning of cabin pressure.

2158:21 Comment to use oxygen mask.

2158:41 Sound similar to oxygen flow starting in oxygen mask.

2201:36 Double engine failure checklist—windmill restart procedure.
Factual Information 26 Aircraft Accident Report

In addition, the Safety Board conducted a CVR sound spectrum study to determine

whether any noise was recorded by the CVR during the four APU-assisted engine restart

attempts that would indicate ATS operation. Each CVR channel was examined across the

full frequency range for signal changes, appearances, and disappearances, but nothing

associated with any of the engine restart attempts was found.

1.16.3 Engine Tests

The accident FDR showed decreasing engine core-driven accessory parameter

indications62 after the double engine failure. About 15 minutes afterward, engine oil

temperature cooling rates leveled off momentarily, and slight engine hydraulic pump

pressure indications were noted. This signal activity was inconsistent with the engines’

zero N2 indications.

Engine tests were performed at Pinnacle Airlines’ maintenance facility in

Memphis and the Bombardier Aerospace Flight Test Center in Wichita, Kansas. A test to

evaluate the engine oil temperature anomalies demonstrated that, after a period of normal

engine operation, changes in engine oil temperature that were consistent with the accident

Time Event

2202:14 Double engine failure checklist—APU bleed air restart procedure.

2204:06 Comment to use oxygen masks.

2204:09 Sound similar to oxygen flow starting in oxygen mask.

2204:13 Comment regarding cabin altitude of 15,400 feet and need to be on oxygen.

2206:23 Sound similar to oxygen mask removal.

2207:04 Double engine failure checklist—relight attempt of No. 1 engine using APU bleed air

procedure.

2207:20 Sound similar to oxygen flow in oxygen masks.

2207:41 Double engine failure checklist—relight attempt of No. 2 engine using APU bleed air

procedure.

2208:11 Sound similar to oxygen mask removal.

2208:15 Sound similar to oxygen mask removal.

2209:32 Double engine failure checklist—relight attempt of engine using APU bleed air

procedure.

2211:42 Double engine failure checklist—relight attempt of engine using APU bleed air

procedure.

62 These parameters included fuel flow, oil pressure, oil temperature, and engine hydraulic pressure.
Factual Information 27 Aircraft Accident Report

FDR anomalies would result when APU-assisted restarts were attempted with the engine

core rotor locked. The test also demonstrated that the FDR could record small hydraulic

pressure signals while the engine core was prevented from rotating. 

A test to evaluate the slight increases (25 to 30 pounds per square inch gauge

[psig]) in core-driven hydraulic pump pressure indications63 showed that hydraulic pump

pressure would begin to indicate on the FDR with about 35 rpm of core rotation. Another

test showed that N2 signals would begin to indicate on the FDR and in the cockpit with

about 70 rpm of core rotation. 

A test demonstrated that the ATS was capable of rotating an engine core from zero

N2 with 10th stage duct pressures as low as 6 psig (as detected by the EICAS) and that 25-

to 30-psig hydraulic pump pressures could be recorded on the FDR as long as engine core

rotation was sustained at a speed of about 35 rpm. This test also showed that, by the time

that engine core rotation had reached a speed of 75 rpm, hydraulic pump pressures had

increased quickly to 1,500 psig. 

1.16.4 Load Control Valve Simulation Study

As stated in section 1.6.2, the LCV allows pneumatic power from the APU to

become available to each engine during the start sequence. In the pneumatic system, the

LCV and its associated ducts are the components that support both engines. Thus, a

malfunction of the LCV could result in a failure to achieve indications of engine rotation

on either engine. To determine the minimum amount of LCV opening needed to result in

initial engine rotation, as indicated by FDR data, and whether a minimum LCV opening

value during the four APU-assisted engine restart attempts could be determined, the

Safety Board conducted a computer-based simulation study that was validated against

existing flight test data provided by Bombardier. 

For the simulation study, the Safety Board used the results of previous ground and

flight tests that provided data about the minimum torque output required from the ATS to

initiate detectable core rotation from 0 rpm. As indicated in section 1.16.3, the tests

showed that about 35 rpm of core rotation was needed to detect an indication of hydraulic

pump pressures64 on the FDR and that about 70 rpm of core rotation was needed to detect

an indication of N2 on the FDR and in the cockpit. The tests also showed, and data from

Honeywell indicated, that about 6 psig at the ATS inlet with 27.5 pounds per minute of

corrected airflow65 could result in detectable core rotation.

FDR data for the accident flight showed that the LCV was open throughout each

APU-assisted restart attempt. Although the LCV normally opens fully (85o) during an

63 Normal hydraulic system operating pressure is 3,000 psig, and signals of 25 to 30 psig are outside of

the system transducer’s validated measurement range.

64 The hydraulic pump is driven by engine core rotation.

65 Because airflow changes based on altitude and temperature, corrected airflow provides a common

reference point that recalculates airflow in terms of a standard day at sea level (that is, 59o F and

29.92 inches of Hg).
Factual Information 28 Aircraft Accident Report

APU-assisted engine restart, the FDR parameter for the LCV position shows that the valve

is open once it reaches a position that is greater than 4.8o from its normally closed

position.

The simulation showed that, for a normally functioning engine, the LCV needed to

be open by about 8o to produce enough torque at the ATS output to initiate detectable core

rotation from a stopped condition.66 However, at this 8o setting, the LCV-supplied air

volume that reached the ATS start valve diminished once the start valve opened, and then

the LCV and other downstream pneumatic system valves closed because the pressure

provided was insufficient to keep them opened. This result was not consistent with the

FDR data from the accident flight, which showed that the 10th stage bleed air valves

remained open from 25 seconds (in accordance with guidance on the double engine failure

checklist, as shown in appendix C) to about 105 seconds during all four engine restart

attempts and that the LCV remained open during each restart attempt. Also, the CVR did

not include any discussion to indicate that the 10th stage or start valve functions deviated

from what the pilots would normally observe during an APU-assisted start on the ground. 

The simulation also showed that, with an LCV opening of at least 18o, all of the

pneumatic supply valves would be kept open, as was seen on the accident FDR. An LCV

opening of at least 18o was also sufficient to initiate and maintain detectable rotation of the

core rotor from 0 rpm.67 

1.17 Organizational and Management Information

Pinnacle Airlines, Inc., is a wholly owned subsidiary of Northwest Airlines, Inc.,

and is based in Memphis. The airline was established in 1985 as Express Airlines I.

Between 1985 and 2000, Express Airlines I operated turboprop airplanes only. In 2001,

Express Airlines I began integrating CRJ turbojet airplanes into its fleet and, in 2002,

changed its name to Pinnacle Airlines. By 2003, Pinnacle Airlines had phased out

turboprop airplanes from its operations and operated CRJ turbojet airplanes only. At the

time of the accident, the company employed about 900 pilots and had a fleet of 110 CRJs

that provided service to destinations in the United States and Canada.

1.17.1 Ground School and Simulator Training

1.17.1.1 Upset Training

Pinnacle Airlines provided upset training to newly hired pilots during ground

school and simulator training. According to a Pinnacle Airlines ground school instructor,

pilots received 6 hours of upset training during the general operational subjects module.

66 This initiation was based on ground start conditions that were corrected for altitude. However, the

pressure, altitude, and temperature did not account for airspeed, which would have reduced the required

onboard pneumatic pressure and flow requirements. 

67 The rotation would not likely be fast enough for an engine’s starting sequence to be completed.
Factual Information 29 Aircraft Accident Report

The subjects covered during this training included swept-wing design characteristics and

high altitude aerodynamics.68 Also, pilots received a copy of the Pinnacle Airlines Jet

Upset Student Guide.

A Pinnacle Airlines simulator instructor stated that pilots received about

20 minutes of upset training in the simulator. The training consisted of Mach tuck and

Mach buffet demonstrations69 and unusual attitude recoveries. Also, the simulator

instructor discussed operations at high altitudes where low indicated airspeeds yielded

high true airspeeds (and a high Mach number) at high AOAs, but the training did not

include any maneuvers or stalls at high altitudes.

After the accident, Pinnacle Airlines revised the upset training sections of its

ground school instructor guide, ground school curriculum, and the Jet Upset Student

Guide to include stalls and airplane maneuvers at an altitude of 37,000 feet. Also, the

airline enhanced upset training in the simulator by having pilots perform maneuvers at

high altitudes.

1.17.1.2 High Altitude Climbs

According to Pinnacle Airlines ground school instructors, high altitude climbs,

recommended climb profiles, and altitude and climb capability charts70 were discussed

with newly hired pilots during the general operational subjects module (specifically, the

upset training and performance sections of the module). Simulator instructors stated that

they discussed high altitude climbs and recommended climb profiles with newly hired

pilots during pre- and postsimulator briefings but did not demonstrate or have the pilots

practice high altitude climb techniques. 

The Pinnacle Airlines Flight Operational Quality Assurance (FOQA) program71

manager stated that the CRJ service ceiling of 41,000 feet was discussed during ground

school. Company check airmen, simulator instructors, and pilots stated that operations at

41,000 feet were neither discussed nor demonstrated during simulator training. A

simulator instructor stated that 41,000 feet was not an altitude at which pilots wanted to

operate very often.

68 High altitude is 25,000 feet and above.

69 A Mach tuck is the result of an aft shift in the center of lift, causing a nose-down pitching moment. A

Mach buffet is the airflow separation behind a shock wave pressure barrier that results when the airflow over

flight surfaces exceeds the speed of sound.

70 See section 1.17.2.1 for more information about Pinnacle Airlines’ altitude and climb capability

charts.

71 A traditional FOQA program is an FAA-approved, voluntary program for the routine collection and

analysis of FDR data gathered during aircraft operations. At the time of the accident, Pinnacle Airlines did

not have a traditional FOQA program in place; instead, the program was designed to manage the check

airmen through flight monitoring. At the time of the June 2005 public hearing for this accident (see

appendix A), Pinnacle Airlines was working toward the deployment of a traditional FOQA program. In

October 2006, the company reported that it was operating an FAA-approved FOQA program and was

collecting an average of 2,000 hours of data each month. 
Factual Information 30 Aircraft Accident Report

In November 2004, Pinnacle Airlines revised the performance section of its

ground school instructor guide to include more specific high altitude climb information

and procedures, including a minimum climb profile speed above 10,000 feet of 250 knots

or 0.7 Mach, whichever was lower.72 Also, the company added a high altitude climb

scenario to its simulator training. 

1.17.1.3 Double Engine Failure

According to postaccident interviews with the CRJ program manager, check

airmen, simulator instructors, and pilots at Pinnacle Airlines, the double engine failure

checklist items were discussed during ground school and one of the simulator briefings.

They stated that the simulator sessions did not include a scenario in which a double engine

failure had occurred or a scenario in which the ADG had been deployed. Also, they stated

that, during ground school, pilots were required to pass written and oral examinations on

all memory checklist items, including those for the double engine failure procedure (see

section 1.17.2.2).

In December 2004, Pinnacle Airlines issued a revised simulator instructor guide to

include single and double engine failures at 35,000 feet during new hire and captain

upgrade simulator training. Pilots are now required to use the ATS-assisted restart

procedures for a single engine failure and windmill restart procedures for a double engine

failure. These exercises familiarize the pilots with emergency power-only procedures and

the effects of ADG deployment. The revised simulator instructor guide also includes an

exercise during which the pilots start the APU as the airplane descends through

30,000 feet.

1.17.1.4 Stall Recognition and Recovery Training

Pinnacle Airlines’ stall recognition and recovery simulator training was conducted

at an altitude of 10,000 feet and with various airplane configurations. For all of the

approach-to-stall profiles, the pilot was expected to initiate actions to recover from an

impending stall when the first indication of a stall (which was usually the activation of the

stickshaker) occurred.73 One purpose of the training was to ensure that a pilot could

prevent a full stall from occurring. Another purpose of the training was to demonstrate that

a pilot had mastered the airplane throughout its speed range and was able to initiate a

standard recovery using the appropriate flight control inputs and callouts. The training did

not include high altitude stalls, full stalls, or recoveries from full stalls.

The Pinnacle Airlines CRJ program manager stated that the company’s

approach-to-stall profiles did not normally progress to stickpusher activation, which he

thought was consistent with industry stall training. He stated that a pilot might experience

72 This information was also incorporated into Pinnacle Airlines’ CRJ FCOM Operating Limitations

section, as indicated in section 1.17.2.1.

73 The Pinnacle Airlines CRJ FCOM, volume 1, Flight Instruments—Air Data System, dated

January 2003, showed that the low speed cue on the airspeed indicator was another indication to the flight

crew of an impending stall.
Factual Information 31 Aircraft Accident Report

stickpusher activation during simulator training if the pilot overcorrected in response to

the stickshaker. According to the program manager, if this situation were to occur,

Pinnacle Airlines instructed the pilot to work with the stickpusher upon activation to

decrease the AOA and gradually return to the starting altitude for the maneuver. Also, the

program manager stated that pilots were required to test the stickpusher before the first

flight of each day as part of the preflight check of the SPS.

In December 2004, Pinnacle Airlines issued a revised simulator instructor guide to

include, for new hire, captain upgrade, and recurrent simulator training, a high altitude

stall demonstration with the autopilot engaged74 and a high altitude stall buffet margin

demonstration. 

1.17.1.5 Crew Resource Management Training

At the time of the accident, Pinnacle Airlines provided 8 hours of CRM training to

pilots during initial training. The course was presented in lecture format and included

PowerPoint slides, scenario-based questions, handouts, and videotapes. The topics

covered during the course were resource management, human factors, communication,

workload management, team building, and technical proficiency. Accident events and

scenarios were also discussed. During recurrent and upgrade training, pilots received a

2-hour version of the course.

Pinnacle Airlines managers, instructors, and pilots stated that CRM concepts were

reinforced and evaluated during simulator training. They stated that crew coordination and

assertiveness were stressed and that instructors discussed crew performance indicators

during debriefings. 

The director of flight operations at Pinnacle Airlines stated that the key measures

of CRM effectiveness were crew coordination, workload management, communications,

and situational awareness. This director also stated that he had seen pilots using good

CRM skills during line operations. The Pinnacle Airlines FOQA manager and a first

officer with the company stated that CRM training provided first officers with the tools

they needed to challenge captains if necessary.

After the accident, Pinnacle Airlines restructured CRM training to provide

additional focus on decision-making and the need to adhere to standard operating

procedures. 

1.17.1.6 Leadership Training

At the time of the accident, Pinnacle Airlines provided a 2-hour leadership training

module during the 8-day captain upgrade training course. Topics covered during the

training were leadership authority, responsibility, and leadership styles.

74 For the training that was in effect at the time of the accident, the autopilot was used only for the

approach to stall in the landing configuration.
Factual Information 32 Aircraft Accident Report

Pinnacle Airlines had a target of 10 percent for its captain upgrade first-time

failure rate. In July 2004, when the rate was 22 percent, FAA and company personnel met

to discuss how to reduce the failure rate. Pinnacle Airlines personnel stated that data

showed that the most cited reasons for upgrade failure were leadership and judgment. The

FAA principal operations inspector (POI) stated that this finding showed that the failures

were primarily because of deficiencies in “captain thinking skills” rather than “stick and

rudder skills.” As a result, Pinnacle Airlines management decided to place more emphasis

on leadership during upgrade training75 and increase the minimum number of hours

required for upgrade operational experience76 from 10 to 25.

A Pinnacle Airlines simulator instructor worked with the company’s CRJ lead

instructor to develop a new 8-hour leadership course. The course includes modules on

leadership, authority, and responsibility; briefing and debriefing scenarios;

decision-making processes, including those during an emergency; dry run line-oriented

flight training scenarios; and risk management and resource utilization. The FAA

observed the leadership course in November 2004 as part of the approval process;

afterward, Pinnacle Airlines added the course to upgrade training. In October 2006, the

company reported that about 92 percent of the pilots upgrading to captain passed the

training the first time and that the overall captain upgrade training pass rate was

95 percent.

1.17.2 Flight Manuals

1.17.2.1 High Altitude Climbs

At the time of the accident, the Pinnacle Airlines CRJ FCOM, volume 2,

Maneuvers, page 7, dated June 2004, listed the following three climb profiles: high speed,

320 knots/0.77 Mach; normal speed, 290 knots/0.74 Mach; and long range,

250 knots/0.70 Mach. Pinnacle Airlines indicated that, to maintain an airspeed at or above

250 knots/0.70 Mach, the airplane’s vertical speed during the climb should be at least

300 fpm. Also, the Pinnacle Airlines CRJ FCOM, volume 2, Operating Limitations,

page 4, dated April 2003, stated that the maximum operating altitude for CRJs was

41,000 feet.

75 During postaccident interviews, Pinnacle Airlines’ FOQA manager stated that a weakness in captains

was their leadership skills, and Pinnacle Airlines’ director of flight operations stated that management

training would help captains with their decision-making.

76 Upgrade operational experience, which occurs after a new captain has completed upgrade training, is

when the new captain conducts flight operations in the presence of a check airman.
Factual Information 33 Aircraft Accident Report

The Pinnacle Airlines CRJ FCOM, volume 2, Performance, pages 50 through 52,

dated June 2002, presented altitude and climb capability charts. Pilots were required to

consult these charts anytime a flight was operating above 36,000 feet because of a flight

management system (FMS) limitation above that altitude.77 A climb capability chart

showed the 300-fpm climb ceiling for an airspeed of 250 knots/0.70 Mach and the

maximum cruise thrust limit altitude for cruise speeds of 0.74, 0.77, and 0.80 Mach and

long range cruise. This information was provided for airplane weights between 34,000 and

52,000 pounds and outside air temperatures from the International Standard Atmosphere

(ISA) temperature to ISA + 10o C.78

After the accident, Pinnacle Airlines added the following restriction to its CRJ

FCOM volume 2 Operating Limitations section: “minimum climb profile speed above

10,000 feet MSL will be 250/.70M whichever was lower.” Also, Pinnacle Airlines added

the altitude and climb capability charts to its Quick Reference Handbook (which is

required to be on all company airplanes) to make it easier for pilots to reference the

information. In addition, on October 22, 2004, Pinnacle Airlines issued Alert

Bulletin 04-54, which stated that all company flights were not to exceed an altitude of

37,000 feet and that flight crews were not to accept or request ATC clearance above this

altitude. Finally, the Pinnacle Airlines Ground School Instructor’s Guide, Performance

section, page 35, dated November 2004, stated the following: “when a 300 FPM rate of

climb cannot be achieved at the minimum climb speed, the aircraft will be leveled off and

a new altitude coordinated with ATC.”

1.17.2.2 Double Engine Failure

The Pinnacle CRJ FCOM, volume 2, Emergency Procedures, pages 8 through 13,

dated July 2003, detailed the procedure for an in-flight double engine failure.79 For this

procedure, the flying pilot is responsible for calling for the double engine failure checklist

memory items, and the nonflying pilot is responsible for performing the memory items

and reading and performing the remaining items on the checklist.

