Investigators say pilot error caused Kirksville plane crash

WASHINGTON -- A string of pilot errors caused the deadly crash of a commuter airliner in northeast Missouri, and the crew's non-stop joking and expletive-laden banter in the cockpit didn't help, federal investigators said Tuesday.

The two-man crew and 11 of 13 passengers aboard Corporate Airlines Flight 5966 were killed in the Oct. 19, 2004, accident -- the deadliest civilian air crash in the nation that year.

The National Transportation Safety Board said the crew failed to follow established procedures for landing at night without precision instruments and descended too low before they could see the ground clearly.

The pilot, Capt. Kim Sasse, 48, focused too much on looking outside the cockpit window instead of monitoring flight instruments as the plane approached Kirksville Regional Airport, the board said.

Based on a transcript of the cockpit voice recorder, investigators also found that Sasse and his co-pilot, Jonathan Palmer, 29, "lacked a professional tone" in the cockpit. A steady stream of quips, laughter and more than 45 expletives distracted the crew from focusing on the flight, investigators said.

"The discipline in that cockpit didn't seem to exist, which really created an environment for mistakes to be made," said NTSB Acting Chairman Mark Rosenker.

"This was extremely disappointing to hear what we heard on that cockpit voice recorder," said Rosenker, who described the recording as one of the most unprofessional he's ever heard.

The NTSB found no mechanical failure or maintenance problems with the twin-engine turboprop and no fault with training procedures at Smyrna, Tenn.-based Corporate Airlines, now called RegionsAir.

The crew had little warning of any problems until the final seconds of the flight that originated in St. Louis. Seconds before it was supposed to land, the plane clipped treetops and stalled before crashing in a field one mile short of the runway.

According to the transcript, Sasse claimed to see the ground and continued descending below 400 feet even though Palmer said he couldn't see anything. The board said Palmer failed to challenge Sasse's observations, defying established rules.

The Kirksville airport is one of about 50 out of 589 airports in the nation that is not equipped with an instrument landing system, which gives pilots more precise guidance about their position off the ground.

The NTSB recommended the Federal Aviation Administration revise its rules to prohibit pilots without precision guidance from descending below a minimum altitude unless they have a clear view of all obstacles on the ground near the runway.

The agency also said the FAA should reemphasize to air carriers the importance of keeping a professional atmosphere in the cockpit, known as the "sterile cockpit rule."

Pilot fatigue also was a factor, said NTSB investigator Malcolm Brenner, as the pilots had been on duty for more than 14 hours at the time of the 7:37 p.m. crash. It was the sixth landing of the day in challenging weather for a crew that reported for duty around 5 a.m.

That's within FAA guidelines, but the NTSB recommended that the FAA upgrade its regulations on how many consecutive hours a flight crew can work to account for the time pilots report for duty, work load and other factors.

Brenner said the United States and France are the only countries that base their aviation hours limits on flight time, while most other countries base them on duty time or a combination of duty and flight time.

Visibility was limited on the night of the accident, but Sasse expressed frustration that they would "go all this (expletive) way" without being able to land.

"Well, let's try it," said Palmer.

"Yeah, we'll try it," Sasse responded.

The plane was less than 300 feet off the ground before Sasse spotted the approach lights of the airport. Less than 10 seconds later, the crew spoke the final words recorded during the flight.

Sasse: "No."

Palmer: "Trees."

Sasse: "No, stop." (Sound of impact.)

Sasse: "Oh, my God." (Sounds of numerous impacts.)

Palmer: "Holy (expletive)."

The 19-seat Jetstream 32 was not equipped with an updated system that warns pilots when they fly too low, though it had an older version of the terrain warning system that met regulations at the time. Corporate Airlines operated the flight under contract with American Airlines' commuter service.

Passengers included doctors and other medical professionals en route to a conference at the Kirksville College of Osteopathic Medicine. The survivors, Wendy Bonham, 44, and Dr. John Krogh, 68, escaped from the wreckage with broken bones and some burns. They had worked together at the college's Orem, Utah, campus.

The crash has spawned a number of lawsuits, including one that alleges the pilots had been on duty longer than the 14-hour limitation set by American Airlines, though less than the FAA standard of 16 hours.

American Airlines has declined to comment on pending litigation.

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National Transportation Safety Board: http://www.ntsb.gov