Salt Lake City - Denver
Flight / Schedule
Salt Lake City - Denver
Aircraft
Mitsubishi MU-2 MarquiseRegistration
N454MA
MSN
1535
Year of Manufacture
1981
Operator
Flight Line - USADate
August 4, 2005 at 02:06 AM
Type
CRASHFlight Type
Cargo
Flight Phase
Landing (descent or approach)
Crash Site
Airport (less than 10 km from airport)
Crash Location
Parker Colorado
Region
North America • United States of America
Coordinates
39.5185°, -104.7613°
Crash Cause
Human factor
Narrative Report
On August 4, 2005 at 02:06 AM, Salt Lake City - Denver experienced a crash involving Mitsubishi MU-2 Marquise, operated by Flight Line - USA, with the event recorded near Parker Colorado.
The flight was categorized as cargo and the reported phase was landing (descent or approach) at a airport (less than 10 km from airport) crash site.
1 people were known to be on board, 1 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 100.0%.
Crew on board: 1, crew fatalities: 1, passengers on board: 0, passenger fatalities: 0, other fatalities: 0.
The listed crash cause is human factor. The commercial pilot was executing a precision instrument approach at night in instrument meteorological conditions when the airplane collided with terrain about four miles short of the runway. A review of air traffic control communications and radar data revealed the pilot was vectored onto the final approach course but never got established on the glide slope. Instead, he made a controlled descent below the glide slope as he proceeded toward the airport. When the airplane was five miles from the airport, a tower controller received an aural low altitude alert generated by the Minimum Safe Altitude Warning (MSAW) system. The tower controller immediately notified the pilot of his low altitude, but the airplane collided with terrain within seconds. Examination of the instrument approach system and onboard flight navigation equipment revealed no pre-mishap anomalies. A review of the MSAW adaptation parameters revealed that the tower controller would only have received an aural alarm for aircraft operating within 5 nm of the airport. However, the frequency change from the approach controller to the tower controller occurred when the airplane was about 10.7 miles from the airport, leaving a 5.7 mile segment where both controllers could receive visual alerts, but only the approach controller received an aural alarm. A tower controller does not utilize a radar display as a primary resource for managing air traffic. In 2004, the FAA changed a policy, which eliminated an approach controller's responsibility to inform a tower controller of a low altitude alert if the tower had MSAW capability. The approach controller thought the MSAW alarm parameter was set 10 miles from the airport, and not the 5 miles that existed at the time of the accident. Subsequent investigation revealed, that The FAA had improperly informed controllers to ensure they understood the alarm parameters for control towers in their area of responsibility. This led the approach controller to conclude that the airplane was no longer her responsibility once she handed it over to the tower controller. Plus, the tone of the approach controller's aural MSAW alarm was not sufficient in properly alerting her of the low altitude alert.
Aircraft reference details include registration N454MA, MSN 1535, year of manufacture 1981.
Geospatial coordinates for this crash are approximately 39.5185°, -104.7613°.
Fatalities
Total
1
Crew
1
Passengers
0
Other
0
Crash Summary
The commercial pilot was executing a precision instrument approach at night in instrument meteorological conditions when the airplane collided with terrain about four miles short of the runway. A review of air traffic control communications and radar data revealed the pilot was vectored onto the final approach course but never got established on the glide slope. Instead, he made a controlled descent below the glide slope as he proceeded toward the airport. When the airplane was five miles from the airport, a tower controller received an aural low altitude alert generated by the Minimum Safe Altitude Warning (MSAW) system. The tower controller immediately notified the pilot of his low altitude, but the airplane collided with terrain within seconds. Examination of the instrument approach system and onboard flight navigation equipment revealed no pre-mishap anomalies. A review of the MSAW adaptation parameters revealed that the tower controller would only have received an aural alarm for aircraft operating within 5 nm of the airport. However, the frequency change from the approach controller to the tower controller occurred when the airplane was about 10.7 miles from the airport, leaving a 5.7 mile segment where both controllers could receive visual alerts, but only the approach controller received an aural alarm. A tower controller does not utilize a radar display as a primary resource for managing air traffic. In 2004, the FAA changed a policy, which eliminated an approach controller's responsibility to inform a tower controller of a low altitude alert if the tower had MSAW capability. The approach controller thought the MSAW alarm parameter was set 10 miles from the airport, and not the 5 miles that existed at the time of the accident. Subsequent investigation revealed, that The FAA had improperly informed controllers to ensure they understood the alarm parameters for control towers in their area of responsibility. This led the approach controller to conclude that the airplane was no longer her responsibility once she handed it over to the tower controller. Plus, the tone of the approach controller's aural MSAW alarm was not sufficient in properly alerting her of the low altitude alert.
Cause: Human factor
Occupants & Outcome
Crew On Board
1
Passengers On Board
0
Estimated Survivors
0
Fatality Rate
100.0%
Known people on board: 1
Operational Details
Schedule / Flight
Salt Lake City - Denver
Operator
Flight Line - USAFlight Type
Cargo
Flight Phase
Landing (descent or approach)
Crash Site
Airport (less than 10 km from airport)
Region / Country
North America • United States of America