77 FCOM volume 2, Operating Limitations, pages 30 and 31, dated June 2004, stated that “the FMS

calculated thrust setting must not be used if the pressure altitude is greater than 36,000 feet.” The

Bombardier chief pilot stated that the reason for the FMS limitation above 36,000 feet was because of the

inaccurate calculations above that altitude. Further, according to Bombardier, at altitudes above 36,000 feet,

the conversion from static air temperature to the International Standard Atmosphere (ISA) deviation is

incorrect within the FMS, resulting in an error in the N1 indication at those altitudes. (A detailed explanation

of ISA appears in the next footnote.) Bombardier’s Flight Planning and Cruise Control Manual and Quick

Reference Handbook contain charts that show the proper N1 indication for altitudes between 36,000 and

41,000 feet. 

78 The International Civil Aviation Organization defines ISA as a sea-level pressure of 1,013.2 millibars

at a temperature of 15o C, with temperature decreasing at a standard rate of 2o C per 1,000 feet until reaching

the tropopause (the boundary between the troposphere—the lowest region of the earth’s atmosphere—and

the stratosphere—the middle region of the earth’s atmosphere). In the standard atmosphere, the tropopause

is at 36,000 feet. On the night of the accident, the tropopause was at 27,600 feet, and the temperature at

41,000 feet, -47.1o C, was 9.4o C more than the ISA temperature for that altitude.

79 This information also appeared in the Quick Reference Handbook.
Factual Information 34 Aircraft Accident Report

The double engine failure checklist required pilots to establish and maintain an

airspeed of 240 knots (a memory item) until they were ready to restart the engines. The

double engine failure checklist also required pilots to use the windmill restart procedure if

the airplane were at an altitude that was at or below 21,000 feet and above 13,000 feet.

Requirements of the procedure included an airspeed of at least 300 knots to achieve an N2

indication of 12 percent. The double engine failure checklist stated, “an altitude loss of

approximately 5,000 feet can be expected when accelerating from 240 to 300 KIAS [knots

indicated airspeed].” 

The double engine failure checklist also required pilots to use the APU bleed air

restart procedure if the airplane were at an altitude of 13,000 feet or below. This procedure

required pilots to maintain an airspeed of between 170 and 190 knots until they were ready

to initiate the APU-assisted engine restart. The procedure also required pilots to attempt to

start one engine at a time and that, if either engine were restarted, an N2 indication of

28 percent was required before the thrust lever could be moved to idle.

The double engine failure checklist also stated that, if neither engine were

restarted, the flight crew should “consider a forced landing or a ditching.”

In May 2005, Pinnacle Airlines issued changes to its double engine failure

checklist. Specifically, the company rewrote the windmill relight procedure to make it

easier for pilots to follow. Also, the company incorporated other changes to the checklist

based on revisions made by Bombardier earlier that month to clarify the information

within the checklist. For example, the double engine failure checklist that was in effect at

the time of the accident indicated that 240 knots was the “target” airspeed to be maintained

until the flight crew was ready to restart the engines, but the revised checklist indicated

that 240 knots was the “minimum” airspeed to be maintained. Also, the revised checklist

included the following caution:

Failure to maintain positive N2 may preclude a successful relight. If required,

increase airspeed to maintain positive N2 indication.

In addition, the windmill relight procedure included the following revised note and

added the following caution, respectively:

An altitude loss of approximately 5,000 feet can be expected when accelerating

from 240 to 300 KIAS and may require pitch attitudes of 10 degrees nose

down.[80]

300 KIAS or greater is required to achieve sufficient N2 for start. Airspeed must

be maintained until at least one engine relights (stable idle) or start attempts

abandoned. 

80 To this note, Pinnacle Airlines added, “if possible, crews should start accelerating to achieve

300 KIAS upon reaching 21,000 feet.”
Factual Information 35 Aircraft Accident Report

Appendix C shows Pinnacle Airlines’ double engine failure checklist at the time of

the accident, and appendix D shows the airline’s revised double engine failure checklist.

1.17.2.3 Stall Protection System

The Pinnacle Airlines CRJ FCOM, volume 1, Flight Controls, pages 10-20 and

10-21, dated January 2003, stated the following about the SPS:81

As a high AOA is approached, continuous ignition is activated. If the AOA

continues to increase, the stick shakers are activated and the autopilot is

disengaged. If the AOA still continues to increase, the stick pusher mechanism is

activated, STALL lights on the glareshield panel flash red, and the warbler

sounds.

1.17.2.4 Flight Operations

Pinnacle Airlines’ Flight Operations Manual, Normal Procedures, section 4.30.1,

“Safe Aircraft Operations,” dated August 2003, stated the following: “Pilots are

prohibited from operating aircraft in a careless or reckless manner so as to endanger life or

property. Maneuvers not necessary for the safe and orderly progress of flight are

prohibited.” Section 4.30.2, “Absence From The Cockpit,” dated August 2003, stated that

“all flight crewmembers shall remain at their duty stations during takeoff, landing and

while enroute.”82

After the accident, Pinnacle Airlines issued a revision to its Flight Operations

Manual. Normal Procedures, section 4.30.6, “Crew Composition,” dated May 2005,

stated, “the minimum flight crew for all operations shall be a Captain and a First Officer.

The Captain must occupy the left seat and the First Officer must occupy the right seat.”

1.17.3 Federal Aviation Administration Oversight

The Memphis Flight Standards District Office (FSDO) is responsible for oversight

of Pinnacle Airlines. The supervisor of the Pinnacle Airlines certificate management unit

stated that, after he was assigned to the position in October 2002, he appointed temporary

principal inspectors because he wanted a “fresh set of eyes” to evaluate the airline’s

compliance with the Federal Aviation Regulations. He also stated that, before his

assignment, Pinnacle Airlines seemed to not pay much attention to the FAA and that the

appointment of temporary principal inspectors would help the FAA achieve a fresh start

with the airline. He further stated that, as a result of this action, Pinnacle Airlines agreed to

improve its working relationship with the FAA.

81 A review of the SPS’ performance during the flight matched the system’s nominal performance

requirements.

82 According to the document, the only exception to this policy is when the absence of a flight

crewmember is necessary for the performance of duties in connection with the operation of the airplane or

for physiological needs. 
Factual Information 36 Aircraft Accident Report

In January 2003, the POI was removed from that position because he did not have

a CRJ type rating. Three acting POIs (including the certificate management unit

supervisor) were on the Pinnacle Airlines certificate until the POI position was

permanently filled in July 2004. The new POI had been the assistant POI for Pinnacle

Airlines from July 2003 to January 2004, at which time he began 5 months of inspector

training at the FAA Academy in Oklahoma City, Oklahoma. The POI currently has two

assistant POIs to help him with his workload.

1.18 Additional Information

1.18.1 Oxygen Mask Use During the Accident Flight

As stated in section 1.6.2, the cabin pressurization system was designed to provide

a cabin altitude/cabin pressure warning at a cabin altitude of 10,000 feet. The CVR

recorded the first activation of the cabin pressure warning about 2157:04. The FDR did

not record the cabin altitude warning signal about this time because FDR operation had

temporarily ceased about 2155:20. The cabin altitude signal was recorded when FDR

operation resumed about 2159:16; at that time, the airplane was descending from an

altitude of 29,200 feet. The FDR showed that the oxygen masks did not deploy until the

airplane descended to an altitude of 22,531 feet (about 2201:45). 

The CVR recorded, about 2204:06, the captain stating, “get on oxygen,” and,

3 seconds later, a sound similar to oxygen flow in oxygen masks.83 About 2204:13, the

CVR recorded the captain stating, “we’re at cabin altitude ... fifteen thousand four

hundred. We need to be on oxygen.” About 2204:45, as the airplane descended through an

altitude of 16,423 feet, the cabin altitude stopped climbing and started descending. About

2206:23, the CVR recorded a sound similar to oxygen mask removal. The CVR again

recorded a sound similar to oxygen flow in oxygen masks about 2207:20 and then a sound

similar to oxygen mask removal about 2208:11 and about 2208:15. The cabin altitude

warning signal was no longer present in the FDR recording when the airplane descended

through an altitude of 10,020 feet (about 2209:05).

1.18.2 Core Lock

During the investigation of this accident, the Safety Board learned that GE CF34-1

and CF34-3 engines84 had a history of failing to rotate during in-flight restart attempts on

airplanes undergoing production acceptance flight testing at Bombardier. The

manufacturers referred to this condition as “core lock.” Bombardier first identified this

problem in 1983 during Challenger certification tests, and GE attributed the problem to

interference contact at an air seal in the high pressure turbine. 

83 The CVR had previously recorded the first officer stating, “we need our oxygen masks,” about

2158:21 and a sound similar to oxygen flow starting in oxygen masks about 2158:41.

84 Bombardier airplanes that are powered by either GE CF34-1 or CF34-3 engine models are the

Challenger 601, Challenger 604, CRJ-100, CRJ-200, and CRJ-440. 
Factual Information 37 Aircraft Accident Report

The CF34 high pressure turbine air seals are designed to control cooling and

balance airflow. The seals include teeth on the rotating components that grind operating

grooves into abradable surfaces on the stationary components. The efficiency of these

seals significantly affects engine performance, so the seals are designed to operate with

minimal clearances.

Bombardier added a procedure that screened for core lock to the production

acceptance flight tests for its airplanes powered by CF34-1 and CF34-3 engines. At the time

of the accident, this screening procedure was as follows:

1. Climb to 31,000 feet.

2. Retard the test engine throttle to idle and stabilize for 5 minutes.85

3. Shut down the test engine.

4. Descend at 190 knots.

5. Slow the aircraft until N2 is reduced to 0 percent.

6. At 8 1/2 minutes from shutdown, push over to 320 knots.

7. If N2 is 0 rpm at 21,000 feet, the engine is declared to be core locked.

Engines that are found to be core locked are reworked using an in-flight “grind-in”

procedure that was designed to remove seal material at the interference location. Engines

that undergo grind-in rework are then rescreened for core lock. The grind-in procedure is

as follows:

1. ATS cross-bleed start.

2. Ascend to 31,000 feet.

3. Repeat core lock screening procedure but descend at an airspeed of

about 240 knots to establish 4 percent N2.

4. Maintain 4 percent N2 for at least 8 1/2 minutes.

5. Confirm that no core lock exists by repeating screening procedure.

As testimony during the Safety Board’s June 2005 public hearing on the Pinnacle

Airlines accident indicated, neither Bombardier nor GE considered core lock to be a

safety-of-flight issue. The manufacturers claimed that engines that passed the screening

procedure, with or without grind-in rework, would not core lock as long as the 240-knot

airspeed was maintained. 

Bombardier’s core lock screening procedure requires a cool-down period before

engine shutdown to stabilize internal temperatures and clearances. However, this procedure

does not produce the more severe thermal distress associated with the high power, high

altitude flameouts that were experienced during the accident flight. As stated in the Safety

Board’s November 20, 2006, safety recommendation letter to the FAA,86 the successful

85 After the accident, Transport Canada mandated that Bombardier change the engine stabilization time

from 5 to 2 minutes.

86 This letter transmitted Safety Recommendations A-06-70 through -76. For information about these

recommendations, see section 1.18.3.1. 
Factual Information 38 Aircraft Accident Report

demonstration of Bombardier’s flight test procedure might not ensure that an engine will

not experience core lock if the core is allowed to stop rotating after a high power, high

altitude flameout. In its letter, the Board noted that the No. 1 accident engine had

successfully passed the screening procedure during initial production acceptance testing.87

The Board further stated that the successful demonstration of Bombardier’s flight test

procedure might not ensure that slowing the airplane to an airspeed of 170 to 190 knots is

sufficient to maintain core rotation during an attempted APU-assisted restart. 

1.18.3 Previous Related Safety Recommendations

1.18.3.1 Core Lock

On November 20, 2006, the Safety Board issued Safety Recommendations

A-06-70 through -76 to the FAA to address the safety hazards associated with core lock,

which can prevent pilots from restarting an engine after a double engine failure during

flight. Safety Recommendations A-06-70 through -76 asked the FAA to do the following:

For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to

perform high power, high altitude sudden engine shutdowns; determine the

minimum airspeed required to maintain sufficient core rotation; and demonstrate

that all methods of in-flight restart can be accomplished when this airspeed is

maintained. (A-06-70)

Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3

engines clearly state the minimum airspeed required for engine core rotation and

that, if this airspeed is not maintained after a high power, high altitude sudden

engine shutdown, a loss of in-flight restart capability as a result of core lock may

occur. (A-06-71)

Require that operators of CRJ-100, -200, and -440 airplanes include in airplane

flight manuals the significant performance penalties, such as loss of glide distance

and increased descent rate, that can be incurred from maintaining the minimum

airspeed required for core rotation and windmill restart attempts. (A-06-72)

Review the design of turbine-powered engines (other than the CF34-1 and

CF34-3, which are addressed in Safety Recommendation A-06-70) to determine

whether they are susceptible to core lock and, for those engines so identified,

require manufacturers of airplanes equipped with these engines to perform high

power, high altitude sudden engine shutdowns and determine the minimum

airspeed to maintain sufficient core rotation so that all methods of in-flight restart

can be accomplished. (A-06-73) 

87 The No. 2 accident engine was installed new as a spare engine and was not subjected to the core lock

screening procedure because it applies only to engines that are installed in Bombardier’s production

airplanes. 
Factual Information 39 Aircraft Accident Report

For those airplanes with engines that are found to be susceptible to core lock

(other than the CF34-1 and CF34-3, which are addressed in Safety

Recommendation A-06-71), require airplane manufacturers to incorporate

information into airplane flight manuals that clearly states the potential for core

lock; the procedures, including the minimum airspeed required, to prevent this

condition from occurring after a sudden engine shutdown; and the resulting loss of

in-flight restart capability if this condition were to occur. (A-06-74)

Require manufacturers to demonstrate, as part of 14 Code of Federal Regulations

Part 25 certification tests, if restart capability exists from a core rotation speed of

0 indicated rpm after high power, high altitude sudden engine shutdowns. For

those airplanes determined to be susceptible to core lock, mitigate the hazard by

providing design or operational means to ensure restart capability. (A-06-75) 

Establish certification requirements that would place upper limits on the value of

the minimum airspeed required and the amount of altitude loss permitted for

windmill restarts. (A-06-76)

Appendix E shows the complete safety recommendation letter.

1.18.3.2 Crew Professionalism

On October 8, 1974, the Safety Board issued Safety Recommendations A-74-85

and -86 as a result of the September 27, 1973, Texas International Airlines flight 655

accident in Mena, Arkansas,88 and the September 11, 1974, Eastern Air Lines flight 212

accident in Charlotte, North Carolina.89 The Board’s final report on the Texas International

Airlines accident stated that the captain failed to follow approved procedures. The

probable cause of the Eastern Air Lines accident was the flight crew’s lack of altitude

awareness at critical points during the approach resulting from poor cockpit discipline

(specifically, the crew did not follow prescribed procedures).90 Safety

Recommendation A-74-85 asked the FAA to do the following: 

Initiate a movement among the pilots associations to form new professional

standards committees and to regenerate old ones. These committees should:

a) monitor their ranks for any unprofessional performance. 

88 For more information, see National Transportation Safety Board, Texas International Airlines, Inc.,

Convair 600, N94230, Mena, Arkansas, September 27, 1973, Aircraft Accident Report NTSB/AAR-74/04

(Washington, DC: NTSB, 1974).

89 For more information, see National Transportation Safety Board, Eastern Air Lines, Inc., Douglas

DC-9-31, N8984E, Charlotte, North Carolina, September 11, 1974, Aircraft Accident Report

NTSB/AAR-75/09 (Washington, DC: NTSB, 1975).

90 The Safety Board’s safety recommendation letter cited five previous air carrier accidents as examples

of a “casual acceptance” of the flight environment (Martha’s Vineyard, Massachusetts, 1971; Fort

Lauderdale, Florida, 1972; New Haven, Connecticut, 1972; Toledo, Ohio, 1973; and Boston, Massachusetts,

1973). The letter added that the Eastern Air Lines accident also reflected “serious lapses in expected

professional conduct.”
Factual Information 40 Aircraft Accident Report

b) alert those pilots who exhibit unprofessionalism to its dangers and try, by

example and constructive criticism of performance required, to instill in

them the high standards of the pilot group. 

c) strengthen the copilot’s sense of responsibility in adhering to prescribed

procedures and safe practices. 

d) circulate the pertinent information contained in accident reports to pilots

through professional publications so that members can learn from the

experience of others.

On October 17, 1974, the FAA stated that it considered it more appropriate to work

with airline management rather than pilot groups to increase and promote crew discipline

and professionalism. The FAA also stated that it discussed this subject at length with the

Air Transport Association,91 which provided assurance that efforts would be made to

stress the importance of professionalism. On March 10, 1977, the Safety Board classified

Safety Recommendation A-74-85 “Closed—Acceptable Action.”

Safety Recommendation A-74-86 asked the FAA to do the following:

Develop an air carrier pilot program, similar to the general aviation accident

prevention program (FAA Order 8000.8A), that will emphasize the dangers of

unprofessional performance in all phases of flight. The program could be

presented in seminar form, using audio/visual teaching aids, to call to the pilots’

attention all facets of the problem. 

On October 17, 1974, the FAA stated that many airlines have established accident

prevention programs and have periodically conducted seminars. The FAA also stated that

it has participated in these seminars and would increase its participation in the future. The

FAA further stated that it would urge its field offices to emphasize the dangers of

unprofessional performance and that it would hold meetings with the Air Transport

Association to discuss this subject. On March 10, 1977, the Safety Board classified Safety

Recommendation A-74-86 “Closed—Acceptable Action.”

1.18.3.3 Flight Data Recorder Data

On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the

FAA because of problems with the quality of FDR data recorded by several regional jet

airplanes. Safety Recommendation A-03-15 asked the FAA to do the following:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair

Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with a

digital flight data recorder system that meets the sampling rate, range, and

accuracy requirements specified in 14 Code of Federal Regulations Part 121.344,

Appendix M.

91 The Air Transport Association is the trade organization of the largest U.S. airlines.
Factual Information 41 Aircraft Accident Report

On June 9, 2005, the FAA stated the following: 

• Regarding the Embraer 145 and 135, Embraer released Service Bulletin (SB)

145-31-0042, Revision 2, to correct known FDR anomalies, and the Brazilian

Department of Civil Aviation issued Airworthiness Directive (AD)

2004-12-03, requiring incorporation of the Embraer SB within 18 months. The

FAA advised U.S. operators of the Embraer 145 and 135 of the Brazilian AD

and planned to release a corresponding AD. (As of December 1, 2006, the FAA

had not issued the corresponding AD.) 

• Regarding the Canadair CL-600-2B19 (CRJ-100, -200, and -440) and

CL-600-2B16 (Challenger 604), the Canadian airworthiness authority,

Transport Canada, reported that Bombardier confirmed that the FDR system on

these airplanes exhibited low update rates on the normal acceleration and pitch

attitude parameters.92 Bombardier and Rockwell Collins, the supplier of the

system that established the parameter update rates on these airplane models,

were planning to develop a plan and schedule for correcting this problem. The

FAA was working with Transport Canada to get expeditious action from

Bombardier on this issue.

• Regarding the Fairchild Dornier 328-300, AvCraft Aviation (which acquired

the rights to the 328 program), in cooperation with Honeywell (the

manufacturer of the 328-300 FDR system), completed an extensive review of

FDR data from two incidents and several flight tests. They concluded that all

FDR parameters were updated at a rate equal to or exceeding those required by

14 CFR 121.344, Appendix M, when the data were analyzed with the proper

frame rate and at the maximum accuracy.

On September 28, 2005, the Safety Board agreed that no problems existed with the

FDR parameters on the Fairchild Dornier 328-300 airplane. The Board also stated that,

pending the FAA’s issuance of an AD that mandated compliance with Embraer

SB 145-31-0042, Revision 2, and an AD that mandated correction to CRJ-100, -200, and

-440 and Challenger 604 FDR systems, Safety Recommendation A-03-15 was classified

“Open—Acceptable Response.”

1.18.4 Federal Aviation Administration Notice

On March 1, 2005, the FAA issued Notice N8000.296, “Pilot Judgment and

Decisionmaking,” after six accidents that occurred between October and November 2004.

These accidents were Pinnacle Airlines flight 3701, Corporate Airlines flight 5966,93 and

92 Bombardier indicated that other recorded parameters on the CRJ-100, -200, and -440 and

Challenger 604 airplanes were updated at rates that were in compliance with the regulations. Bombardier

also noted that the update rates for all FDR parameters on CL-600-2C10 (CRJ-700) and CL-600-2D24

(CRJ-900) airplanes complied with the regulations.

93 For more information, see National Transportation Safety Board, Collision With Trees and Crash

Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE J3201, N875JX, Kirksville,

Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).
Factual Information 42 Aircraft Accident Report

accidents involving a Learjet 35A at San Diego, California; a King Air 200 at Stuart,

Virginia; a Challenger 600 at Montrose, Colorado; and a Gulfstream III at Houston,

Texas.94

The notice was issued to POIs of operators of airplanes with 70 or fewer passenger

seats, corporate managers and trainers, and individual pilots to encourage the promotion

of “soft skills” as a first line of defense against accidents caused by lapses in human

performance. The FAA defined soft skills as those that go beyond the technical knowledge

and psychomotor skills that are necessary to fly an airplane. Such skills include adherence

to standard operating procedures, decision-making, judgment, CRM, and professionalism. 

The notice required POIs to convey information about the importance of soft skills

in preventing human error and the existing FAA guidance on that topic. The notice also

recommended that operators ensure that their programs reflected the human factor

principles that were outlined in FAA guidance about CRM and standard operating

procedures. In addition, the notice indicated that individual pilots should examine their

own decision-making habits in terms of professionalism, thoroughness of preparation, and

adherence to standard operating procedures. The notice expired on March 1, 2006.95 In a

November 2006 memorandum to the Safety Board, the FAA stated that it incorporated

soft skills into Part 121 CRM training requirements and that a rewrite (which is currently

in progress) of FAA Order 8400.10, Air Transportation Operations Inspector’s Handbook,

would emphasize soft skills.

1.18.5 Bombardier All Operator Message

On December 14, 2004, Bombardier issued an all operator message that included

the following information about high altitude operations:

Climb profiles as detailed in the AFM [airplane flight manual] must be strictly

adhered to. Climbing below the recommended profile speed may place the

airplane behind the energy curve when it arrives at the desired altitude and it may

not be capable of remaining at that altitude. This may be evident by an aircraft

nose-high attitude and its failure to accelerate.

The autopilot should be engaged and performance closely monitored during the

upper portion of the climb and immediately following the level off. When the

selected altitude is reached, under normal conditions, the aircraft will accelerate to

the desired cruise speed.

94 For more information on these accidents, see LAX05FA015, IAD05MA006, DEN05MA029, and

DCA05MA011, respectively, at the Safety Board’s Web site at <http://www.ntsb.gov>.

95 All FAA notices expire 1 year after issuance. Because the notices are temporary by nature, they are

rarely renewed.
Factual Information 43 Aircraft Accident Report

Situational awareness must be maintained at all times when the aircraft reaches

the desired cruising altitude. If the ... [AOA] is excessively high, the performance

may be such that the aircraft is not capable of maintaining the altitude and the

airspeed may begin to decay. Under these circumstances, a descent must be

initiated immediately.

Do not wait for the onset of continuous ignition or stick shaker before attempting

a descent from an altitude where continued operation is not possible. Descend

immediately.

In the event that a stick shaker/approach to stall occurs, the crew should expect

that a deliberate loss of altitude will likely be required in order to restore the

aircraft to a normal energy state and to prevent an aerodynamic stall and possible

departure from controlled flight.
44 Aircraft Accident Report

2. Analysis

2.1 General

The captain and the first officer were properly certificated and qualified under

Federal regulations. No evidence indicated any medical or behavioral conditions that

might have adversely affected their performance during the accident flight. Flight crew

fatigue and hypoxia were not factors in this accident. 

The accident airplane was properly certified, equipped, and maintained in

accordance with Federal regulations. The recovered components showed no evidence of

any structural or system failures or any engine failures before the time of the upset event.

Weather was not a factor in this accident. The accident was not survivable. 

This analysis discusses the accident sequence, including the flight crew’s decision

to climb to 41,000 feet and the improper climb speed; the crew’s improper actions during

the stall event; and the crew’s failure to restart the engines, inform air traffic controllers of

the double engine failure, and initiate an emergency landing in a timely manner. The

analysis also addresses flight crew training (in the areas of high altitude climbs, stall

recognition and recovery, and double engine failures) as well as flight crew

professionalism. In addition, the analysis addresses problems with the quality of some

parameters recorded by FDRs on regional jet airplanes, including the CRJ-200. 

2.2 Accident Sequence

2.2.1 Climb to 41,000 Feet

The flight plan for the accident flight indicated that the planned cruise altitude was

33,000 feet. However, the ATC and CVR transcripts showed the flight crew’s desire to

climb to an altitude of 41,000 feet, which is the CRJ maximum operating altitude.96

During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had

expressed curiosity about operating the airplane at 41,000 feet and that a “[flight level]

410 club” existed at the airline. 

When the airplane was at an altitude of 450 feet, the first of three aggressive

pitch-up maneuvers during the ascent occurred. During the first maneuver, the flight crew

moved the control column to 8o ANU, causing the airplane’s pitch angle to increase to 22o

and resulting in a vertical load of 1.8 Gs. The maneuver also caused the stickshaker and

96 It is not known which pilot first suggested that the flight be operated at an altitude of 41,000 feet.

However, CVR evidence showed that both pilots were willing participants in the decision to climb to

41,000 feet.
Analysis 45 Aircraft Accident Report

stickpusher to activate. After stickpusher activation, the FDR recorded a full nose-down

control column deflection. When the airplane was at an altitude of 15,000 feet, the second

pitch-up maneuver occurred. The flight crew moved the control column to 3.8o ANU,

causing the airplane’s pitch angle to increase to 17o and resulting in a vertical load of

2.3 Gs. Afterward, the flight crew made rudder inputs of 4.2o to the left, 6.0o to the right,

and 0.4o to the left followed 17 seconds later by a 7.7o right rudder input. When the

airplane was at an altitude of 24,600 feet, the third pitch-up maneuver occurred. The flight

crew moved the control column to 4o ANU, causing the pitch angle to increase to more

than 10o and resulting in a vertical load of 1.87 Gs. The pilots’ intentional maneuvers,

which were not required for any operational reason or safety consideration, placed the

airplane in a flight regime that likely exceeded the airplane’s certificated flight envelope.97

The CVR recording showed that both pilots repeatedly expressed excitement

before and after reaching the 41,000-foot altitude. For example, the CVR recorded the

first officer stating, “man we can do it. Forty one it,” “there’s four one oh my man,” and

“this is ... great.” The CVR also recorded the captain stating, “look how high we are.” In

addition, when one of the air traffic controllers handling the flight stated to the flight crew,

“I’ve never seen you guys up at forty one there,” the captain replied, “we don’t have any

passengers on board so we decided to have a little fun and come on up here” and “this is

actually our service ceiling.” The Safety Board concludes that the pilots’ aggressive

pitch-up and yaw maneuvers during the ascent and their decision to operate the airplane at

its maximum operating altitude (41,000 feet) were made for personal and not operational

reasons. 

Pinnacle Airlines required that a climb to 41,000 feet be conducted at an airspeed

of 250 knots (0.70 Mach).98 However, FDR data showed that the flight crew conducted

the climb from 37,000 to 41,000 feet at an airspeed that decreased from 203 knots

(0.63 Mach) at the start of the climb to 163 knots (0.57 Mach) as the airplane leveled off at

41,000 feet. FDR data also showed that the flight crew conducted the climb from 37,000

to 41,000 feet with the autopilot vertical speed mode engaged and a commanded vertical

speed of 500 fpm. The airplane could not sustain the required airspeed while climbing at

500 fpm, which resulted in the 40-knot loss of airspeed, and, once level at 41,000 feet, the

airplane was operating in a “region of reversed command”99 in which available thrust was

not sufficient to increase airspeed. The flight crew should have used the autopilot airspeed

mode rather than the vertical speed mode to prevent the loss of airspeed. The Safety

Board concludes that the flight crew’s inappropriate use of the vertical speed mode during

the climb was a misuse of automation that allowed the airplane to reach 41,000 feet in a

critically low energy state. 

97 The pilots were experienced in the airplane, so the maneuvering would not have been the result of

improper control inputs by a pilot who was unfamiliar with the airplane’s handling characteristics.

98 Specifically, the climb should be conducted at 250 knots until Mach 0.7 is reached, at which point

Mach 0.7 becomes the primary indicator of airspeed.

99 Region of reversed command is also known as operating “on the back side of the power curve.” It

occurs when the available engine thrust cannot overcome the increased induced drag associated with low

airspeed. As a result, the airplane cannot accelerate and may decelerate.
Analysis 46 Aircraft Accident Report

Statements on the CVR recording indicated that the pilots did not fully understand

the aerodynamic and performance considerations associated with operations at an altitude

of 41,000 feet. Specifically, about 2154:07, the captain stated, “we’re losing here. We’re

gonna be ... coming down in a second here.” About 3 seconds later, the captain stated,

“this thing ain’t gonna ... hold altitude. Is it?” The first officer responded, “it can’t man.

We ... (cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated,

“yeah that’s funny we got up here it won’t stay up here.”100

Pinnacle Airlines’ ground school upset training addressed high altitude

aerodynamics, swept-wing design characteristics, and the use of performance charts. Also,

the company’s ground school performance training provided pilots with instruction on

how to use climb capability charts to determine thrust settings for altitudes above

36,000 feet. The CVR recording did not indicate whether the flight crew consulted the

company’s altitude and climb ability charts before initiating the climb to 41,000 feet.

However, the Safety Board concludes that the improper airspeed during the climb

demonstrated that the pilots did not understand how airspeed affects airplane performance

and did not realize the importance of conducting the climb according to the published

climb capability charts. Section 2.3.1 discusses high altitude training for regional jet

operations.

2.2.2 Aerodynamic Stall and Upset Event

Even though the pilots recognized that the airplane’s performance was

deteriorating, neither pilot appeared to respond to this situation with urgency. The pilots

contacted the controller about 2154:32 and requested a lower altitude; however, during the

time that the controller was coordinating the descent, the airplane’s airspeed further

deteriorated to Mach 0.53 (150 knots), and the stickshaker activated for the first of five

times. Afterward, the stickshaker activated four times, and the stickpusher activated four

times, pushing the control column forward automatically.101 The flight crew responded to

the stickpusher each time by pulling back on the control column. These control column

inputs caused the airplane’s pitch angle to increase to a maximum ANU value of 29o about

2154:59, and then the airplane entered an aerodynamic stall. Afterward, the airplane’s

pitch angle decreased to a maximum AND value of 32o about 2155:06. While the pitch

angle was decreasing, a left rolling motion began, which eventually reached 82o left wing

down, and the N1 and fuel flow indications for both engines declined steadily to zero,

indicating that both engines had flamed out. The Safety Board concludes that the upset

event exposed both engines to inlet airflow disruption conditions that led to engine stalls

and a complete loss of engine power. The double engine failure is further discussed in

section 2.2.3.

100 During postaccident interview, several company pilots stated that, even though they had been able to

climb the CRJ to 41,000 feet, the airplane was not able to stay at that altitude for an extended period because

the airplane’s performance had deteriorated.

101 During the public hearing on this accident, a Bombardier engineer testified that the stickpusher had

functioned normally during the flight.
Analysis 47 Aircraft Accident Report

During the investigation, the aircraft performance group determined that the

stickshaker was functioning normally102 but that the airspeed indicator’s low speed cue

was 10 knots low. As a result, at the time of stickshaker activation, the low speed cue was

indicating that the airplane’s speed was 10 knots above the stickshaker speed. The

erroneous information shown by the low speed cue resulted from a software error.103

According to Pinnacle Airlines, its flight crewmembers were taught that the top of

the low speed cue indicated the airspeed at which the stickshaker would initially activate.

However, the flight crews were also trained to respond to stickshaker activation,

regardless of whether the airspeed was above the low speed cue, because the stickshaker is

the primary warning to pilots of an impending stall. In addition, when an airplane’s speed

is about 10 knots from the top of the low speed cue, especially when operating at an

altitude of 41,000 feet, pilots should realize that the airplane is dangerously close to an

impending stall. When the stickshaker activated during the accident flight, the pilots

should have immediately attempted to accelerate the airplane to a safe airspeed by

descending; sufficient reserve power was not available from the engines while the airplane

was at 41,000 feet. Thus, the accident pilots should have responded appropriately to the

stickshaker and used the low speed cue only as a secondary indication showing that the

airspeed was dangerously slow.

Even though the flight crew was eventually able to recover the airplane from the

upset event, the flight control inputs made during the upset were opposite of what was

required to recover the airplane. FDR data showed that the flight crew moved the control

column aft after the first stickpusher activation and that the crew moved the control

column aft with increasing magnitude after the next three activations of the stickpusher. 

A reason that might explain why the pilots made these flight control inputs, which

exacerbated the upset event, was that Pinnacle Airlines’ stall recognition and recovery

simulator training focused on recovery with a minimum loss of altitude (which is common

throughout the aviation industry). As a result, the pilots were trained to apply power to

restore the energy state of the airplane and to maintain altitude.104 In this accident, the

pilots’ inputs could have been the result of their attempt to recover using a minimal

altitude loss recovery technique, and, as the repeated stall events occurred with increasing

nose-down pitch attitude, the pilots could have been instinctively trying to arrest the

102 The Safety Board compared the AOA recorded on the FDR at the time of the stickshaker activations

with Bombardier’s stickshaker design criteria for the flight condition and determined that the stickshaker

activated at the expected AOA (about 7.8o) and airspeed (about 150 knots).

103 In December 2004, the FAA sent a letter to Transport Canada that recommended, among other things,

that Bombardier change “the airspeed tape display software to more accurately depict the top of the Low

Speed Awareness (top of the red band) at all altitudes and Mach Numbers.” In February 2005, Bombardier

indicated that it would include an appropriate design change the next time the stall protection computer and

the air data computer were modified and that, in the interim, its FCOM would be revised to provide

necessary guidance material on changes to the computation required to determine the low speed cue. In

November 2006, Bombardier stated that it had not yet scheduled the modification; in December 2006,

Bombardier issued the revised FCOM.

104 The Safety Board could not determine whether the pilots applied power because the throttle lever

angle parameter was not recorded on the FDR.
Analysis 48 Aircraft Accident Report

nose-down pitch moment or responding inappropriately to the stickpusher. The Safety

Board concludes that the pilots’ lack of exposure to high altitude stall recovery techniques

contributed to their inappropriate flight control inputs during the upset event. Section 2.3.2

discusses stall recognition and recovery training.

2.2.3 Double Engine Failure

About 2155:06, the flight crew declared an emergency and asked the controller to

stand by. CVR evidence showed that the flight crew recognized the nature of the

emergency; specifically, about 2155:23, one pilot stated to the other, “we don’t have any

engines.” However, the CVR also showed that the flight crew did not begin the first item

of the double engine failure checklist (which is a memory item) until 1 minute 19 seconds

after the statement on the CVR recording about the double engine failure. Also, FDR data

showed that the pilots did not achieve and maintain the target airspeed of 240 knots

(another memory item on the checklist). Because the flight crew did not achieve this

airspeed, both engines’ cores had decelerated and stopped before the airplane descended

through an altitude of 28,000 feet.

The double engine failure checklist indicated that, between the altitudes of 21,000

and 13,000 feet, the windmill restart procedure should be used to relight the engines. This

procedure required that the pitch attitude of the airplane be reduced to and maintained at

-8o to accelerate the airplane to an airspeed of 300 knots or greater. However, the pitch

inputs made by the flight crew were not of sufficient magnitude and were not sustained.

As a result, the crew did not achieve the 300-knot or greater airspeed required for the

procedure; FDR data showed that the highest airspeed attained during the restart attempt

was 236 knots and that the engines’ N2 (core rotation) indications remained at zero. The

Safety Board concludes that the captain did not take the necessary steps to ensure that the

first officer achieved the 300-knot or greater airspeed required for the windmill engine

restart procedure and then did not demonstrate command authority by taking control of the

airplane and accelerating it to at least 300 knots. The Safety Board further concludes that

the first officer’s limited experience in the airplane might have contributed to the failed

windmill restart attempt because he might have been reluctant to command the degree of

nose-down attitude that was required to increase the airplane’s airspeed to 300 knots.

Because the flight crewmembers were unsuccessful in their attempt to relight the

engines using the windmill procedure, they elected to descend the airplane to an altitude of

13,000 feet so that they could attempt to restart the engines with the APU. Once the

airplane descended to an altitude of 13,000 feet, the flight crew attempted four

APU-assisted engine restarts (two attempts per engine) during a 5-minute period (2207:04

to 2212:07) and between the altitudes of about 12,900 and about 5,000 feet. FDR data

showed that the N2 indications for both engines remained at zero during the restart

attempts. The Safety Board concludes that, despite their four APU-assisted engine restart

attempts, the pilots were unable to restart the engines because their cores had locked.

Without core rotation, recovery from the double engine failure was not possible.105

105 Section 2.2.3.1 discusses the flight crew’s performance of the double engine failure checklist.
Analysis 49 Aircraft Accident Report

The Safety Board considered whether engine hardware was a factor contributing to

the lack of core rotation. However, engine teardowns found no mechanical failures or

evidence of any condition that would have prevented engine core rotation.

The Safety Board then considered whether an electrical or mechanical problem

interfered with the ability of the cores to achieve rotation. However, inspection and testing

of the APU and other airplane start system components found no conditions that would

have prevented torque delivery to either engine during the four APU-assisted restart

attempts. Also, FDR data showed that the LCV was open during these restart attempts,106

and testing showed that it was capable of providing pneumatic power from the APU to

start initial rotation in each engine. A systems simulation study (see section 1.16.4)

showed that the LCV had likely opened by at least 18o during the flight, which should

have resulted in some detectable core rotation if the engine cores were capable of rotation.

In addition, the change in engine oil temperatures107 showed that air was flowing through

the ATS. This finding, along with the results of the airplane start system component

testing, showed that the LCV was likely fully open.

The Safety Board considered whether the slight increases in core-driven hydraulic

pump pressures shown on the FDR during the final minutes of the flight (as described in

section 1.16.3) were evidence of engine core rotation. The airplane’s start system was

operating normally during the restart attempts; thus, if the cores were free to rotate, they

would have quickly accelerated. As a result, the Board determined that the slight increases

in hydraulic pump pressures that were recorded on the FDR were not the result of engine

core rotation.

On the basis of the information discussed in section 1.18.2, the Safety Board

concludes that the GE CF34-1 and CF34-3 engines had a history of failing to rotate during

in-flight restart attempts on airplanes undergoing production acceptance testing at

Bombardier. GE attributed the problem to interference contact at an air seal in the high

pressure turbine and, along with Bombardier, referred to this condition as core lock. The

lack of core rotation on the accident airplane engines was similar to the instances of core

lock experienced by CF34 engines during Bombardier’s acceptance testing, except that

the accident airplane engines were exposed to more severe thermal distress than the

engines on the production airplanes. Specifically, the accident airplane’s engines flamed

out from high power and high altitude, whereas the engines installed on the production

airplanes were shut down only after their internal temperatures were stabilized.108

Flameouts at high power and high altitude produce even greater thermal distress

because internal temperatures are the hottest at high power settings and the air is colder at

high altitudes. The increased thermal shock exacerbates the loss of component clearance

106 The FDR parameter for the LCV position shows that the valve is open once it reaches a position that

is greater than 4.8o from its normally closed position.

107 The FDR recorded a steady decline in engine oil temperature after the upset and showed that this

steady decline ceased at the time of the engine restart attempts. 

108 On November 20, 2006, the Safety Board issued recommendations to the FAA to address this and

other core lock-related issues; see sections 1.18.3.1 and 4.3 for information.
Analysis 50 Aircraft Accident Report

and alignment. Because the accident engines flamed out under these conditions, axial

misalignment caused the seal teeth, which were positioned aft of their normal operating

grooves, to contact stationary abradable material when radial seal clearances closed down.

Once core rotation stopped, binding prevented core rotation from resuming during the

windmill and APU-assisted restart attempts. No physical evidence of core lock was found

inside the engines because the thermally induced interference occurred after core rotation

had stopped and operating clearances were restored afterward as the engine cooled. 

The Safety Board concludes that both engines experienced core lock because of

the flameout from high power and high altitude, which resulted from the pilot-induced

extreme conditions to which the engines were exposed, and the pilots’ failure to achieve

and maintain the target airspeed of 240 knots, which caused the engine cores to stop

rotating; both of these factors were causal to this accident. 

2.2.3.1 Performance of the Double Engine Failure Checklist

A critical error made by the flight crew while performing the double engine failure

checklist was failing to establish and maintain an airspeed of 240 knots before beginning

the procedures to restart the engines. During the public hearing on this accident, a GE

manager testified, “as long as core rotation is maintained, you will not have core lock ...

we have a body of data that shows that 240 knots maintains core rotation.”

Another critical error made by the flight crew was failing to increase the airspeed

to at least 300 knots before beginning the windmill restart procedure. About 2159:16,

when the FDR resumed operation after a loss of power lasting about 4 minutes, the

airplane’s airspeed was 178 knots. About 2200:38, the captain told the first officer to

increase the airspeed to above 300 knots, and the first officer acknowledged this

instruction. About 1 minute later, the captain again told the first officer to increase the

airspeed to 300 knots. However, FDR data showed that the maximum airspeed achieved

during the procedure—236 knots—was achieved only briefly.

Other errors in the performance of the double engine failure checklist included the

captain’s failure to call out the items using standard phraseology and indicate when the

checklist was complete. According to the simulator instructor who conducted part of the

captain’s upgrade training, the captain did not always perform checklists according to

company procedures.109 This reported behavior in the simulator was consistent with the

captain’s performance of the double engine failure checklist. Specifically, although the

checklist procedures were clear, the captain did not effectively manage the execution of

the checklist or ensure that the first officer had achieved the necessary airspeed, which is

inconsistent with the basic tenets of CRM and basic airmanship. 

109 As discussed in section 1.5.1, the instructor stated that the captain would, at times, misstate the status

of a checklist item, read a checklist item but not accomplish it, take action on an airplane system that was not

the one noted in the checklist, or see the appropriate checklist displayed in an EICAS message but still call

for the wrong checklist.
Analysis 51 Aircraft Accident Report

In addition to the captain’s previous difficulties in executing checklists, two

additional factors likely played a role in the flight crew’s performance of the double

engine failure checklist. The first factor was the stress associated with the situation. The

stress included changes to the cockpit environment, such as the reduced cockpit lighting

and the increase in ambient noise associated with the deployment of the ADG. Another

stressor was the instrumentation available to the captain during the 4-minute period in

which the ADG was the sole source of power—from the right seat, he would not have had

a primary flight display showing airspeed and altitude; thus, he would have had to look

over to the left side of the instrument panel or use the standby instruments in the center of

the panel while performing the double engine failure checklist and other nonflying pilot

duties. Also, the stress of the situation might have caused both pilots to experience

attentional tunneling, that is, the focusing of attention on a single task or portions of a task,

which results in neglecting other critical tasks. For example, the captain did not recognize

that the airspeed required for N2 rotation (which was necessary for restarting the engines)

had not been achieved. The second factor was that the pilots had only received ground

school instruction on the double engine failure checklist. Thus, it is possible that they

were executing it for the first time. 

Even though maintaining an airspeed of 240 knots was a memory item on the

checklist, it is possible that the pilots did not realize the importance of this airspeed to the

success of the restart sequence. The Safety Board concludes that the importance of

maintaining a minimum airspeed to keep the engine cores rotating was not communicated

to the pilots in airplane flight manuals. For example, at the time of the accident,

Bombardier’s and Pinnacle Airlines’ double engine failure checklists stated that 240 knots

was the “target” airspeed for the procedure but did not indicate that this airspeed was

essential to the success of the restart procedure. As a result of the accident, Bombardier

and Pinnacle Airlines revised their double engine failure checklist to indicate that

240 knots was the “minimum” airspeed and that the failure to maintain positive core

rotation might prevent a successful restart. It is also possible that, after the double engine

failure, the pilots were attempting to operate the airplane at its best glide speed of

170 knots, which is 70 knots less than the speed needed to maintain engine core rotation. 

The Safety Board examined whether the seat swap would have affected the pilots’

performance during the double engine failure checklist.110 The captain, who was

responsible for performing the checklist, had significant experience in the right seat of the

airplane, so the position of the controls and switches would have been familiar to him.

Further, the tasks that the captain was performing for the checklist were not well practiced

because of the lack of training in this area (as discussed in section 2.3.3), so he would not

have developed any habit patterns or motor memory skills from the left seat that would

have interfered with his ability to perform from the right seat. The lack of a flight display

on the right side of the cockpit should not have affected the captain’s ability to recognize

that the required airspeeds had not been achieved because airspeed was clearly presented

on the standby instrument and the left-side primary flight display. The first officer was

110 It is not known which pilot suggested that the first officer sit in the captain’s seat during most of the

accident flight. However, both pilots demonstrated poor judgment in allowing the seat swap to occur.
Analysis 52 Aircraft Accident Report

responsible for flying the airplane, and the seat swap should not have affected his ability to

achieve the commanded speeds. Thus, the pilots’ seat swap, although contrary to standard

operating practice, was not a factor that affected the pilots’ performance of the double

engine failure checklist.111

The Safety Board concludes that the captain’s previous difficulties in checklist

management, the situational stress, and the lack of simulator training involving a double

engine failure contributed to the flight crew’s errors in performing the double engine

failure checklist. 

2.2.4 Communications With Air Traffic Controllers and 

Management of Forced Landing

About 2206:40, the controller (at the sector 53 position) asked the pilots whether

they wanted to land. The captain, during his reply to the controller, failed to disclose the

true nature of the emergency, stating, “just stand by right now we’re gonna start this other

engine and see ... if everything is okay.” About 2209:06, the first officer informed the

controller that the airplane was experiencing a double engine failure. This notification

happened almost 14 minutes after the flight crew first recognized (according to CVR

evidence) that a double engine failure had occurred. During that time, the flight crew had

numerous opportunities to notify the controller of the double engine failure. For example,

the controller (at the sector 30 position) had earlier asked the flight crew about the nature

of the emergency, but the captain responded, “we had an engine failure up there ... so

we’re gonna descend down now to start our other engine.” This controller then stated,

“understand controlled flight on a single engine right now,” but the captain did not correct

this information by informing the controller of the actual situation. Thus, the

transmissions describing a loss of only one engine indicated that the captain intentionally

conveyed information to the controllers that did not represent his own understanding of

the situation. 

During postaccident interviews, company pilots stated that, if an emergency

situation (such as the loss of one or both engines) were to occur, they were instructed to

provide relevant information to air traffic controllers, as workload and conditions allowed,

about the nature of the emergency and the assistance that was needed. By misleading the

controllers about the true nature of the emergency, the captain lost the full use of a

valuable resource in an emergency situation.112 For example, if the captain had notified the

controller early in the descent about the double engine failure, the controller would have

likely provided the pilots with suggested vectors for a descent to and landing at an airport

within the airplane’s best glide range. 

111 About 2208:17, after the sound of oxygen mask use ceased, the CVR recorded the captain stating

“switch,” indicating that the captain was preparing to return to the left seat and have the first officer return to

the right seat.

112 The captain’s inaccurate communications to the controllers about the loss of only one engine were

also inconsistent with the basic tenets of CRM.
Analysis 53 Aircraft Accident Report

The company’s double engine failure procedure stated that, if neither engine was

restarted, the flight crew should consider a forced (emergency) landing. Five airports that

were suitable for an emergency landing were located within 60 miles of the upset location

(see section 1.16.1.3). However, the flight crew did not consider making an emergency

landing at any of these airports. Between the time that the flight crew first realized that a

double engine failure had occurred and the time that the captain notified the controller of

the actual situation, the airplane had descended from 35,000 to 10,000 feet. When the

airplane was at an altitude of 10,000 feet, only one airport (AIZ) was still within the

airplane’s best glide range, but the pilots had already overflown that airport. At that

altitude, JEF was just outside the airplane’s best glide range.113 The aircraft performance

study for this accident showed that drag produced by the 5.6o spoiler deployment had a

minimal effect on the airplane’s ability to reach JEF.

A double engine failure in a two-engine airplane is an emergency situation that

requires timely action to stabilize the situation and effective coordination of all available

resources and options to ensure a successful outcome. The flight crew’s failure to discuss

an emergency landing during most of the descent demonstrated the crew’s poor judgment.

Also, the captain’s failure to inform the controllers about the true nature of the situation

early in the descent demonstrated the pilots’ apparent reluctance to have their deviation

from standard operating procedures and their unprofessional behavior detected. 

Multiple opportunities existed during the descent for the pilots to talk with

controllers and between themselves about the need to make an emergency landing. The

pilots acted in a manner that was not consistent with ensuring safety of flight or effectively

managing an in-flight emergency. The Safety Board concludes that the pilots’ failure to

prepare for an emergency landing in a timely manner, including communicating with air

traffic controllers immediately after the emergency about the loss of both engines and the

availability of landing sites, was a result of their intentional noncompliance with standard

operating procedures, and this failure was causal to the accident. 

2.2.5 Accident Sequence Summary

This accident was not the result of a single action, decision, or mistake by the

flight crew. Instead, the accident was the result of poorly performing pilots who

intentionally deviated from standard operating procedures and basic airmanship. Also,

CVR evidence showed that the pilots’ tone in the cockpit was unprofessional114 and that

their attitude was inconsistent with the demands associated with, and the precision

required for, flying a high performance turbojet airplane. 

113 On the basis of the airplane’s location at this point in the flight, the air traffic controller correctly

directed the airplane to JEF, which was essentially straight ahead along the airplane’s flightpath. If the

airplane had been directed to AIZ, a 160o left turn would have been required, which would have cost the

airplane altitude, airspeed, and distance.

114 As indicated in the CVR transcript in appendix B, the flight crew’s conversation was generally

casual, and sounds of joking and laughing were heard during the recording. Also, the transcript showed that

the captain left his duty station unnecessarily to get a soft drink.
Analysis 54 Aircraft Accident Report

According to models of human error, the pilots’ performance during the climb and

their decision to operate at 41,000 feet can be described as “optimizing violations,” which

occur when someone disregards defined procedures intentionally to make a job more

interesting or engaging, to push limits, or to impress another.115 For example, the pilots’

CVR statements about operating at an altitude of 41,000 feet were consistent with

thrill-seeking behavior. It is not possible to determine the specific reasons that the pilots

demonstrated these optimizing violations. However, according to situational control

theory, the chance that someone will violate a rule increases when such a violation results

in personal achievement and is likely to go undetected.116 In this case, the Part 91

repositioning flight with no passengers or other crewmembers on board presented the

pilots with an opportunity to reach personal milestones associated with aggressive

maneuvering and operating the airplane at its maximum operating altitude. 

The Safety Board’s investigation of this accident did not reveal any evidence that

the pilots had previously engaged in the unprofessional behavior demonstrated during the

accident flight. Also, the CVR recording contained no indication that the pilots anticipated

the adverse outcome resulting from their intentional deviations from standard operating

procedures. Such intentional deviations can compromise the margins of safety that are in

place as a result of procedures established by the company, the manufacturer, and the

FAA. A consequence associated with compromising these margins of safety is that the

operator becomes more vulnerable to the catastrophic effects of unintentional errors.117 

Evidence indicated that the critical human performance failures during the flight

were the result of intentional behavior and were not consistent with typical errors (slips,

lapses, and mistakes) found in most flight crew-involved accidents involving Part 121

operators. Although the pilots demonstrated some performance failures and deficiencies

in basic airmanship that were consistent with the more typical errors found in accidents,

such as their failure to achieve required airspeeds during the descent (see section 2.2.3),

the pilots’ overall actions during the accident flight were not consistent with the degree of

discipline, maturity, and responsibility required of professional pilots. The Safety Board

concludes that the pilots’ unprofessional operation of the flight was intentional and causal

to this accident because the pilots’ actions led directly to the upset and their improper

reaction to the resulting in-flight emergency exacerbated the situation to the point that they

were unable to recover the airplane.

The Safety Board is concerned about the willful misconduct demonstrated by the

pilots during the accident flight. The Board has investigated other recent accidents in

which pilots did not adhere to standard operating procedures and demonstrated a lack of

cockpit discipline. Section 2.4 discusses this problem and the need for broad industry

action involving pilots, operators, and the FAA to address the problem.

115 J.T. Reason, Human Error (New York: Cambridge University Press, 1990).

116 D. Huntzinger, “Pilots Behaving Badly,” Vector (New Zealand: Civil Aviation Authority,

January/February 2001).

117 P.T.W. Hudson, W.L.G. Verschuur, D. Parker, R. Lawton, and G. van der Graff, “Bending the Rules:

Managing Violation in the Workplace.” For more information about this paper, see

<http://www.energyinst.org.uk/heartsandminds/docs/bending.pdf>. 
Analysis 55 Aircraft Accident Report

2.3 Flight Crew Training

2.3.1 High Altitude Training

High altitude climbs were not practiced during Pinnacle Airlines’ simulator

training. The circumstances of the accident flight and the actions taken by Pinnacle

Airlines and Bombardier after the accident to increase awareness of CRJ performance

capabilities and limitations during high altitude operations118 indicate that high altitude

training at regional jet operators may not be adequate.

Regional airlines are typically the journeyman career step for professional pilots

seeking employment with major air carriers. Until the advent of the regional jet, pilots at

regional airlines typically operated turboprop airplanes. Because turboprop airplanes do

not have the performance capabilities of, or operate at the same speeds and flight levels as,

a regional jet, it is possible that some regional airline pilots were not adequately trained to

make the transition to a turbojet airplane. Also, regional airline pilots with military flight

training may have received more thorough high altitude training compared with civilian

pilots; however, the number of regional airline pilots who had previously received military

flight training has decreased since the 1980s.119

Because of advances in airplane equipment (turboprop to turbojet airplanes) at

regional airlines and changes in the pilot force transitioning to regional jet operations, the

current training methods and syllabuses for high altitude training at these operators may

be in need of an industrywide revision. The Safety Board concludes that revised high

altitude training syllabuses for pilots who operate regional jet airplanes would help ensure

that these pilots possess a thorough understanding of the airplanes’ performance

capabilities, limitations, and high altitude aerodynamics. Therefore, the Safety Board

believes that the FAA should work with members of the aviation industry to enhance the

training syllabuses for pilots conducting high altitude operations in regional jet airplanes.

The syllabuses should include methods to ensure that these pilots possess a thorough

understanding of the airplanes’ performance capabilities, limitations, and high altitude

aerodynamics. The Safety Board further believes that the FAA should determine whether

the changes to be made to the high altitude training syllabuses for regional jet airplanes, as

requested in Safety Recommendation A-07-1, would also enhance the high altitude

118 As previously stated, Bombardier issued an all operator message to remind pilots of the importance

of adhering to prescribed performance charts when operating at high altitudes and to inform them that

climbing at a too-slow airspeed might result in performance deterioration once altitude is achieved. Pinnacle

Airlines revised its FCOM to limit the minimum climb speed above 10,000 feet to 250 knots/0.70 Mach,

whichever was lower. The company also placed altitude and climb capability charts into the Quick

Reference Handbook for easy access during flight and issued guidance to pilots regarding the need to limit

operation of the airplane to 37,000 feet or below. In addition, the company’s ground training now includes

additional emphasis on these issues in the performance and high altitude training segments and a

demonstration of these areas during simulator training. 

119 During the 1980s, about 80 percent of the pilots hired by all commercial airlines had military flight

training, but, according to the FAA in 2001, this number has decreased to about 40 percent.
Analysis 56 Aircraft Accident Report

training syllabuses for all other transport-category jet airplanes and, if so, require that

these changes be incorporated into the syllabuses for those airplanes. 

2.3.2 Stall Recognition and Recovery Training

The stall recognition and recovery training at Pinnacle Airlines, as well as

elsewhere in the aviation industry, focuses on approach to stalls and recovery with

minimum loss of altitude. Because most stalls occur when the airplane is maneuvering at

lower altitudes,120 recoveries are practiced during training by applying power to restore

the energy state of the airplane and maintaining pitch. Although this strategy can be

effective at lower altitudes where the airplane has excess thrust, it is not effective when the

airplane is at high altitudes, as demonstrated by the circumstances of this accident, or

when a full stall has developed with resulting disruption of airflow to the engines, as

demonstrated by the circumstances of the 1996 ABX Air accident in Narrows, Virginia.121

After the accident, Pinnacle Airlines added to its simulator training a high altitude

buffet demonstration that emphasizes the need to get the airplane’s nose down to increase

airspeed when engine thrust is marginal. Also, Bombardier’s all operator message that

was issued after the accident stated, in part, the following: “in the event that a stick

shaker/approach to stall occurs, the crew should expect that a deliberate loss of altitude

will likely be required to restore the aircraft to a normal energy state and to prevent an

aerodynamic stall and possible departure from controlled flight.” The Safety Board

concludes that, because most training for stalls occurs with the airplane at low altitudes,

the training methods may introduce a bias in stall recovery techniques by encouraging

pilots to minimize altitude loss and not fully recognizing other available recovery

techniques. Therefore, the Safety Board believes that the FAA should require that air

carriers provide their pilots with opportunities to practice high altitude stall recovery

techniques in the simulator during which time the pilots demonstrate their ability to

identify and execute the appropriate recovery technique.

Another factor that might have contributed to the improper control inputs during

the stall event was the flight crew’s unfamiliarity with the stickpusher system on this

airplane. The crew would have been exposed to stickpusher activation during systems

training and the first-flight-of-the-day operational checks of the system, and, in the case of

the accident flight, the crew experienced the system’s activation during one of the pitch-up

maneuvers made during the climb. However, it is unclear the extent to which either pilot

120 At the time of the accident, Pinnacle Airlines conducted its stall recognition and recovery simulator

training at an altitude of 10,000 feet.

121 During that accident investigation, the Safety Board found that the flying pilot applied inappropriate

control column back pressure during the stall recovery attempt and that his performance of the stall recovery

procedure, which was established in the company’s operations manual, was inadequate. In its final report on

the accident, the Safety Board stated that the probable causes included “the inappropriate control inputs

applied by the flying pilot during a stall recovery attempt” and “the failure of the nonflying

pilot-in-command to recognize, address, and correct these inappropriate control inputs.” For more

information, see National Transportation Safety Board, Uncontrolled Flight Into Terrain, ABX Air (Airborne

Express), Douglas DC-8-63, N827AX, Narrows, Virginia, December 22, 1996, Aircraft Accident Report

NTSB/AAR-97/05 (Washington, DC: NTSB, 1997).
Analysis 57 Aircraft Accident Report

had experience with the stickpusher system during simulator training because the industry

standard for stall training was to initiate recovery at the onset of the stickshaker, which,

during a proper recovery, would preclude stickpusher activation. 

During the Safety Board’s public hearing on this accident, a Bombardier training

pilot testified that he had seen pilots during training respond incorrectly to stickpusher

activation because “they are scared, and they don’t know what to do [or] how to react.”

He added, “proper training is a huge factor, to make sure that if you end up on a pusher,

this is what you need to do.”

The Safety Board acknowledges that additional training may be required to

improve pilot response to stickpusher activation. However, current training protocols and

FAA standards train pilots to initiate stall recovery before stickpusher activation. As a

result, there may be unintended consequences and negative transfer associated with the

inclusion of stickpusher training into simulator training protocols without careful and

deliberate study. Because of these concerns, the Safety Board concludes that additional

training might improve pilot response to stickpusher activation, but such training, if not

provided correctly, could have an adverse impact on existing stall recognition and

recovery protocols. Therefore, the Safety Board believes that the FAA should convene a

multidisciplinary panel of operational, training, and human factors specialists to study and

submit a report on methods to improve flight crew familiarity with and response to

stickpusher systems and, if warranted, establish training requirements for

stickpusher-equipped airplanes based on the findings of this panel.

2.3.3 Double Engine Failure Training

At the time of the accident, double engine failure scenarios were not practiced

during Pinnacle Airlines’ simulator training. After the accident, the company incorporated

a double engine failure scenario into its simulator training syllabus. During this scenario,

a double engine failure occurs at an altitude of 35,000 feet, and flight crews are required to

use the windmill restart procedure to relight the engines. The Pinnacle Airlines CRJ

program manager stated that this scenario would help familiarize the crew with the

emergency power-only procedures and the effects of an ADG deployment.

Also, in May 2005, Pinnacle Airlines made changes to its double engine failure

checklist based on the changes made by Bombardier earlier that month. These changes

highlighted the airspeeds required for the procedure. For example, the revised checklist

stated that a minimum (rather than target) airspeed of 240 knots must be maintained until

the pilot was ready to restart the engines. Also, the changes indicated that 300 knots or

greater was required to achieve a sufficient N2 for the windmill restart and that this

airspeed must be maintained until at least one engine was restarted or restart attempts were

abandoned. Further, the revised checklist recognized the need to sacrifice altitude for

airspeed by indicating that the 5,000-foot altitude loss that could be expected when

accelerating from 240 to 300 knots might require pitch attitudes of 10o AND and that

pilots should start accelerating to achieve 300 knots at an altitude of 21,000 feet.
Analysis 58 Aircraft Accident Report

In addition, Pinnacle Airlines’ revised double engine failure checklist placed the

following information in a box labeled “CAUTION”: “failure to maintain positive N2 may

preclude a successful relight. If required, increase airspeed to maintain N2 indication.”

According to the FAA’s guidance on checklist design,122 a caution is defined as “an

instruction concerning a hazard that if ignored could result in damage to an aircraft

component or system – which would make continued safe flight improbable.” The FAA’s

guidance defines a warning as “an instruction about a hazard that, if ignored, could result

in injury, loss of aircraft control, or loss of life.” Because of the circumstances of this

accident, the Safety Board questions the appropriateness of placing information about the

consequences of not maintaining positive N2 into a cautionary note when the FAA’s

definitions suggest that a warning box would be a more appropriate transmission of that

information to pilots.

Pinnacle Airlines’ revised simulator training provides company pilots with an

opportunity to reinforce the knowledge they obtained in ground school on the double

engine failure checklist items, and the company’s revised checklist generally highlights

the information that is necessary for pilots to successfully perform the double engine

failure procedure. The Safety Board concludes that some of the changes made by

Pinnacle Airlines to its double engine failure training and checklist guidance would

benefit pilots at other air carriers that operate the CRJ because such training would

provide pilots with the opportunity to practice double engine failure restart procedures in

the simulator and the guidance would ensure that pilots were aware of the minimum

airspeeds needed during the procedures. Therefore, the Safety Board believes that the

FAA should verify that all CRJ operators incorporate guidance in their double engine

failure checklist that clearly states the airspeeds required during the procedure and require

the operators to provide pilots with simulator training on executing this checklist. 

2.4 Flight Crew Professionalism

2.4.1 Part 91 Operations

As stated in section 2.2.5, the accident flight, a Part 91 repositioning flight with no

passengers or other crewmembers on board, presented the pilots with an opportunity to

aggressively maneuver the airplane and operate it at the CRJ maximum operating altitude.

Section 2.2.5 also noted that these behaviors were examples of optimizing violations,

which occur when someone disregards defined procedures intentionally to make a job

more interesting or engaging, to push limits, or to impress another. Although Pinnacle

Airlines had protections in place for minimizing errors and unprofessional behavior

during line operations,123 the company did not have effective protections in place for

preventing optimizing violations during Part 91 operations. For example, even though the

122 Federal Aviation Administration, Human Performance Considerations in the Use and Design of

Aircraft Checklists (Washington, DC: FAA, 1995).

123 These protections included pilot selection criteria, pilot training, company policies and procedures,

and pilot oversight (line checks and pilot reports).
Analysis 59 Aircraft Accident Report

accident pilots were generally described favorably by instructors, check airmen, and other

pilots,124 the FAA’s operations supervisor of the Memphis FSDO stated, during the Safety

Board’s public hearing on the accident, that, before this accident, “we had no idea that

anybody would ever switch seats during a flight and not operate in accordance with the

standard operating procedures for the company.”125

After the accident, Pinnacle Airlines began to review FDR data for all nonrevenue

flights.126 The company’s decision to examine FDR data from these flights directly

addressed the vulnerability of these operations to optimizing violations. During the Safety

Board’s public hearing for this accident, the company’s chief pilot stated that the review of

FDR data would serve as oversight for Part 91 flights because “the pilots will know that

they’re being monitored.” Also, the company’s vice president of safety and regulatory

compliance testified, “we want to make sure the aircraft is being operated in non-revenue

operations exactly the way it’s being operated in [Part] 121 operations.” 

During the investigation of this accident, a management pilot from another

company with a CRJ fleet stated that “repositioning flights seemed to bring out the worst

in their company’s pilots.” This pilot also stated that a review of FDR data from his

company’s repositioning flights showed that high bank angles and steep descents occurred

often and that pilots were taking the opportunity to perform excessive maneuvers that they

could not perform with passengers on board. 

The Safety Board investigated an April 1993 accident in which an airplane

operated by two GP Express Airlines pilots (with no passengers or other crewmembers

aboard) crashed during a Part 91 training flight while the pilots were attempting to execute

a prohibited aerobatic maneuver at night. The Board determined that the probable causes

of that accident included the pilots’ deliberate disregard for company and Federal

124 There were a few exceptions to these favorable comments. For example, the simulator instructor

who conducted part of the captain’s upgrade training stated that, in addition to the captain’s problems

performing checklists in accordance with company procedures (as discussed in section 2.2.3.1), his biggest

weaknesses were his critical decision-making and judgment. Also, the first officer was described as average

by the captain who flew with him during his last trip before the accident flight.

125 The Safety Board notes that, during the investigation of the January 1983 takeoff accident at DTW

involving United Airlines flight 2885 (a cargo flight), the Board determined that the second officer had

occupied the seat of the first officer and conducted the takeoff. The Board also determined that, on the basis

of postaccident interviews with United Airlines pilots, seat swapping was not a prevalent practice at the

airline. In its final report on this accident, the Board stated its concern about the flight crew’s “disregard of

federal and company rules and regulations.” The Board determined that the probable cause of the accident

included the flight crew’s failure to follow procedural checklist requirements. Contributing to the cause of

the accident was the captain’s decision to allow the second officer, who was not qualified to act as a pilot, to

occupy the seat of the first officer and to conduct the takeoff. For more information, see National

Transportation Safety Board, United Airlines Flight 2885, Detroit, Michigan, January 11, 1983, N8053U,

McDonnell Douglas DC-8-54F, Aircraft Accident Report NTSB/AAR-83/07 (Washington, DC: NTSB,

1983).

126 In October 2006, Pinnacle Airlines stated that it was sampling random Part 91 flights and that a

review of these data showed no abnormalities associated with these flights. 
Analysis 60 Aircraft Accident Report

procedures and the company’s failure to instill in their pilots professionalism that is

consistent with the highest levels of safety.127

The circumstances of the Pinnacle Airlines and the GP Express Airlines accidents

and the statements of a management pilot from another company with a CRJ fleet

demonstrate the opportunity for pilots to behave unprofessionally during Part 91

operations that are conducted without passengers or other crewmembers. Even when

protections are in place to mitigate risks during regional airline operations, unprofessional

behavior by pilots during Part 91 flights still occurs for multiple reasons, including the

perception of a low risk of detection. 

The airplanes used by regional airlines are lighter, smaller, and more agile than

those used by larger air carrier operators, which may increase the potential for

unprofessional behavior during Part 91 flights. For regional operators that have the ability

to download FDR data, routine monitoring of Part 91 flights can be an effective method to

ensure that the flights are conducted according to standard operating procedures. For

those operators that do not have the ability to review FDR data from Part 91 flights,

alternative methods to mitigate risk include specific guidance to pilots on the expectations

of performance for these flights and additional oversight for flight crews conducting the

flights. 

The Safety Board concludes that more scrutiny of regional air carrier pilots during

nonrevenue flights would minimize the opportunity for unprofessional behavior to occur.

Therefore, the Safety Board believes that the FAA should require regional air carriers

operating under 14 CFR Part 121 to provide specific guidance on expectations for

professional conduct to pilots who operate nonrevenue flights. The Safety Board further

believes that, for those regional air carriers operating under 14 CFR Part 121 that have the

capability to review FDR data, the FAA should require that the air carriers review FDR

data from nonrevenue flights to verify that the flights are being conducted according to

standard operating procedures.

2.4.2 Industrywide Issues

In addition to the Pinnacle Airlines accident, the Safety Board has investigated

recent accidents involving the lack of cockpit discipline and adherence to standard

operating procedures. These accidents include the following:

• Corporate Airlines flight 5966, Kirksville, Missouri, October 19, 2004. The

flight crew did not follow established procedures for a nonprecision approach

at night in instrument meteorological conditions, did not adhere to the

127 National Transportation Safety Board, Controlled Flight Into Terrain, GP Express Airlines, Inc.,

N115GP, Beechcraft C-99, Shelton, Nebraska, April 28, 1993, Aircraft Accident Report NTSB/AAR-94/01

SUM (Washington, DC: NTSB, 1994).
Analysis 61 Aircraft Accident Report

established division of duties between the flying and nonflying pilot, and did

not adhere to the sterile cockpit rule.128

• Air Tahoma flight 185, Covington, Kentucky, August 13, 2004. The captain

did not follow crossfeed procedures for balancing the fuel in the airplane’s fuel

tanks, which led to fuel starvation in the left tank.129

• Executive Airlines flight 5401, San Juan, Puerto Rico, May 9, 2004. The

captain failed to execute proper techniques to recover from bounced landings

and failed to execute a go-around.130

• Aviation Charter King Air A100, Eveleth, Minnesota, October 25, 2002. The

flight crew was not adhering to company approach procedures and was not

effectively applying CRM techniques during the approach segment of the

flight.131

• Federal Express Flight 1478, Tallahassee, Florida, July 26, 2002. The flight

crew failed to adhere to company procedures for flying and monitoring a

stabilized approach.132

Pilots and operators have responsibility for a flight crew’s cockpit discipline and

adherence to standard operating procedures, as discussed in sections 2.4.2.1 and 2.4.2.2. 

2.4.2.1 Pilot Responsibilities

The Safety Board has long been concerned about issues of crew professionalism

and adherence to standard operating procedures. For example, on October 8, 1974, as a

result of several fatal air carrier accidents involving pilot performance (as described in

section 1.18.3.2), the Board issued Safety Recommendation A-74-85, which asked the

FAA to initiate a movement among pilot associations to form new, and regenerate old,

professional standards committees to promote crew discipline and professionalism. (The

Safety Board classified Safety Recommendation A-74-85 “Closed—Acceptable Action”

on March 10, 1977.)

128 In its final report on this accident, the Safety Board concluded that the pilots’ nonessential

conversation below 10,000 feet msl “was contrary to established sterile cockpit regulations and reflected a

demeanor and cockpit environment that fostered deviation from established standard procedures, crew

resource management discipline, division of duties, and professionalism, reducing the margin of safety well

below acceptable limits during the accident approach and likely contributing to the pilots’ degraded

performance.” For more information, see NTSB/AAR-06/01.

129 National Transportation Safety Board, Crash During Approach to Landing, Air Tahoma, Inc.,

Flight 185, Convair 580, N586P, Covington, Kentucky, August 13, 2004, Aircraft Accident Report

NTSB/AAR-06/03 (Washington, DC: NTSB, 2006).

130 National Transportation Safety Board, Crash During Landing, Executive Airlines (doing business as

American Eagle) Flight 5401, Avions de Transport Regional 72-212, N438AT, San Juan, Puerto Rico,

May 9, 2004, Aircraft Accident Report NTSB/AAR-05/02 (Washington, DC: NTSB, 2005).

131 National Transportation Safety Board, Loss of Control and Impact With Terrain, Aviation Charter,

Inc., Raytheon (Beechcraft) King Air A100, N41BE, Eveleth, Minnesota, October 25, 2002, Aircraft

Accident Report NTSB/AAR-03/03 (Washington, DC: NTSB, 2003).

132 National Transportation Safety Board, Collision With Trees on Final Approach, Federal Express

Flight 1478, Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002, Aircraft Accident Report

NTSB/AAR-04/02 (Washington DC: NTSB, 2004).
Analysis 62 Aircraft Accident Report

Most pilot unions have professional standards committees, which are peer

consultation programs that are designed to, among other things, provide counseling and

support to pilots who have demonstrated behavior that might adversely affect their ability

to perform their duties in a professional manner. Trained volunteer pilots who are

members of these committees provide peer support, counseling, intervention, and

mediation to pilots at the airlines that the unions represent. Airline pilots can seek these

services on their own, or they can be referred to the professional standards committee by,

for example, company managers who have become aware of a potential problem.

Pilot union professional standards committees appear to be an effective structure to

help promote and ensure professionalism among pilots. However, not all air carrier pilots

have access to these professional standards committees. For those pilots without such

access, communications about the importance of professionalism can be delivered through

company and FAA personnel.

It is clear, on the basis of the overall safety and reliability of the National Airspace

System, that most pilots conduct operations with a high degree of professionalism.

Nevertheless, a problem still exists in the aviation industry with some pilots acting

unprofessionally and not adhering to standard operating procedures, as demonstrated by

the recent accidents investigated by the Safety Board that are cited in section 2.4.2.

After a series of six accidents between October and November 2004, the FAA

issued Notice N8000.296, “Pilot Judgment and Decisionmaking” (see section 1.18.4). The

notice, among other things, highlighted the pilot’s role in ensuring safety of flight.

Specifically, the notice recommended that individual pilots examine their own

decision-making habits in terms of professionalism, thoroughness of preparation, and

adherence to standard operating procedures. The FAA stated that it has since incorporated

soft skills into Part 121 CRM training requirements and that a rewrite of FAA

Order 8400.10, Air Transportation Operations Inspector’s Handbook, would emphasize

soft skills. 

Pilots are ultimately responsible for safely conducting a flight and for recognizing

the importance of adhering to standard operating procedures and acting professionally.

Although broad, systemwide interventions can be applied to help address the problem of

pilots not adhering to standard operating procedures or acting unprofessionally, the most

direct intervention is to address any deficiencies in these areas at the level of the pilot.

Because pilot unions have expertise in safety, training, and operations and have a vested

interest in advancing professional standards among the pilots they represent, these groups

are well positioned to take a leadership role to establish new educational approaches for

reinforcing professionalism in the aviation industry. The Safety Board concludes that

providing additional education to pilots on the importance of professionalism could help

reduce the instances of pilots not maintaining cockpit discipline or not adhering to

standard operating procedures. Therefore, the Safety Board believes that the FAA should

work with pilot associations to develop a specific program of education for all air carrier

pilots that addresses professional standards and their role in ensuring safety of flight. The

program should include associated guidance information and references to recent
Analysis 63 Aircraft Accident Report

accidents involving pilots acting unprofessionally or not following standard operating

procedures. 

2.4.2.2 Operator Responsibilities

Operators also are responsible for monitoring their pilots’ adherence to standard

operating procedures and reinforcing expectations for professional standards of behavior.

Operators have traditionally identified nonstandard performance in line operations during

checkrides or line observations conducted by company check airmen or management

personnel. A problem with this method of oversight is that pilots might perform

differently during a checkride or a line observation because of the presence of a company

check airman in the cockpit.

To help evaluate pilot performance during line operations, air carriers can

implement voluntary safety programs, such as the FOQA program. This program is

especially well suited for detecting exceedances that may occur during flight, such as high

bank angles and unstabilized approaches, and assessing whether crews are conducting

flights according to standard operating procedures. However, the FOQA program requires

equipment and support structures that some air carriers may not be able to maintain, such

as the capability to download FDR data. According to the FAA, as of November 2006,

18 air carriers operating under Part 121 had implemented approved FOQA programs.

Another FAA-approved, voluntary safety program is the Aviation Safety Action

Program (ASAP). This program encourages pilots to report safety concerns in a

nonpunitive environment, which allows the air carrier and the FAA to act on this

information before an accident or an incident occurs.133 Although an ASAP does not have

the technical requirements associated with a FOQA program, an ASAP depends on the

willingness of pilots to voluntarily submit reports about other pilots or themselves. The

FAA stated that, as of November 2006, it had accepted 51 ASAP memorandums of

understanding for pilots.134 (Of these ASAP memorandums of understanding, 49 were for

Part 121 operators, and 2 were for Part 135 operators.)

In addition to the FOQA program and the ASAP, operators can assess pilot

performance during line operations with the Line Operations Safety Audit (LOSA), which

was developed in 1994 through FAA-sponsored research, known as the Human Factors

Research Project, at the University of Texas at Austin.135 The LOSA program is an

observational process that assesses CRM practices, the management of threats to safety,

and human error during flight operations. Trained personnel associated with the project

conduct line observations under conditions of confidentiality so that the operator is

provided only with details of the observations and no information about the pilots who

133 At the time of the June 2005 public hearing, Pinnacle Airlines had committed to establishing an

ASAP for its pilots. In October 2006, the company reported that it was operating an FAA-approved ASAP

for its pilots. 

134 The ASAP also includes dispatchers, flight attendants, and mechanics. Pinnacle Airlines reported

that it planned to expand its ASAP to the company’s maintenance department during 2007. 

135 For more information, see <http://homepage.psy.utexas.edu/homepage/group/HelmreichLAB>.
Analysis 64 Aircraft Accident Report

were involved. As a result, in contrast to a company line check, LOSA observations do

not result in adverse actions against pilots who did not perform well during their

observation. 

LOSA methodology is well suited to assess the soft skills used by air carrier pilots

(see section 1.18.4), and the observations can be used to identify intentional deviations

from standard operating procedures or prescribed rules and allow the operator to identify

reasons for these deviations. Notably, LOSA can address and document these issues to a

greater extent than the FOQA program or the ASAP because, as previously stated, FOQA

programs require the capability to download FDR data and an ASAP requires the

willingness of pilots to submit reports about fellow pilots or themselves.136 Also, LOSA

observations have identified rule violations and deviations from procedures, which

suggests that the pilots being observed do not view the LOSA observers as a threat (as

they might view company check airmen) and would be likely to perform in the same

manner as they would without an observer present.

After the accident, and as a result of a high initial failure rate for upgrading

captains before the accident (see section 1.17.1.6), Pinnacle Airlines made several

changes to its training program to address professionalism. These changes included

increasing the minimum number of hours (from 10 to 25) that are required for upgrade

operational experience, restructuring CRM training to provide additional focus on

decision-making and the need to adhere to standard operating procedures, and placing

additional emphasis on leadership during upgrade training. However, the effectiveness of

these changes in increasing professionalism, leadership, and adherence to standard

operating procedures would be difficult to evaluate fully without LOSA observations.137

On April 27, 2006, the FAA issued Advisory Circular (AC) 120-90, Line

Operations Safety Audits. The AC provides the rationale and procedures for conducting a

LOSA observation at an air carrier and explains that the program is distinct from, but

complementary to, the FOQA program and the ASAP. By incorporating LOSA

observations into their internal oversight programs, Part 121 air carriers would have

another method to monitor their pilots’ adherence to standard operating procedures and

standards of professionalism. The Safety Board concludes that LOSA observations can

provide operators with increased knowledge about the behavior demonstrated by pilots

during line operations. Therefore, the Safety Board believes that the FAA should require

that all 14 CFR Part 121 operators incorporate into their oversight programs periodic

LOSA observations and methods to address and correct findings resulting from these

observations. 

In addition to the need for air carriers to incorporate LOSA observations into their

oversight methods, air carriers need to ensure safety through a formalized system safety

136 Despite these issues, the Safety Board recognizes that the FOQA program and the ASAP provide air

carriers with valuable information about the quality of their operations.

137 The LOSA program samples all activities in normal operations, whereas the FOQA program and the

ASAP rely on outcomes (flight parameter exceedances and adverse pilot-reported events, respectively) to

generate data.
Analysis 65 Aircraft Accident Report

process. One such process is a safety management system (SMS) program, which

incorporates proactive safety methods for air carriers to identify hazards, mitigate risk,

and monitor the extent that the carriers are meeting their objectives. Program components

include safety policy, safety risk management, safety assurance, and safety promotion.

Tools such as the FOQA, ASAP, and LOSA programs are relevant to the safety assurance

component of an SMS program because they provide a direct means for air carriers to

evaluate the quality of their training and operations. These tools can also be used in the

safety risk management component of an SMS program because they can help uncover

hazards to system operation.

SMS program initiatives have been developed in the international aviation

industry. For example, the European Joint Aviation Authorities recommend, but do not

require, air carriers to establish an SMS program. Also, in June 2005, Transport Canada

passed regulations requiring that air carriers operating under Canadian Aviation

Regulations Part 705 (Part 121 equivalent) fully implement an approved SMS program by

September 2008. In addition, International Civil Aviation Organization (ICAO) Annex 6,

“Operation of Aircraft,” states the following: “from January 1, 2009, [Member] States

shall require, as part of their safety program, that an operator implements a safety

management system acceptable to the State of the Operator that, at a minimum:

(a) identifies safety hazards; (b) ensures that remedial action necessary to maintain an

acceptable level of safety is implemented; (c) provides for continuous monitoring and

regular assessment of the safety level achieved; and (d) aims to make continuous

improvement to the overall level of safety.”138

In June 2006, the FAA published AC 120-92, “Introduction to Safety Management

Systems for Air Operators.” The AC provides guidance for SMS program development

for air carriers and others in the aviation industry. The guidance was based on the FAA’s

review of existing SMS programs worldwide, its own internal SMS programs, and other

system safety approaches. An appendix to the AC contains a listing of functional

requirements for operators to use as minimum standards when creating an SMS program.

During a December 14, 2006, briefing to the Safety Board, the FAA stated that it

intended to comply with the ICAO requirement for Member States to require that

operators implement an SMS program by January 1, 2009. A rulemaking project team has

been formed, and the rulemaking project team leader stated that the team’s first meeting

was held in December 2006. In addition to these initial rulemaking activities, the FAA

stated that it planned to initiate a series of SMS proof-of-concept trials in late 2007.

During these trials, the FAA intends to work with a few operators that have voluntarily

implemented SMS to gather the data needed for additional guidance material and to

support the agency’s rulemaking efforts. The Board is encouraged by the FAA’s initial

activities to implement an SMS program. However, until the FAA issues a notice of

proposed rulemaking, the Board cannot fully evaluate whether the FAA will meet ICAO’s

minimum requirements for an SMS program. 

138 In November 2005, ICAO asked Member States to provide the organization with information about

the development of SMS programs. During 2006, ICAO published a safety management manual that

addressed concepts and processes required to implement an SMS program.
Analysis 66 Aircraft Accident Report

Historically, the FAA’s approach to its oversight of air carriers has emphasized

surveillance to ensure regulatory compliance. However, in 1998, the FAA established the

Air Transportation Oversight System (ATOS), a systems safety approach to air carrier

oversight. The ATOS program was initially deployed at the 10 largest U.S. air carriers.

The benefits of the ATOS program’s system safety approach to air carrier oversight,

compared with the oversight conducted as part of the National Work Program

Guidelines,139 include a more integrated approach to oversight that better identifies risks

to system safety and a more effective allocation of oversight resources to problem areas.140

The Safety Board has previously expressed concerns about the ATOS program. In

its March 12, 2001, letter to the FAA about Safety Recommendation A-98-51,141 the

Board stated its concern that the FAA had not addressed how the ATOS program would

ensure that systemic problems were identified and corrected before they resulted in an

accident. As a result, the Board classified Safety Recommendation A-98-51 “Open—

Unacceptable Response.” Also, in its report on the Alaska Airlines accident, the Board

addressed its concerns about ATOS implementation and the program’s ability to detect

problem areas.142

Other concerns about the FAA’s implementation of ATOS have been noted. For

example, according to a Government Accountability Office (GAO) report,143 the FAA’s

ATOS transition plan, dated March 1, 2004, did not set dates beyond fiscal year 2005 for

moving additional air carriers to the ATOS program, and, as of September 2005, 15 air

carriers were under the ATOS program. Also, the GAO testified in November 2005 that

the National Work Program Guidelines were still being used at those passenger airlines

that were not covered under ATOS.144

The FAA acknowledged that staffing and budgetary resources were affecting

ATOS deployment. During October 2005, the FAA initiated its System Approach for

Safety Oversight CFR Part 121 Pilot Project. The objectives of the project are to revise

ATOS so that the program can handle all Part 121 air carriers; provide new policies,

processes, and tools for measuring safety; and roll out the latest version of the ATOS

program to all Part 121 air carriers by December 31, 2007.145 The FAA stated that

139 The National Work Program Guidelines are part of a traditional inspection program to ensure that

airlines comply with safety regulations. The guidelines have been in effect since 1985.

140 To apply some benefits of the system safety approach used in the ATOS program to those air carriers

that were not covered by ATOS, the FAA deployed the Surveillance and Evaluation Program during 2002 to

augment the oversight conducted as part of the National Work Program Guidelines. 

141 This recommendation, which was issued as a result of the Safety Board’s investigation of the

August 7, 1997, Fine Airlines flight 101 accident, can be found on the Board’s Web site. 

142 National Transportation Safety Board, Loss of Control and Impact With Pacific Ocean, Alaska

Airlines Flight 261, McDonnell Douglas MD-83, N963AS, About 2.7 Miles North of Anacapa Island,

California, January 31, 2000, Aircraft Accident Report NTSB/AAR-02/01 (Washington, DC: NTSB, 2002).

143 Government Accountability Office, Aviation Safety: System Safety Approach Needs Further

Integration Into FAA’s Oversight of Airlines, GAO-05-726 (Washington, DC: GAO, 2005)

144 Government Accountability Office, Aviation Safety: FAA’s Safety Oversight System Is Effective but

Could Benefit From Better Evaluation of Its Programs’ Performance, GAO-06-266T (Washington, DC:

GAO, 2005). 
Analysis 67 Aircraft Accident Report

preparations were underway to keep this transition on schedule. Even if this project is

completed according to its intended timetable, it will still take time to determine whether

ATOS is an effective oversight method. 

The Safety Board is concerned about the delay in deploying ATOS to additional

Part 121 air carriers because they are not receiving the benefits of a system safety

approach to oversight.146 Although the ATOS and SMS programs are complementary and

are designed to work in an integrated manner, an air carrier does not need to be under

ATOS oversight to effectively develop its own SMS program. The FAA’s initial guidance

in AC 120-92 should facilitate the process of developing and implementing an SMS

program. Existing voluntary system safety tools, such as the FOQA, ASAP, and LOSA

programs, have demonstrated their effectiveness in monitoring flight operations and are

considered integral safety assurance components to an SMS program, but these programs

do not have universal application in the aviation industry. The Safety Board concludes

that all air carriers would benefit from SMS programs because they would require the

carriers to incorporate formal system safety methods into the carriers’ internal oversight

programs. Therefore, the Safety Board believes that the FAA should require that all

14 CFR Part 121 operators establish SMS programs. 

The Safety Board acknowledges that it may take time for the FAA to complete

SMS rulemaking and for air carrier SMS programs to become fully operational. In its

review of air carriers with FOQA programs at the end of 2006, the Board found that,

besides Pinnacle Airlines, only one other regional air carrier had a FOQA program. (The

Board is aware of at least one other regional air carrier that is working toward

implementing a FOQA program.) Although system safety tools such as FOQA and ASAP

have demonstrated safety benefits, the Board is concerned that these programs are not

used more widely by regional air carriers. Because of the limited number of regional air

carriers in the lists of approved ASAP and FOQA programs, the Safety Board concludes

that the establishment of an ASAP and a FOQA program at regional air carriers would

provide the carriers with a means to evaluate the quality of their operations. Therefore, the

Safety Board believes that the FAA should strongly encourage and assist all regional air

carriers operating under 14 CFR Part 121 to implement an approved ASAP and an

approved FOQA program. 

145 For more information, see System Approach for Safety Oversight Program Update, dated

July 7, 2006, at <http://www.faa.gov/safety/programs_initiatives/oversight/saso/update>. Also, in

December 2006, the FAA stated that 46 air carriers operating under Part 121 were under the ATOS program.

146 The Safety Board notes that some air carriers that are not covered under ATOS, including Pinnacle

Airlines, have begun using ATOS job aids and inspection guidelines generated for FAA inspectors in their

own internal audit programs. 
Analysis 68 Aircraft Accident Report

2.5 Quality of Flight Data Recorder Data for Regional

Jet Airplanes

On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the

FAA because of problems with the quality of FDR data recorded by several regional jet

airplanes. Safety Recommendation A-03-15 asked the FAA to do the following:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair

Challenger CL-600, and Fairchild Dornier 328-300 airplanes[147] be modified with

a digital flight data recorder system that meets the sampling rate, range, and

accuracy requirements specified in 14 Code of Federal Regulations Part 121.344,

Appendix M.

On June 9, 2005, the FAA stated that Embraer had released an SB to correct known

FDR anomalies on the Embraer 145 and 135 and that the Brazilian Department of Civil

Aviation issued an AD that required incorporation of the Embraer SB within 18 months.

The FAA also stated that it planned to release a corresponding AD. In addition, the FAA

stated that it was working with Transport Canada to get expeditious action from

Bombardier regarding the problem of low update rates on the normal acceleration and

pitch attitude parameters for Canadair CL-600-2B19 (CRJ-100, -200, and -440) and

CL-600-2B16 (Challenger 604) airplanes. On September 28, 2005, the Safety Board

stated that, pending the FAA’s issuance of ADs that mandated correction to the Embraer

145 and 135 and CRJ-100, -200, and -440 and Challenger 604 FDR systems, Safety

Recommendation A-03-15 was classified “Open—Acceptable Response.” 

Since the time of the Pinnacle Airlines accident, the Safety Board has downloaded

FDR data from seven events involving CL-600-2B19 airplanes—the most recent of which

occurred on August 27, 2006.148 All of these downloads showed that the FDRs recorded

the vertical acceleration and pitch parameters from sources that did not meet the recording

intervals required by 14 CFR 121.344, Appendix M, as was the case with the FDR

installed on the Pinnacle Airlines accident airplane. 

In November 2006, Bombardier told the Safety Board that production of

Challenger 604 airplanes had ceased and that the Challenger 605 model had replaced the

Challenger 604 model. Bombardier also stated that the sampling rate problem had been

corrected in the FDRs installed on Challenger 605 airplanes. However, the Board notes

that Challenger 604 airplanes that are currently in service will still have FDRs with

sampling rate problems.

Bombardier further stated that, for FDRs installed on CRJ-100, -200, and -440

airplanes, the sampling rate problem would be corrected during the next applicable digital

147 As stated in section 1.18.3.3, on September 28, 2005, the Safety Board stated that no problems

existed with the FDR parameters on the Fairchild Dornier 328-300 airplane.

148 This FDR was installed aboard the Comair Airlines flight 5191 accident airplane, which crashed in

Lexington, Kentucky, after the pilots attempted to take off from the wrong runway. For information about

this accident, see DCA06MA064 at the Safety Board’s Web site at <http://www.ntsb.gov>.
Analysis 69 Aircraft Accident Report

control unit update, which was scheduled for the second or third quarter of 2007, and that

airplanes would be retrofitted within the 18 months that followed. Thus, if this schedule

were maintained, the sampling rate problem would not be fixed on all CL-600-2B19

airplanes until late 2008 or early 2009. Also, as of December 1, 2006, the FAA had not

issued an AD to correct FDR anomalies on Embraer 145 and 135 airplanes. The Safety

Board concludes that the parameter quality problems with the FDR systems installed on

Canadair CL-600-2B19, Challenger 604, and Embraer 145 and 135 airplanes need to be

corrected so that future investigations involving these airplane models are not hindered by

inaccurate or incomplete data. Therefore, the Safety Board reiterates Safety

Recommendation A-03-15. Further, the Board classifies Safety Recommendation A-03-15

“Open—Unacceptable Response.”
70 Aircraft Accident Report

3. Conclusions

3.1 Findings

1. The captain and the first officer were properly certificated and qualified under Federal

regulations. No evidence indicated any medical or behavioral conditions that might

have adversely affected their performance during the accident flight. Flight crew

fatigue and hypoxia were not factors in this accident.

2. The accident airplane was properly certified, equipped, and maintained in accordance

with Federal regulations. The recovered components showed no evidence of any

structural or system failures or any engine failures before the time of the upset event. 

3. Weather was not a factor in this accident. 

4. The accident was not survivable. 

5. The pilots’ aggressive pitch-up and yaw maneuvers during the ascent and their

decision to operate the airplane at its maximum operating altitude (41,000 feet) were

made for personal and not operational reasons. 

6. The flight crew’s inappropriate use of the vertical speed mode during the climb was a

misuse of automation that allowed the airplane to reach 41,000 feet in a critically low

energy state.

7. The improper airspeed during the climb demonstrated that the pilots did not

understand how airspeed affects airplane performance and did not realize the

importance of conducting the climb according to the published climb capability

charts. 

8. The upset event exposed both engines to inlet airflow disruption conditions that led to

engine stalls and a complete loss of engine power. 

9. The pilots’ lack of exposure to high altitude stall recovery techniques contributed to

their inappropriate flight control inputs during the upset event. 

10. The captain did not take the necessary steps to ensure that the first officer achieved

the 300-knot or greater airspeed required for the windmill engine restart procedure

and then did not demonstrate command authority by taking control of the airplane and

accelerating it to at least 300 knots. 
Conclusions 71 Aircraft Accident Report

11. The first officer’s limited experience in the airplane might have contributed to the

failed windmill restart attempt because he might have been reluctant to command the

degree of nose-down attitude that was required to increase the airplane’s airspeed to

300 knots. 

12. Despite their four auxiliary power unit-assisted engine restart attempts, the pilots

were unable to restart the engines because their cores had locked. Without core

rotation, recovery from the double engine failure was not possible.

13. The General Electric CF34-1 and CF34-3 engines had a history of failing to rotate

during in-flight restart attempts on airplanes undergoing production acceptance

testing at Bombardier.

14. Both engines experienced core lock because of the flameout from high power and

high altitude, which resulted from the pilot-induced extreme conditions to which the

engines were exposed, and the pilots’ failure to achieve and maintain the target

airspeed of 240 knots, which caused the engine cores to stop rotating; both of these

factors were causal to this accident.

15. The importance of maintaining a minimum airspeed to keep the engine cores rotating

was not communicated to the pilots in airplane flight manuals.

16. The captain’s previous difficulties in checklist management, the situational stress, and

the lack of simulator training involving a double engine failure contributed to the

flight crew’s errors in performing the double engine failure checklist.

17. The pilots’ failure to prepare for an emergency landing in a timely manner, including

communicating with air traffic controllers immediately after the emergency about the

loss of both engines and the availability of landing sites, was a result of their

intentional noncompliance with standard operating procedures, and this failure was

causal to the accident.

18. The pilots’ unprofessional operation of the flight was intentional and causal to this

accident because the pilots’ actions led directly to the upset and their improper

reaction to the resulting in-flight emergency exacerbated the situation to the point that

they were unable to recover the airplane.

19. Revised high altitude training syllabuses for pilots who operate regional jet airplanes

would help ensure that these pilots possess a thorough understanding of the airplanes’

performance capabilities, limitations, and high altitude aerodynamics.

20. Because most training for stalls occurs with the airplane at low altitudes, the training

methods may introduce a bias in stall recovery techniques by encouraging pilots to

minimize altitude loss and not fully recognizing other available recovery techniques.
Conclusions 72 Aircraft Accident Report

21. Additional training might improve pilot response to stickpusher activation, but such

training, if not provided correctly, could have an adverse impact on existing stall

recognition and recovery protocols.

22. Some of the changes made by Pinnacle Airlines to its double engine failure training

and checklist guidance would benefit pilots at other air carriers that operate the

Canadair regional jet because such training would provide pilots with the opportunity

to practice double engine failure restart procedures in the simulator and the guidance

would ensure that pilots were aware of the minimum airspeeds needed during the

procedures.

23. More scrutiny of regional air carrier pilots during nonrevenue flights would minimize

the opportunity for unprofessional behavior to occur.

24. Providing additional education to pilots on the importance of professionalism could

help reduce the instances of pilots not maintaining cockpit discipline or not adhering

to standard operating procedures.

25. Line Operations Safety Audit observations can provide operators with increased

knowledge about the behavior demonstrated by pilots during line operations.

26. All air carriers would benefit from Safety Management System programs because

they would require the carriers to incorporate formal system safety methods into the

carriers’ internal oversight programs.

27. The establishment of an Aviation Safety Action Program and a Flight Operational

Quality Assurance program at regional air carriers would provide the carriers with a

means to evaluate the quality of their operations.

28. The parameter quality problems with the flight data recorder systems installed on

Canadair CL-600-2B19, Challenger 604, and Embraer 145 and 135 airplanes need to

be corrected so that future investigations involving these airplane models are not

hindered by inaccurate or incomplete data.
Conclusions 73 Aircraft Accident Report

3.2 Probable Cause

The National Transportation Safety Board determines that the probable causes of

this accident were (1) the pilots’ unprofessional behavior, deviation from standard

operating procedures, and poor airmanship, which resulted in an in-flight emergency from

which they were unable to recover, in part because of the pilots’ inadequate training;

(2) the pilots’ failure to prepare for an emergency landing in a timely manner, including

communicating with air traffic controllers immediately after the emergency about the loss

of both engines and the availability of landing sites; and (3) the pilots’ improper

management of the double engine failure checklist, which allowed the engine cores to stop

rotating and resulted in the core lock engine condition. Contributing to this accident were

(1) the core lock engine condition, which prevented at least one engine from being

restarted, and (2) the airplane flight manuals that did not communicate to pilots the

importance of maintaining a minimum airspeed to keep the engine cores rotating.
74 Aircraft Accident Report

4. Safety Recommendations

4.1 New Recommendations

As a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations to the Federal Aviation Administration:

Work with members of the aviation industry to enhance the training

syllabuses for pilots conducting high altitude operations in regional jet

airplanes. The syllabuses should include methods to ensure that these pilots

possess a thorough understanding of the airplanes’ performance

capabilities, limitations, and high altitude aerodynamics. (A-07-1)

Determine whether the changes to be made to the high altitude training

syllabuses for regional jet airplanes, as requested in Safety

Recommendation A-07-1, would also enhance the high altitude training

syllabuses for all other transport-category jet airplanes and, if so, require

that these changes be incorporated into the syllabuses for those airplanes.

(A-07-2)

Require that air carriers provide their pilots with opportunities to practice

high altitude stall recovery techniques in the simulator during which time

the pilots demonstrate their ability to identify and execute the appropriate

recovery technique. (A-07-3)

Convene a multidisciplinary panel of operational, training, and human

factors specialists to study and submit a report on methods to improve

flight crew familiarity with and response to stickpusher systems and, if

warranted, establish training requirements for stickpusher-equipped

airplanes based on the findings of this panel. (A-07-4)

Verify that all Canadair regional jet operators incorporate guidance in their

double engine failure checklist that clearly states the airspeeds required

during the procedure and require the operators to provide pilots with

simulator training on executing this checklist. (A-07-5)

Require regional air carriers operating under 14 Code of Federal

Regulations Part 121 to provide specific guidance on expectations for

professional conduct to pilots who operate nonrevenue flights. (A-07-6)
Safety Recommendations 75 Aircraft Accident Report

For those regional air carriers operating under 14 Code of Federal

Regulations Part 121 that have the capability to review flight data recorder

(FDR) data, require that the air carriers review FDR data from nonrevenue

flights to verify that the flights are being conducted according to standard

operating procedures. (A-07-7)

Work with pilot associations to develop a specific program of education for

air carrier pilots that addresses professional standards and their role in

ensuring safety of flight. The program should include associated guidance

information and references to recent accidents involving pilots acting

unprofessionally or not following standard operating procedures. (A-07-8)

Require that all 14 Code of Federal Regulations Part 121 operators

incorporate into their oversight programs periodic Line Operations Safety

Audit observations and methods to address and correct findings resulting

from these observations. (A-07-9)

Require that all 14 Code of Federal Regulations Part 121 operators

establish Safety Management System programs. (A-07-10)

Strongly encourage and assist all regional air carriers operating under

14 Code of Federal Regulations Part 121 to implement an approved

Aviation Safety Action Program and an approved Flight Operational

Quality Assurance program. (A-07-11)

4.2 Previously Issued Recommendation Reiterated and 

Classified in This Report

The Safety Board reiterates the following recommendation to the Federal Aviation

Administration:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair

Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified

with a digital flight data recorder system that meets the sampling rate,

range, and accuracy requirements specified in 14 Code of Federal

Regulations Part 121.344, Appendix M. (A-03-15)

Further, Safety Recommendation A-03-15 (previously classified “Open—

Acceptable Response”) is classified “Open—Unacceptable Response” in section 2.5 of

this report. 

For information about this recommendation, see sections 1.18.3.3 and 2.5 of this

report. 
Safety Recommendations 76 Aircraft Accident Report

4.3 Previously Issued Recommendations Resulting 

From This Accident Investigation

As a result of the investigation into this accident, the Safety Board issued the

following recommendations to the Federal Aviation Administration on

November 20, 2006:

For airplanes equipped with CF34-1 or CF34-3 engines, require

manufacturers to perform high power, high altitude sudden engine

shutdowns; determine the minimum airspeed required to maintain

sufficient core rotation; and demonstrate that all methods of in-flight restart

can be accomplished when this airspeed is maintained. (A-06-70) 

Ensure that airplane flight manuals of airplanes equipped with CF34-1 or

CF34-3 engines clearly state the minimum airspeed required for engine

core rotation and that, if this airspeed is not maintained after a high power,

high altitude sudden engine shutdown, a loss of in-flight restart capability

as a result of core lock may occur. (A-06-71)

Require that operators of CRJ-100, -200, and -440 airplanes include in

airplane flight manuals the significant performance penalties, such as loss

of glide distance and increased descent rate, that can be incurred from

maintaining the minimum airspeed required for core rotation and windmill

restart attempts. (A-06-72)

Review the design of turbine-powered engines (other than the CF34-1 and

CF34-3, which are addressed in Safety Recommendation A-06-70) to

determine whether they are susceptible to core lock and, for those engines

so identified, require manufacturers of airplanes equipped with these

engines to perform high power, high altitude sudden engine shutdowns and

determine the minimum airspeed to maintain sufficient core rotation so that

all methods of in-flight restart can be accomplished. (A-06-73)

For those airplanes with engines that are found to be susceptible to core

lock (other than the CF34-1 and CF34-3, which are addressed in Safety

Recommendation A-06-71), require airplane manufacturers to incorporate

information into airplane flight manuals that clearly states the potential for

core lock; the procedures, including the minimum airspeed required, to

prevent this condition from occurring after a sudden engine shutdown; and

the resulting loss of in-flight restart capability if this condition were to

occur. (A-06-74)
Safety Recommendations 77 Aircraft Accident Report

Require manufacturers to determine, as part of 14 Code of Federal

Regulations Part 25 certification tests, if restart capability exists from a

core rotation speed of 0 indicated rpm after high power, high altitude

sudden engine shutdowns. For those airplanes determined to be

susceptible to core lock, mitigate the hazard by providing design or

operational means to ensure restart capability. (A-06-75)

Establish certification requirements that would place upper limits on the

value of the minimum airspeed required and the amount of altitude loss

permitted for windmill restarts. (A-06-76)

For additional information about these recommendations, see section 1.18.3.1 of

this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER

Chairman

ROBERT L. SUMWALT

Vice Chairman

DEBORAH A. P. HERSMAN

Member

KATHRYN O. HIGGINS

Member

STEVEN R. CHEALANDER

Member

Adopted: January 9, 2007

79 Aircraft Accident Report

5. Appendixes

Appendix A

Investigation and Hearing

Investigation

The National Transportation Safety Board was initially notified of this accident on

October 14, 2004, after air traffic controllers lost contact with the airplane. A go-team was

assembled and departed for Jefferson City, Missouri, on the morning of October 15, 2004,

and arrived on scene later that day. Accompanying the team to Jefferson City was former

Member Carol Carmody.

The following investigative teams were formed: Aircraft Operations, Human

Performance, Aircraft Structures, Aircraft Systems, Powerplants, Air Traffic Control,

Meteorology, Aircraft Performance, Maintenance Records, Cockpit Voice Recorder, and

Flight Data Recorder. While the investigative team was in Jefferson City, specialists were

assigned to conduct the readout of the flight data recorder and transcribe the recording

from the cockpit voice recorder at the Safety Board’s laboratory in Washington, D.C.

Parties to the investigation were the Federal Aviation Administration (FAA),

Pinnacle Airlines, the Air Line Pilots Association (ALPA), the National Air Traffic

Controllers Association, General Electric (GE) Engines, Honeywell, Hamilton Sunstrand,

and Rockwell Collins. In accordance with the provisions of Annex 13 to the Convention

on International Civil Aviation, the Transportation Safety Board of Canada (the Safety

Board’s counterpart agency in Canada) participated in the investigation as the

representative of the State of Design and Manufacture. Transport Canada and Bombardier

Aerospace participated in the investigation as technical advisors to the Transportation

Safety Board of Canada, as provided in Annex 13.

Public Hearing

A public hearing was held from June 13 to 15, 2005, in Washington, D.C. Member

Deborah A.P. Hersman presided over the hearing. The issues discussed at the public

hearing were aircraft and engine certification and operator and FAA oversight of flight

operations and flight crew training. Parties to the public hearing were the FAA, Pinnacle

Airlines, ALPA, Bombardier Aerospace, GE Engines, and Honeywell.
80 Aircraft Accident Report

Appendix B

Cockpit Voice Recorder

The following is the transcript of the Fairchild A100S cockpit voice recorder,

serial number 02804, installed on Pinnacle Airlines flight 3701, a Bombardier CL-600-

2B19, N8396A, which crashed in Jefferson City, Missouri, on October 14, 2004.

	


	

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B+G/9;"/:  /9;;9:/ 
143 Aircraft Accident Report

Appendix C

Pinnacle Airlines’ Double Engine Failure Checklist 

at the Time of the Accident
Appendix C 144 Aircraft Accident Report
Appendix C 145 Aircraft Accident Report
Appendix C 146 Aircraft Accident Report
Appendix C 147 Aircraft Accident Report
Appendix C 148 Aircraft Accident Report
149 Aircraft Accident Report

Appendix D

Pinnacle Airlines’ Revised Double Engine

Failure Checklist

 REVISION 8—MAY 31, 2005 EP 1-5

POWERPLANT EMERGENCIES

QUICK REFERENCE HANDBOOK

Northwest Airlink Pinnacle Airlines CANADAIR REGIONAL JET

CAUTION

Failure to maintain positive N2 may preclude a successful relight. If required, increase airspeed to maintain N2 indication.

6. Oxygen Masks (if required)................................................... DON 

7. Proceed to nearest suitable airport in preparation for a possible dead- stick landing.

8. APU (below 30,000 feet) ................................................... START 

9. APU GEN (if APU available) ................................................... ON 

Windmilling relight possible (requires airspeed of not less than 300 KIAS):

(From 21,000 feet or below)

9. Relight Using Windmilling Procedure

(See Page EP 1-6) ................................................. ACCOMPLISH

Maintain 240 KIAS until ready to initiate windmill

start.

(From 13,000 feet and below)

9. Relight Using APU Bleed Air Procedure

(See Page EP 1-8))................................................ ACCOMPLISH 

Maintain between 190 KIAS (51,000 pounds) and 170

KIAS ( 36,000 pounds).

 — CONTINUED — 

Double Engine Failure

1. CONT IGNITION .................................................................... ON 

If engines continue to run down:

2. Thrust Levers (both) .................................................... SHUT OFF 

3. ADG Manual Deploy Handle............................................... PULL 

When ADG power is established:

4. STAB TRIM CH 2.......................................................... ENGAGE 

5. Minimum Airspeed.................................................... ESTABLISH 

AIRPLANE FLIGHT LEVEL MINIMUM AIRSPEED

ABOVE FL 340 0.7 MACH

BELOW FL 340 240 KIAS

Maintain airspeed until ready to restart engines.

NO

? YES
Appendix D 150 Aircraft Accident Report

EP 1-6 REVISION 8—MAY 31, 2005

POWERPLANT EMERGENCIES

QUICK REFERENCE HANDBOOK

Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET

NOTE

An altitude loss of approximately 5,000 feet can be

expected when accelerating from 240 to 300 KIAS

and may require pitch attitudes of 10° nose down. If

possible, crews should start accelerating to achieve

300 KIAS upon reaching 21,000 feet.

Attempt to start both engines at the same time:

1. Airspeed................ ACCELERATE TO 300 KIAS OR GREATER 

CAUTION

300 KIAS or greater is required to achieve sufficient N2

for start. Airspeed must be maintained until at least one

engine relights (stable idle) or start attempts abandoned.

At 21,000 feet and below:

2. CONT IGNITION ................................................. CONFIRM ON 

3. L and R FUEL BOOST

PUMP Switches..................................................... CONFIRM ON 

When ITT is 90°C or less and N2 is: ● At least 12% (above 15,000 feet) or ● At least 9% (15,000 feet and below):

4. Thrust Levers (both) .............................................................. IDLE 

5. Engine Indications....................................................... MONITOR 

At least one engine relights within 25 seconds:

1. Thrust Lever(s) .................................................... AS REQUIRED 

2. Affected GEN............................................................. CHECK ON 

 Operative engine:

3. L AND/OR R 10th STAGE BLEED(s) ................. CHECK OPEN 

4. Applicable PACK(s) ................................................... CHECK ON 

 Reestablish normal power:

5. ADG Manual Deploy Handle.............................................. STOW 

6. ADG PWR TXFR....................................................... OVERRIDE 

7. Single Engine Procedures

(See Page AP 1-2)................................................. ACCOMPLISH 

IF REQUIRED

—END—

6. Thrust Levers................................................................ SHUTOFF 

 — CONTINUED — 

Double Engine Failure (Cont)

Relight using windmilling:

NO

? YES
Appendix D 151 Aircraft Accident Report

 AUGUST 1, 2002 EP 1-7

POWERPLANT EMERGENCIES

QUICK REFERENCE HANDBOOK

Northwest Airlink Pinnacle Airlines CANADAIR REGIONAL JET

Another windmilling relight attempt still possible: 

7. Airspeed ............................................................ 300 TO 335 KIAS 

8. Wait 30 seconds, then repeat relight procedure.

7. Relight using APU bleed air.

 — CONTINUED — 

Double Engine Failure (Cont)

Relight using windmilling:

NO

? YES
Appendix D 152 Aircraft Accident Report

EP 1-8 REVISION 8—MAY 31, 2005

POWERPLANT EMERGENCIES

QUICK REFERENCE HANDBOOK

Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET

 From 13,000 feet and below:

1. Target airspeed...................................................... REESTABLISH 

AIRPLANE WEIGHT TARGET BEST GLIDE SPEED

51,000 lb 190 KIAS

36,000 lb 170 KIAS

2. CONT IGNITION ................................................. CONFIRM ON

3. L and R FUEL BOOST PUMP Switches............. CONFIRM ON 

4. ANTI-ICE, WING and COWL Switches ....................... ALL OFF 

5. L and R 10th STAGE BLEED Switches ......... SELECT CLOSED 

6. APU LCV Switch................................................. SELECT OPEN 

Attempt to start one engine at a time:

7. L or R ENG START ............................................................. PUSH 

 When N2 is 28% or greater and ITT is 90°C or less:

8. Thrust Lever .......................................................................... IDLE 

9. Engine Indications....................................................... MONITOR 

 Engine relights (within 25 seconds): 

1. Thrust Lever ......................................................... AS REQUIRED 

2. Operative GEN .......................................................... CHECK ON 

Operative engine:

3. Applicable 10TH STAGE BLEED........................ CHECK OPEN 

4. Applicable PACK ....................................................... CHECK ON 

Reestablish normal power:

5. ADG Manual Deploy Handle.............................................. STOW 

6. ADG PWR TXFR....................................................... OVERRIDE 

7. Single Engine Procedures

(See Page AP 1-2)................................................. ACCOMPLISH 

— END —

8. Affected Engine, Thrust Lever ..................................... SHUTOFF 

9. Affected ENG STOP ............................................................ PUSH 

10. Attempt relight on other engine.

 — CONTINUED — 

Double Engine Failure (Cont)

Relight usingAPU bleed air:

NO

Neither engine is restarted:

? YES
Appendix D 153 Aircraft Accident Report

 REVISION 8—MAY 31, 2005 EP 1-9

POWERPLANT EMERGENCIES

QUICK REFERENCE HANDBOOK

Northwest Airlink Pinnacle Airlines CANADAIR REGIONAL JET

1. Consider a forced landing or ditching. Notify cabin crew.

2. Thrust Levers (both) ..................................................... SHUTOFF 

3. Target airspeed ..................................................... REESTABLISH 

AIRPLANE WEIGHT TARGET BEST GLIDE SPEED

51,000 lb 190 KIAS

36,000 lb 170 KIAS

4. Prepare for a forced landing or ditching (See Page EP 7-2).

— — — END — — —

Double Engine Failure (Cont)

Neither engine is restarted:
154 Aircraft Accident Report

Appendix E

Core Lock Safety Recommendation Letter

E PLURIBUS UNUM

NATIONAL TRA SPORTATION

B OAR D

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Safety Recommendation 

Date: November 20, 2006

In reply refer to: A-06-70 through -76 

Honorable Marion C. Blakey 

Administrator 

Federal Aviation Administration 

Washington, DC 20591 

On October 14, 2004, Pinnacle Airlines flight 3701 (doing business as Northwest 

Airlink), N8396A, a Bombardier CL-600-2B191

 equipped with General Electric (GE) CF34-3 

turbofan engines, crashed into a residential area about 2.5 miles south of Jefferson City 

Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight2

from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International 

Airport, Minneapolis, Minnesota. The captain and the first officer were killed, and the airplane 

was destroyed. No one on the ground was injured. The flight was operating under the provisions 

of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual 

meteorological conditions prevailed at the time of the accident. 

The accident flight crew decided to climb to the airplane’s maximum operating altitude of 

41,000 feet.3 The airplane arrived at 41,000 feet at less than its best rate of climb speed and 

slowed to its stall speed. An aerodynamic stall followed, which resulted in a loss of control of 

the airplane. The flight data recorder (FDR) and the cockpit voice recorder (CVR) indicated that 

the engines were operating normally before the upset. The flight crew recovered the airplane 

from the upset at an altitude of 34,000 feet. However, during the upset, the airflow to the engine 

inlets was disrupted, and both engines flamed out.4 The rotation speed of both engines’ cores 

(N2) continued to decrease.5

 Before the airplane descended to an altitude of 28,000 feet, the core 

1

 The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in the 

CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired Canadair in 

December 1986. 2

 A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled. 

Repositioning flights do not carry passengers or cargo. 3

 A maximum operating altitude is the maximum density altitude at which the best rate of climb airspeed 

will produce a 100-feet-per-minute (fpm) climb at maximum weight, while in a clean configuration, and with 

maximum continuous power. For the CRJ-200, the maximum operating altitude represents the maximum capability 

of the airplane; the actual climb capability will primarily depend on airspeed, weight, and ambient temperature. The 

accident airplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at an 

altitude of 41,000 feet if the airspeed had been maintained at Mach 0.7 during the climb and at altitude. 4

 A flameout is an interruption of a turbine engine’s combustion process that results in an uncommanded 

engine shutdown. 5

 A turbine engine gas generator section is commonly referred to as the core. 

7695A
Appendix E 155 Aircraft Accident Report

2

rotation speed of both engines had reached 0 indicated rpm. The flight crew attempted to restart 

the engines several times but was unable to do so. The flight crew then attempted to make an 

emergency landing at JEF, but the airplane crashed before reaching the airport.6

This accident is still under investigation, and the National Transportation Safety Board 

has not yet determined the probable cause of the accident. Nonetheless, the investigation has 

revealed a safety issue regarding a condition that can preclude pilots from restarting an engine 

after a double engine failure. 

Restart Attempts for Accident Engines 

Pinnacle Airlines’ double engine failure checklist at the time of the accident indicated that 

pilots were to maintain a target airspeed of 240 knots.7

 The purpose of maintaining this airspeed 

was to keep the engine cores rotating at an appropriate speed for either a windmill restart8

 or an 

auxiliary power unit (APU)-assisted restart.9

 FDR data and the CVR recording showed that the 

flight crew did not accelerate the airplane after the upset and that the engine core rotation slowed 

to 0 indicated rpm. FDR data also showed that the crew did not achieve the 240-knot airspeed 

before or after attempting to restart the engines. 

The flight crew first attempted to restart the engines using the windmill restart procedure. 

A windmill restart requires accelerating the airplane to an airspeed of at least 300 knots to 

increase the core rotation speed before the attempted restart. FDR data showed that the crew did 

not achieve the 300-knot airspeed (the maximum airspeed recorded by the FDR was 236 knots) 

and that the engine cores remained at 0 indicated rpm during the restart attempt. The CVR 

recording indicated that the flight crewmembers then elected to descend to an altitude of 

13,000 feet so that they could attempt to restart the engines using the APU-assisted restart 

procedure, which requires slowing the airplane to 170 or 190 knots (depending on the airplane’s 

weight) before initiating the restart. Once the airplane descended to an altitude of 13,000 feet, 

the flight crew attempted four APU-assisted engine restarts (two attempts per engine), but FDR 

data showed that the engine cores still remained at 0 indicated rpm. 

The accident airplane’s APU and start system components were found mostly intact at the 

accident scene. Examination and testing of these components found nothing that would have 

prevented adequate torque from being delivered to the engines for the restart attempts. Engine 

disassembly inspections found no mechanical failures or evidence of any condition that would 

have prevented engine core rotation. Although the inspections disclosed thermal damage in the 

No. 2 engine that would have impeded the engine’s ability to produce thrust, this damage would 

not have prevented core rotation during an attempted restart.10

6

 For more information about this accident, see DCA05MA003 at the Safety Board’s Web site at 

<http://www.ntsb.gov>. 7

 All airspeeds cited in this letter are knots indicated airspeed. 8

 A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing through 

the engine as the airplane moves through the air provides rotational energy to turn the core. 9

 Pinnacle Airlines’ double engine failure checklist indicated that the windmill restart procedure was to be 

used at altitudes from 21,000 to 13,000 feet and that the APU-assisted restart procedure was to be used at altitudes of 

13,000 feet and below. 10 The inspections found no preimpact damage to the No. 1 engine. 
Appendix E 156 Aircraft Accident Report

3

Manufacturer’s Core Lock Screening Procedure 

During the accident investigation, the Safety Board learned that GE CF34-1 and CF34-3 

engines11 had a history of failing to rotate during in-flight restart attempts on airplanes 

undergoing production acceptance flight testing at Bombardier. The manufacturers referred to 

this condition as “core lock.” Bombardier first identified this problem in 1983 during Challenger 

certification tests, and GE attributed the problem to interference contact at a high pressure 

turbine (HPT) air seal. 

The CF34 HPT air seals are designed to control cooling and balance airflow. The seals 

include teeth on the rotating components that grind operating grooves into abradable surfaces on 

the stationary components. The efficiency of these seals significantly affects engine 

performance, so the seals are designed to operate with minimal clearances. 

Bombardier added a procedure to the production acceptance flight tests for its CF34-1- and 

CF34-3-powered airplanes to screen engines for the potential to experience core lock. At the time 

of the accident, this screening procedure was as follows:

1. Climb to flight level 310. 

2. Retard the test engine throttle to idle and stabilize for 5 minutes. 

3. Shut down the test engine. 

4. Descend at 190 knots. 

5. Slow the aircraft until N2 is reduced to 0 percent. 

6. At 8 1/2 minutes from shutdown, push over to 320 knots. 

7. If N2 is 0 rpm at flight level 210, the engine is declared to be core locked. 

Engines that are found to be core locked are reworked using an in-flight “grind-in” 

procedure that was designed to remove seal material at the interference location.12 Engines that 

undergo grind-in rework are then rescreened for core lock. The grind-in procedure, which 

includes a cross-bleed start for the core locked engine, is as follows: 

1. Air turbine starter cross-bleed start. 

2. Ascend to flight level 310. 

3. Repeat core lock screening procedure but descend at an airspeed of about 240 knots 

to establish 4 percent N2.

4. Maintain 4 percent N2 for at least 8 1/2 minutes. 

5. Confirm that no core lock exists by repeating screening procedure. 

As testimony during the Safety Board’s June 2005 public hearing on the Pinnacle Airlines 

accident indicated, neither Bombardier nor GE considered core lock to be a safety-of-flight issue.

The manufacturers claimed that engines that passed the screening procedure, with or without 

grind-in rework, would not core lock as long as the 240-knot airspeed was maintained. 

11 Bombardier airplanes that are powered by either GE CF34-1 or CF34-3 engine models are the 

Challenger 601, Challenger 604, CRJ-100, CRJ-200, and CRJ-440. 12 Newly manufactured engines undergo a test cell seal grind-in before delivery. 
Appendix E 157 Aircraft Accident Report

4

Turbine Engine Shutdowns 

The operating temperatures in parts of the HPT reach more than 2,000q Fahrenheit. After 

a turbine engine has been operating, its rotating and stationary components have expanded to 

their normal operating dimensions and clearances. When an engine is shut down, its rotating and 

stationary components do not contract at the same rates because of differences in their material 

properties and their exposure to cooling air. Temporary losses of clearance between the rotating 

and stationary components and misalignment between the rotating teeth and stationary grooves 

of the air seal occur until the temperatures of the components reach equilibrium. Because of this 

characteristic, turbine engine shutdown procedures include operation for several minutes at a 

lower power setting to permit internal temperatures and clearances to stabilize. Engines that 

flame out suddenly in flight experience more severe thermal changes that may result in losses of 

clearance so that the rotating and stationary components rub or bind. 

More importantly, flameouts at high power and high altitude conditions produce even 

greater thermal distress because internal temperatures are the hottest at high power settings and 

the air is colder at high altitudes. The increased thermal shock exacerbates the loss of component 

clearance and alignment. Because the accident engines flamed out under these conditions, axial 

misalignment caused the seal teeth, which were positioned aft of their normal grooves, to contact 

stationary abradable material when radial seal clearances closed down. Once core rotation 

stopped, binding prevented core rotation from resuming during the windmill or APU-assisted 

restart attempts. Thus, the lack of core rotation on the accident airplane engines could be 

explained by the core lock phenomenon. 

Potential for Core Lock in CF34-1 and CF34-3 Engines 

Bombardier’s core lock screening procedure requires a cool-down period before engine 

shutdown to stabilize internal temperatures and clearances.13 However, as previously discussed, 

this procedure does not produce the more severe thermal distress associated with the high power, 

high altitude flameouts that occurred during the accident flight. Thus, the successful 

demonstration of Bombardier’s production flight test procedure may not ensure that an engine 

will not experience core lock if the core is allowed to stop rotating after a high power, high 

altitude flameout. In fact, the Safety Board notes that the No. 1 accident engine had successfully 

passed the screening procedure during initial production acceptance testing.14 Also, the 

successful demonstration of Bombardier’s production flight test procedure may not ensure that 

slowing the airplane to an airspeed of 170 to 190 knots is sufficient to maintain core rotation 

during an attempted APU-assisted restart. 

 During the public hearing for the Pinnacle Airlines accident, a GE manager testified, 

“As long as core rotation is maintained, you will not have core lock ... we have a body of data 

13 After the accident, Transport Canada mandated that Bombardier change the engine stabilization time 

from 5 to 2 minutes. 14 The No. 2 accident engine was installed new as a spare engine and was not subject to the the core lock 

screening procedure because it applies only to engines that are installed in Bombardier’s production airplanes. 
Appendix E 158 Aircraft Accident Report

5

that shows that 240 knots maintains core rotation.”15 This testimony suggests that the most 

effective way to mitigate the safety risk of core lock during in-flight restarts is to use an 

operational procedure to keep an engine’s core rotating until a restart can be attempted. The 

Safety Board is unaware of flight test data that demonstrate that 240 knots is sufficient to keep 

the core rotating after the more severe thermal distress associated with a high power, high 

altitude flameout. Thus, the Board is concerned that sufficient testing and engineering analysis 

have not been performed to demonstrate whether the 240-knot airspeed is effective in 

maintaining core rotation and preventing core lock after high power, high altitude flameouts. 

The Safety Board concludes that it is critical to identify the airspeed needed to maintain 

core rotation in CF34-1 and CF34-3 engines after high power, high altitude flameouts and to 

ensure that restart procedures can be accomplished under such conditions. Therefore, the Safety 

Board believes that, for airplanes equipped with CF34-1 or CF34-3 engines, the Federal Aviation 

Administration (FAA) should require manufacturers to perform high power, high altitude sudden 

engine shutdowns; determine the minimum airspeed required to maintain sufficient core rotation; 

and demonstrate that all methods of in-flight restart can be accomplished when this airspeed is 

maintained.16

The importance of maintaining a minimum airspeed to keep the engine cores rotating was 

not communicated to pilots in airplane flight manuals (AFM). For example, at the time of the 

accident, Bombardier’s and Pinnacle Airlines’ double engine failure checklists stated that 

240 knots was the “target” airspeed for the procedure but did not indicate that this airspeed was 

essential to the success of the restart procedure. As a result of the accident, Bombardier and 

Pinnacle Airlines revised their double engine failure checklists to indicate that 240 knots was the 

“minimum” airspeed and that the failure to maintain positive core rotation might prevent a 

successful restart.

 The Safety Board concludes that it is important for pilots to be aware of the possibility of 

core lock and the specific actions that are needed to preclude this condition. Therefore, the 

Safety Board believes that the FAA should ensure that AFMs of airplanes equipped with CF34-1 

or CF34-3 engines clearly state the minimum airspeed required for engine core rotation and that, 

if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss 

of in-flight restart capability as a result of core lock may occur. 

Performance Penalties for CRJ-100, -200 and -440 Airplanes 

The 240-knot airspeed included in Bombardier’s and Pinnacle Airlines’ double engine 

failure checklists is 70 knots greater than the airplane’s best glide speed17 (at an airplane weight 

of 36,000 pounds) of 170 knots. To maintain the 240-knot airspeed with no engine power and 

15 The GE manager further testified that the 240-knot airspeed also served to maintain a minimal hydraulic 

pressure. 16 The Safety Board notes that Bombardier Aerospace and Transport Canada have performed high altitude, 

high power engine shutdowns to verify the 240-knot target airspeed included in Bombardier’s double engine failure 

checklist. The APU-assisted in-flight restart process has not yet been verified. 17 An airplane’s best glide speed provides the airplane with the most distance forward for a given loss of 

altitude. 
Appendix E 159 Aircraft Accident Report

6

transition to a 300-knot airspeed for a windmill restart, a flight crew must significantly increase 

the airplane’s descent rate, thereby reducing the range of available landing locations if a forced 

(emergency) landing were to become necessary as a result of a failure to restart at least one 

engine. Because of the effect that this loss of glide range could have on a flight crew’s ability to 

find a viable emergency landing site, the Safety Board concludes that CRJ-100, -200, and -440 

pilots must be fully aware of the performance penalties that can be incurred while maintaining 

core rotation and attempting a windmill restart. Therefore, the Safety Board believes that the 

FAA should require that operators of CRJ-100, -200, and -440 airplanes include in AFMs the 

significant performance penalties, such as loss of glide distance and increased descent rate, that 

can be incurred from maintaining the minimum airspeed required for core rotation and windmill 

restart attempts. 

Potential for Core Lock in Other Engine Models 

Turbine-powered airplanes other than the Challenger 601 and 604 and the CRJ-100, -200, 

and -440 have turbine engine components with a similar physical design as those for the CF34-1 

and CF34-3 engines. As a result, the Safety Board concludes that other turbine engines may also 

be susceptible to core lock after high power, high altitude flameouts. Therefore, the Safety 

Board believes that the FAA should review the design of turbine-powered engines (other than the 

CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-70) to determine 

whether they are susceptible to core lock and, for those engines so identified, require 

manufacturers of airplanes equipped with these engines to perform high power, high altitude 

sudden engine shutdowns and determine the minimum airspeed to maintain sufficient core 

rotation so that all methods of in-flight restart can be accomplished. Further, the Safety Board 

believes that, for those airplanes with engines that are found to be susceptible to core lock (other 

than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-71), the 

FAA should require airplane manufacturers to incorporate information into AFMs that clearly 

states the potential for core lock; the procedures, including the minimum airspeed required, to 

prevent this condition from occurring after a sudden engine shutdown; and the resulting loss of 

in-flight restart capability if this condition were to occur. In addition, the Safety Board believes 

that the FAA should require manufacturers to determine, as part of 14 CFR Part 25 certification 

tests, if restart capability exists from a core rotation speed of 0 indicated rpm after high power, 

high altitude sudden engine shutdowns. For those airplanes determined to be susceptible to core 

lock, the FAA should mitigate the hazard by providing design or operational means to ensure 

restart capability. 

Windmill Restart Requirements 

Airplane manufacturers rely on the windmill method as the primary means of restart after 

an all-engine flameout event. Consequently, the portion of the flight envelope in which a 

windmill restart is effective is critical to flight safety. However, increases in the bypass ratios of 

turbofan engines over the years have significantly reduced the windmill restart portion of the 

in-flight restart envelope. Specifically, the engines powering many current transport-category 

airplanes bypass between 80 and 90 percent of the airflow entering the inlet around the engine 

core, so as little as 10 percent of the inlet air enters the core during normal operation. Thus, the 
Appendix E 160 Aircraft Accident Report

7

cores of high bypass ratio engines, such as the CF34,18 require significantly higher airspeeds to 

achieve windmill restart than the cores of low bypass engines installed on older generation 

airplanes.

After an all-engine high power flameout, pilots need to sacrifice a substantial amount of 

altitude to achieve the higher airspeeds that are necessary for a windmill restart with high bypass 

engines. However, depending on the altitude where the shutdown occurred, a pilot may not have 

enough altitude available to use this restart option.

Certification requirements currently address the minimum airspeed needed to ensure 

windmill restart capability. However, there is no upper limit on the value of the minimum 

airspeed required for a windmill restart and no limit on the amount of altitude loss that can occur 

during a windmill restart. If the minimum airspeed value is too high, an excessive amount of 

altitude loss may be needed to accomplish a windmill restart. In September 1999, the FAA 

issued a notice of availability and request for comments on a proposed Propulsion Mega 

Advisory Circular,19 which addressed this and other engine certification-related issues, but the 

FAA has taken no subsequent action. 

The Safety Board concludes that, during design, airplane manufacturers must consider 

that a pilot’s ability to restart high bypass turbine engines after an all-engine flameout might be 

compromised if an excessive airspeed or an excessive amount of altitude loss were needed for 

the restart. Therefore, the Safety Board believes that the FAA should establish certification 

requirements that would place upper limits on the value of the minimum airspeed required and 

the amount of altitude loss permitted for windmill restarts. 

Therefore, the National Transportation Safety Board recommends that the Federal 

Aviation Administration: 

For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to 

perform high power, high altitude sudden engine shutdowns; determine the 

minimum airspeed required to maintain sufficient core rotation; and demonstrate 

that all methods of in-flight restart can be accomplished when this airspeed is 

maintained. (A-06-70) 

Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3 

engines clearly state the minimum airspeed required for engine core rotation and 

that, if this airspeed is not maintained after a high power, high altitude sudden 

engine shutdown, a loss of in-flight restart capability as a result of core lock may 

occur. (A-06-71) 

Require that operators of CRJ-100, -200, and -440 airplanes include in airplane 

flight manuals the significant performance penalties, such as loss of glide distance 

and increased descent rate, that can be incurred from maintaining the minimum 

airspeed required for core rotation and windmill restart attempts. (A-06-72) 

18 The CF34 engine bypasses about 85 percent of inlet air past the core. 

19 For more information, see 64 Federal Register 52819, September 30, 1999. 
Appendix E 161 Aircraft Accident Report

8

Review the design of turbine-powered engines (other than the CF34-1 and 

CF34-3, which are addressed in Safety Recommendation A-06-70) to determine 

whether they are susceptible to core lock and, for those engines so identified, 

require manufacturers of airplanes equipped with these engines to perform high 

power, high altitude sudden engine shutdowns and determine the minimum 

airspeed to maintain sufficient core rotation so that all methods of in-flight restart 

can be accomplished. (A-06-73) 

For those airplanes with engines that are found to be susceptible to core lock 

(other than the CF34-1 and CF34-3, which are addressed in Safety 

Recommendation A-06-71), require airplane manufacturers to incorporate 

information into airplane flight manuals that clearly states the potential for core 

lock; the procedures, including the minimum airspeed required, to prevent this 

condition from occurring after a sudden engine shutdown; and the resulting loss 

of in-flight restart capability if this condition were to occur. (A-06-74) 

Require manufacturers to determine, as part of 14 Code of Federal Regulations

Part 25 certification tests, if restart capability exists from a core rotation speed of 

0 indicated rpm after high power, high altitude sudden engine shutdowns. For 

those airplanes determined to be susceptible to core lock, mitigate the hazard by 

providing design or operational means to ensure restart capability. (A-06-75) 

Establish certification requirements that would place upper limits on the value of 

the minimum airspeed required and the amount of altitude loss permitted for 

windmill restarts. (A-06-76) 

Chairman ROSENKER, Vice Chairman SUMWALT, and Members HERSMAN and 

HIGGINS concurred with these recommendations. 

[Original Signed]

By: Mark V. Rosenker 

 Chairman